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Land Disposal Aification and Certification Form (C Constituents of Concern (For F001 - F005 EPA Waste Codes Only) 9b.1/ 9b.2/ 9b.3 /9b.4 Constituent 9b.1/ 9b.2/9b.3/9b.4 Constituent 9b.1/ 9b.2/9b.319b.4 Constituent J, Acetone _ _ _ _ Cyclohexanone _ _ _ _ Nitrobenzene Benzene _ _ _ _ o -Dichlorobenzene _ _ _ _ Pyridine n -Butyl Alcohol _ _ _ _ Ethyl Acetate _ _ _ _ Tetrachloroethylene Carbon Tetrachloride _ _ _ _ Ethyl Benzene _ _ _ _ Toluene Carbon Disulfide _ _ _ _ Ethyl Ether _ _ _ _ 1,1,1 -Trichloroethane Chlorobenzene _ _ _ _ Isobutyl Alcohol _ _ _ _ 1,1,2 -Trichloroethane Cresol Mixed Isomers _ _ _ _ Methanol _ _ _ 1,1,2-Trichloro-1,2,2-Tdfluoroethane _ Cresol; -p -isomers Methylene Chloride _ _ _ _ Trichloroethylene-- - _ Cresol, m -isomers _ _ _ _ Methyl Ethyl Ketone _ _ _ _ Trichloromonofluoromethane o -Cresol _ _ _ _ Methyl Isobutyl Ketone _ _ _ _ Xylenes (Total) Underlyinq Waste Constituents for. Characteristics Wastes (From 40 CFR 268.48, not applicable for Lab Packs) 9b.1 9b.2 9b.3 9b.4 Certifications 91b.1 9b.2 9b.3 9b.4 Waste Does Not Meet Applicable Treatment Standards 17- I F-1 ❑ F-1Wastedoes not meet applicable treatment standards in 40 CFR 268.40 or exceeds applicable prohibition ``�' levels of 40 CFR 26$.32 or RCRA Section 3004(d). Waste or Contaminated Soil Meets Treatment Standard At Original Point of Generation. I certify under penalty of law that I personally have examined and am familiar with the waste through ❑ ❑ ❑ ❑ andlysis and testing or through knowledge of the waste to support this certification that the waste complies with the treatment standards specified in 40 CFR part 268 subpart D and in CCR, Title 22, Division 4.5, Chapter 18, Article 4. 1 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 and imprisonment. Contaminated Soils Certification (Mark appriopriate answers in certification statement.) I certify under penalty of law that I personally have examined this contaminated soil and it [DOES / DOES ❑ ❑ ❑ ❑ NOT] contain listed hazardous waste and [DOES / DOES NOT] exhibit a characteristic of hazardous waste and requires treatment to meet the soil treatment standards as provided by 40 CFR 268.49(c) and CCR Title 22 §66268.49(c). Lab Pack Alternate Treatment Standard Certification I certify under penalty of law that I personally have examined and am familiar with the waste and the lab ❑ 0 ❑ ❑ pack contains only wastes that have not been excluded under appendix IV to 40 CFR part 268 and 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. I hereby certify that all inform supplied is complete and accurate to the best of my knowledge and information. Signature: � Printed Name: Ssm Title: Date: 5 (LI