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r <br /> PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY PHONE N0. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING <br /> PHONE N0.JZ <br /> 5. INDIVIDUAL ADDRESS <br /> E <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> � t <br /> *AST K QUESTED.FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE 11O110 �� <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE E <br /> SIGNATURE OF RELEASING OFFICIAL <br /> DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 <br /> 4/83 <br />