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7 <br /> PUlpe-,IC RECORD RELEASE-KEQUEST <br /> . 1. REQUEST RELEASE DATE G �� <br /> 2. REQUESTING AGENCY ; f PHONE NO. <br /> 3. AGENCY ADDRESS 3-�- �o z <br /> 4. INDIVIDUAL REQUESTING HONE NO. -2- <br /> 5. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM.REOUESTED DATE PURPOSE OF REQUEST <br /> le,)d - <br /> � e <br /> ASTERISK ITP-M EQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE/ <br /> PUBLIC HEALTH SERVICES USE ONLY <br /> PROJECTED RELEASE DATE <br /> r <br /> SIGNATURE OF RELEASING OFFICIAL ATE <br /> NAMES OF STAFF MEMBERS INVOL THE RELEASE AND MONITORING OF THE <br /> R CORDS. <br /> /�%W--e < L <br /> EH 00 14 <br />