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y9 C� vlean Harbors Environmental Services, Inc, California Land Disposal/Restriction Information Notification/Certification Form ; Fhis fors;is submitted in accordance with the requirements of 22 CCR 66268.7(a)Chapter 18 which restricts land 0spaial of certain hazardous wastes. The appropriate ;aliforria waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions of Part 1. Ifthe waste is non- 7azardous or not restricted then complete only the applicable portions in Part I and sign/date the Form at the bottorl of page. Otherwise complete Part i, ll;and Ili, and sig,,'date the Form at the bottom of page. (For RCRA wastes,use Clean Harbors RCRA FORMS) , GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM --P`E Stockton.LLC PHONE: 209-320-3712 SITE_2526 West Washington Street Stockton,CA.95203 E PROFILE NUMBER: CHQ41753B IS THIS WASTE NON HAZARDOUS? X NO ""YES (if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA iD#: CAL00069102 MANIFEST#:d M510 CA WASTE CORE(S): 571 _IS THIS WASTE RESTRICTED? x YES NO ff NO,stop here and sign/date form at the bottom of page) THIS COTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION; 9(I,) HEWCAUPHYS)CAL 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 certifications/notifications,the appropriate choices from Part 1(1-3)may 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 111(A), 1.3,you are a raking the certification/notification noted in Part 11, I. TYPE OF LDR NOTIFICATION 1 CERTIFICATION E1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=,22 CCR§66268.7(8)(1) X-- 22 CCR§66268.7{a)f2) I certify underpenalty of law that 1 personally have examined and am familiar with the waste through analysis and testing through knowledge 1. 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 I I and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)t42 U.S.0 Section 6924(d)).I believe that the information I submitted is true,accurate and complete.I am aware th��t there are significant penalties far 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 A5 TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=>22 CCR §66268.7(b)(5) /certify under penalty 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,A rticles 4 and l l and all applicable prohjbitions set forth in CCR Title 22,Section 66268.32 o r 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 thatthere are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. k3 III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (al (c) (D) apt ropr:ate Check 112,or 3from Corresponding l)UMO:S handling informatian Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-ml and Treatment Standard {part 8) Effective Date Treatability Groupie)66268.100(a)(1-141 {From 22 CCRi N 1.- -.1 "'2 3 1i26r90 Aqueous wastes containing metals[56268.29dai&66268.100{al{1i) 1 66268.707 TabEc II CCW 2. 1 2 .3 511191 Auto shredder waste 166268.29(c)&56268.100(ai(X] 2 66268.106 Table-A M E 3. 1 2 3 111191 Hazardous waste foundry sand f66258.29(e)&66268.100(a1(5)1 4 66268.106 Table 1-B CCWE 4.X 1 )t2 3 111191 Fly ash,bottom ash,retort ash or bughouse waste 166268.2Nh)&BQ68.190(ai!8!1 7 66268.106 Table I-a CME 5.: =1 2 :_3 1!1191 Baghouse waste from foundries[66268.26(1)&66266.100(a)(9ii 8 66266.106 Table I-E CWE 6. 1 _2 -3 MJ93 Asbestos containing waste identified in section I66268.291m)&662n6.3064a]f13;, 12 66258.114 7. 1 -2 -3 Other ISpeclfy}: 13 Codes of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above. N: GENERATOR AUTHORIZATIONICERTIFICATION I hereby certify that ail information submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information.and th2t,no omissions or errors exist.I warrant that I am an authorized representative of the generator. s ,l `� Af/rsr 19 Authorized S& ature Printed Mame Tltle Date THIS DOCUMENT, WITH AN ORfGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE REFA3NED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CCR§88268.7 Rev.11162 Page_of 9