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P `' I C RECORD RELEASE REQUEST <br /> 9 <br /> THIS REQUEST WILL BE HONORED WHEN ITEMS 1-14 ARE TYPED, OR PRINTED CLEARLY IN INK <br /> 1 . REQUEST DATEAlA2. REQUEST TIME <br /> 3. RELEASE IS REQUESTED FOR WHAT DATE? :AZI °1 4. TIME <br /> 5. REQUESTING AGENCY <br /> 6. AGENCY ADDRESS A0 6 9 6 <br /> s44 5,206 <br /> 7. INDIVIDUAL REQUESTING <br /> 8. INDIVIDUAL ADDRESS 4 <br /> qs 5 9. TELEPHONE NO. L,6Q-pt92 <br /> 10. TITLE OF REQUESTED FILE <br /> 11 . ADDRESS OF REQUESTED FILE <br /> 12. ITEMS REQUESTED ` 13. ITEM DATE <br /> *STAR ITEMS REQUESTED FOR PHOTOCOPYING <br /> 14. SIGNATURE OF REQUESTING PARTY DATE i <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE -t 3 TIME <br /> SIGNATURE OF RELEASING OFFICIAL DATE - 7 <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE OF RECORDS �I <br /> i <br />