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- CITY OFOAKLAND - OFFICEOFTHE CITY CLERK

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(Official Date
AKLANo .,
UEST FORM
r.DEC '9 AM 10= 5.
III DEC '9 AM 10: 5. .. DfC '9 APt 10= "
Clerks Initials: - Clerks Initials: Clerks Initials:
Request Received Request Completed/ RequestPicked-up/
Notification Given Mailed/Faxed
pwWalk-ln o Immediate Request o Picked-up
o Mail o 1 Day Request o Mailed
o Phone / Fax o Faxed o Within 3 days
o Other o Other o Greater than 3 da s
To BeCompleted bythe Date: IlL/lit lOI)
Name of Requester: I J t r J / . IPhone:.J/
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ttl(P1 Fax: _
Agency/Company: 12 0,) Cot1s " !it /7
Address: "3 DO OjOr../Ci rl4 'Zy 5:c..,ftJ :3
Howdoyouwantto receive thisdocument? 0 Email _
Requested Documents/Information (Please be as specific as possible)
Resolution Number: _ OrdinanceNumber: _
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Resolution/Ordinance/Report- Title/KeyWords: __d=- _
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Agenda Item: _
Meeting(s)' _ Meeting Date(s):
ForOffice UseOnly
Number of Copies: _____ X price per page: Time Spent on Research _
Copy Charges $ (number of pages x price per page)
Total for Items Sold $ Description: _
Total Money Collected: I ICash I Check I Money Order Cash Receipt#: _
Cashier'sInitial: Date: _
Received byCustomer: Date: _
Please useaseparateform foreach request! Fax number510-238-2228.

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