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} <br />I�- <br />�' <br />R��UCST P�R RECORbS <br />CITY CLLRY.'S OFFICP <br />�VERLTT, t71�SHI17G'I'OIJ <br />P r i n t �-� ���.t,vl,,�...1 <br />Wame % �// i`� ll�lDE/2.ShcJ Sianature � .. --- <br />Address � (�{ C-vL6�� ' <br />Telephone <br />F'�E'IZETI 4.1�+ yc�2.01 Number o"ZS.,Z-DIC16 <br />Records <br />Requested <br />� <br />�c/dn,rT <br />� <br />ZL�2l�h[�G(F'�/ Date d� J'4 3 Time <br />Signature <br />t * Request �' � Received <br />' forwarded to 4-� o BY <br />� Departmen � <br />** Response Due Date <br />Zp vi� �V�JGf7Fl�Nr' <br />i� ��- <br />/� !nLr:� <br />0 ,' ad �-�--� <br />** Department receiving the request should attach inforMation requested <br />or a statement as to why the record is not being dispensed and <br />reLurn to the City Clerk for issuance to req��estor. (Ord. 313-79) <br />Deli.vered Uate <br />Fxempt _ Time <br />Attachments <br />ACT]:ON TA1:IiN ON RECORD <br />. REQUEST <br />No. Pages Certified <br />No. Copies <br />Lmployees Sign. <br />� <br />J <br />'l <br />�Z � <br />�i <br />