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PUBLIC RECORD RELEASE REQUEST <br /> I . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE NO. _ <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING c✓ PHONE NO. <br /> 5, INDIVIDUAL ADDRESS�� / <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *A Et ISK ITEMS REQUESTED FOR PHOTOCOPYING -- <br /> SIGNATURE OF REQUESTING PARTY . kl 1�� DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE — �('— <br /> SIGNATURE OF RELEASING OFFICIAL - DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> Etl 00 1.1 n ini <br />