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10VUBLIC RECORD RELEASE REQUTET <br /> 1 . REQUEST RELEASE DATE S 13 gss <br /> 2 REQUESTING AGENCY J o ti C, eZ�A� o� PHONE NO. <br /> 3. AGENCY ADDRESS 6 3 p N s ,Her <br /> 4. INDIVIDUAL REQUESTING L c-(- s PHONE NO. �166-c3\ \ <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS \ /ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> _16 a�1 P� � t�V1 I.LoSu fLE Wpo-- S a e � <br /> - � A-AN\C coo SJnG ZN&wt�4+"O - <br /> k-(Y t I P LA-v) <br /> 'ASTEISK ITEMS1\RgQUESTIE)D POR PHOTOCOPYING <br /> i1GNATURE OF REQUESTING PARTY \ x�� DATE S t3 IF <br /> .00AL HEALTH DISTRICT USE ONLY <br /> i 'ROJECTEO RELEASE DATE -4;= <br /> .IGNATURE OF RELEASING OFFICIAL DATE -!5— <br /> S OF TAFq MEMBERS INVOLVE N THE RELEASE AND MONITORING OF THE RECORDS. <br /> H 00 14 <br />