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Y PUBLIC RECORD RELEASE VEST <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 REQUES ED DATE PURPOSE OF REQUEST <br /> T � <br /> -(� Z. 7, l9 z 9 <br /> *ASTER SKS RE UESTFD FOR PHOTOCOPYIG <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 />