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PUBLIC RECORD RELEASE REQUEST <br />1. REQUEST RELEASE DATE /-- g/- <br />2 . REQUESTING AGENCY <br />3. AGENCY ADDRESS 2-721-0 2 <br /> <br />/4,0 j-6Pi-iONE N 0 . Z.F9-710 a 2- <br /> <br />( / Lfl14 <br /> <br />4. INDIVIDUAL REQUESTING L-vri)P% <br />5. INDIVIDUAL ADDRESS ° 6D <br /> <br />PHONE NO .1 <br /> <br />FILE ADDRESS <br />z/5-ef <br />ITEM REQUESTED DATE PURPOSE OF REQUEST <br />ro4e 1117 /(Lf <br />#eefi <br />*ASTERI K ITEMS REQUESTED FOR PHOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY DATE <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE -2/ ---e <br />SIGNATURE OF RELEASING OFFICIAL DATE <br />NAME§_QF STAFF MEMBERS INVOLVED THE RELEASE AND MONITORING OF THE RECORDS. <br />4id /r <br />4/81 <br />EH 00 14