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_ UNIFORM ORDINANCE CITATION /28'029 <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> ..a STATE OF WISCONSIN DEPOSIT,�ERM TED B.C. N9 296 <br /> $ Penalty Assess. <br /> y -THE UNDERSIGNED,BEING DULY SWORN AND UNDER '� 6% / $ Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY f'\/ <br /> BELIEF,THAT ON OR ABOUT, $ / TOTAL <br /> Dt.F WEEK 12/ IE VLATION TIME ❑ AM OUNTY CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK 0 NAT.AM. <br /> / �) / `V PM R'-/ft MTeA 1,4A-c/ 0 ASN 0 HSP 0 NON-HSP <br /> NAME - LAST FIRST _MI DATE OF BIRTH AGE EYES <br /> y <br /> / , 1-..-1C)1( MO. DAY YR. -. HAIR <br /> STREET OR ROUTE CITY,STATE,ZIP CODE 5534.Y SEX — M WGT. <br /> , s �- <br /> ❑ F HGT. <br /> DID UNLAWFULLY i ; Y t.4 i(L <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> ` a <br /> 4. / <br /> , <br /> L )iciQ . , i, <br /> G .1 <br /> in violation of section(s) ti of the 0 Ordinance ►7 <br /> and prays that he/she may be held to answer therefor. 0 Burnett Co.ordinance adopting.eee. Pk' I IS ``' ' ' ` <br /> Signature of Officer -r'%--' r- ,-&,-- co,- <br /> SUBSCRIBED <br /> `SUBSCRIBED AND SWORN TO Before me this date 19 Title - , t:" t <br /> Name Title -Department or Agency <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT i: r 'i" <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ -- '' ' / ,4 f <br /> A.M. <br /> ON 19 L.AT ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />