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zz <br /> American Stone Quarry Complaint Form <br /> SECTION I: GENERAL INFORMATION <br /> StalFMember Taking Complain: _By: relephortatJ Mail Select tnaamu <br /> TMEIL �-. J� iP DAT//E\\:�� a l4)J Of <br /> roperty omplammt Telephone Numb4WJ!9a-9111 a�tuq <br /> Telephone Number F7 Qb!h —404 r <br /> Propert smet Address:1122E 6.A4 aSL <br /> Complain <br /> y� <br /> LI <br /> �Lw.vo6ss.a..c...14w.zr <br /> h <br /> SECTIONS• PROCEDURAL STEPS <br /> E Property located within 3,000 feet ofNe quesry,distract bow YES NO tnm.aK <br /> If YES,a copy of this font shall be sent to ASC by either: ach report) <br /> 2)CERTIFIED MAIL (keep receipt) 3)IN PERSON m..rwn <br /> DATE complaint odlernd to American Slone Company: J\ Dar .3041 <br /> Who,n ASC,was the complaint referred to: do BNj Phone: <br /> DATE the ASC report returned <br /> If complaint is resolved by ASC,complete the Resolution of Complaint rexdicn below. <br /> If ASC sport states failure not due to a result of quarry,operations OR the subject pmpeny is <br /> over 3,000 feet Dem the quarry,distract boundary,then a copy of complaint form and,if <br /> applicable,ASC report shall be sent to EnvoorunenW Health <br /> DATE complaint form ASC report referred to Environmental Health: <br /> Copy of complaint form and ASC report sent by: 1)FAX 2)INPERSON <br /> Who in Environmental HealN was the complaint ref dto: <br /> DATE tat complaint reactant was received ham Enviromnwtal Hea des <br /> RESOLUTION OF COMPLAINT: <br />