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glean Harbors Environmental Services, Inc, California Land Disposal/Restriction Information Notification/Certification Form rhis form Is submitted in accordance with the requirements of 22 CCR 66268.7(x)Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate ,alifomia waste Code(s)and applicable non-RCRA hazardous waste listings from CCR.66268.29 are noted below.Complete ail portions of Part I. If the waste is non- 7azardous or not restricted then complete only the applicable portions in Part I and sign i date the Form at the bottom of page. Otherwise complete Part I, 11, and Ill, and sign/date the Form at the bottom of page. (For RCRA wastes,use Clean Harbors RCRA FORMS) GENERAL INFORMATION REGARDING GENERATOR&WASTE:STREAM DTE Stockton,LLC PHONE:_209-320-3712 SiTE_2526 West Washington Street Stockton,CA.95203 PROFILE NUMBER: jZHQ417638 IS THIS WASTE NON HAZARDOUS? X NO :-.YES (f YES,stop here and sigrdda to form at the bottom of page) GENERATOR'S EPA iD#: CALQ059102 MANIFEST#:a6L5tJ_ZeLa CA WASTE CODE(S): 571 IS THIS WASTE RESTRICTED? x YES NO(rf NO,stop here and sigrl/date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: R(A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE; -(B)GENERATOR KNOWLEDGE OF THE WASTE;OR (C)BOTH 3heck the appropriate boxes in Parts 11 and 111.If only one applies,then I II(A)is not required.For multiple certifications/notifications,the appropriate choices from Part 1(1-3)maybe marked in Part III(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions. 8y selecting an item in Part IIl(A),1-3,you are -laking the certification 1 notification noted in Part 11. 'I. TYPE OF 1_DR NOTIFICATION/CERTIFICATION D 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=>.22 CCR§66268.7(a)(1) X- 22 CCR§66268.7(a)(2) 1 certify underpenalty of law that l personally have examined and am familiar with the waste through analysis and testing th rough 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,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 6924(d)J.1 believe that the information/submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibilityofa fine or imprisonment. 3.>NOTIFICATION&CERTIFICATION: NDN-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO ' MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS,=>22 CCR 966268.7(b)(5) 1 certify underpanalty of law that/personally have examined and am familiar with the waste through analysis and testing through knowledge ' of the waste to support this certification,than the waste complies with the treatment standards specified in CCR Title 22,Division 4.5,Chapterr 18,A rtic/es 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 6924fdJ).1 believe that the information 1 submitted is true,accurate and complete.1 am aware that there are sig nificantpena/ties for submitting a false certification,including the possibility ofa fine or imprisonment III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 220CR Cheek IN (a) i0 (p) appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-m)and Treatment Standard (Part V) Effective Date Treatability Grouptsl W268.1OON)11.143 (From 22 CCR) 1. _ �1 2 .3 1126190 Aqueous wastes Containing metals 166268.29(a)&66268.imainji 1 66268.107 Table II CCW 3. -1 -2 3 518191 Auto shredderwaste t66268,291c)&66268.100(a011 2 66268,106 Table-A CCWE 3. 1 _2 :73 t1119T Hazardous waste foundry sand[66268.291el&66268.1Mall5)1 4 66266.106 Table 1-B CCWE 4.X -1 R2 - -3 111191 Fly ash,bottom ash,retort ash orbaghousewaste 166268.291h)&66268.100(a)(61i 7 66268.106 Table 1-0 CCWE 5.- -1 2 3 111P91 Baghou3ewaste from foundries[66268.29P&66268-100{91(9)1 8 66268.106 Table I-E CWE 6._. 1 --2 -3 3:1193 Asbestos containing waste idendrad in section 166268.29(m)&66268.1=a)11311 12 86268.114 7.- :'1 _2 73 Other(sppxifvl: 13 Copies of appfcable treatment standards and waste analysis data(where available)are maintained at the facility identified on the mandest referenced above. N. GENERATOR AUTHORIZATION/CERTIFICATION f 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 that no omissions or errors exist.I warrant that l am an authorized representative of the generator. Authorized S' alure Printed arne Tittle 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§66268.7 Rev.11102 Page_of