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SUSPENSION OF WORK APPLICATION FORM <br /> FOR OFFICIAL USE ONLY <br /> Date Received <br /> USTCF� <br /> PART B STATE BOARD REVIEW <br /> 1. Does this site pose an imminent threat to human health,safety,or the environment? Y 0 N, 0 <br /> Explanation: <br /> 2. Do your records support the applicant's certification that the Preliminary Site Assessment Items I through 3, as applicable, <br /> have been satisfactorily completed? Y 0 N 0 <br /> Explanation: <br /> 3. Do you recommend in favor of granting a Suspinsion of Work? Y 0 N El <br /> Explanation: <br /> Signature of SWRCS Representative: Date: <br /> PART C - REGULATORY AGENCY REVIEW <br /> I Does this site pose an imminent threat to human health,safety,or the environment? Y C1 N <br /> Explanation: <br /> 2. Do your records support the applicant's certification that the Preliminary Site Assessment Items i through 3. as applicable. <br /> have been satisfactorily completed? Y N C1 <br /> Explanation: <br /> 3. Do you recommend.in favor of granting a Suspension of Work? Y N <br /> ❑ <br /> Explanation: <br /> Date: <br /> Signature of Regulatory Agency Representative: <br /> Print Name and Title: <br /> DECISION. <br /> S;VRCB SWA Form(Version 1/97) <br /> Page 2 of 2 <br />