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PUBLIC RECORD RELEASE REQUEST <br /> I • REQUEST RELEASE DATE <br /> REQUESTING AGENCY <br /> ' PHONE N0. <br /> 3. AGENCY ADDRESS -- <br /> 4. INDIVIDUAL REQUESTING <br /> �/ . C? .--- PHONE N O. <br /> S. INDIVIDUAL ADDRESS - <br /> r' Ile — <br /> FILE ADDRESS ITEM REQUESTED DATE <br /> PURPOSE OF REQUEST <br /> --------------- <br /> -------------- <br /> ------------ <br /> ------------- <br /> *ASTE SK TEMS RE D FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY <br /> _ DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE y <br /> SIGNATURE OF RELEASING <br /> OFFICIAL <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECODATE /�2-- <br /> RDS. <br /> Ell 00 14 <br />