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PUBLIC RECORD RELEASE RE(IUEST <br /> I . REQUEST RELEASE DATE � > _ L j�> <br /> 2. REQUESTING AGENCY— 4,, Ge'GtGc%, r/ PHONE N0. <br /> 3, AGENCY ADDRESS s <br /> 4. INDIVIDUAL REQUESTING %�/c�2n r PHONE NO. s� <br /> 5, INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> 'G _ <br /> 1 <br /> 1 _ <br /> / *ASTERISK ITEMS RESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DAT <br /> 'AMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> 1 !r! <br />