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PUBLIC RECORD RELEASE REQUEST <br /> s REQUEST RELEASE DATE �� ` 0 <br /> PHONE N0. <br /> 2. REQUESTING AGENCY <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING PHONE N0.7 <br /> 5. INDIVIDUAL ADDRESS <br /> C <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> ,,2 f <br /> J <br /> *ASTE ISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE 2aa ` <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 /> EH 00 14 4/81 <br />