Laserfiche WebLink
PUBLIC RECORD <br /> RELEASE REQUEST Q <br /> 1 . REQUEST RELEASE DATE I� l Is I <br /> 2. REQUESTING AGENCY S,1 —,ToEt;, n L' ['per tc S Q CSnu. PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING (jp_b V 0. PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> I5DI). SlnC.&a fnoL,_� CTC 'r7LR 3(2g1 � Qeu1'e �) <br /> *ASTE MS REQ UE E FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE : � g <br /> SIGNATURE OF RELEASING OFFICIAL DATE �f— <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> PL4----) <br /> EH 00 14 4/81 <br />