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PUBLIC RECORD RELEASE REQUEST <br /> I . REQUEST RELEASE DATE <br /> REQUESTING AGENCY_ �'/�rc,1 �A/U/'d)(/ ' 11,,,� PHONE N0. �/ � 7 � <br /> 3. AGENCY ADDRESS <br /> 4. ' INDIVIDUAL REQUESTING <_ C�iY ' V . PHONE NO. <br /> 5. INDIVIDUAL ADDRESS33i <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> /Y700 <br /> "ASTERI I IT RE IUESTED POR HOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE 1� <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE 19-17Lf <br /> SIGNATURE OF RELEASING OFFICIAL ,✓ DATE <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> J <br /> Af <br /> j . <br /> FM M IL <br />