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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 PHONE NO.y <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> /l/ ✓/ _ �i/ �CL�®�lJ � 7 z 3 8 �dt lI/,uNO/1 _ <br /> !/QST G <br /> *ASTERI�K ITEMS REQUESTED FOR PHOTDCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE Z3 87 <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE 7 3 7 <br /> SIGNATURE OF RELEASING OFFICIALKn:��/ DATE ?3 K7 <br /> NAME OF STAFF MEMBERS INVOLVED IN THE RELEASE AND ONITORING OF THE RECORDS. <br />