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#OLIC RECORD RELEASE REQqW <br />THIS REQUEST WILL BE HONORED WHEN ITEMS 1-14 ARE TYPED, OR PRINTED CLEARLY IN INK <br />1. <br />REQUEST DATE15 <br />2. REQUEST TIME <br />q'loaam <br />3. <br />RELEASE IS REQUEST FOR WHAT DATE? t/[y '7 R' 4. <br />D <br />TIME <br />5. <br />REQUESTING AGENCY /) <br />, <br />6. <br />AGENCY ADDRESS <br />7. <br />INDIVIDUAL REQUESTING <br />8. <br />INDIVIDUAL ADDRESS Al - <br />9. TELEPHONE NO. <br />10. <br />TITLE OF REQUESTED FILE <br />G <br />11. <br />ADDRESS OF REQUESTED FILE ?,o- <br />®' <br />moi° S <br />12. <br />ITEMS REQUESTED <br />13. <br />ITEM DATE 7 <br />*STAR ITEMS REQUESTED <br />FOR PHOTOCOPYING <br />14. <br />SIGNATURE OF REQUESTING PARTY <br />_DATE <br />l 5 l <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE TIME <br />SIGNATURE OF RELEASING OFFICIAL DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE OF RECORDS <br />