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P , IC RECORD RELEASE REQUE <br />THIS REQUEST WILL BE HONORED WHEN ITEMS 1-14 ARE TYPED, OR PRINTED CLEARLY IN INK <br />1. REQUEST DATE A q 'j 2. REQUEST TIME 4,'ct5- Pl <br />3. RELEASE IS REQUESTED FOR WHAT DATE? (312q 4. TIME 2:OO AA <br />5. REQUESTING AGENCY <br />6. AGENCY ADDRESS F0- P.,vl 45'67 <br />7. INDIVIDUAL REQUESTING <br />8. INDIVIDUAL ADDRESS <br />10. TITLE OF REQUESTED FILE <br />11. ADDRESS OF REQUESTED FILE <br />12. ITEMS REQUESTED <br />e �'S2m6 <br />I <br />-5- 9. TELEPHONE NO. 4iU-o/72- <br />*STAR ITEMS REQUESTED FOR PHOTOCOPYING <br />14. SIGNATURE OF REQUESTING PARTY <br />LOCAL HEALTH DISTRICT USE ONLY <br />13. ITEM DATE /d ;7-W <br />TE <br />PROJECTED RELEASE DATE -t3 _ TIME <br />SIGNATURE OF RELEASING OFFICIAL DATE a 7 <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE OF RECORDS <br />