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PUBLIC RECORD RELEASE REOUEST <br /> 1 . REQUEST RELEASE DATE > __L ) <br /> 2. REQUESTING AGENCY PHONE NO. Vii/ -Uf2,3Y <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING /r,r PHONE NO. --- <br /> 5. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> s` 67 -- <br /> *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY � _� /� DATE <br /> LOCAL HEALTH DISTRICT USE ONLY4 - <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE-4-104J <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 !4 <br />