HomeMy WebLinkAboutNOV 6/30/20154-
UNIFIED PROGRAM INSPECTION CHECKLIST
NOTICE TO COMPLY / SUMMARY OF VIOLATIONS
MINOR VIOLATIONS
Owner/Operator:
jVr
Facility:
Address:
❑ I There were NO violations observed during this inspection.
Notice to Comply.- Minor Violations were found during this inspection as noted in the following
El
Summary of Violations.
The violations indicated in this inspection report must be corrected within 30 days, unless
otherwise noted.
Formal enforcement may be initiated for any violations noted, and for those not corrected in a
timely manner. This report does not represent that there are no otherviolations at this facility. A
re-inspection may occur to determine compliance status. -A':
SUMMARY OF VIOLATIONS
Item
#
VIOLATION
REQUIREMENT FOR CORRECTION OF
VIOLATION
DATE FOR
CORRECTION
N
F—hone:
TPrint Name: 'J.
Date:
Date:
if
,Inspectors
Received by:
Signature.
F—hone:
TPrint Name: 'J.
Date:
Date:
CERTIFICATION OF RETURN TO COMPLIANCE
I certify that the violations noted above on this Notice to.Comply/Summary of Violations have been
corrected. I have personally examined any documentation attached to the certification to establish that
the violations have been corrected.
Signatulw. r1n.
Title:
Print Name:.
Date:
KPS #8446
White — Business Copy Yellow — Business Copy to be sent in after Return-to-Compliance Pink — Prevention Services Copy