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PHONE NO. INDIVIDUAL REQUESTING <br />INDIVIDUAL ADDRESS <br />DATE SIGNATURE OF REQUESTING PARTY <br />94s t4f. <br />DATE PURPOSE OF REQUEST <br /> e'5" <br />*ASTE ISK IT REQUE D POR PHOTOCOPYING <br />FILE ADDRESS ITEM REQUESTED <br />PUBLIC RECORD RELEASE REQUEST <br />1. REQUEST RELEASE DATE <br />REQUESTING AGENCY <br />3. AGENCY ADDRESS 9Z4'5.- <br /> <br /> PHONE <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 <br /> 4/81