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Facility. P` - -,
Address:'?,,., Z21 --
SUMMARY, OF VIOLATIONS i
Notice: Of ViOlation: Class H and /or Class l Vio /ations .were found :during this inspection as
l.
noted in the following Summary of Violations.
Item!
The violations indicated in this inspection report must be corrected within: 30 days, unless -'
REQUIREMENT FOR CORRECTION
otherwise noted.
Formal enforcement will be initiated for all Class I Violations, and for any:C ass LI violations not
corrected within t. e: required timeframe. This: report does not represent that there are no other.
OF VIOLATION
violations at this facility. A re:, inspection may occur to- determine. compliance status.
SUMMARY, OF VIOLATIONS i
Item!
REQUIREMENT FOR CORRECTION
DATE FOR
VIOLATION
OF VIOLATION
CORRECTION
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Inspectors: -
Received by:
S i n atu re
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Phone: '" _ �'
Print`Narne:
Date: `,
Date:
KPS #8447
-to- Compliance Pink
White - Business Copy Yellow — Business Copy to be sent in after Return - Preventiron Services Copy