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Fc- <br /> UBLIC RECORD LEAS E9Utot <br /> REQUEST RELEASE DATE ✓ G%� <br /> 1 . QU /� 2�� 8� <br /> REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING PHONE NOT <br /> 5. INDIVIDUAL ADDRESS /2z7- 7 peer <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> L <br /> *AST K ITEfg— QUESTED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY l l�C DATEZ�/ <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE /- <br /> SIGNATURE OF RELEASING OFFICIAL ✓ DATE <br /> NAMES OF STAFF MEMBERS INVOL,V,, IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />