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ver <br />Tobacco Hearing and Penalty Notice <br />Violation: Tobacco Sales to a Person Under Age 21 <br />First Violation <br />Second Violation <br />N Third Violation <br />Licensed Location: 19262 EVANS ST NW <br />Date of Violation: August S, 2024 <br />Complete the following information and submit by day, month, year. <br />I wish to request an administrative hearing. Staff will contact you to coordinate a hearing date <br />before the Elk River City Council. <br />N I waive my right to an administrative hearing and am submitting the applicable penalty. <br />Number of Violations within 36-month period Administrative Penalty <br />First Violation 300 <br />Second Violation 600 <br />Third Violation 1,000 and license suspension for not less than <br />seven days as determined by the city. The city <br />mar also revoke the license. <br />Options for submittal are as follows: <br />Email this form to '1(-re]kriveri iii.-_,c and make payment at: htips:/ i cin ofelkriver.revtrak.net. <br />Mail this form and a check payable to the Office of the City Clerk at 13065 Orono Parkway, Elk <br />River, MN 55330. <br />ignature Date <br />OVAc US.e v-\ <br />Print Name & Title <br />Page 286 of 379