Laserfiche WebLink
PUBLIC RECORD RELEASE REQUEST <br /> t <br /> rI . REQUEST RELEASE DATE _ 6 2- / <br /> 2. REQUESTING AGENCY v 6 /L ,VC. PHONE N0. 3%6 2C /L 7 <br /> 3. AGENCY ADDRESS,,-3,;5- <br /> 4. INDIVIDUAL REQUESTING ��% %/ �/jl�/� _ PHONE NO. S � <br /> 5. INDIVIDUAL ADDRESS -2-3-3 - <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST*ASTERIS !I FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY Q DATE S 7/,-,c <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE — 9 <br /> SIGNATURE OF RELEASING OFFICIAL DATE_ <br /> NAM OF ST FF MEMQERS NVOLVED IN <br /> l' <br /> AND MONITORING OF THE RECORDS. --�-=-� <br /> 111 00 1 <br />