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PUBLIC RECORD RELEASE REQUEST <br /> 1. REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING y9 ,,Jbti t PHONE NO. <br /> S. INDIVIDUAL ADDRESS ?,8S I �PcxY{oti Fc) <br /> S cu b< l c <br /> FILE•ADDRESS ITEM REQUESTED_ DATE PURPOSE OF REQUEST <br /> 3931 NC�rraa �D Q�UmiuAUY 1�2T' <br /> lz-L9-9a <br /> ` ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNA'T`URE OF REQUESTING PARTY ��e .�« ( R �-- DATE <br /> PUBLIC HEALTH SERVICES USE ONLY <br /> ROJECTED RELEASE DATE <br /> GNATURE OF RELEASING OFFICIAL DATE <br /> WES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF 'I HE <br /> RECORDS. <br /> 1)- m - &!:� Iluar—�r, <br /> - I l �gl90 <br /> EH 00 14 <br />