Seriousness of Violation | ______________ |
Negligence/Good Faith | X ______________ |
Subtotal: | ______________ |
Adjustment Factor | X ______________ |
Subtotal: | ______________ |
Unique Factor | X ______________ |
Subtotal: | ______________ |
History of Noncompliance | + ______________ |
Total Assessment: | ______________ |
W. Va. Code R. agency 33, tit. 33, ser. 33-22, tbl. J