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PUBLIC RECORD RELEASE REQUEST- <br /> 1 . REQUEST RELEASE DATE r S <br /> P REQUESTING AGENCY ( <br /> f,2 �i�zr�/L'� PHONE NO. 7,?„ Z 7,61 <br /> 3. AGENCY ADDRESS`4. � <br /> 4. INDIVIDUAL REQUESTINGa L PHONE NO. _ <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> C. J <br /> *AST RI ITEMS REQ ESTED OR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE 9' <br /> SIGNATURE OF RELEASING OFFICIAL /{ DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> �r <br /> ' . IL <br /> _FLrH <br /> EH 00 14 �: �� 7't; "_4'tL 4/81 <br />