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-s. - SUSPENS&ilN-OFFWORK APPLIC41ON-FOIRM <br /> r <br /> FOR OFFICIAL USEONLY ; <br /> USTCF# -7 L4 <br /> Date Received <br /> 1. Does`this site pose'an imminent threat to human health,safety, or the environment? Y ❑ hi ❑ <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 ❑ - <br /> Explanation: -: <br /> �. Do you recommend in favor of granting a Suspension of Work? Y ❑ N ❑ <br /> Explanation: <br /> ..4 s <br /> Signature of SWRCB Representative: f <br /> Date: <br /> :PART C REGULATOtY A: NC`Y.: EW <br /> I. `Does this site pose an imminent threat to human health,safety,or the environment? Y ❑ - 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 J8( N ❑ � .� .. <br /> Explanation:- <br /> 3. <br /> xplanation:3. Do you recommend in favor of granting a Suspension of Work? Y N ❑ <br /> Explanation:' '. <br /> Signature of Regulatory Agency Representative: , rL �, "" �1� J <br /> -Date: <br /> - �Ltr�ccr� LCc ; A p <br /> Print Name and Title: _ _ ri <br /> - i <br /> Page 2 of 2 y <br /> SWRCB SWA Form(Version 1/97) <br />