Laserfiche WebLink
PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE NO.� - rdc�zscJ <br /> 3. AGENCY ADDRESSLy VIP I� LGQ' I K� <br /> 4. INDIVIDUAL REQUESTING PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> v x}25 N �.ad✓� 1 Qn� r {�nah.a� � ��s f /�/�i`i'=� „' [' <br /> *ASTE I K ITEMS REQUESTED YOR P)F TOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTA DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE /' <br /> SIGNATURE OF RELEASING OFFICIAL _ DATE <br /> NAM pF STAFF MEWERS INVOLVE N THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />