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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY l�U�fUrYmQ r�,� TP�hrlr�oG�— -- PHONE N0.14�d23' <br /> 3. AGENCY ADDRESS O6 aerjAianUQ <br /> se <br /> PHONE NO. <br /> 4. INDIVIDUAL REQUESTING_. t&gg4 I lnoI uak —� <br /> 5. INDIVIDUAL ADDRESS hO� N,fLW) 40Q" <br /> SG n J� (� <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> 10 So• Cherokee,Lodi US7 Clur�� �— �I1Vif Prof InoeS�rtrr�+an �Or I ends <br /> So <br /> X131 • • y 2-�Q <br /> *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE 2-18 88 <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE I <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLV THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />