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PUBLIC RECORD RELEASE REQUEST <br /> (. REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY ` Q c0 E PHONE N0. <br /> 3. AGENCY ADDRESS I SCb K a t k1T0 �VA A/ <br /> 2 Z- <br /> 4. <br /> 4. INDIVIDUAL REQUESTING lJ L PHONE N0. <br /> 5. INDIVIDUAL ADDRESS SA E <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> a <br /> 5/C221 <L 6r e r5 <br /> *AS``T/lERIS ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY r DATE `/ <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE l- Is- 86 <br /> NAMES OF STAFF MEMBERS INVOLVED THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />