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PUBLIC RECORD RELEASE REQUEST <br /> i . REQUEST RELEASE DATE + <br /> REQUESTING AGENCY - PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUEST L. a PHONE NO. <br /> 5. INDIVIDUAL ADDRESS 1 <br /> /oC,�fic -r ��2o Z <br /> FILE ADDRESS I€EM REQUESTED DATE PURPOSE OF REQUEST <br /> x 1-790 x `� 7 /Lw6 r r r <br /> G <br /> F <br /> F <br /> *ASTERISK ITEMS REQUESTED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE��.__Z4,/gam 7 <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIA DATE <br /> NAMES OF STAFF MEMBERS INVOLV IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />