Laserfiche WebLink
v � <br /> PUBLIC RECORD RELEASE REQUEST <br /> i <br /> 1 . REQUEST RELEASE DATE - --- <br /> 2. REQUESTING AGENCY _ PHONE NO. <br /> 3. AGENCY ADDRESS ( IJ p r -z�l lea- <br /> ll <br /> 4. INDIVIDUAL REQUESTING S2 C ilsusf PHONE NO.(q (A �(ola leo I <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> Zr51 ( R1L1STRs� CLug 1^7 luSe 4-3-85 �►J��sn�m� ar� 2,C�', Cc, <br /> 2oF�1 ��T2� Ciufi lam— c� nix C��c— z(o B� <br /> ��uk IkTjT a-ap fit- 5`5 <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 -jS f) <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />