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PUBtmtC RECORD RELEASE n.'QUEST <br /> 1. REQUEST RELEASE DATE //- <br /> 2. REQUESTING AGENCY �S'T //�n/L PHONE NO. <br /> 3. AGENCY ADDRESS / <br /> 4. INDIVIDUAL REQUESTING�iT 000 P,-, ,�//PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REOUESTED DATE PURPOSE OF REQUEST <br /> 0,c DoT PLIV.v ii Z -7�51^�e 4CAeOc/4c- <br /> * ASTERISK ITEMS REQUES PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PART — DATE2L- 7-8 <br /> PUBLIC HEALTH SERVICES USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE <br /> RECORDS. <br /> EH 00 14 <br />