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OO <br /> OBLIC RECORD RELEASE REQUE <br /> 1 . REQUEST RELEASE DATE 5 Z 8ts <br /> 2 REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING KLC_ivyr 0 QZ PHONE <br /> 5. INDIVIDUAL ADDRESS 1975 E STX7tF_T' <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> Z`-I 17 wLsi Lo,,K3_. t Lt �v LTJ <br /> `AST K MS ES OR PHOTOCOPYING <br /> _)IGNATURE OF REQUESTING PAR Y DATE Z r� <br /> .00AL HEALTH DISTRICT USE ONLY <br /> RELEASE E GATE <br /> 'ROJECT 0 46anp/es <br /> ;IGNATURE OF RELEASING OFFICIAL ��1c�-� -- OATEN`' g� <br /> ES OF S AFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> • t <br /> H 00 14 4/81 <br />