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0 IC RECORD RELEASE REQL1-^T <br /> THIS REQUEST WILL BE HONORED WHEN ITEMS 1-14 ARE TYPED, OR PRINTED CLEARLY IN INK <br /> 1 . REQUEST DATE 'A, h S 11717 2. REQUEST TIME lloal" <br /> 3. RELEASE IS REQUESTED FOR WHAT DATE? 4. TIME /,° 30If A <br /> 5. REQUESTING AGENCY <br /> 6. AGENCY ADDRESS O o-/°,tel 1,.5 6 17 <br /> 5.�� , � �s�o6 <br /> 7. INDIVIDUAL REQUESTING _�,r, � 7 <br /> 8. INDIVIDUAL ADDRESS <br /> ql_.265 9. TELEPHONE NO. q61-0/1?2 <br /> 10. TITLE OF REQUESTED FILE <br /> 11 . ADDRESS OF REQUESTED FILE o 015-6"7 _ <br /> 12. ITEMS REQUESTED 13. ITEM DATE 2 !s 79 <br /> • I <br /> I <br /> I <br /> *STAR ITEMS REQUESTED <br /> FOR PHOTOCOPYING <br /> 14. SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE m TIME <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE OF RECORDS 1 <br /> zz <br /> r <br />