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4 Notice Of Violation Class / nd /or Class I Violations were found during this. inspection as
noted in the following Summary. of Violations.
The violations indicated in this inspection report must be corrected within 30.days, unless
otherwise noted.
DATE FOR
Formal enforcement will be initiated. for all Class] Violations, and for any Class 11 violations. not
corrected within the required timeframe.: This report does not represent that there are no other
OF VIOLATIONOF
violations at this facility: A re- inspection may occur to determine compliance status,
SUMMARY OF VIOLATIONS
Item REQUIREMENT FOR CORRECTION DATE FOR
VIOLATION OF VIOLATIONOF
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Inspectors Received by! J
Si nature:
Phone: °.— Print Name:
Date:.. ,'r _`"" Date:
KPS #8447
White - Business Copy Yellow - Business Copy to be sent in after Return -to- Compliance Pink. - Prevention 'Services Copy