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• ` RECEIVED NGV 13'" <br /> I PUBLIC RECORD RELEASE REQUEST NOV 21 '1 00 <br /> ENVIROMENTAL HEALTH <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY q� PHONE N0. I 7 77 Zk% <br /> 3. AGENCY ADDRESS /JO <br /> i <br /> 4. INDIVIDUAL REQUESTING r (;17? & 23 al- _ PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> v <br /> 1 *ASTERISK ITEMS REQUESTED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY��7 <br /> DATE / 1y $ <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 /> 4/81 <br /> EH 00 14 <br />