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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE_ 9-2.`/-*�C( <br /> 2. REQUESTING AGENCY LG94¢ Y't4o fLog"l Ser v, 7P PHONE <br /> 3. AGENCY ADDRESS_ /yc)e ��J2 S✓�s� <br /> 4. INDIVIDUAL REQUESTING 9!' e e PHONE NO. �S�FfZu� <br /> 5, INDIVIDUAL ADDRESS SO 9 W/ 46-,e4 <br /> 6477, c4L. q,26 <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *AST ISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTYjtjre,< DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL �yw DATE <br /> N Of AFF M BE VOL ED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> Qo_1 <br /> Ell 00 14 <br />