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*r <br /> PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE NO. c�L- 3l 170 <br /> 3. AGENCY ADDRESS p <br /> S <br /> 4. INDIVIDUAL REQUESTING PHONE N0. --ePZ <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS L/ ITEM REQUESTED �DATE J� PUURRPOrSyE� OF REQUEST <br /> ;�X�� S �Y/f 1�1�-T W/9r/ �U f-N /5/OC.y�.YIU 7'7 _ �1Sz /•v v.L/ I, La .✓T l o�iisR/ <br /> *ASTER ITEMS EQUE ED P PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN E R LEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />