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PUBLIC RECORD RELEASE RrQUEST <br /> 1 . REQUEST RELEASE DATE % _ 3 ' <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 /> i <br /> *ASTERISK ITEMS REQUESTED POR,,PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY - - �� DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE -7/) ,3 7 <br /> SIGNATURE OF RELEASING OFFICIAL �' DATE 73 r7 <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND ONITORING OF THE RECORDS. <br />