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Land Disposal Notification and Certification Form (Cont.) <br /> Constituents of Concern (For F001 - F005 EPA Waste Codes Only) <br /> 9b.1/9b.2/9b.3/9b.4 Constituent 9b.1/9b.2/9b.3/91J.4 Constituent 9b.1/91J.2/9b.3/9b.4 Constituent <br /> Acetone ____Cyclohexanone ____Nitrobenzene <br /> Benzene ____o-Dichlorobenzene ____Pyridine <br /> n-Butyl Alcohol ____Ethyl Acetate ____Tetrachloroethylene <br /> Carbon Tetrachloride ____Ethyl Benzene ____Toluene <br /> _ Carbon Disulfide ____Ethyl Ether ____1,1,1-Trichloroethane <br /> Chlorobenzene ____Isobutyl Alcohol ____ 1,1,2-Trichloroethane <br /> Cresol Mixed Isomers Methanol 1,1,2-Tdchloro-1,2,2-Tdfluoroethane <br /> Cresol,p-isomers ____Methylene Chloride ____Trichloroethylene <br /> _ Cresol,m-isomers ___Methyl Ethyl Ketone ____Trichloromonofluoromethane <br /> o-Cresol ____Methyl Isobutyl Ketone __ _Xylenes(Total) <br /> Underlying Waste Constituents for Characteristics Wastes <br /> (From 22 CCR 66268.48, not applicable for Lab Packs) <br /> 9b.1 <br /> 9b.2 <br /> 9b.3 <br /> 9b.4 <br /> Certifications <br /> 9b.1 9b.2 9b.3 9b.4 Waste Does Not Meet Applicable Treatment Standards <br /> ❑ ❑ ❑ Waste does not meet applicable treatment standards in 22 CCR 66268.40 or exceeds applicable <br /> prohibition levels of 22 CCR 66268.32 or RCRA Section 3004(d). <br /> Waste or Contaminated Soil Meets Treatment Standard At Original Point of Generation <br /> I certify under penalty of law that I personally have examined and am familiar with the waste through <br /> ❑ ❑ ❑ ❑ analysis and testing or through knowledge of the waste to support this certification that the waste complies <br /> with the treatment standards specified in 40 CFR part 268 subpart D and in CCR,Title 22,Division 4.5, <br /> Chapter 18,Article 4. 1 believe that the information I submitted is true,accurate,and complete. I am <br /> aware that there are significant penalties for submitting a false certification,including the possibility of a <br /> fine and imprisonment. <br /> Contaminated Soils Certification (Mark appriopriate answers in certification statement.) <br /> I certify under penalty of law that I personally have examined this contaminated soil and it[DOES/DOES <br /> ❑ ❑ ❑ NOT]contain listed hazardous waste and[DOES/DOES NOT]exhibit a characteristic of hazardous waste <br /> and requires treatment to meet the soil treatment standards as provided by 40 CFR 268.49(c)and CCR <br /> Title 22§66268.49(c). <br /> Lab Pack Alternate Treatment Standard Certification <br /> I certify under penalty of law that I personally have examined and am familiar with the waste and the lab <br /> ❑ El ❑ 1:1 that <br /> contains only wastes that have not been excluded under CCR,Title 22, Division 4.5,Chapter 18 and <br /> that this lab pack will be sent to a combustion facility in compliance with the alternative treatment <br /> standards for lab packs under CCR,Title 22, Division 4.5,Chapter 18,Section 66268.42(c). I am aware <br /> that there are significant penalties for submitting a false certification, including the possibility of fine or <br /> imprisonment. <br /> I hereby certify that all information supplied is complete and accurate to the best of my knowledge and information. <br /> Signature: Printed Name: <br /> Title: Date: <br /> Page 2 of 2 Rev 2.0 [Effective 1/27/2012] <br />