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11 i1?6gg/0pp1pp pp ~ gg15 : 32 pp 9944h1ART I N t"IAR I ETTA ~ 97321643 _ Np , B57 <br />111~111~28817~10:~~ ~191~35443882 Nortberi ~~. CTV..PL1~d~IhiSNG PAGE X82 1~ <br />• <br />• <br />.t~.x~erfc~azt Starve t~u~ar~c~~pl, a~fntr~ <br />SECTION 1~ Gr~~11'ERAL INEpYtM,~~ <br />staf~'Me~obar Taking complavaa: ~' y: h .Math ~£eancal t~~ <br />Prapszty Ovvnac/C~p1 ' t „~„ elepbaae Numbs: ,.,4 ~-~~ . <br />Tenant: ekphome lWttshbr: <br />prapexty Street Address: •~ `' <br />Co~on}~lsint: ` <br />- - <br />~TI(~1~T 2; PR,CI~'Lr~T.TI:IA~,,,,~,~,S <br />Is grapacty toeaYOCt wisbiu 3,040 feat of the quarry ditctrict bo (~.~Bi---a iY0 t~+• ens <br />~£ ICES, a spy of thjts faro, sha11. be seat't4 A,SC by eith~zz: i I+' r+eporL~ <br />2) CERI3 MAII~ (1ce+ap teaeipt) 3) II11 AER80N ~:~ ane) <br />DACE complaint rafeA'ad to Americas Stone Campsu~-: 1~~~ Qa ~, <br />Wba, at ASC, was the wxaplxiat tefert+ed to: ay.~ ~eatGS~ ~~~harna: ~b&~~1__~ ! __ <br />DATE the ASC report retsa~ned; <br />If ceanplaiut is resolved by A&C, completa tlse Rr~aludon o!'Connplaint ssotian bcla~w, <br />If ASG report failtiure mot sup tp a result of quauY apezatioa~s DR the anbj tct propacty is <br />over 3,000 feet ftaoa the quarry district bdnmdatlt, then a copy of romplsint farm a~+d, iu~ <br />applicable, ASC report shall ba sent vo Bnvirvnm~eatal ~eatth, <br /> <br />• <br />• <br /> <br />?ATE complaint formfASC report referred to Bnvixonmaaatsl 8ttillth; <br />G~opy of eeamplaimt fama amd ASC rspo~ct seat by: 1) FA~i 2} II~T PSItSl3N <br />~O ~ ~~II'atauCet81 ~~~ 'Duns the C4II1,p~At t~Qtr+ed tA: - <br />DA'~'l~ that cernpla~iat resolution wes rcoeived Pram Eavira~ncntal YYesalth: <br />R~SOL„oN +~F coNfPLanV"I': <br />• <br />