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y <br /> 20 <br /> American Stone Quarry Complaint Form <br /> SECTION 1: GENERAL INFORMATION <br /> Staff Member Taking Complaint: By: . 69D Mail Referral (circle one) <br /> TMBL: 4, it-2.A .. Ivfl PIN: DATE: (9� <br /> roperty wne omplainant Telephone Numbe�t) t L 1 t � q <br /> '� — Telephone Number: 4a? <br /> Property Street Address: ��7._"' \. ��� ��` C� N L <br /> Complaint: <br /> t jr / <br /> SECTION 2: PROCEDURAL STEPS <br /> Is property located within 3,000 feet of the quarry district boundi4 YES NO (circle one <br /> If YES,a copy of this form shall be sent to ASC by either: dTTAX4�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. A>��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 />