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.I <br />PUBLIC RECORD RELEASE REQUEST <br />1 . REQUEST RELEASE DATE � / ©/I,,, <br />2. REQUESTING AGENCY(�Ljr dj,,(' �/ <br />1�f'1'rl `if'%. i -PHONE NO.(?/G ' <br />3. AGENCY ADDRESS 14- <br />96- zr- 4 <br />4. INDIVIDUAL REQUESTING / <br />PHONE NO(1?1b) 97�-33,�Q <br />5. INDIVIDUAL ADDRESS <br />FILE ADDRESS ITEM REQUESTED <br />DATE PURPOSE OF REQUEST <br />a,J�Od rJ Itl <br />�� c/c t�itJ �l t <br />+C -H-,` <br />T-, dt5&,5vj <br />-sem <br />* ER ITEMS EQ <br />s;ri F R PHOTOCOPYING <br />i� <br />SIGNATURE OF REQUESTING PART <br />DATE ` <br />`� <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL <br />DATES; <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE <br />AND MONITORING OF THE RECORDS. <br />EH 00 14 <br />4/81 <br />