Laserfiche WebLink
PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE o <br /> 2. REQUESTING AGENCY PHONE NO. -3,f/ <br /> 3. AGENCY ADDRESS________,'V <br /> (/✓�I C �JGCci� C�/T %�� <br /> 4, INDIVIDUAL REQUESTING ����2., �� PHONE NO. <br /> 5, INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQ UESTED� ,J DATE PURPOSE OF REQUEST <br /> -�C/�� _S/�.�i,'�G�� -- SUc,�✓�h /v(c'T'Zl /r/;��^;r ��y __ �G �" . <br /> 1-. <br /> *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE- <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE -O <br /> N,4MES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> Eli 00 1.4 - <br />