Laserfiche WebLink
PUBLIC RECOR�LEASE REQUEST <br /> THIS REQUEST WILL BE HONOREDWHENITEMS 1-14 ARE TYPED, OR PRINTED CLEARLY IN INK <br /> A rY1 <br /> 1 . REQUEST DATE _ 1�tA �_ l�- � _ 2. REQUEST TIME } - <br /> 3. RELEASE IS REQUESTED FOR WHAT DATE? Z / 7 q 4. TIME <br /> 5. REQUESTING AGENCY __Z g&,4-7 V.¢L.[_e-V_T -1 t"S -- <br /> b. AGENCY ADDRESSLc <br /> t E t✓ZC _.__.. - - -- - <br /> 7. INDIVIDUAL REQUES-TING <br /> 8. INDIVIDUAL ADDRESS 3 13 SATE 0,D ) J),e , MdDED 5T-6 . C'A(:-ice 9S3SS <br /> 9. TELEPHONE N0. 5Z/_(oOZO <br /> 0. TITLE OF REQUESTED FILE LuA�� <br /> 1 . ADDRESS OF REQUESTED FILE l03 O <br /> 2. ITEMS REQUESTED Sia u ,Tj-T�o-J PE/?M T # Z I S(a/ 13. ITEM DATE 3 - 7- 6 7 <br /> 7o -- 791 110-19- 70 <br /> zZ33 0 <br /> I <br /> Zo829 `7- <br /> 73 -33 8 73 <br /> i-/v - 6 y <br /> M 7l <br /> -Z OF 2 2-- 7/ <br /> ► J� USZ_ 7- 2 - G 3 <br /> I <br /> *STAR ITEMS REQUESTED FOR PHOTOCOPYING <br /> 4. SIGNATURE OF REQUESTING PARTY � � DATE V/z,"79' <br /> _OCAL HEALTH DISTRICT USE ONLY <br /> 'ROJECTED RELEASE DATE / C /7 Z TIME <br /> SIGNATURE OF RELEASING OFFICIAL DATE y 2� <br /> SAME OF STAFF MEMBERS INVOLVED IN THE RELEASE OF RECORDS <br />