Laserfiche WebLink
4ABLIC RECORD RELEASE REQUAR <br /> 1 . REQUEST RELEASE DATE / �j lie <br /> REQUESTING AGENCY ,�T�12,t/� 1//gZt�fjE Jq yC�-S. PHONE NO. �9- Bt p//Q <br /> 3. AGENCY ADDRESS �SIS- C�•¢/� si� e/� 7^j'ZD/ <br /> 4. INDIVIDUAL REQUESTING p ,✓ io e a �.S PHONE NO. ?�tg -611iq <br /> 5. INDIVIDUAL ADDRESSS- <br /> ST.�✓ e ¢. 9 <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> Z-/1-,4 �eo.�O oma- 'A" /�. S <br /> /630 azq <br /> *ASTER K TE MS REQUESTED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE g <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIALDATE 1-1-2- <br /> le r4 <br /> NAMES OF -�TAFF MEMBERS INVOLV IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> ru nn is - —- - - alat <br />