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1 or PUBLIC RECORD RELEASE JkUEST <br /> 1 . REQUEST RELEASE DATE• <br /> 2. REQUESTING AGENCY .eC PHONE NO. • ��(-$'r/j cL <br /> 3. AGENCY ADDRESS •,30 G- <br /> �• �'P !� �7- <br /> _ � G lk <br /> 4. INDIVIDUAL REQUESTING' �,.L. PHONE N0.• `f��-5 �9 <br /> ` �-� <br /> 5. INDIVIDUAL. ADDRESS • -�� <br /> FILE ADDRESS )ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> 14 C <br /> tb <br /> /g 7 a <br /> • *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIA c DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING 'OF THE RECORDS. <br /> - <br /> T <br /> EH 00 14 4/81 <br />