Laserfiche WebLink
m <br />1. REQUEST RELEASE DATE <br />REQUESTING AGENCY K <br />3. AGENCY ADDRESS 9,)g <br />4. <br />5. <br />INDIVIDUAL REQUESTI <br />INDIVIDUAL ADDRESS <br />PUBLIC RECORD RELEASE REQUEST <br />�G�cln�e��ef <br />S PJB-.sw-.ss <br />CIA <br />n c <br />PHONE NO. qI6 - <br />c,-/ PHONE NO. ':�/6-T"-120I <br />FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br />it U&c, kyGnttL5 <br />Z l!%LySiS� den <br />U sr s� <br />«ASTER ITEMS <br />SIGNATURE OF REQUESTING PARTY <br />PHOTOCOPYING <br />DATE <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL A � � DATE <br />Ern 9 STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br />EH 00 14 <br />4/81 <br />