820352_Waiver of Right_20210929

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
MARY J. ROBINSON )
)
)
)
PERMIT NO. AWS820352 ) FILE NO. DV-2021-0111

Having been assessed civil penalties totaling $8,956.06 for violation(s) as set forth in the
assessment document of the Division of Water Resources dated September 29, 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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