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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE �j�- 3— �7 <br /> REQUESTING AGENCY /Vac, ,l(e„_ LEa*q,.zryjzL,�, PHONE. NO. q y�--k z vo <br /> 3. AGENCY ADDRESS_ <br /> 4. ' INDIVIDUAL REQUESTING PHONE <br /> 5. INDIVIDUAL ADDRESS S^,,, <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *AST ITEMST D POR PHOTOCOP G <br /> SIGNATURE OF REQUESTING PARTY <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIA ,i DATE_ 3 <br /> ES OF STAFF MEMBERS INVOL N} THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />