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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE_ 1_117— 3 �� f <br /> 2. REQUESTING AGENCY 9�,A -- rKlEg f M. lwa✓�_ c® PHONE NO. _-L-! S-46 -J-SIS- <br /> 3. AGENCY ADDRESS JZ.. <br /> 4. INDIVIDUAL REQUESTING t� ^ ^^s PHONE NO. <br /> 5. INDIVIDUAL ADDRESS *E 3 <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> I <br /> *ASTER KIT hS RpCI�ED FOR PHOTOOPYING <br /> SIGNATURE OF REQUESTING PARTY .- fff G�"+"` � DATE ✓ ' "j <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE /— 2- 3— S9 <br /> SIGNATURE OF RELEASING OFFICIAL �,_ _ DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 ` <br /> 4/81 <br />