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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 r C� PH_ ONE NO. n <br /> 5. INDIVIDUAL ADDRESS ,� 3 <br /> FILE ADDRESS ITEM REQUESTED DATE . PURPOSE OF REQUEST <br /> -- - <br /> *AST EMS REQUEST P.0 HOTOCOPY NG <br /> SIGNATURE OF REQUESTING PARTY (7DATE <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. MONORING OF THE RECORDS. <br /> EH 00 14 4/81 - <br />