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fr"UMBLIC RECORD RELEASE REOUES%.4 <br /> i <br /> 1 . REQUEST RELEASE DATE <br /> 2 REQUESTING AGEN PHONE N0-� - <br /> 3. AGENCY ADDRESS - <br /> 4. INDIVIDUAL REQUESTINGPHONE N0. '5' I- <br /> 5. INDIVIDUAL ADDRESS (d <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *AST ITUESTED POR PHOTOCOPYING �1 <br /> SIGNATURE OF REQUESTING PAR DATE <br /> LOCAL HEALTH DISTRICT USE ON YY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE } -Z s-�ZL <br /> NAMES OF STAFF MEMBERS INVOLVE THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 -- — — — 4/81 <br />