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PU LIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE N0.^ <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING �ac S�,j �aEbl��;L- �eSo�� , PHONE NO. (41') -J57-��-5� <br /> 5. INDIVIDUAL ADDRESS 2((, -1 <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> Z07 os �k_cdm C4 <br /> *ASTEREQ ED FOR PHOTOCOPYING <br /> OF REQUESTING PARTY ' G DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE , <br /> SIGNATURE OF RELEASING OFFICIAL � ._ DATES' / <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 T 4/81 <br />