Laserfiche WebLink
PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY �jry/I,CLG/�,� PHONE NO. _��a-�7 <br /> 3. AGENCY ADDRESS__ �jp�6 ivy ® <br /> 4. INDIVIDUAL REQUESTING PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *ASTERS ITEMS REQ ESTED F PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY _DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF FF�MEMBEROR$SINVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> U <br /> EH 00 14 4/81 <br />