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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE_ <br /> 2. REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING PHONE NO. <br /> 5. INDIVIDUAL ADDRESS \2 <br /> FILE ADDRESS IITEM REQUESTED DATE PURPOSE OF REQUEST <br /> , , ^/^^ <br /> *ASTERISK ITEMS RE UESTE�HOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY �o w= DATE <br /> LOCAL HEALTH DISTRICT USE ONLY �J <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NA7S OF TAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> 1h, <br /> EH 00 14 4/81 <br />