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1. REQUEST RELEA! <br />2 REQUESTING AGE <br />3. AGENCY ADDRESS <br />PALIC RECORD RELEASE REDUES+i <br />4. INDIVIDUAL REQUESTING <br />5. INDIVIDUAL ADDRESS <br />FILE ADDRESS <br />ila9V�;,✓. <br />d <br />ITEM REQUESTED DATE PURPOSE OF REQUEST <br />*ASTE K ITEMS QUESTED POR PHOTOCOPYING <br />IGNATURE OF REQUESTING PARTY f DATE <br />OCAL HEALTH DISTRICT USE ONLY <br />ROJECTED RELEASE DATE <br />IGNATURE OF RELEASING OFFICIAL DATE _ <br />/-� 5 �X <br />aMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br />00 14 <br />4/81 <br />