[Village of Sussex] SFD Inspection Compliance

Sussex Fire Department

Inspection Violation Correction Form

Business Name

Original Inspection Date

Submitters Email

Contact Phone Number

Specify Each Violation

Violation *

Date of Compliance *

Violation #2

Violation

Date of Compliance

Violation #3

Violation

Date of Compliance

Violation #4

Violation

Date of Compliance

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Signature accepting responsibility for above violations.

First Name

Last Name

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I hereby certify that all listed fire code violations have been corrected.