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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESi <br /> 4. INDIVIDUAL REQUESTING PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> �--� FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> aa <br /> Z <br /> •1 <br /> *ASTE�K ITEMS RE NESTEDR PXO�TOCOPYING <br /> SIGNATURE OF REQUESTING PARTY �u ��, J LQ DATE /'0// <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE zl =' - <br /> SIGNATURE OF RELEASING OFFICIAL r >' .� DATE .Z/; <br /> NAM OF STAFF MEFR5 INVOLVE NTHE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />