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PUBLIC RECORD RELEASE REQULI <br />l. REQUEST RELEASE DATE <br />REQUESTING AGENCY PHONE NO. 6/0 , cb0/4-57 _ <br />AGENCY ADDRESS (.(57 6", 4c,.2. ,.--",i,c,‘ iby gplcra,64-, <br />INDIVIDUAL REQUESTING e9F11- /(71-90N PHONE NO. f4111/NE__ <br />INDIVIDUAL ADDRESS A04akFS-7 5"L„-raa›7, 22,t, 51(1-7t),. <br />FILE ADDRESS ITEM REQUESTED DATE <br />Lts--Th Act 10;1 2+5 242.1i,.:„v/ Arssossi3O,:3 <br /> <br />c°A t <br /> ckse A-M;cct,,k <br /> <br />-77/8C. /// p 5 <br />*ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY ArJa....A. <br /> <br />DATE <br /> <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL DATE <br />NAMES/0 STAFF M M8ERS INVOL VTN THE RELEASE AND MONITORING OF THE RECORDS. <br />PURPOSE OF REQUEST <br />EH 00 14 4/81