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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY PHONE <br /> 3. AGENCY ADDRESS__ <br /> 4. INDIVIDUAL REQUESTING E f PHONE NO. <br /> 5. INDIVIDUAL ADDRESS_ 3�Ei <br /> S/hy gsa�,9 <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> *ASTERISK ITEMS REQUESTED POR PHOTOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE_ <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE -2 <br /> SIGNATURE OF RELEASING OFFICIAL �� DATE �2 7z- <br /> NAME OF STAFF MEMBERS INVOLV I HE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />