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<br />',lean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information
<br /> Notification/Certification Form
<br /> his fora 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
<br />;alifomia waste Code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete ap portions of Part 1. If the waste is non- u
<br /> azardoas cr not restricted then complete only the applicable portions in Part I and sign/date the Form at the bottom of page. Otherwise complete Part 1, ll, and Ill,
<br /> nd sigr:'date the Form at the bottom of page. (For RCRAwastes,use Clean Harbors RCRA FORMS)
<br /> GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM 5
<br /> 0':E Stockton,LLC PHONE:,209-320-3712 SITE_2526 West Washington Street Stockton,CA.95203
<br /> PROFILE NUMBER: CH641753B IS THIS WASTE NON HAZARDOUS? X NO YES M'
<br /> i
<br /> (if Y:S, stop here and sigrt/date form at the bottom of page)
<br /> GENERATOR'S EPA ID#: -CALQ035RIQ2 MANIFEST#:Ggajy f92& CAWASTE GODE(S): 571_ _IS THIS WASTE RESTRICTED? x YES y
<br /> NO 'ff NO,stop here and sign/date form at the bottom of page) k
<br /> THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: -
<br /> R(A)GHEMICALIPHYSICAL ANALYSIS OF THE WASTE; -(B)GENERATOR KNOWLEDGE OF THE WASTE;OR (C)BOTH
<br />;heck tie appropriate boxes in Parts II and III.If only one applies,then I11(A) is not required.For multiple certifications/notifications,the appropriate choices from Part
<br /> 1(1-3)maybe 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/notification noted in Part 11.
<br /> I. TYPE OF LDR NOTIFICATION/CERTIFICATION
<br /> E.
<br /> C� 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT '
<br /> STANDARDS:�>22 CCR§68268.7(a)(1) �
<br /> X -PO> ; 22 CCR§66268.7(al(2)
<br /> 1 certify under penalty of law that 1 personally ha ve examined and am familiar with the waste through analysis and testing through knowledge
<br /> n
<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 66268.32 or RCRA Section 3004(d)J42 U.S.C. Section
<br /> 69241d)).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-SITE TREATMENT FACILITY SO AS TO _
<br /> MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS.=>22 CCR §66268.7(b)(5)
<br /> I certify under penalty of law that 1 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 /> 78,Articles 4 and 71 and all applicable prohibitions set forth in CCR 77tle 22,Section 66268.32 or RCRA Section 3004(d)142 V.SC. Section
<br /> 69240))./believe that the information I submitted is true,accurate and complete./am aware thst there are significant penalties for submitting v
<br /> a false certification,including the possibility of fine or imprisonment.
<br /> Ill.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR
<br /> Check IN (B) (Cl in) ik
<br /> apF rope-ate. Check 1,2,or 3 from Corresponding
<br /> hoxe:; handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-n)and Treatment Standard
<br /> (Part 1111 Effective Date Treatability Groupts)66268.1 W1ali1-14) (from 22 CCRI
<br /> 1, 1 2 3 1,26190 Aqueous wastes containing metals 166268.29(a)&66268.1DOW(1l) 1 66268.507 Table 11 CCW
<br /> 2. - -.1 -2 .2 518)91 Auto shredderwasts166268.29(cl&6626&160(a)(311 2 66268.106 Tahle-A CO E
<br /> a'a
<br /> 3. 1 '_2 .3 Hazardous waste foundry sand?66268.2$e)&66266.130(at15)) 4 66268.166 Table 1-E CCrrE )i
<br /> )
<br /> 4.x -1 X2 :3 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29ihi&6s268.100fa)!8)11 7 86268.166 Table I-D CG".E
<br /> 5-- ::'1 -2 -3 Vial( BaghauseWaste from foundries i66268.29(i)&66268.100(a)f9)i 8 66266-106 Table I-E CWE
<br /> 6.-_ -.1 2 -.-3 3i1193 Asbestos containing waste identified in section i66268.29(ml&662i0.1wQ al,'13)l 12 65258,114
<br /> 7- 1 -2 -3 Other[Specify;: 13 '
<br /> s
<br /> Ceples of applicable treatment standards and waste analysis data(where available)are maintained atthe facility dentified on the manifest referenced above.
<br /> N- GENERATOR AUTHORIZATIONICERTIFICATION
<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 no omissions or errors east.I warrant that l am an authorized representative of the generator.
<br /> A:thorized S' ature Printed game Title Date
<br /> THIS DO,'UMENT, 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,,fl2 Page_of
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