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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.1190), WIS. STATUTES $ f Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B C. 1831 <br /> $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER $— Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY <br /> BELIEF,THAT ON OR ABOUT, $ TOTAL <br /> DAY OF WEEK I DATE VIOLATION I TIME AM COUNT / TWP-VILLAGE-CITY <br /> S—ttO— �-�}G ❑ PM <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> IF'(7x 04).0 e I MO. DAY YR. <br /> STREET OR r ROUTE �''1 / ,' CITY,STATE,ZIP CODE SEX ❑ M <br /> /rglF33 It"�InG LJf?�E' —,4NC' .. •°(5 S�I� ❑ F <br /> DID UNLAWFULLY t'.' j�v�E.' :::�t , err G_•/!r <br /> ON TVE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION-STATE FACTS) <br /> ! <br /> in violation of section(s) `3 of the El � Ordinance <br /> and prays that he/she may be held to answer t Burnett Co.ordinance adopting sec. <br /> , Signature of Officer <br /> SUBSCRIBE ND S <br /> Atfoem'etp9 Title <br /> Name 0 Department or Agency <br /> YOU ARE HEREBY NO IED TO AWAR4000FHE <br /> ABOVE NAMED COURT <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> / r� A.M. <br /> ON-Z7u� 1/ 4 197 AT/ ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> BURNETT COUNTY GOVERNMENT CENTER REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />