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UNIFORM ORDINANCE CITATION <br />BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES <br />STATE'OF WISCONSIN DEPOSIT PERMITTEDI B.0 #24 <br />`' <br />THE UNDERSIGNED, BEING DULY SWORN AND UNDER t <br />OATH, COMPLAINS FOR AND ON BEHALF OF THE <br />COUNTY OF BURNETT UPON INFORMATION AND <br />BELIEF, THAT ON OR ABOUT, <br />'X//Y OF WEEK DATE VIOLATION TIME E (AM COUPM <br />CIRCUIT COURT OF BURNETT COUNTY <br />$ Forfeiture <br />Penalty Assess. <br />$ Court Costs <br />$ TOTAL <br />NAME LAST <br />FIRST MI <br />DATE OF BIRTH <br />AGE <br />Yt 4 <br />N/E' <br />11 j MO. �` DAY YR. <br />STREET OR ROU A) <br />t , �,)/l. It/ <br />TY, STATE, ZIP CODE <br />!r'E f1!'._c tU" J� <br />SEX J M <br />❑ F <br />DID UNLAWFULLY11 <br />1W <br />ON THE ABOVE STATED TIME, DATE <br />AND LOCATION, THE DEFENDANT (DESCRIBE VIOLATION — STATE FACTS) <br />OV17-/Cc <br />It"1f't_0 I -ILC <br />N t L. -le' �...c S e � el 5 J . £'/h G�- r7h •'- t rfn CTS <br />in violation of section(s) , �` -A ! �'� of the ❑ t 1" f r f Ar Ordinance <br />and prays that he/she may be held to answer therefor. ❑ Burno. ordinance opting sec. <br />Signature of Officer <br />SUBSCRIBED AND SWORN TO Before me this date 19 Title'` <br />Name Title Department or Agency <br />YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />ABOVE NAMED COURTT�( <br />�( <br />A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS $ , <br />- r J �/ <br />ON �� 19-_ AT ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES, CONFISCATE ALL EVIDENCE AND <br />BURNET COUNTY GOVERNMENT CENTER REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />