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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE PHONE N0. — — <br /> 2. REQUESTING AGENCY <br /> 3. AGENCY ADDRESS <br /> PHONE N0. d <br /> 4. INDIVIDUAL REQUESTING <br /> 5. INDIVIDUAL ADDRESS 00, �. <br /> n •,� Sem <br /> V V <br /> FILE ADDRESS <br /> ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> �Ei✓7�7��✓'� l`'nS n o � <br /> l�P� `lurk <br /> *ASTE S TEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY_ �. _ DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE a2— S$ 0 <br /> SIGNATURE OF RELEASING OFFICIAL <br /> NAMES OF STAFF MEMB/E/RSA INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> E H 00 14 ------ 4/81 - <br />