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PUBLIC RECORD RELEASE REQUEST D <br />1 . REQUEST RELEASE DATE <br />2. REQUESTING AGENCY Y'ctZ�Yh '3 Assic 5 PHONE NO.,,�cj I -_�j -5-_) <br />3. AGENCY ADDRESS > 5Syo ti <br />Firf5 hc' ) G R 1 <br />4. INDIVIDUAL REQUESTING "Sv \J PHONE N0. ? ._I � — 2. 7 3 g <br />5, INDIVIDUAL ADDRESS <br />FILE ADDRESS ITEM REQUESTED _DATE PURPOSE OF REQUEST <br />-7Z RdNlWlPll� W Vl C) <br />V. a..( i :iTite. ( <br />Ec,y vk o L- U Ji <br />�Cir�% <br />1 46c� !L lgavn►silo G�itn� it r <br />c+xcvn U; C <br />W (7o -y <br />'7 `400 <br />------------ <br />*ASTERISK ITEMS REQU�ES,TED FOR PIOTUCOPYING <br />SIGNATURE OF REQUESTING PARTY � .. � �•{ <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL <br />DATE <br />DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br />F!t nn In <br />