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Section IV (Cont.) Check mark the underlying hazardous constituents likely to be present. <br /> Pentachlorodibenzo-furans Tetrachlorodibenzofurans _Vemolate <br /> — _ <br /> Pentachloroethane _,1,1,1,2-Tetrachloroethane _Vinyl chloride <br /> Pentachloronitrobenzene _1,1,2,2-Tetrachloroethane _Xylenes(total) <br /> _Pentachlorophenol Tetrachloroethylene —Antimony <br /> Phenacetin2,3,4,6-Tetrachlorophenol _Arsenic <br /> —Phenanthrene Thiodicarb _Barium <br /> _Phenol Thiophanate-methyl _Beryllium <br /> o-Phenylenediamine Tirpate ®Cadmium <br /> _Phorate Toluene Chromium(total) <br /> Phthalic acid =Toxaphene ®Cyanide(total) <br /> _Phthalic anhydride Triallate ®Cyanide(amenable) <br /> !Physostigmine Tribromomethane(Bromoform) _Fluoride <br /> —Physostigmine salicylate 2,4,6-Tribromophenol Lead <br /> Promecarb —1,2,4-Trichlorobenzene —_Mercury(retort residues) <br /> Pronamide _1,1,1 -Trichloroethane Mercury.(all others) <br /> Propanenitrile(Ethyl cyanide) —1,1,2-Trichloroethane _Nickel <br /> _Propham Trichloroethylene _Selenium <br /> _ <br /> Propoxur Trichloromonofluoromethane _Silver <br /> _Prosulfocarb 2,4,5-Trichlorophenol _Sulfide <br /> _Pyrene _2,4,6-Trichlorophenol —Thallium <br /> _Pyridine ®2,4,5-Trichlorophenoxyacetic acid Vanadium <br /> _Safrole (2,4,5-1) ®Zinc <br /> Silvex(2,4,5-TP) _1,2,3-Tdchloropropane <br /> _1,2,4,5-Tetrachlorobenzene —1,1,2-T6chloro-1,2,2-trifluoroethane <br /> Tetrachlorodi-benzo-p-dioxins Triethylamine <br /> tris(2,3-dibromopropyl)phosphate <br /> Section V Certification for wastes that meet the treatment standard as required by 40 CFR 268.7 (a) (3). <br /> Note: Complete and sign this section only if your are certifying that the waste meets the treatment standards specked in 40 CFR <br /> 268,Subpart D at the original point of generation. <br /> I certify under penalty of law that I personally have examined and am familiarwith the waste through analysis and testing or through <br /> knowledge of the waste to support this certification that the waste complies with the treatment standards speed in 40 CFR part 268 <br /> Subpart D. I believe that the information I submitted is true,accurate,and complete. I am aware that there are significant penalties <br /> for submitting a false certification,including the possibility of a fine and imprisonment. <br /> Authorized Signature <br /> Print Name <br /> Title <br /> Company TTin fi6rl0Ice, <br /> Date � -2 <br /> Systech has prepared this form for the convenience of its customers to comply with the notification requirements under the Land Disposal <br /> Restrictions(LDR)Program in 40 CFR Part 268. Systech believes that it addresses all of the notification requirements imposed by the <br /> LDR regulations as they apply to our customers. The regulations impose on the generator the responsibility for proper LDR notification. <br /> Therefore,the generator should ensure that he has complied with all of the LDR notification requirements when using this form. <br /> NOTIFICATION REVISION OCT.98(TSV <br />