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<br /> Clean Harbors Environmental Services, Inc. California Land DisposaVRestriction Information
<br /> otiricaFor
<br /> Phis form is submitted in accordance with the requirements of 22 CCR 66268.7(a)Chapter 18 which restricts land disposal of certain hazatdours wasttes, The appropriate
<br /> :;aJifor,a waste codes)and applicable non-RCRA hazardous waste iiistings from CCR 66268.29 are not
<br /> araous or not resed below.Complete all portions of part€. If the waste is nonrestricted then complete only the applicable portions in Part I and sign/date the Form at the botto-n of page. Otherwise complete Part I, 31, and Ili,
<br /> and siprildate the Form at the bottom of page. (For RCRA wastes,use Clean Harbors RCRA FORMS)
<br /> GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM
<br /> C,TE 5 o kten LLC PHONE:. 2Q9-320-Q712 SITE_2526 West Washington Street Stockton,CA.95203
<br /> PROFI_E NUMBER: _-QH641MB IS THIS WASTE NON HAZARDOUS? X NO --YES
<br /> (if)ES,stop here and sign/date form at the bottom of page)
<br /> GENERATOR'S EPA ID#: CAL00359102 MANIFEST#:p/J5839�IFC�AWASTECODE(S): 571 IS THIS WASTE RESTRICTED? x YES
<br /> NO 0f P10,stop here and sigrVdate form at the bottom of page)
<br /> E
<br /> S NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION:
<br /> 1)C-1EMICAL/PHYSICAL ANALYSIS OF THE WASTE; =(B)GENERATOR KNOWLEDGE OF THE WASTE- -
<br /> OR (C)BOTH
<br /> jr
<br /> heck the appropriate boxes in Parts 11 and 11€.If only one applies,then III(A) is not required.For multiple certifications/notifications,the appropriate choices from Part
<br /> 1(1-3)may be marked in Part I11(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 />-naking the certification/not'€fication noted in Part II,
<br /> 1. TYPE OF LDR NOTIFICATION/CERTIFICATION
<br /> 'a
<br /> 4y
<br /> ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT
<br /> STANDARDS:=>22 CCR§66268.7(a)(1)
<br /> X:. :-�'=>22 CCR§66268.7(a)(2)
<br /> 1 certify underpenalty of law that I personally have examined and am familiar with the waste through analysis and testing th rough knowledge
<br /> of the waste to support this certification,that the waste complies with the treatment standards specified in CCA Title 22,Division 4.5, Chapter
<br /> 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or,4CRA Section 3004(d)(42 U.S.C. Section
<br /> 6924(d))•I believe that the information I submitted is true,accurate and complete.I am aware that there are significant penalties for submitting
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<br /> a false certification,including the possibilityofa fine or imprisonment,
<br /> 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO
<br /> MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=;.22 CCR §66268.7(b)(5)
<br /> /certify underpenalty 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 sTecified 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 66268.32 or RCRA Section 3004(d)(42 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 ofa fine or imprisonment.
<br /> 11.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR
<br /> Check (A)
<br /> rel
<br /> appropriate Check 1,2,or 3 from rC) rDl
<br /> boxes handling infortnation Prohibition Subcategory of Restricted Waste(22 CCR 96268.29 a-m)and Corresponding -.n
<br /> (Part N Treatment Standard
<br /> Effective Date Treatability Group[y}66268.100(a)[1-14) (From 22 CCRI ,
<br /> 2 li26i)C Aqueous wastes containing metals 16626a.29(a)&66268.100(a'(1}] 1 66268.107 Table II CCW f'
<br /> 2. - 1 2 3 5i8i91 Auto shredderwaste[66268.29(ci&6626a.lWa[311 2 66268.106 Table-A CC%NE FI.
<br /> 3.. 1 2 3 111191 Hazardous wane foundry sand[66268.29(el&6626a.100{al(511 4 56268.10,6 Tahle.1-R CC TI
<br /> 4,X -1 )1,2 _3 11/91 Fry ash,bottom ash,retort ash or baghouse waste[66268.29(h)&65:'68.100f.a 68�; r- tl
<br /> 7 66268.165 Table€-D_f_4VE
<br /> f
<br /> 5.- 1 2 3 V1191 Baghousewaste from fourdHes[66268.290)&66268.100(a}(9)1 8 6626a.106Table f-E CWE
<br /> ._1 2 3 11193 Asbestos containing waste identified in section[66268.29(m� &6626Ef.100ja`.(_13j', 12 66258.114
<br /> 7.:. � 1 .2 73 Other ISpecityl: 13
<br /> Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility icendfied on the manifest referenced above.
<br /> V. GENERATOR AUTHORIZATION/CERTIFICATION g
<br /> I 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
<br /> that ro omissions or errors east.I warrant that I am an authorized representative of the generator.
<br /> Autf.Grized S" nature Printed Name Title > -- Date
<br />-HIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL
<br /> SUPPORTING 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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