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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE 7- <br /> 2 REQUESTING AGENCY - PHONE w�� <br /> 3. AGENCY ADDRESS L, _ y} � GQ <br /> Sm c lug <.,4 <br /> 4. INDIVIDUAL REQUESTING.`e/q>Llt=. at t,-Z_j� I PHONE N0. <br /> S. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> X235 1Ik) <br /> i <br /> s <br /> 'ASTERISK ITEMS REQUESTED POR PHOTOCOPYING <br /> iIGNATURE OF REQUESTING PARTY DATE <br /> .00AL HEALTH DISTRICT USE ONLY <br /> 'ROJECTED RELEASE DATE <br /> ;IG ATURE OF RELEASING OFFICIAL �,��. _ _DATE <br /> LAM OF ST F MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> -- ' ILI <br /> H 00 14 4/81 <br />