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• <br />PUBLIC RECORD RELEASE REQUEST C� <br />I REQUEST RELEASE DATE 7 <br />2. REQUESTING AGENCY slrgzfxy y A5PHONE NO. ,j'cI <br />3. AGENCY ADDRESS IQ � ti' v, -e r <br />A `I <br />4. INDIVIDUAL REQUESTING -T�,h, '\I , l P 1 r PHONE NO. 3 g <br />5. INDIVIDUAL ADDRESS <br />FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br />Q <br />2�2 C�QV'IVhP✓1/�O/W 41 _- 0"A*;�V:1..vtC� <br />LCCY Y\lJ✓i\ T' f t.! Vl� .. 15 ! ::� 1 C� 1 Lj C' <br />T GIG Wt r✓Lt�Y Lit to �t <br />W f7a— <br />'7 4 Oo <br />-------------- <br />*ASTERISK ITEMS REQ EVED FOR PiOTOCOPY1NG <br />SIGNATURE OF REQUESTING PARTY c` �a <br />DATE <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE _ <br />SIGNATURE OF RELEASING OFFICIAL <br />DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br />Cil AA 1 A <br />