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PW$- IC RECORD RELEASE'AEQUEST <br /> 1. REQUEST RELEASE DATE L U /2 I4 O <br /> 2• REQUESTING AGENCY -D-4-j'l WC PHONE NO. 4" - q a) l <br /> 3. AGENCY ADDRESS ni(0 t5 A\/tr' <br /> 4• INDIVIDUAL REQUESTING DPOJIt 1 Oi ( PHONE NO. *'pG -jjo) ( LrX Zj <br /> 5. INDIVIDUAL ADDRESS 2,714 S, _ N ttj" M67' <br /> FILE' DDRESS TEM REQUESTED DATE PURPOSE OF REQUEST <br /> _2-11(91. RJVa0 <br /> Ito N. F►l.P�c�21 to15n ��tJ� J <br /> • ASTERISK ITEMS ;Q S PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE Z 9 <br /> PUBLIC HEALTH SERVICES USE ONLY <br /> PROJECTED RELEASE DATE p <br /> SIGNATURE OF RELEASING OFFICIAL <br /> DATE <br /> NAMES OF AFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE <br /> RECORD <br /> EH 00 14 <br />