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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY PHONE NO._9 Z r s Z <br /> 3. AGENCY ADDRESS - <br /> r <br /> 4. INDIVIDUAL REQUESTINGeA jPHONE NO. <br /> 5. INDIVIDUAL ADDRESS f <br /> FILE ADDRESS ITEM- REQUESTED DATE PURPOSE OF REQUEST <br /> a. <br /> *ASTERISK MS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />