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safer n LDR NOTIFICATION FORM Generator Name Ed Manifest No.,a 2d Pursuant to 40 CFR§268.7(a,I l6rby notify,that this shipment contains waste restricted under 40 CFR Part 268 Land Disposal Restrictions(LDR). A. GENERAL WASTE NOTIFICATION Form EPA Waste Codes Waste Constituent Notification Line SK Profile No. &LDR Subcategories(if any) NW W WW Check the "None"box or No. List codes or use Attachment 1 List Legend Constituent#or use Attachment 2 14 ' r y^ Il { O Check if Attachment I has been used dNorie O Check if Attachment 2 has been used O Check if Attachment 1 has been used one O Check if Attachment 2 has been used O Check if Attachment 1 has been used 1�»>f 4 O Check if Attachment 2 has been used �� o _ . O Check if Attachment 1 has been used C31'1 ne ;:Check if Attachment 2 has been used bila Z-- s r� 0/ O Check if Attachment 1 has been used LDLNotaf— O Check if Attachment 2 has been used iW 46, O Check if Attachment I has been used one O Check if Attachment 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION Q This hazardous debris,as identified above on Line Nola). is subject to the alternative treatment standards of 40 CFR§268.45. The waste contains the following contaminants subject to treatment(check all that apply): O Toxicity characteristic debris C]Debris contaminated with listed waste Cl Cyanide reactive debris C. CONTAMINATED SOIL NOTIFICATION&CERTIFICATION Q This contaminated soil,as identified above on Line Nola). is subject to the alternative treatment standards of 40 CFR§268.49(c). Complete the following: "I certify under penalty of law that I personally have examined this contaminated soil&it[O does/O does not]contain listed hazardous waste& [O does/O does not] exhibit a characteristic of hazardous waste & [O is subject to/O complies with] soil treatment standards as provided by §268.49(c)or the universal treatment standards". Note: Constituents subject to treatment are any constituents listed in 40 CFR§268.48 Universal Treatment Standards that are reasonably expected to be present in any given volume of contaminated soil, except fluoride, selenium,sulfides,vanadium&zinc,&are present at concentrations greater than ten times the universal treatment standard. D. LAB PACK(INCINERATION)N TIFICATION&CERTIFICATION 's lab pack,as identified above on Line No(s). _6s subject to the alternative treatment standards of 40 CFR§268.42(c). I certify under penalty of law that I personally have examined&7am familiar with the waste&that the lab pack contains only wastes that have not been excluded under Appendix IV to 40 CFR Part 268&that this lab pack will be sent to a combustion facility in compliance with the alternative treatment standards for lab packs at 40 CFR§268.42(c). I am aware that there are significant penalties for submitting a false certification,including the possibility of fine or imprisonment". E. EXTENSIONS&VARIANCES Q This waste,as identified above on Line No(s). is not prohibited from land disposal&is subject to a deadline extension or variance, e.g.,treatability variance,case-by-case extension. Describe below any extension or variance that applies to this waste&include applicable data: Generator's Authorized Signature Name&Title(Printed or Typed Date DWALx KLDR.NOTIFICAT[ON(6199) GENERATOR Y