Laserfiche WebLink
I Lx A it b(+- <br /> H <br /> .C LIC RECORD RELEASE REQUE,7 <br /> 1 , REQUEST RELEASE DATE— <br /> REQUESTING <br /> ATE—REQUESTING AGENCYja PHONE NO.�QrgZp� <br /> 3. AGENCY ADDRESS p ihow GQ <br /> ,`t-0CIUBj,) ('A <br /> 4, INDIVIDUAL REQUESTING�64-LII)F, GpI F:e PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> 123A, Dig t �1?c Fi i <br /> IZAE <br /> --- <br /> *ASTERISK ITEMS REQUESTED POR PHOTOCOPYING <br /> :GNATURE OF REQUESTING PARTY DATE <br /> -------------------- <br /> iCAL HEALTH DISTRICT USE ONLY <br /> :OJECTED RELEASE DATE <br /> G AT <br /> URE OF RELEASING OFFICIAL_ / ,- <br /> DATE S ? <br /> M OF ST F MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS_ <br /> PAYMENT <br /> RECEIVED <br /> JUN 1 boo <br /> ENVIROENVIROMEnTAE H:ALTH <br /> 00 14 NAMENT NI tT{# ---- — RMSEytVlttS-- <br /> PERMITISERVICFS 4 /Al <br />