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PUBLIC RECORD RELEASE REQUEST <br /> 1 . REQUEST RELEASE DATE <br /> 2. REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS /Q <br /> 4. INDIVIDUAL REQUESTING PHONE NO. <br /> 5. INDIVIDUAL ADDRESS <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> all 6/ <br /> A2 Zlt,4 <br /> .��t=lka <br /> Q.0 •{ <br /> *ASTER K ITEMS RE STED FOR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PART 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 /> EH 00 14 4/81 <br />