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I-rtSUSTAI ABQL <br /> Land Disposal Restriction NotifiOa#ion <br /> enera#er Name- 99certsOrxlyoin EPA Number CALO003$9$=1, <br /> Gerierator Address- 1120>_-Hammer Lana St4od",CA <br /> Manifest Tracking Number: 013692126F1E <br /> Insfrtrcfions <br /> Column 1,LJU the M96kmt Line mjmber or rulanifest Brea Item. <br /> Column 2:Identify at1 Ll-S.EPA hazard:,us Wa ke COOe3 that apply to this shut. <br /> Column 3:Chasse the appropriate treatability group-Mora-Waste vaW(NVVW)or Wastemater(WVV)- <br /> Column 4:Enter the appFopnate Subcategacy(per 40 OFR 258.40),if appr abW and also enter"Cordaminated Seip or"Debris"f the waste will he <br /> treat-,d using one of the atternativemmTem tachnaragies provided by 268.49(c}�oil,or MA debris, <br /> Column&F-74e#the kftr of the apprq iate pu graph from bebw(seeAppwbft 7 fpr other options if nom) <br /> Column 0,For FgO1-FOM Diem enter ttte R6E9r xe Nurlt %s)k>uated below far the constituents m your waste stream subgeet to m t n". <br /> Column 7:Fee F039,D0014D043,Debris&Oontdminab d$oil;piease Gs#the Reference Numbars fisted:in Appondix 2 far any tlndertygng Haaafdous <br /> Ganstituenfs. <br /> Cheek One <br /> How rVust This Regulated UrKiartying Hazardous <br /> hhaniiest!-nte hJusitt-ier U-S.t=f'A Hazardous Sv�Cat�gory waste Be Gacrstlttle4lts consUvents <br /> for=1 X7043, <br /> or M�ifest Lme I VVeste Codes waa1 B7 For f001-FOO5 Debris or qiI <br /> r WN W N <br /> 1-101993 D0€19 Yes High Mercury A <br /> tnOr€�af31C <br /> Golumn 5 Wasto Managernent Godless <br /> A THIS RESTRFCTED WASTE REQUIRES TREATMENT TO THE APPLIOABLE STANDARD-This waste must be treated to <br /> the appkabte perfOfmr based treatment standard set forth ai 4DCM Part 268 Sint G,266.32,Subpart D,268.40 or <br /> RCFL4 Section 3DO4(d)prior t#land dlsposa <br /> Column 5 001-FO05 Reference Nurnftem <br /> Column 7 D001-DW Reference Numbers <br /> I hereby certify that aH i;r f ftnation subscribed at this and all asswc ated documents fs complete and amurats m the best of my knm6edga and <br /> irifgrnlati�n, <br /> Generator Signature: -� /�� �� DC7 Tide: Ile <br /> PrinteG Natte= "t ,JL,7 f <br />