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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE ► IIG ta 9 _ <br /> 2. REQUESTING AGENCY p t) ()IL PHONE NO�Z�l��2Z1-823fl <br /> 3. AGENCY ADDRESS 4 ,5o Oqi - zT. <br /> CLe,vF,4 1-7 64 NU125 <br /> 4. INDIVIDUAL REQUESTING 12 . J. d' d PHONE NO(ZIt,)�11 -8?3a <br /> 5. INDIVIDUAL ADDRESS :506�co Dl t- t�o. <br /> CLF_vp,moo, otA <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> � 1 <br /> *ASTERISK ITEMS REqUESTED FOR PHOTOCOPYING / <br /> SIGNATURE OF REQUESTING PARTY - DATE <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 /> Eli 00 14 4/81 <br />