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PUBLIC RECORD RELEASE OOUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING^ _ PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> 17 <br /> 71 / 7-2- <br /> *ASTERISK ITEMS 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 />