HomeMy WebLinkAboutNOV 2017Owner/Operator: f::3 4 � c (,V�
Receive
F a c i I i lxl r
Phone:t. i3-
Address:. L41 c 0 C �� rt
v.
Name:
Date: Z 8
There were NO violations observed during this
nspection.
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during this inspection as noted in the following
Notice to Comply. Minor Violations were found
Summary of violations.
The violations indicated in this inspections
port 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 other violations at this-facility.. A
re- inspection may occur to determine complian
a status.
i
SUMMARY OF VIOLATIONS
t
Item REQUIREMENT FOR CORRECTION OF DATE FOR
# VIOLATION VIOLATION: CORRECTION
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Inspectors
Signature: � , � _
Receive
d by:
Phone:t. i3-
Print
v.
Name:
Date: Z 8
bate:.
CERTIFICATION OF RETURN TO COMPLIANCE
I certify that the violations noted above on this Notice o .Comply /Summary of Violations have been
corrected. I have personally examined any documen ation .attached to the certification to establish hat
the. violations have been corrected.
Signature:
[Title: .
Print Name:
Date:
KPS #8446'
Rf icinacc (',nnv to he sent in after Return -to- Compliance Pink - Prevention Services Copy
Owner /Operator: P 4 ^^ '
to Comply /Summary of Violations have been*
attached to the certification to establish that
FaciIit
Address: o, iz2� �4 L.t � ( (.1 04 A V
0
There were NO violations :observed during this
inspection.
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.
Notice to Comply. Minor Violations were fo
nd durin this inspection noted. in the�followin
g p g
.
Summary of Violations.
The, violations indicated in this inspection r
port 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 notTepresent
that there are no other.violations .at this facility. A.:
re-inspection may occur to determine complian
a status.
certify that the violations noted above on this Notice
corrected: I have personally .examined .any documentation
the violations have been corrected.
to Comply /Summary of Violations have been*
attached to the certification to establish that
Signature:
Title:
I.Print'Name:
Date:
KPS #8446
,>„�: VcII^IAI — Ri icinccc rnnV tn ha _ ant in after Return -to- Compliance Pink —'Prevention Services Copy