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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATEerow <br /> REQUESTING AGENCY P5v "PHONE N 7 7 7 g// <br /> 3. AGENCY ADDRESS /.2O 17;�juy,24W 57L- Svc fe <br /> Sam lo s <br /> 4. INDIVIDUAL REQUESTING I ,r a'4. 4/ 9y✓ s PHONE N0. <br /> 5. INDIVIDUAL ADDRESS <br /> W4Aod-/- 6141-eeE C4 <br /> 9 yS9G <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> In 5 S, (Jai�'I i n��-Iyt�'uyI � /g g� Pre <br /> o m P y /9-55 ess rhe <br /> Alafi-/-re-d <br /> *ASTERISK ITEMS REQUE TED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE 8 <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE _ <br /> SIGNATURE OF RELEASING OFFICIAL DATE Z —/ <br /> NAME OF FF MEMBERS, INVOLVED N THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />