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Land Disposal Notification and Certification Form (Cont.) <br /> Constituents of Concern (For F001 - F005 EPA Waste Codes Only) <br /> 9b.1/9b.2/9b.3/9b.4 Constituent 9b.1/9b.2/9b.3/9b.4 Constituent 9b.1/9b.2/9b.3 19b.4 Constituent <br /> Acetone __--C+clohexanone _---Nitrobenzene <br /> T Benzene _ -Dichlombenzene _---Pyridine <br /> n-Butyl Alcohol _---Ethyl Acetate ----Tetrachloroethylene <br /> Carbon Tetrachloride _--_Ethyl Benzene ----Toluene <br /> CarbonDisulride _---Ethyl Ether ---- 1,10-Trichloroethane <br /> Chlorobenzene _---IsobW Alcohol ---_1,1,2-Trichloroethane <br /> Cresol Mixed Isomers _--_Methanol ---1,1,2-TriGiloro-1,2,2-Tdfluoroethane <br /> Cresol,p-isomers ----Methylene Chloride _---Trichloroethylene <br /> Cresol,m-isomers _---Methyl Ethyl Ketone _---Trichloromonofluoromethane <br /> o-Cresol _--_Methyl Isobutyl Ketone -_--Xylenes(Total) <br /> Underlying Waste Constituents for Characteristics Wastes <br /> (From 40 CFR 268.48, not applicable for Lab Packs) <br /> 9b.1 <br /> 9b.2 <br /> 9b.3 <br /> 9b.4 <br /> Certifications <br /> 9b.1 9b.2 9b.3 9b.4 Waste Does Not Meet Applicable Treatment Standards <br /> C� F-1 F--j F-� Waste does not meet applicable treatment standards in 40 CFR 268.40 or exceeds applicable prohibition <br /> levels of 40 CFR 268.32 or RCRA Section 3004(d). <br /> Waste or Contaminated Soil Meets Treatment Standard At Original Point of Generation <br /> I certify under penalty of law that I personally have examined and am familiar with the waste through <br /> ❑ ❑ ❑ analysis and testing or through knowledge of the waste to support this certification that the waste complies <br /> ❑ <br /> with the treatment standards specified in 40 CFR part 268 subpart D and in CCR,Title 22, Division 4.5, <br /> Chapter 18,Article 4. 1 believe that the information I submitted is true,accurate,and complete. I am <br /> aware that there are significant penalties for submitting a false certification,including the possibility of a <br /> fine and imprisonment. <br /> Contaminated Soils Certification (Mark appriopriate answers in certification statement.) <br /> I certify under penalty of law that I personally have examined this contaminated soil and it[DOES/DOES <br /> 0 F'� F NOT]contain listed hazardous waste and[DOES/DOES NOT]exhibit a characteristic of hazardous waste <br /> and requires treatment to meet the soil treatment standards as provided by 40 CFR 268.49(c)and CCR <br /> Title 22§66268.49(c). <br /> Lab Pack Alternate Treatment Standard Certification <br /> I certify under penalty of law that I personally have examined and am familiar with the waste and the lab <br /> ❑ E] F-1 E] pack contains only wastes that have not been excluded under appendix IV to 40 CFR part 268 and that <br /> this lab pack will be sent to a combustion facility in compliance with the alternative treatment standards for <br /> lab 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 /> I hereby certify that all informa'on suppli d is complete and accurate to the best of my knowledge and information. <br /> Signature: <br /> Printed Name: 70-a w 5'7 fa 0 <br /> Title: Date: —7 ' a 6 — 21 <br />