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*UBLIC RECORD RELEASE REST <br />1. REQUEST RELEASE DATE I <br />2. REQUESTING AGENCY PHONE NO. 4(e6- 6'1�- <br />3. AGENCY ADDRESS <br />4. INDIVIDUAL REQUESTING PHONE NO. <br />5. INDIVIDUAL ADDRESS ' <br />FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br />*ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY DATE <br />LOCALDISTRICT ONLY <br />PROJECTED r ; DAT <br />...r�!> <br />SIGNATURE OF RELEASING OFFICIAL DATE Z —A>l <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br />1 <br />