Laserfiche WebLink
Land Disposa, Aification and Certification Form (C( t� <br /> ,ents of Concern (For,F001 - F005 SPA Waste Codes Only) <br /> ,.2/9b.3 MA Constituent 9b.1/9b.2/9b.3/9b.4 Constituent 9b.1/9b.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 __T_Methyl Isobutyl Ketone ___Xylenes(Total) <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 /> Certifications <br /> =1v.1 9b.2 9b.3 9b.4 Waste Does Not Meet Applicable Treatment Standards <br /> gf E-1 D 7 __.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 /> ❑ ❑ ❑ <br /> El with <br /> 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 /> F 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 /> Ejpack 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 submitting a false <br /> certification, including the possibility of fine or imprisonment. <br /> iereby certify that all information supplied is complete and accurate to the best of my knowledge and information. <br /> Signature: Printed Name: <br /> Title: �! '�a Date: tlZ l� <br />