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n <br />PUBLIC RECORD RELEASE REL, -ST <br />1. REQUEST RELEASE DATE <br />REQUESTING AGENCY PHONE N0.-,,�3 9 <br />3. AGENCY ADDRESS <br />4. <br />5. <br />INDIVIDUAL REQUESTING, <br />INDIVIDUAL ADDRESS /. <br />PHONE NO. Z VS 7, V -- <br />FILE ADDRESS REQUESTED DATE. <br />.4.�2o221j gol,24 /),0— <br />PURPOSE OF REQUEST <br />*ISK RE ED FOR PHOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY:! DATE <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIA DATE 1-1-25-06 <br />NAM OF STAFF MEMBERS INVOLVE lN THE RELEASE AND MONITORING OF THE RECORDS. <br />EH 00 14 <br />4/81 <br />