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oUBLIC Rf <br /> _CORD RELEASE REO OU-,. <br /> I . REQUEST RELEASE UAIE_ 7' 02-�l--,k3' <br /> REQUESTING AGENCY �/ , _��� �j PHONE NO. AK-_-? <br /> 3. AGENCY ADDRESS_/Kr/ <br /> 4. INDIVIDUAL REQUESTING % PHONE NO. <br /> 5. INDIVIDUAL ADDRESS ,- . <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> A.11 P <br /> T � j <br /> *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> IGNATURE OF REQUESTING PARTY DATE 1�e4— <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE,2, <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE REL ASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />