Orange County NC Website
Browse       Search
zo <br />American Stone Quarry Complaint Form <br />SECTION 1: GENERAL INFORMATION <br />Staff Member Taking Complaint: By:: ele ho Mail Referral (~~nir ono) <br />TMBL: ~-, ~~ Z.A ., lafl PIN: <br />roperty wne omplainant <br />Property Street Address: <br />DATE: g ~\~ ~ ©1 <br />Telephone Number<w~(o~~r~ t l l r ~~q <br />Telephone Number: ~'~ ~{ ham- -'~Q~} <br />Is property located within 3,000 feet of the quarry district bound YES NO (circle ooe <br />If YES, a copy of this form shall be sent to ASC by either: CI~:~f~tach report) <br />2) CERTIFIED 11~IAIL (keep receipt) 3) IN PERSON (~~~~~ one) <br />DATE complaint referred to American Stone Company: ~ \ ~ ~~ ~ DO 1 <br />Who, at ASC, was the complaint referred to: ~ v ~ R13~ Phone: y~ <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 />SECTION 2: PROCEDURAL STEPS <br />