Laserfiche WebLink
J ' <br /> PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE k - `/ - C <br /> 2. REQUESTING AGENCYc-,5 I -C- 2- PHONE NO. <br /> 3. AGENCY ADDRESS �!1 U� K1 f�CJ qQ Ff <br /> 4. INDIVIDUAL REQUESTING PHONE NO. <br /> 5. INDIVIDUAL ADDRESS - !� <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> � -�-sem P�Ic9-. � ow��-S�ft� � L ,s - <br /> *ASTER TEMS , Q TED FOR PHOTOCOPYING r <br /> SIGNATURE OF REQUESTING PARTY-- / + 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 /> 4/81 <br /> EH 00 14 <br />