Laserfiche WebLink
,%LIC RECORD RELEASE REOUE, <br /> 1 . REQUEST RELEASE DATE 4enn�e� 91 \�-% ') <br /> 2 REQUESTING AGENCY -� \M PHONE NO. 1o1 --14( _ <br /> 3. AGENCY ADDRESS q a._, <br /> 4. INDIVIDUAL REQUESTING K6'E PHONE <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> GVUN GwunJ wa� �MlY. WR\\ SW ,--\ <br /> Irate � umoN <br /> �'ho ca(/!C s <br /> 1plqvez 5 <br /> addn55�� <br /> *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY - DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE ,a <br /> SIGNATURE OF RELEASING OFFICIAL DATE 9 <br /> NAMES OF STAFF MEMBERS INVOLV N" THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 _--- - -_ 4/81 <br />