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PUBLIC RECORD RELEASE REQUEST <br /> 1 . - REQUEST RELEASE DATE /- z Z - �-, <br /> 2. REQUESTING AGENCY ,E 8l-q PHONE N0. <br /> 3. AGENCY ADDRESS /�9- O, ,Cox tl 0-3 <br /> Ora'/► e me l t C C 9 <br /> 4. INDIVIDUAL REQUESTING PHONE NO <br /> 5. INDIVIDUAL ADDRESS /� <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> OG <br /> be <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 DATE �- <br /> NAMES nF STAF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />