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California Land Disposal/Restriction Information Clean Harbors Environmental Services,Inc. NotiTication/Certiiication 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 �alifomia waste code(s)and applicable non-RCRA hazardous wasti listings rt l�altd sig66268.29 are n/date theForm tat thed e bottom oflpage.ete l Otherwise comp[e a Part 1,11,of Part 1. if the waste land![, lazardous or not restricted then complete only the applicable portionsg and sign/date the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS) GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM T L PHONE:X09-320-3712-SITE_2526 West Washington Street Stockton,CA.95203 PROFILE NUMBER: H 17 B IS THIS WASTE NON HAZARDOUS? X NO YES (if YES,stop here and sigNdate form at the bottom of page) GENERATOR'S EPA 1Dit: AL 1 2 MANIFEST 11:6/15g3�ir3F CA WASTE CODE(S):571_IS THIS WASTE RESTRICTED? RYES NO.(it NO,stop here and signidate form at the bottom of page) THiS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: K(A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE, T(B)GENERATOR KNOWLEDGE OF THE WASTE;OR =(C)B TH _ r :,heck the appropriate boxes in Parts 11 and Ill.If only one applies,then III(A)is not required.For multiple certificationsInotifications,the appropriate choices from Part 1(1-3)may be marked in Part IIIA)to indicate how waste is to be managed to conform with Land Disposal Resirictions. By selecting an item in Part I II(A),1-3,you are flaking the certification/notification noted in Part 11. .,1. TYPE OF LDR NOTIFICATION I CERTIFICATION F6924(d)). NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT NDARDS-�22 CCA§66268.7(a)(1)22 CCR§66268.7(a)(2) tify underpenaltyof law that fpersonally have examined and am familiar with the waste through analysis and testing th rough knowledge e waste to support this certification,that the waste complies with the treatment standards specified in CCR Title 22,Division 4.5, Chapter Articles 4 and l 9 andallapplicable prohibifion5 set forth in CCR Title 22,Section 662.68.32 orRCRA Section 3a04(d)(42 U.S C. Section I believe that the information 1 submitted is true,accurateand complete.Iam aware that there are significant pens/ties forsubmittinclse certification,including the possibilityofa fine or imprisonment. NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS 13EEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=;�22 CCR §66268.7(b)(5) 1 certify underpenalty of law that 1 personallyhave 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 4.6, Chapter IS 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 I submitted is true,accurate and complete.1 am aware that there are significant penalties for submittin,7.:-, a false certification,including the possibility of a fine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR [Cl (DI Chock (A) IBI Corresponding appropriate Cheek 1,2,ar 3 from Treatment Standard boxes handtog intormatlon Prohibition 6ubeategory of.Aestrietm Waste[22 CCR 66268.29 atnl and {From 22 CCRI (Part N) Effective 0ate Treatability Groupie)66268.100(a)(1-141 1.7 -.# - __2 -3 - 1126+90 Aqueouswastes containing metals[66269.29(a)&66268.1001a1{111 1 66258.107 Table 11 CCW 2 - .1 72 ".3 5+9191 Auto shredder waste[66269.29{c7&66268.100{al(3)i 2 -66268.106Table-ACME 3 - -1 _2 -3 111191 Hazardous waste foundry sand I66268.29(e1&66269.1001a1i511 4 56269.106 Table 1-B CCWE 4 x _1 _,3 111!91 Fly ash,bottom ash,retort ash or baghouse waste[66268.29(h)&66269.100{al{911 7 66268.106 Table 1-D CC%Ni 5._ -1 -'2 ':3 11V91 Baghousewaste from foundries[66268.2910&66268.10013119}1 8 66268.106Table I-E CWE '_3 3x1793 Asbestos containing waste identified in section[66268.29(m)&66268.1001a1OV 12 55768.113 7. -1 _.2 -3 Other(SQailyl: 13 - Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the man'rfest referenced above. N. GENERATOR AUTIIORQATIONiCERTIFICATION 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,End that no omissions or errors e)dst.I warrant that I am an authorized representative of the generator. Date Authorized S" ature Printed ams Tttle _ CH WASTE SHIPMENT. A COPY OF THIS SUIS DOCUMENT, WITH AN ORIGINAL PPORTING DATA ST BE RETAINED SBYITHEUGENERATOR FOR ARE, MUST L EASANYT F VE(5)YEARS AS PER 22 CCR§86266.7 Rev.11'02TfFlPagef-of D ALL S