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1 <br />3 <br />4 <br />5 <br />REQUEST RELEASE DATE <br />REQUESTING AGE <br />AGENCY ADDRESS <br />PUBLIC RECORD RELEASE REQUEST <br />INDIVIDUAL REQUESTING <br />INDIVIDUAL ADDRESS <br />FILE ADDRESS ITEM REQUESTED <br />O 19n fys f f RD / <br />i nu}ef No <br />��' f1Y fps %7i�nCft unitt No <br />l�Ae i1/o . l yg 7 <br />Sr3n 1� s 12�9n cd1 Lets No 3 <br />0 <br />PHONE NO. <br />DATE PURPOSE OF REQUEST <br />SyM les /e c� n ti l te w -c <br />L'st c <br />SIGNATURE OF REQUESTING PARTY <br />K ITEMS Q ESTED FOR PHOTOCOPYING <br />_DATE <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br />FH 00 14 <br />4/81 <br />