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Part A: Nature of Complaint
• Initiator's Name:
• Address: �-
• Telephone:
• Owner Name:
• Address: c ` :,+ JKil
• Telephone:
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• Department of Concern
❑ Clerical Building ❑ Health ❑ Comm Development ❑ Fire
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• Area of Concern:" n
❑ Process Delay ❑ Personnel ❑ Policy/Fee ❑ Code Violation ❑ Other 1J
Refer to Director
• Location of Concern: _
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• Nature of Concern: 61.1 1
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Part B: Concern Intake and Referr; o f hor M,,An Aja,� be //..4/7
Received By: Referred To: Response Date: (f
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Part C: Findings
Referral Forwarded to: _l1uk� 2 ❑N/A
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Findings: 'r t 15`1
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Part D: Resolu ion
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Name 41,` Date
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Intake Copy-White File Copy-Yellow' Referral Copy-Pink
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