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i <br /> PUBLIC RECORD RELEASE RE9UEST <br /> i <br /> I <br /> 1 . REQUEST RELEASE DATE - <br /> REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. - INDIVIDUAL REQUESTING PHONE NOI�� �f Ol6✓' <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE . PURPOSE OF REQUEST <br /> r <br /> v <br /> l <br /> *AST K �IT�UESTED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY <br /> DATEZylkEff <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE 4z 4z <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> NAMES OF STAFF MEMBERS INVOL N THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />