Laserfiche WebLink
'UBLI C iiEURD RELEASE REQ 11 ,,.I_ <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING_�E wL-6t PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *ASTE SK ITEMSRMSTED FOR PH OCOPYING <br /> SIGNATURE OF REQUESTING PART DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE- <br /> NAMES OF STAFF MEMBERS INVOLVE THE RELEASE AND MONITORING OF THE RECORDS. <br /> Ell 00 14 4/81 <br />