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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE c2 -- <br /> 2. REQUESTING AGENCY PHONE NO. _ <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING A / J HONE NO. �` ��Z <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> /1/p Cofy<.a� Xei;'e/e<s f� <br /> *ASTERISK REQU TED F OTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY L�_ c �� DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE -1`17-S°j <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> Yu <br /> EH 00 14 4/81 <br />