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u <br />i <br />• <br />American Stone Quarry Complaint Form <br />SECTION 1: GENERAL INFORMATION <br />Staff Member Taking Complaint: By:. ele ho Mail Referral (circle one) <br />TMBL: ~, ~IZA .. left PIN: <br />roperty wne omplainant <br />Property Street Address: <br />DATE: ~ ~ 0 ~ <br />Tele hone Numbe . <br />p _ w~~o~~ 1 l 1 ~ X:~.~ <br />Telephone Number: ~~ ~{ L~~- - ~~~~ <br />Is property located within 3,000 feet of the quarry district boundar YES NO (circle one <br />If YES, a copy of this form shall be sent to ASC by either: ~~~ tach report} <br />2) CERTIFIED MAIL (keep receipt) 3) IN PERSON (circle one) <br />DATE complaint referred to American Stone Company: ~ \ ~~~ ~ DO 1 <br />Who, at ASC, was the complaint referred to: a v~ R~~ Phone: ~ ~~ <br />DATE the ASC report returned: <br />If complaint is resolved by ASC, complete the Resolution of Complaint section below. <br />If ASC report states failure not due to a result of quarry operations OR the subject property is <br />over 3,000 feet from the quarry district boundary, then a copy of complaint form and, if <br />applicable, ASC report shall be sent to Environmental Health. <br />DATE complaint form/ASC report referred to Environmental Health: <br />Copy of complaint form and ASC report sent by: 1) FAX 2) IN PERSON <br />Who in Environmental Health was the complaint referred to: <br />DATE that complaint resolution was received from Environmental Health: <br />RESOLUTION OF COMPLAINT: <br />• <br />• <br />22 <br />SECTION 2: PROCEDURAL STEPS <br />