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INVESTIGATION REPORT FORM
Revised 10/6/94
Part A: Natured Complaint
• Initiator's Name:
1 a • Address: N
• Telephone:
• Owner Name:
i
• Address: J . 1,... .t- <..
1
• Telephone: �
• Department of Concern C11
❑ Clerical ❑ Building ❑ Health ❑ Comm Development ❑ Fire
• Area of Concern:
❑ Process Delay ❑ Personnel ❑ Policy/Fee ❑ Code Violation ❑ Other
Refer to Director
• Location of Concern: D I it �/ /o i / / Ca(I l n S /aa 12-�e
n 0{ j r-fE M�_ C-16i Ce)IIIAS I
• Nature of Concern: f S r> C a i n Gt -+A-A- j j2 1-1 d Cie et r I ►7 C
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} Part B: Concern Intake and Referral
Receivgd By: Referred To: Response Date:
L
—Na Le Date Name Date ' Date L�
Part C: Findings
Referral Forwarded to: ❑N/A
Name 1 Date
Findings: G SC r p 1 C's r�C.. - -�J C t (�; y 1��. F
r
Part D: Resolution '
1
17.
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Name'
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Date
Intake Copy-White File Copv- flow Referral Copy-Pink