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PUBLIC RECORD RELEASE REQUEST <br />1 . REQUEST RELEASE DATE <br />REQUESTING AGENCY PHONE NO. <br />3. AGENCY ADDRESS <br />4. INDIVIDUAL REQUESTING PHONE NO. <br />5. INDIVIDUAL ADDRESS d, , ox (3Q <br />FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br />Al I <br />�F j - S i �ee.f <br />*AST RIK EMS R UESTED FOR P OTOCOPYING <br />SIGNATURE OF REQUESTING PARTY �1`f DATE <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL C C� <br />N S OF STAFF MEMBERS INVOLVED IN THE RELEASE <br />rvb- DATE `y /I <br />MONITORING OF THE RECORDS. <br />EH 00 14 4/61 <br />