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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboratory Manifest No. 005870767 JJK Pursuant to 40 CFR§268.7(a),I hereby notifv that this shipment contains waste restricted under 4)CFR Part 268 Land Disposal Restrictions(LDR). A. GENERAL WASTE NOTIFICATION j Form EPA Waste Codes Waste Constituent Notification Line Profile No. & LDR Subcategories(if any) iNAVNV WW Clieck the "Xone"box or No. List cotles or ntse Atlaclurtent I List Legend Constituent#or use Atttrchnient 2 DOW r, 1 LI\L-LC1'6-1 0 L ❑Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been used ❑Check if Ailachrnenl 1 has been used ❑done ❑Check if Attachment 2 has been used 3 ❑ ❑Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been used 4 ❑ ❑ ❑Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been used ❑Check if Attachment I has been used ❑None ❑Check if Anachnient 2 has been used 6 ❑ ❑ ❑Check if Auaclument 1 has been used ❑None ❑Check if Attachment 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION n This hazardous debris.as identified above on Line No(s), is suhiect to the alternative treaunent standards of 40 CFR M8.45. The waste contains the following contaminants subject to tcatmcni(check all that apply): ❑Toxicity characteristic debris ❑ Debris contaminated with listed waste ❑Cyanide reactive debris C. CONTAMINATED SOIL NOTIFICATION&CERTIFICATION subject is sub to the alternative treatment standards of 40 CFR,2 Phis contarnlnated soil.as identified above on Line Nols), j• fi_68 49(c). Complete the follosing: "I certify under penalty of law that I personally have examined this contaminated soil& it[❑does!❑does not]contain listed hazardOUS waste& [❑does 1 ❑does not] exhibit a characteristic of hazaltlous waste& [❑is subject to/❑complies%%itlt]soil Ireatntcnt standards as provided by §268.49(c) or the univcrsal trealrnent standards". ,fore: Corrsttuenis subject to treatment are airy,constituents listed in 40 CF1?§26S 4& Umversal Treatment 5lattilards shut are reasonably expected to be present in any given rohmne of contantinaled soil, except fluoride,selenium.sulfides. vanathrun&zure,&are present at conceyaratioits greater tharr ten times the universal treatinvorr slandard. D. LAB PACK IINCINERATION)NOTIFICATION&CERTIFICATION n This lab neck,as identified above on Line Nots). is subject to the alternative treatment standards of-10 CFR§268,42(c). '•I certifj under penalty of Eau•that I personally hate examined&ant familiar with the caste&that lite lab pack contains only tastes that have not hcen excluded under Appendix IV to 40 CFR Part 268 & that this lab pack will be sent to a combustion I•acility in compliance with the alternative treatment standards for lab packs at 40 CI-R§268.42(c). I am aware that there ate significant penalties for submitting a false certification,including the possibility of fine or imprisomnent". E. E\TENSIONS&VARIANCES n This waste,as idcntitied above on Line No(s). is not prohibited from land disposal&is subject to a deadline extension or variance, e.g•,treatability variance,case-by-case extension. Describe below any extension or variance that applies to this waste el include applicable dates: Scott A.Graliam,Shipping Coordinator 02 / 27 1 2018 Generatur's Authorized Signature Name&Title(Printed or Typed) Date DWALKER LDR`;0TWICATION I D.Y