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appropriate checkbox <br />Waste Determination Documentation <br />' Does the waste contain components <br />listed in 22 CCR, Div. 4.5, Ch. 11, <br />Appendix X? <br />Index <br />❑ I No hazardous waste presumption <br />Toxic - TCLP I Material not toxic <br />Is the waste extremely haza I <br />dous per 22 CCR §66261.110? <br />... .. <br />U Lab Analysis <br />SDS <br />YES ❑ Other <br />NOL3ME <br />a waste is destined for a non-approv TSDF, please explain. <br />MI <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />Include lab report <br />IncludeMSDS <br />Additional Info here <br />Waste is not disposed on land <br />If NO, explain reason & <br />Page 4 of 5 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />Toxic - TTLC/STLC <br />Material not toxic <br />Toxic - LD50, LC50, %wt. <br />Material not toxic <br />Material not <br />El <br />Reactive <br />reactive <br />Material not <br />❑ <br />Ignitable <br />ignitable <br />❑ <br />Material not <br />Corrosive <br />corrosive <br />Is the waste extremely haza I <br />dous per 22 CCR §66261.110? <br />... .. <br />U Lab Analysis <br />SDS <br />YES ❑ Other <br />NOL3ME <br />a waste is destined for a non-approv TSDF, please explain. <br />MI <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />Include lab report <br />IncludeMSDS <br />Additional Info here <br />Waste is not disposed on land <br />If NO, explain reason & <br />Page 4 of 5 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />