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go. • CALIFORNIA LNOTIFICATION Rt CERTIFICATION (NON-11 HAZAlznoue WASTE ONLr) This form is submitted in accordance with the requirements of 22 CCR 66268.7(a) Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate California waste code(s) and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below. Complete all portions of Part I. If the waste is no hazardous or not restricted then complete only the applicable portions in Part I and sign / date the Form at the bottom of page. Otherwise complete Part I, II and III ,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME i51PltY -14ih PHONE:�2� - 3�''��'® SITE LOCATION:-7/gQZ-7' ,e'�tl&2&YArf1, �sT� PROFILE NUMBER: V IS THIS WASTE NON-HAZARDOUS? ❑ YES(if YES,stop here and sigr✓date form at the bottom of page) J GENERATOR'S EPA IDR: � .`� MANIFEST R: 263;,7171 CA WASTE CODE(S): IS THIS WASTE RESTRICTED? ❑ YES, [ _W-of NO,stop here and sigrvdate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑ (A)CHEMICAUPHYSICAL ANALYSIS OF THE WASTE; ❑ (B)GENERATOR KNOWLEDGE OF THE WASTE;OR Q (C)BOTH Check the appropriate boxes in Parts 11 and III. If only one notification applies,then III(A) is not required. For multiple certifications/notifications,the appropriate choices from Part II (1-3)may be marked in Part 111(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions.By selecting an item in Part III(A), 1-3,you are making the certification/notification noted in Part If. If. TYPE OF LDR NOTIFICATION/CERTIFICATION ❑ 1. NOTIFICATION ONLY. WASTE THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: a 22 CCR §66268.7(a)(1) 1 ❑ 2. 4 NOTIFICATION&CERTIFICATION: WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED: - 22 CCR §66268.7(x)(2) I certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification,that the waste complies with the treatment standards specified in CCR Title 22, Division 4.5, Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C. Section 6924(d)).I believe that the information 1 submitted is true,accurate and complete. I am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment 2 ❑ 3. 4 NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS: ® 22 CCR §66268.7(b)(5) I certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification, that the waste complies with the treatment standards specified in CCR Title 22, Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d)).I believe that the information I submitted is true,accurate and complete. I am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. 4 111. LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Cheek (A) (B) (C) (D) approprlata Check 1,2, or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-m) and Treatment Standard (Part II) EMscdw (late Tractability Group(s) 66268.100(a)(1-14) (From 22 CCR) 1.❑ ❑1 ❑2 C33 1126/90 Aqueous wastes containing metals[66268.29(a)&66268.100(a)(1)] 1 66268.107 Table II CCW 2. 13 ❑1 ❑2 C33 5/8/91 Auto shredder waste[66268.29(c)&66268.100(a)(3)] 2 86268.106 Table 1-A CCWE 3.❑ El El [_13 1/1/91 Hazardous waste foundry send(66268(e)8 66268.100(a)(5)] 4 66268.106 Table 1-B CCWE 4.❑ [If ❑2 ❑3 1/1/91 Fly ash,bottom ash,retort ash or baghouse waste[66268.29(h) 68268.100(x)(8)] 7 66268.106 Table I-D CCWE 5.❑ ❑1 ❑2 ❑3 111/91 Baghouse waste from foundries[66268.29(i)&66268.100(a)(9)] 6 66268.106 Table 1-E CCWE 6.❑ ❑1 ❑2 Q 3 3l 1/93 Asbestos containing waste ident�ed in section(66268.29(m)&68268.100(8)(13)] 12 86268.114 7. ❑ ❑1 ❑2 ❑3 Other(SPecity): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above. IV. GENERATOR AUTHORIZATION/CERTIFICATION 1 hereby certify that all information submitted In this and all associated documents is true,complete,and accurate to the best of my knowledge and informatio nd that no omissions or errors exist.I warrant that I am an authorized representative of th generator. h0nzed Signature Printed Name' TitleD e THI DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR AT LEAST FIVE(5)YEARS AS PER 22 CCR 166268.7 - Rev. 1/96 Page-of- FORM NSW7523