820634_Waiver of Right_20210825

STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL
QUALITY
COUNTY OF SAMPSON

IN THE MATTER OF ASSESSMENT ) WAIVER OF RIGHT TO AN
OF CIVIL PENALTIES AGAINST ) ADMINISTRATIVE HEARING AND
) STIPULATION OF FACTS
TAMMY BUTLER PETERSON )
)
)
)
PERMIT NO. AWS820634 ) FILE NO. DV-2021-0110

Having been assessed civil penalties totaling $6,779.14 for violation(s) as set forth in the
assessment document of the Division of Water Resources dated, August 25, 2021, the undersigned,
desiring to seek remission of the civil penalty, does hereby waive the right to an administrative
hearing in the above-stated matter and does stipulate that the facts are as alleged in the assessment
document. The undersigned further understands that all evidence presented in support of remission
of this civil penalty must be submitted to the Director of the Division of Water Resources within
thirty (30) days of receipt of the notice of assessment. No new evidence in support of a remission
request will be allowed after thirty (30) days from the receipt of the notice of assessment.

This the ____________________ day of _______________________, 2021

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Signature

ADDRESS

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TELEPHONE

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