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PUBLIC RECORD RELEASE REO PST <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY L ,v _ PHONE N0. <br /> 3. AGENCY ADDRESS.24/—ZeD 5 GcJ�Z gyp <br /> 4. ' INDIVIDUAL REQUESTING PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM-REQUESTED DATE . PURPOSE OF -REQUEST <br /> i <br /> Ll <br /> * RISK ITEMS REQUESTED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY - DATE/�z 30 <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE -- — <br /> SIGNATURE OF RELEASING OFFICIAL_ ���- DATE <br /> NAMESOF, AFF MEINVOLVED THE RELEASE AND- MONITORING OF THE RECORDS. <br /> .- <br /> EH 00 14 4/81 <br />