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1. REQUEST RELEASE DA <br />REQUESTING AGENCY_ <br />3. AGENCY ADDRESS <br />PUBLIC RECORD RELEASE REQUEST <br />PHONE NO. <br />4. <br />'INDIVIDUAL <br />REQUESTING ��� `� �n;� r r,�L <br />PHONE NO. <br />5. <br />INDIVIDUAL <br />ADDRESS <br />yr n n <br />FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br />7-,0, '.S -,? J- /1 <br />*ASTERISK ITEMS <br />SIGNATURE OF REQUESTING PARTY =3 <br />R PHOTOCOPYING <br />DATE 22-�h <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL �,�- �_=,�z-- <br />DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br />-EH 00 14 <br />4/01 <br />