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PUBLIC HEALTH SERVICES <br /> PUBLIC RECORD RELEASE REQUEST <br /> 1. REQUEST RELEASE DATE <br /> 2 . REQU98TINd AGENCY PHONE NO. <br /> 3. AGENCY AbbAE55 <br /> 4 . INDIVIDUAL REQUESTING PHONE NO. - Z <br /> 5. INDIVIDUAL ADDRESS &,%p) ? a 7-2 c <br /> F_XtR ADDRESS ITEM REQUESTED ­DATE PURPOSE OF REQUEST <br /> ASTERISK I'T'EMS REQUESTED F HOT OP ING <br /> SIGNATURE OF REQUESTING PARTYD ATE -90 <br /> PUBLIC HEALTH SERVICES USE ONLY <br /> s PROJECTED RELEASE DATE <br /> • SIGNATURE OF RELEASING OFFICIAL'`? DATE - (3 <br /> NAMES OF STAPP MEMBERS INVOLVED IN THE RELEASE AND MONITORING <br /> OF THE RECORDS, <br /> EH 0014 Wp <br /> • <br />