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')UBLIC RECORD RELEASE REV' <br />1. REQUES1 RELEASE [)AIL <br />: REQUESTING AGENCY <br />3. AGENCY ADDRESS <br /> <br />PHONE NO. <br /> <br />INDIVIDUAL REQUESTINGL47A,/,‘,Af‘ <br />INDIVIDUAL ADDRESS <br /> <br />PHONE NO. <br /> <br />FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br />44-99,23U9r-dret <br />*ASTER SLT REQUESTED FOR PHOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY • DATE <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL %ak. Nt0442., DATE q-v-k -es <br />NAMES OF STAFF MEMBERS INVOLVED I THE RELEASE AND MONITORING OF THE RECORDS. <br />7/2 ,1 a.kf <br /> <br />EH 00 14 4/81