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Land Disposa,-tification and Certification Form (C <br />Constituents of Concern (For F001 - F005 EPA Waste Codes Only) <br />9b.1/ 9b.2/ 9b.3 /9b.4 Constituent <br />T _ Acetone <br />Benzene <br />n -Butyl Alcohol <br />Carbon Tetrachloride <br />Carbon Disulfide <br />Chlorobenzene <br />Cresol Mixed Isomers <br />Cresol, p -isomers <br />Cresol, m -isomers <br />o -Cresol <br />9b.1/ 9b.2/ 9b.3 /9b.4 Constituent <br />Cyclohexanone <br />o -Dichlorobenzene <br />Ethyl Acetate <br />Ethyl Benzene <br />Ethyl Ether <br />Isobutyl Alcohol <br />Methanol <br />Methylene Chloride <br />_ Methyl Ethyl Ketone <br />Methyl Isobutyl Ketone <br />Underlying Waste Constituents for Characteristics Wastes <br />(From 40 CFR 268.48, not applicable for Lab Packs) <br />9b.1 <br />9b.2 <br />9b.3 <br />9b.4 <br />9b.1/ 9b.2/ 91b.3 /9b.4 Constituent <br />Nitrobenzene <br />Pyridine <br />Tetrachloroethylene <br />Toluene <br />1,1,1 -Trichloroethane <br />1,12 -Trichloroethane <br />1,1,2-Tdr-hloro-1, 2, 2-Trifluoroethane <br />Trichloroethylene <br />Trichloromonofluoromethane <br />Xylenes (Total) <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 40 CFR 268.40 or exceeds applicable prohibition <br />levels of 40 CFR 268.32 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 />❑ ❑ ❑ ❑ pack contains only wastes that have not been excluded under appendix IV to 40 CFR part 268 and that <br />this lab pack will be sent to a combustion facility in compliance with the alternative treatment standards for <br />lab packs at 40 CFR 268.42(c). I am aware that there are significant penalties for subrInitting a false <br />certification, including the possibility of fine or imprisonment. <br />I hereby certify that all inform -tl supplied is complete and accurate to the best of my knowledge and information. <br />`;�ASignature: ✓�ly--� Printed Name:ry-�C <br />Title: Date:' <br />