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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE //- 8 - b5S <br /> 2. REQUESTING AGENCY Dohs � 54cTo, - 7OV(?,S PHONE NO.R/(, ) <br /> 3. AGENCY ADDRESS /7I q P STfUc-"T <br /> s (,-Ysco CA qS-V4 <br /> 4. INDIVIDUAL REQUESTING J/" PlkPf AAA-0 PHONE NO.( 16) <br /> 5. INDIVIDUAL ADDRESS lal�1 `< STS rr <br /> 3kcaA-mi.--to c), CSA cj�SsI �f <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> hPe.✓ s x-(77 <br /> b4-7 <br /> " - k,,) 5277 <br /> ,7 <br /> EZZ <br /> V - b-2--7 7 <br /> * K TEMS . TED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PART DATE// <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL_ DATE /( oW S <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEA E AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />