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PUBLIC RECORD REL REQUEST <br /> 1 . REQUEST RELEASE DATE f <br /> 2. REQUESTING AGENCY PHONE NO <br /> 3. AGENCY ADDRESS <br /> �.Z <br /> 4. INDIVIDUAL REQUESTING C PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> -t A <br /> *ASTE ITEMS UESTE R HOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY � DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIADATE 3-�s 8s� <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />