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�- IJUBLIC RECORD RELEASE REST <br /> 1 • REQUEST RELEASE DATE <br /> 2 REQUESTING AGENCY Q -- -- - - <br /> 3• AGENCY ADDRESS �� -_ PHONE Np, �a5 <br /> I u�4 =S S35 <br /> 4• INDIVIDUAL REQUESTING <br /> � ��`" "- �-�� � PHONE NO. <br /> S• INDIVIDUAL ADDRESS c�� .Z <br /> FILE ADDRESSITEM PF011PUrn DATE PURPOSE OF REQUEST <br /> �,\t\ <br /> r <br /> — 1 a 6 c� 1 <br /> Q c- <br /> a a L� i abler I q r> <br /> o <br /> l <br /> 'ASTERISK ITEMS REQU 6R-P'FTOTOCOPYING <br /> ')IGNATURE OF REQUESTING PARTY <br /> DATE - <br />.00AL HEALTH DISTRICT USE ONLY <br /> ROJECTED RELEASE DATE <br /> IGNATURE OF RELEASING OFFICIAL - <br /> M1ES OF S T Ff _ DATE '- '� , f <br /> MEMBERS OVOLV�O I HE RELEASE AND MONITORING OF THE RECORDS. <br />