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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY 2E SAf ONE NO. B 3 -3SZ7 i <br /> 3. AGENCY ADDRESS / `7 / D P4,41 AJ 45 <br /> 6 S d-A-L.o ►j CA <br /> 4. INDIVIDUAL REQUESTING L, l s PHONE NO. ASn7 <br /> 5. INDIVIDUAL ADDRESS :5pji-o 6 tq--S ke- V - <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> 222 /J• ELDa ALS- • � C�J�2ts�nlp- RC�i �)c� �2 si TE <br /> �-tzsc-K�rJ &/c_c A&f D eo-ro rza S eon/T rn t,�/,4�o&J <br /> LE✓�t_S 7D DE72f2/u ,NE <br /> l V-ft- Ex,r S r lArG <br /> C_hLI F35 un L� �fl <br /> *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE ! L <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> Q <br /> 4/81 <br /> EH 00 14 _ _ _ - ,_ -- -• <br />