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Clean Harbors Environmental Services, Inc. Califoriia Land Disposal/Restriction Information
<br /> Notification/Certification Form
<br /> this fora is submitted in accordance with the requirements of 22 CCR 66268.7(a)Chapter 18 which restricts land dL-posal of certain hazardous wastes. The appropriate
<br /> :; lMnmia waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268,29 are noted below.Complete all portions of Part 1. If the waste is nor7-
<br /> 7aziirdous or notrestricted then complete only the applicable portions in Part I and sign/date the Form at the bottom of page. Otherwise complete Part I, 11, and [I1,
<br /> and sign/date the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS)
<br /> GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM
<br /> b--E Stockton,LLC PFIONE: 209-3203712 SITE_2526 West Washington Street Stockton,CA.95273
<br /> PROFILE NUMBER: CH641753B IS THIS WASTE NON HAZARDOUS? X NO - YES
<br /> ,'rf YES,stop here and sign/date form at the bottom of page)
<br /> GENERATOR'S EPA ID4: CAL00359102 MANIFEST 1#:0,0739SOFCC CA WASTE CODE(S):h571_IS THIS WASTE RESTRICTED? RYES
<br /> V 0(if NO,stop here and sign/date form at the bottom of page)
<br /> THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION:
<br /> X (A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE; =(8)GENERATOR KNOWLEDGE OF THE WASTE:OR (C)BOTH
<br /> heck the appropriate boxes in Parts 11 and III.If only one applies,then I11(A) is not required.For multiple cerfificationslnotifications,the appropriate choices from Part
<br /> 1(1-3)may be marked in Part III(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions. By selecting an item in Part III(A), 1-3,you are
<br /> 11aP ing the certification i notification noted in Part II.
<br /> I. TYPE OF LDR NOTIFICATION/CERTIFICATION
<br /> 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENTTO MEET THE 22 CCR ARTICLE 11 TREATMENT
<br /> STANDARDS:X22 CCR§66268.7(a)(1)
<br /> X=: _fib: 'sem 22 CCR §66268.7(a)i2)
<br /> I certify under penalty of law that l personally have examined and am familiar with the waste through analysis and testing through knowledge
<br /> of the waste to support this certification,that the waste complies with the treatment standards specified in CCR Title 22,Division 4.5, Chapter
<br /> 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.31 or RCRA Section 3004(d)/42 U.S.C. Section
<br /> 6924(d)).1 believe that the information I submitted is true,accurate and complete.lam aware that there are significant penalties for submitting
<br /> a false certification,including the possibility of a fine or imprisonment.
<br /> 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SrrE TREATMENT FACILITY SO AS TO
<br /> MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:==:,22 CCR §66268.71,b)(5)
<br /> 1 certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing through knowledge
<br /> of the waste to support this certification,that the waste complies with the treatment standards specified in CCR Title 22,Division 4.5,Chapter
<br /> 18,Articles 4 and I I and all applicable prohibitions set forth in CCR Title 22,Section 66268.3.7 or RCRA Section 3004(d)142 U.S.C. Section
<br /> 6924(d)).I believe that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting
<br /> a false certification,including the possibility of a fine or imprisonment.
<br /> Ill.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR
<br /> check (A) (B) (C) (Cu
<br /> aprropriate Check 1,2,or 3from Corresponding
<br /> as es handling informationProhibition Subcategory of Restricted Waste(22 CCR 66268.29 a-ml and Treatment Standard
<br /> (Part W Effective Date Treatability Groups}66258.100(a)(1-14) (From 22 CCR)
<br /> 1i26190 Aqueous wastes containing metals[66268.29Iai&66268.100{a 110 1 65268.107 Table fl CCW
<br /> _. 1 2 3 518,191 Auto shredderwaste[66268.29!cl&66268.100(a1i311 2 615268.106 Table-A CC"IL
<br /> 3. .1 "_2 .3 - 1111,191 Hazardcus waste foundry sand 1662M.23(el&66268.100{ai(5i 4 66268.106Tahle 1-8 CC%14E
<br /> 4,X 1 .3 1.1151 Fly ash,bottom ash,retort ash or hagh0u5ewasta[6626&29(h &66268.100!a1181 7 66268.106 Table 1-0 CCME
<br /> 5.. -1 -'2 ._3 li191 9aghouse waste from foundries[66268.296}&66268.100(alt9}; 8 66268.106 Table I-E CWE
<br /> 6, t 2 _3 3:1153 Asbestos containing waste identified In section[66268.29(mi 8.66268.1001aH1311 12 66268.114
<br /> 7.- :.1 2 -3 Other{Specify;: 13
<br /> Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above.
<br /> IV. GENERATOR AUTHORIZATION/CERTIFICATION
<br /> 1 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,ar 1
<br /> that no omissions or errors east. I warrant that I am an authorized representative of the generator.
<br /> ALthorized S" ature Printed Ware Title Date
<br /> TF:!S DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION. AND ALL
<br /> Stir'PORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5) YEARS AS PER 22 CCR§66268.7 Rev.11,02 Page-of
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