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lean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information Notification/Certification Form Fhisfor-1 is submitted in accordance with the requirements of 22 CCR 66268.7(a)Chapter 18 which restricts land dispo:;al of certain hazardous wastes. The appropriate 'alifomA waste code(s)and applicable non-RCRA hazardous waste list[ngs from CCR 66268.29 are noted below.Cumpiete all portions of Part 1. If the waste is non- lazardaus or not restricted then complete only the applicable portions in Part I and sign/date the Format the bottonf of page. Otherwise complete Part I, II, and III, and signAate the Form at the bottom of page-(For RCRA wastes,use Clean Harbors RCRA FORMS) GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM 1 >i D"rE S'(ockton.LLC PHONE:-_209-320-3712 SITE_2526 West Washington Street Stockton,CA.95203 PROPII.E NUMBER: CH$4175313 IS THIS WASTE NON HAZARDOUS? X NO --YES ¢' (if YES,stop here and sigrVdate form at the bottom of page) :^ GENERATORS EPA ID#: CAL00 59102 MANIFEST#py1S8tpydFe6 CA WASTE CODE(S): 571-1S THIS WASTE RESTRICTED? x YES NO(if NO,stop here and sigrt/date form at the bottom of page) e TH13 NOTIFICATION&CERTIRCATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: R(A)CHEMiCALIPHYSICAL ANALYSIS OF THE WASTE; -(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ['(C)BOTH heck theappropriate boxes in Parts II and 111.if only one lies,then IIIA is not required.For multiple certifications/notifications,the Y applies, ( ) • eq p appropriate choices from Part 1(1-3)rnay be 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 Taking the certification i notification noted in Part 11. 1. TYPE OF LDR NOTIFICATION 1 CERTIFICATION 11 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=>22 CCR§66268.7(a)(1) %s X- [ 22 CCR §66268.7(a)(2) ; I certify underpenalty of law that I personaliyhave 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 treatmentstandards specified in CCR Title 22,Division 4.5, Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR irtle 22,Section 66268.32 or RCRA Section 3004(d)/42 U.S.C. Section 6924(d)),I belie ve that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO a MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=>22 CCR §66268.7(b)(5) I certify under penalty of law that 1 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 rifle 22,Division 4.5, Chapter 78,Articles 4 and 17 and all applicable prohibitions set forth in CCR Title 22,Section 66269.32 or RCRA Section 3004(d)142 U.S.C. Section 6924(d)).I believe that the information/submitted is true,accurate and complete./am aware that there are significant penalties for submitting a false cernfrcation,including the possibility of a fine or imprisonment. III•LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) Is) (cl (ole appropriate Check 1,1,or 3 from Corresponding hoze!; handling information Prohb(tion Subcategory of Restricted Waste(22 CCA 66268.25 a-nI and Treatment Standard (Part 0) Effective Date Treatabi8ty Group(sl 66268.10019)(1-141 (From 22 CCR) 1.". 1 :2 3 112&90 Aqueous wastes containing metals 166268.291a)&66268.100(8)[1)( t 66268.107 Table II CCW - j 2. .1 :2 3 5111191 Auto shrodderwaste[66268.2%c}&66268.100(aV3)[ 2 66268.106Tahle-A CC45E 3. -1 2 3 VV91 Hazardous waste foundry sand[66268.2%el&66266.100(81(5)1 4 66268.106 Table 1-R CONN 4.X 1 )(2 3 1+1191 Fly ash,bottom ash,retort ash or bagliouse waste(66268.29('0&66268.1Wia;jl8)] 7 66268.106 Table I-D CC44E 5. .1 _2 _3 I1,1191 Baghousewaste from foundries[66258.29111&66268.100(aR9i1 8 66268.106 Table I-E CWE w 1 _3 _3 311193 Asbestos contalning waste Aanbfiedin sec¢en[56266.29(m)&662#'AADO1a'1131 12 66268,714 . 7 Copes of app -2 -3 Other(Specify}: 13 7 licable treatment standards and waste analysis data(where available) are maintained at the facility identified on the manifest referenced above. pa IV. GENERATOR AUTHORIZATIONICERTIFICATION rt reby 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 :no omissions or errors exist.4 warrant that I am an authorized representative of the generator.imorized S" ature Printed game Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE RETA)NED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CGR§66268.7 Rev.11,02 Page of 'i �G �a