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PUBLIC RECORD RELEASE REQUEST <br />1. REQUEST RELEASE DATE ?S `1 <br />2. REQUESTING AGENCYJSYg7�x� , A� , �,+e 5 PHONE N0. ,� <br />3. AGENCY ADDRESS :�> `B76,o ti �, . <br />Fr f5 h c> > G A `I 7 <Z <br />4, INDIVIDUAL REQUESTING \j PHONE NO. 3 8 <br />5, INDIVIDUAL ADDRESS <br />FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF RCQUEST <br />-7 272 I-��.���V f� w �� �����►� ,�:,�t�I �'��1�5 �--j-g<t > <br />617v <br />1,210 <br />W 5 DO' �nfcrl�v 5r5 — <br />•7 4 C -o <br />*ASTERISK ITEMS REQU�S,TED FOR PIOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY C <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 />Etl 00 14 <br />