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Clean Harbors Environmental Services,Inc. California Land DisposaVRestriction Information This form is submitted in accordance with the requirements of 22 CCR 66268.7(a)Ch Notification/Certification Form California waste codes and ( ) apter 1 B which restricts land disposal of certain hazardous wastes. The appropriate _ ( ) applicable no-RCRA hazardous waste listings from CCR 6626829 are noted below.Complete all portions of Pad I. 8 the waste is non- and rd sign/date or not the Form led then the bottom fete Only the applicable portion in Part I and sign/date the Form at the bottom of page. Otherwise complete Pan 1,11,and 111. I. GENERAL INFORMATION REGARD NG GENERATOR&WASTE STREA. (For RCRA wastes,use Glean M RCRA FORMS) F(GfFENERATOR'S Stockton, Q PHONE 20212137�SITE_2526 West Washington Street Stockton,CA 95203 R: CH1346380 ISTHISWASTENON HAZARDOUS? XNO -:YES nd sgnidare form at the bottom of page) A IDN: CALO0349102 MANIFEST N:ah9397?li WASTE CODE(S): 571 IS THIS WASTE RESTRICTED? Lc YES NO fd NO,stop here and sigrddate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: F.(A)CHEMICAUPHYSICAL ANALYSIS OF THE WASTE; --(13)GENERATOR KNOWLEDGE OF THE WASTE;OR '(C)BOTH Check the appropriate boxes in Parts 11 and Ili.If Only one applies,then lll(A)is not required.For multipie I (1-3)maybe marked in Part III(A)to indicate how waste is tO be managed to conform with Land Disposal Restrictions.nBy se tecotl gtan later inPartIriate C(AD)C993mm are making the certification/notification noted in Part it. IL TYPE OF LOB NOTIFICATION/CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTESTHAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 22 CCR§66261 X- ssi 4s.i 22 CCR 966268.7(a)(2) !certify underpenahyof law that l 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,Amides 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66266.32 orRCRA Section 300th (42 U.S.0 Section 6924(d)) l believe that the information/submitted is tore,accurate and complete./am aware that theta are significant penalties for submitting a false certification,including the possibility of a fine orimprfsonnal 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) /certify underpenahyof law that/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,Amides 4and 11 and a//app/icable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 30g41d)l42 U. Section 6924/dD./believe that the information!submitted is titre,accurate and complete.lam aware that then are significant penalties forsubmiting a false certification,including the possibility ofe fine orimprisonment. III.LDR NOTIFICATION t CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IAI aAProeriat. Cheri 1,2,.,afro. lel ICI IDI boxes ha.6rginfor,nation Prohibition S.Insiegoryof Restiieted Warta 121 CCR 6626&29.1 any Twm,ecorresponding ill all Eaecah,.pm Treatabilityryls)Gret66269.100(.)11-10( Irrom a CCRI 1.� _1 iJ tn9e39 Aqua Ws wastes containitg real(66269.791a11661fi113.10 11111 1 962®.10]Table6 CCW 2.-- -1 50(,97 Auro shre00er waste 166%e.291e1&66268,1001 2 Small Tal CCM 3.- `1 .2 `-� trust Familial waste foundry sane 166258.291.1&662661001111511 4 66MI06 Table 1-8 CCWE C x _'1 u"ti( 3 trust Fly ash,bottan ash,ret0n ash of bagheusewaste I5c26629IhI&s626 mola1fa11 7 616269.106 Table t-U CCWE 5- --1 3 111911 sagh°use waste from foundries(66M291i)&e6I I00(al(ell 6 66269.106 Table IE C1UE 5. r7 -2 -3 3n93 Asbestos containing waste ieentified in section 166268.294m)&fi6269.100(a111311 12 66269.114 7. 'l r2 _3 calls lSpecltyl 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the tactility identified on the manifest referenced above. IV. GENERATOR AUTHORIZATION/CERTIFICATION I hereby certify that all information submitted in this and all associated documents is true,compete,and accurate to the best of my knowledge and nfommatio,and that no omissions or errors eaust.I warrant that I am an authorized reptesenta9ve of the generator. thozed Sginature FMl Name Tole / 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§08288.7 Rev 11/02 Page_d