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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(2gL3)ZSZ_-ZQ�3__ <br /> 5. PNDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> r <br /> *ASTERISK ITEMS REQUESTED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DAVE <br /> N E5 <br /> �OST�FEMIERS INVOLVED�INHE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />