Laserfiche WebLink
N PUBLIC RECORD RELEASE REQUEST <br /> 1. REQUEST RELEASE DATE orl. 9, lgqo <br /> 2. REQUESTING AGENCY , W40 uVaL PHONE NO. �- <br /> 3. AGENCY ADDRESS <br /> omm <br /> �/I PQ QD�t <br /> 4. INDIVIDUAL REQUESTING JW PHONE NO. <br /> 5 . INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY 6 /G/( DATE <br /> PUBLIC HEALTH SERVICES USE ONLY <br /> PROJECTED RELEASE DATE 9 / 9 O <br /> SIGNATURE OF RELEASING OFFICIAL DATE /6 - qo <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE <br /> RECORDS, <br /> EH 00 14 <br />