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PUBLIC RECORD RELEASE REQUEST <br />1. <br />REQUEST RELEASE DATE <br />2. <br />REQUESTING AGENCY Jr <br />PHONE NO. _ 41�'� 3 l,- 1761 <br />3. <br />AGENCY ADDRESS "?7 9S ��,.0 55 i�n� L `D <br />Sr• _ - <br />4. <br />INDIVIDUAL REQUESTING <br />PHONE NO. <br />5. <br />INDIVIDUAL ADDRESS <br />FILE ADDRESS <br />ITEM REQUESTED <br />DATE PURPOSE OF REQUEST <br />- <br />3 t2Po i <br />j-IAz. wsE+ ri-- <br />- I- A <br />*ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY fN DATE 6 <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE /- <br />SIGNATURE OF RELEASING OFFICIAL y <br />DATE <br />NAMES 0 STAFF MEMBERS INVOLVEJ);,-Cg I THE RELEASE AND MONITORING OF THE RECORDS. <br />