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Land Disposal Restriction Page : 1 of 1 <br /> CIewnHarbor3 Notification Form <br /> ® Printed Date :Jun 30, 2020 <br /> ENVIRONMENTAL SERVICES <br /> MANIFEST INFORMATION <br /> Generator: CCSF-PUC Tesla Treatment Facility Manifest Tracking Info. <br /> Address: 9000 West Vernalis Road 014552504FLE <br /> Tracy,CA 95377 I <br /> EPA ID#: CAR 0 0 0 2 8 5 9 3 2 Sales Order No: 2003310780 <br /> TI---------------------------------------------------------------------------'------------------------------------------------------------- <br /> LINE ITEM INFORMATION <br /> LineItem:-----r----e No:---------i -------------------r--------------'F6G---------------------------------------------------------- <br /> Line Item: ;Page No: ;Profile No: ;Treatability Group: ; LDR Disposal Category <br /> -----------------r-------------------r-------------------T---------------_-_--_-------------- <br /> ------7------�--:_-------_--_--______________________--. <br /> 1. ;1 ;CH434055 ;NON-WASTEWATER ;2 (This is subject to LDR.) <br /> - ---------------- -------------------L-------------------L-------------------------------J------------------------------------------------• <br /> EPA Waste Code ; EPA Waste SubCategory <br /> ------------------------------------------------------------------------------------------------------------------------------------------- <br /> D001 Ignitables,except High TOC Liquids <br /> D002 Corrosive Characteristic <br /> -----------------------------------------------L----------------------------------------------------------- <br /> LINE ITEM INFORMATION <br /> LineItem:-----r----eNo:---------r-------------------r--------------------------------1:TUl ---------------------------------------- <br /> Line Item: ;Page No: ;Profile No: ;Treatability Group: ; LDR Disposal Category <br /> ---------------T-------------------r-------------------r-------------------------------;---- ----p------------ ----p ------------------------- -------------;1 ;CH349223 ;NON-WASTEWATER ; 11 Lab ack Alternate Standard <br /> - -----------------------------------L-------------------L-------------------------------J------------------------------------------------• <br /> EPA Waste Code EPA Waste SubCategory <br /> ------------------------------------------------------------------------------------------------------------------------------------------- <br /> D002 Corrosive Characteristic <br /> D004 Toxicity Characteristic for Arsenic <br /> --------------------------------------------------------------------------------L-------------------------------------- -• <br /> Certification Applies to <br /> Manifest Line <br /> Items <br /> ----------------- ---------------------------------------------------------------------------------------------------------------------- <br /> Pursuant to 40 CFR 268.7(a), I hereby notify that this shipment contains waste restricted under 40 CFR 1. <br /> Part 268. I <br /> --------------------------------------------------------------------------=--------------------------------------------t----------------- <br /> This Iabpack is subject to the treatment standards specified in 40 CFR 268 Subpart D. I certify under :2. <br /> penalty of law that I personally have examined and am familiar with the waste and that the lab pack ; <br /> contains only wastes that have not been excluded under appendix IV to 40 CFR part 268 and that this lab <br /> pack will be sent to a combustion facility in compliance with the alternative treatment standards for lab F__________________. <br /> packs at 40 CFR 268.42(c). I am aware that there are significant penalties for submitting a false <br /> certification, including the possibility of fine or imprisonment. <br /> ----------------------------------- ------ ----------------------------------------------------------------------------------------------- <br /> Waste analysis data, where ilabl , is attac . <br /> Signature : _____ ______ _________- Print Name v�mbP_�_✓_ , i_v_\=L•CZ <br /> Title : lr�- _ _Ql— ,Y_________ Date ��� ,J2C) <br /> --------------------------------------------------------------------------------------------------------------------------------------------- <br />