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dean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information Notification/Certification Farm Fhis for-1 is submitted in accordance with the requirements of 22 CCR66268.7(a)Chapter 16 which restricts land disposal of certain hazardous wastes. The appropriate :;alifotr a waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.C(nrtplete all portions of Part 1. If the waste is non- §y 7azardous or not restricted then complete only the applicable portions in Part l and sign/date the Form at the bottoms of page. Otherwise complete Part 1, ll,and III, and sigi;'date the Form at the bottom of page-(For RCRA wastes,use Clean Harbors RCRA FORMS) GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM EI DTE 5(gckton,LLC PHONE:_ 2p9-320 3712 SITE_2526 West Washington Street Stockton,CA.95203 PROFILE NUMBER: _CH641753B IS THIS WASTE NON HAZARDOUS? X NO =YES ' a(rf YES,stop here and sign/date form at the bottom of page} GENERATOR'S EPA ID#: CAL00359102 MANIFEST#: SSS CA WASTE CODE(S): 571_ _IS THIS WASTE RESTRICTED? x YES NO(fi NO,stop here and sign/date form at the bottom of page) THIS N DTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: se (A)CHEMiCAL/PHYSICAL ANALYSIS OF THE WASTE; -(B)GENERATOR KNOWLEDGE OF THE WASTE;OR (C)BOTH heck the appropriate boxes in Parts II and III.If only one applies,then IiI(A) is not required.For multiple certification:;/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. By selecting an item in Part III(A),1-3,you are making the certification I notification noted in Part 11. 1. TYPE OF LDR NOTIFICATION 1 CERTIFICATION 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT E T STANDARDS:=>22 CCR§66268.7(a)(1) a� X. ; -b:�:i->22 CCR§66268.7(a){2) /certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and testing th rough knowledge y 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 g 6924(d))•/believe that the information I submitted is true,accurate and complete./am aware tho t there are significant penalties for submitting a false certification,including the possibility of fine or imprisonment. w �I 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO A5 TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=:�22 CCR §66268.7(b)(5) i� 1 certify underpenaliy of law that I personally have 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 4.5, Chapter 18,Articles 4 and 71 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.lam aware thet there are significant penalties for submitting a false certification,including the passibility of a fine or imprisonment. Ili.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Checz (A) (B) (C) zl aprropr4te Check L2,or 3 from Corresponding I noses handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-fn)and Treatment standard (Part Lt Effective Date Treatability Group(s)66268.1f10fal(1.14) (From 22 CCR[ 2 _3 1126,8C Aqueous wastes containing metals 166258.29(a}&66268.100(a){111 1 66268.107 Table It CCPV ,z!, 2. .-.1 -'2 ..�3 58,91 Auto shredder waste 166268.29M&66268.100(aO)) 2 66268.106 Tab le-ACCWE : 3. 1 2 3 11v91 Hazardous waste ioundry sand€66268.29{e€&66268.100(a)f5)1 4 66268.106 Table 1-8 CC'NE 4.7 -1 Jd,2 _3 11191 Fly ash,bottom ash,retort ash or baghouse waste[66268.29111)&5G268.100(a;(8il 7 66268.106 Table I-D CME 5.- -1 -'2 -.3 111191 Baghouse waste from feundrios[66268.29(i)&66268.100{a MI 8 66268.106 Table I-E CNE 6.- 1 2 .3 3;1,'93 Asbestos containing waste identified In section[56268.29(m1&66268.1001a"13il 12 66268.174 - I 1 -2 -3 Other(Specify}: 13 Ccpies of applicable treatment standards and waste analysis data(where available)are maintained at the facility dentified on the manifest referenced above. IV. GENERATOR AUTHORIZATION/CERTIFICATION 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 that rici omissions or errors exist.I warrant that I am an authorized representative of the generator. ) Authorized S' ature Printed game Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL y SUPPORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CrR§56258.7 Rev.11102 Page_of ,a