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"''OUBLIC RECORD RELEASE REQUEST <br /> I . REQUEST RELEASE DATE_ <br /> REQUESTING AGENCY_ PHONE N0. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING PHONE N0. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> of <br /> *AST ISK ITE RE TED P R PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE " 0 <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE - a �- <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF ,.STAFF MEMBE NVOLVE HE RELEASE AND MONITORING OF THE RECORDS. <br /> .C�/ M_ IL. 1/Al <br />