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Vation of <br />Complaint <br />Received By <br />Person Respoffisibore <br />for Premises <br />RECORD OF COMPLAINT <br />Complaint <br />Number <br />By <br />❑ Letter ❑ Telephone ;2Hn Person Date <br />I /J , .f.Phnne <br />Number <br />( Name) ,., , , �F jAddress) <br />Phone <br />Complaint Number <br />(Name) (Address) <br />Representing <br />Group or Agency <br />Specific Details <br />Of Complaint <br />Phone <br />Number <br />(Name) <br />Is Another Agency <br />Responsible? ❑ Yes <br />" / —,7- 'Jointly ❑ <br />No Wholly ❑ <br />(Name) (Address) phone Number <br />Date Agency <br />Notified By: ❑ Letter ❑ Telephone ❑ In Person ❑ Other <br />To Be T r <br />Investigated By ✓� 9 �� G �G� Date Assigned Lb <br />RESULTS OF INVESTIGATION <br />Was Complaint Justified?—)I Yes ❑ No <br />(Show Dates and Results of Investigation and Re- investigation Below.) <br />//aW /left <br />Final Disposition: Abatement ❑ Referral <br />(Signature of Investigator) Date <br />Other <br />k-2-11f- <br />El <br />Signature aLkIsaWLIlLeclor Date <br />LHS -140 Rev. 1/75 �v ~n <br />