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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY S Z7,211L PHONE N0. <br /> 3. AGENCY ADDRESS C: ✓� l" <br /> 4. INDIVIDUAL REQUESTING Q�/f�c O �Y•�_ ,6� PHONE NO. iTfZ <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS / ITEM REQUESTED /DA'T'E-r/ PURPOSE OF REQUEST <br /> Y4 <br /> *ASTER ITEMMS REQUUE ED Fp, PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY � � Y�4 DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN 'Th R LEASE AND MONITORING OF THE RECORDS. <br /> 4/81 <br /> EH 0014 <br />