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PLIC RECORD RELEASE REQUEST• <br /> 1 . REQUEST RELEASE DATE /ra7/`fl ��� If F 7 <br /> REQUESTING AGENCY_ PHONE N0. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING PHONE N0. a 39-a iS <br /> 5. INDIVIDUAL ADDRESS � 1� Cera c S Sv <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> TERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE Z", /4 l� <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE R . ASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />