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1. <br />3. <br />5. <br />b. <br />BLIC RECORD RELEASE REQOT <br />THIS REQUEST WILL B HONORED WUEN ITEMS 1-14 ARE TYPED, OR PRINTED CLEARLY IN INK <br />r <br />REQUEST DATE _ 2. REQUEST TIME <br />as <br />RELEASE IS REQUESTED FOR IAT DATE? / �'�9 - 4. TIME l JO <br />REQUESTING AGEN <br />AGENCY ADDRESS <br />7. INDIVIDUAL REQUESTING <br />8. INDIVIDUAL ADDRESS <br />W, =0 <br />�.1 11 <br />i <br />9. <br />TITLE OF REQUESTED FILE <br />ADDRESS OF REQUESTED <br />TELEPHONE NO. <br />12. ITEMS REQUESTED 13. ITEM DATE tS '7. _ <br />*STAR ITEMS REQUESTED FOR PHOTOCOPYING <br />14. SIGNATURE''OF REQUESTING PARTY DATE 1� <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE TIME <br />SIGNATURE OF RELEASING OFFICIA DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE OF RECORDS <br />