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PUBLIC RECORD RELEASE REQUEST <br /> 1 , REQUEST RELEASE DATE / 3 ' i x - <br /> 2. REQUESTING AGENCY PHONE N0. -- <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING^ �j ,`Ij,'� <br /> �.a'C���YY1��1 PHONE NO. <br /> 5. INDIVIDUAL ADDRESS pp7 <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *ASTEITEEQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES} OF STAFF MEMBERS INVO E 'IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> 4/81 <br /> EH 00 14 <br />