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^`ter Nom/ raI'l <br /> yya ti .. <br /> PUBLIC RECORD RELEASE REQUEST <br /> APR 281989 <br /> T , REQUEST RELEASE DATE--25 I � ��� <br /> 2. REQUESTING AGENCY " T <br /> _ U�vt��rc�rs�\ �NGSaE�iZLn1G- _ PHONE�`N1�Ef� `� _ <br /> 3. AGENCY ADDRESS !p l f a —r <br /> cnn�e�Il k. g45tC3 __- --- -- <br /> 4. INDIVIDUAL REQUESTING A , 1N t6v-vr PRONE 140. -7o--1- 744 - 6,01 <br /> 5, INDIVIDUAL ADDRESS <br /> � C iF X510 . <br /> FIpLE ADDRESS ITEM REQUESTED DATE I'tIP,POCF OF RFQUFST <br /> to Wl N-ji C-Eks7 f�w1A k�AT�, ? eF�bQC��`f TtLR�.rSFE <br /> c7 2 C f0D Uy' 1L �'O %1 0SESSM�EN <br /> s K-lt Z 0 5 th Xerac can r�5e��. --- <br /> �q ice W- U8 <br /> NYL <br /> 4% <br /> § Cxp;res, 89 <br /> j *AS RISK ITEMS EQUESTED FOR <br /> At�URE OF REQUESTING PARTY <br /> DATE <br /> LOCAL HEALTH DISTRICT 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 RECORDS. <br /> EII 00 14 - <br /> n gni <br />