LOS ANGELES COUNTY - DEPARTMENT OF HEALTH SERVICES
C
ounty
W
ide
I
ntegrated
R
adio
S
ystem
2024 Radio Distribution Inventory
All fields are required
Date :
mm/dd/yyyy
SUID# :
LID :
Radio Type :
Serial # :
HSA# :
IP Address :
(i.e. XG-15,P7100,P5400)
Name :
Dept :
Assignment :
Office Address :
Employee # :
City :
Room # :
Zip :
Telephone # :
(###) ###-####
EMail :
Fax # :
(###) ###-####
Print Name :
Title :
Signature :
Date :
mm/dd/yyyy
By submitting this electronic form I am assuming responsibility for the listed radio
Please Print a copy of this form for your records before submitting
______________________________________________________________
RADIO RETURNED TO EMS AGENCY
Released By :
Date :
Received By :
Date :
2024