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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY J/ PHONE NO <br /> 3. AGENCY ADDRESS <br /> a O <br /> 4. INDIVIDUAL REQUESTING 5 PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> '74- <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *ASTERISK ITEMS REQUE TED OR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY--:: E_. DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE 3,2-S <br /> T <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />