HomeMy WebLinkAboutExtensive Land Clearing - GRD Letters / Memos - 9/22/2016 Case Number: 00/bj
Mason County Investigation Report Form
Parcel Number.
Piolation Site Address: ����� q Lille r 6k b-) 94C Eli i /
Property Owner(s):O -r�'�O Cam CpgE Phone 9:
Mailing Address: l l b E 12 �v
Tenant/Contractor/Operator on site:
Directions to Site: 1Ur N ve__ N� Y CY
Description of Concern: 611- t 1
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Under t provisions of the Public Di closure Law, RCNF 42.56.240, the complainant nary indicate a desire
for disclosure or non-disclosure of their identity. If non-disclosure is chosen, this portion of this form will
not be released to the public unless this case is filed in court. If filed,your name will be disclosed if you are
a witness in the case.
Mason County investigates possible violations on a complaint basis only. Therefore,the name of the person filing
the complaint should be provided.
Please check one of the following:
❑ Please do Dot disclose my identity. I understand that disclosure may be required by court order or if this
matter goes to court
❑ You may disclose my identity.
Name(please print): 1 U '7 Phone:
Address:
Street City State Zip
Signature of Complainant Date:
TffiS SECTION FOR AL•SON COUNU Y USE ONLY
Complaint Received by. Date:
Complaint Received by: f�'Phone ❑ Email ❑ Web Site ❑ In Person
Depamnentof Concern: U.Buiilding YPlanning ❑Fire ❑ Public Works
Environmental Health: ❑ Solid ❑ On-site ❑ Wells ❑Food ❑ Other
Investigation Date and Findings:5pn *::I- L'--L t-k-_ OLJ-L,—
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Date Closed:1-z3-t to Reason Closed U�t.� c'o�-•-�(a �. -fi- Initials: Z_