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16 <br />IC RECORD <br />RELEASE <br />REQUEST <br />op <br />THIS REQUEST WILL BE HONORED <br />WHEN ITEMS <br />1-14 ARE <br />TYPED, OR PRINTED CLEARLY IN INK <br />1. REQUEST DATE 4-1Lrl9' 2. REQUEST TIME 4:4S/°/'! <br />3. RELEASE IS REQUESTED FOR WHAT DATE? 317� 4. TIME _,2 1014 <br />5. REQUESTING AGENCY aa*�- <br />6. AGENCY ADDRESS P o• se- 6S6'7 <br />'11a. 9'S 206 <br />7. INDIVIDUAL REQUESTING <br />8. INDIVIDUAL ADDRESS <br />9. TELEPHONE NO. 4412- v19-�L <br />10. TITLE OF REQUESTED FILE 7fw� S��ti� LG�w <br />11. ADDRESS OF REQUESTED FILE <br />12. ITEMS REQUESTED <br />13. ITEM DATE <br />*STAR ITEMS REQUESTED FOR PHOTOCOPYING <br />14. SIGNATURE OF REQUESTING PARTY DATE 2 I 1.7h7 <br />677 <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE ;2-i 3--7 q TIME <br />SIGNATURE OF RELEASING OFFICIAL (c.Y-� `1 a.�� DATE J.-9- I'l <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE OF RECORDS <br />