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PUBLIC RECORD RELEASE REAST <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS_ 995 tisiil2ss fez <br /> 4. - INDIVIDUAL REQUESTING k PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> •ASTE ' ISK ITEMS RE TED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE ;7--5- <br /> LOCAL <br /> 7-5LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE -�Z- S <br /> SIGNATURE OF RELEASING OFFICIAL DATE_s— <br /> NAMES OF TAFF MEMBERS NVOL 7THE RELEASE AND MONITORING OF THE RECORDS. <br />