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California Land Disposal/Restriction Information Notification/Certification Form This form is submitted in accordance with the requirements of 22 CCR 66268.7(a) Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate California waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions of Part I. If the waste is non-hazardous or not restricted then complete only the applicable portions in Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part I,II,and III,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Lnborntory PHONE: 925422-1925 SITE LOCATION: Corral Ifollow itd,Trncv.CA 95376 PROFILE NUMBER DOIIG047-1 IS THIS WASTE NON-HAZARDOUS?©NO, ❑YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2S90090002 MANIFEST#: 005870814.1.TK CA WASTE CODE(S): 512 IS THIS WASTE RESTRICTED? ❑YES (ENO(if NO,stop here and sigrl/date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE, ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts II and III If only one applies,then III(A)is not required For multiple certificationstnotifiications,the appropriate choices from Part 11(1.3)may be marked in Part ill(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions. By selecting an item in Part lll(A), 1-3,you are making the certification I notification noted in Part 11. it. TYPE OF LDR NOTIFICATION i CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 22 CCR§66268 7(a)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=22 CCR§66268.7(a)(2) l certify under penalty of taw that t personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification, that the waste complies with the treatment standards specified in CCR Title 22,Division 4.5,Chapter I8,Articles 4 and I I and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d)).I believe that the information 1 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 or imprisonment. ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFFSITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=22 CCR §66268.7(b)(5) l certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification, that the waste complies with the treatment standards specified in CCR Title 22,Division 4.5,Chapter 18,Articles 4 and i f and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCR4 Section 3004(d)(42 U.S.C. Section 6924(d)), t believe that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. Ill.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (B) (C) (D) appropriate Check 1,2,or 3 from Corresponding bases handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66265.29 a-m)and Treatment Standard (Part Ill Effective Date Troatabltity Group(s)66266.100(a)(1.14) (From 22 CCR) 1 ❑ Ill 02 03 126190 Aqueous wastes containing metals ISS26829(a)&66268.I�C(av111 1 66268.107 Table II CCW 2 ❑ ❑1 02 ❑3 518191 Auto shredder waste[66268 29(e)&65268.100(a)(3)1 2 66268 105 Table•A CCWE 3 ❑ 171 02 03 111191 Hazardous wasta foundry sand(66268 29:a)&66268.100(a)(5)1 4 66268.106 Table t-B CCWE 4 ❑ ❑1 02 03 11t191 Fly ash,bottom ash,retort ash or baghoise waste(66268 29(h)&66268 100(a)(B)l 7 66268.106 Table I•D CCWE 5-❑ ❑1 ❑2 03 VIM Baghouse waste from foundries(66268 29(i)&66268 100(a)(9)1 6 66268.106 Table I•E CWE 6 ❑ Eli 02 ❑3 311193 Asbestos containing waste identified at section[66268 29(m)&66268.100(a)(13)) 12 66268.114 7 ❑ ❑1 ❑2 03 Other(Specify): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above IV. GENERATOR AUTHORIZATIONICERTIFICATION hereby certify that all information submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information and that no om'ssions r s ex' .I warrant that I am an authorized representative of the generator. 011 SCOTT A.Gl2AHAif Shipp-ine Coordinator 05/21/2018 u horized Signature Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CCR§66268.7 Rev.11102 Page 07 of 13