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MAAH FILE RECORD INFORMATION#M <br /> SWE S <br /> A<IKOn County P ro g/Sub E l e m Canputw No. <br /> 0 j .tql F I <br /> R- F T F I I '- -1 <br /> Lf I q1 ;7/ FoTo I 10 11 <br /> E . H . (assigned by clerk) <br /> P/S . E . Local Com . Number OUA_.11-7 <br /> Dist . location CodeFee Ex: <br /> aw <br /> c z ELI Il <br /> Previous Camp. NumaEn Effective nate Other Program Activity <br /> FF I -I I 1 1 . 1 [0 1 g-J .:2-1 q1 q 1 .1 1 1 1 <br /> SITE NAME (30 ctwracto(s) <br /> '7 � <br /> S4TE Address (no./Vir/Street/Suffix/Suite) Site City/State/Zi <br /> -2 cJ 0S'EM i I`-� s.J7fc�¢ C 4'S 33,6 <br /> PREVIOUS DBA /UJ <br /> Billing Mame _ <br /> I 2-240F A-r4,l'7- �,c�Gticc uJdr�,�S' �j ��4l�"77Y �J7� <br /> Billing Address (No/Dir/Street/Suffix/Suite) Billirg'City/State%Zip <br /> ES1 542E 547E TELL•PttOr:E NU►40CH <br /> Jr Seats �„�� ,� <br /> Sq I'td � <br /> Uts 2 3 � � �JCJ) <br /> O NER NAME (30 characters) . <br /> F—,(? f C) ,)-/-7E-c- <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> J1001 CA)- (�1E �ST - 1 / Cf 3,6 <br /> SPECIAL PROGRAM 1HFOR-01ATION No.of S4rvlce source of Treatment Population <br /> Conrwtlont supply Type Served <br /> Rac. Health =at LLJ <br /> ADDITIONAL COMMENTS <br /> L��u�� <br /> !1,IvLjee / r <br /> San. Sun. AC St' a <br />