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KITTITAS COUNTY <br />BOARD OF COUNTY COMMISSIONERS <br />Chair <br />Vice Chair <br />Commissioner <br />Date Signed <br />ATTEST: <br />Julie Kjorsvik, Clerk of the Board or <br />Mandy Buchholz, Deputy Clerk of the Board <br />APPROVED AS TO FORM: <br />Deputy Prosecuting Attorney <br />KITTITAS COUNTY PUBLIC HEALTH <br />Print N ame1-;;1 <br />[a <br />[Title] '30-7 <br />M tl ( � <br />[Address] <br />cl <br />T {� <br />[Ci , State, Zip' <br />bq- - Sf� <br />[Teiephv e] <br />''3 A)- <br />[Date Signed] <br />