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M <br /> PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE (�/ I3)(i�< _ <br /> 2. REQUESTING AGENCY �,P-' PHONE NO(_'�bS�3S$-�IJ�S <br /> 3, AGENCY ADDRESS ( ZZ0 r rnnE� �C ti� <br /> _ C.P�t.�.pGv�-���0 GI's °I 36710 <br /> 4. INDIVIDUAL REQUESTING {� c�skt �S �Q�� PHONE NO. 14411�_ <br /> 5. INDIVIDUAL ADDRESS- <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *A$ ISK TEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY �� ���' '-" "" DATE S� 13 8 <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE ��� <br /> NAMES O.F�STAFF MEMB INVO IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> ,4 <br /> L <br /> EH 00 14 4/81 <br />