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/PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY eon 11)vr PHONE NO. 36;! '-/rnr <br /> 3. AGENCY ADDRESS Q e <br /> 4. INDIVIDUAL REQUESTING Tr,af�y PHONE NO. 366 -170/ <br /> S. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> 6 fes, G <br /> _()ARy <br /> It r 0/ 5 wxl/4g <br /> k. 15141 <br /> t <br /> r <br /> *ASTERISK ITEMS�EQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTYDATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE 6 — <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF 17RS ,INV THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />