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®VEOLIA LAND DISPOSAL NOTIFICATION AND CERTIFICATION FORM PHASE IV EWF,0hIMENTAI searimaS ) 1/ Page .f of/ Generator Name:/j7E.WCa LeLR6G S4C'iEmSEPA ID#eALLAPA89:303Manifest Tracking 1.It waste Is a Wastewater(see 40 CFR 268.2)place neat to the applicable code(s) Profile# 2.CODES WITH SUBCATEGORIES(place appropriate letter from section 8 before each code that applies)(See 40 CFR 268 for details) .._._Door HI-TOC _Does Lead acid batteries —K069 Not Calcium Sanwa _POeS LO RMERC Res. _Ut51 Hi Hg —pool Exerts HiTOC _ Code Organic Hg>2600jm _K071 Rmedc Res. ?065 Not I.IRMERC Res. _ UZ402,4 U D003 Reactive Clo no. _DW9lrwcg.Hg>260 _K071 Net Rm m Res. _AM Hi Ine1RME IC Res. _ 112402.4 esters A Sall% DD03 Readve Sulfide D009 Hg<260 KIM L0 Fnmm Has. _Po92 Lo lilt.Ras. -- -DD03 Explosive _Fen tight ends —KIM Not Rmerc Res. _P092 Lo RMERC Hes. —0.U3 Water Reareves FD25 Street get _K106>260 ppm Hg _P092 Not InURMERC Has. _DD03 Urcelp Ord.E:g _Kobe Hydrated _P047 Saks _P092 Hi h a',48AERC Res. DOW Other Resolves _K006 Anhydrous _ Fear Nosels _ U151 Le RMERC Res —0006 Beke4as _News Calcium swat. _P065 Le Inc.Rona. _U1SI Lo Not RMERC Res. The subcategory for D018-DO43 waste is treated in nonCWA+nonSDWA faclW Unless the following box is checked:❑'treated in CWA/SDWA facdiTf 3.COMMON CODES(Place appropriate letter from section 8 before each code that applies) _DOoo _PGI2 _P030 _ PMI _POSS _PIM _P205 _F006 _F007 FOM _F009 RID FOII F012 F019 _FIXi9 _DWI 0005 _ DDD6 D007 DOM _0009 0010 _0011 D012 _D013 _D014 _D015 _0016 —_0017 _DOt8 _DD19 _0020 _0021 —D022 —D023 _DON 0025 _DO% 0027 _0028 0('29 _0030 _0031 _Dp32 17033 _0034 0035 _0036 _0037 _0038 _0039 _0040 _Db41 _0042 _0043 _F001 _DM F003 F1104 _F6b5 =0002 _lgD3 _0006 _IAxr/ _11044 —UM _0072 _tX@0 _D1C8 _U117 _U122 _U123 .,,U136 „_U1S4 _U188 __U213 1220 U226 _1279 ADDITIONAL CODES(Enter an codes hot FdanlRied above which aro assxiatetl with waste) _KWt 4.USEPA HAZARDOUS WASTE 5.TREATMENT STANDARDS FOR NONPHASE II STATESINDICATE THE APPLICABLE S.HOW MUST THE WASTE BE CODECS) TREATMENT STANDARD 266.41,269.4308 SPECIFIED TECHNOLOGY BELOW} MANAGED?ENTER THE LETTER FROM BELOW To identity ROSS,or UHCs managed in nae-CWA,use Na'F039/Urdadyfr0 Hazardous CorolOuents Form'provided and check hare:0 It M UHC,she Preaem upon generation check here:0 Check here 8 disposal facility we check for 4 UHCS O(1.e.p UHC form required) To lend addRbnal EPA waste cereals),use the supplemenMl sheat and check how❑le Use of supplemental sheet you may use mundele copies of this font. 7.SOLVENT CONSTITUENTS(Foot-F005)Check We it dieposed tardily will chodt for a0 spend sai ants_ _ _AOMOra _Benzes _n-Buyl alcohol _Carbo,disuff. _Carbon Telrachbrae _Cnbmbenzane _O-Cresol Cresols(m8p) _Cydorwar. _a-0Ichlorobenzes _2-Ethasyomast Ethyl scalars _Ethyl bonzes _Ethyl other _orbbularol _Methanol _Mwhywrw chiwide Methyl ethyl ketone _Methyl isobutyl kolas ...__NiMbam. _24iiampmpane _Pyridine _Telre0hia0eMylep Tdsne 1,1,1 Tdchlaroelhane _1,1,2-TdchloroelMoe _1,1,246dlioro.1,2,2-tnfluapmma _Trichloroethylene _Trichemaonofluanmathane _Xylenes B. (States 8,11immed by EPA to mange Me MR Program may have regulatory rotational different from rite 40 CFR ceatfons now below.Where these,egWatory orations differ,your ow ifi alion wee be deaned to tele,10 those area,dmiions Imead d the 40 CFR dtatie e.) A.orJ RESTRICTED WASTE REQUIRES TREATMENT This waste must be,treated to the applkabte treatment standards sat form N 40 CFR Pan 26840. ❑ For Harwrlaos Debris:'This ha rredow&lids Is stroecl to the alternative treaanent standards or 40 GFR 269.45.' 8.1 RESTRICTED WASTE TREATMENT TO PERFORMANCE STANDARDS -1 teddy under penalty of law thin I have personally euantktad and am familiar with Me treatment technology and operation of he beatmen+process used la support we owidicati0n.Based on my mquiry of those in6viduals immediately maponside ler W,Wnir,IN¢intonation,I balieve that the treatment process has been opeaated And maintained property so as to tom ty with We misheard standards specified in 40 CFR 269.40 aiM l fmpamisoloe dludion or the prohibited wash.I am aware new there are significant pnal9os far suhndding a II ossification,fncludng ft Personality of a Tma am impisear"M' 8.2 (CERIIFICAM7N REMOVED BY PHASE 8.3 GOOD FAITH AND ANALYQCAL CERTIFICATION•FOR INCINERATED ORGANICS "1 rarely under penally of law that I have prsorelly examined and am laminar with the Vealmani torMlobgy and operation.lire 4ownrord process used to wi pen Itefs cedi5cailem Based en my Mq my of lhpe inedvidows'anmeQaley responsible for obtaining this Inlomafer,I beral that IM snwastewater organic cons01uen1a have been treated by combuatfon ones as spediietl h 269.42.Table 1.1 have been unable to detect the nonwasluwater organic constituents,despte having used best good faith efforts t,analyze for such constituents.l am aware that Ihare ere significant penakies for submitting a false certification,Including he pssbllity W en,act impnsonmenL^ BA DECHARACTEJiRE)WASTE REQUIRES TREATMENT FOR UNDERLYING HAZARDOUS CONSTITUENTS "1 candy under Penalty of Mw that the waste has Doan treated in secondaries with me requkeeents of 40 CFO 268.4010 remove the hazardous UMracn:islic.This decnametwil waste contains underling hazardces constituents that mqu4e further treatment to mead universal towthena standards.I am aware that there are significant penalties for sobmldhg a false oetincafion,including Mo pros ets iry 0Tena and indemonnant." O RESTRICTED WASTE SUBJECT TO A VARIANCE This waste I subject to a national capacity vuiwwo,a Ireaabllity variance,or a case-by-case oxem"n.Enter the¢elective date el pronibilion in column 5 above. D For hazodws debds:'fhis hazardous debris is subject to the akeffee,hualnaM standards of 40 CFR 263.45" D. RESTRICTED WASTE CAN BE LAND DISPOSED WITHOUT FURTHER TREATMENT 'I cediy under panaly of law that I have Personaey examined and am IamiGar with 1M waste Mrough aslyss and testing or through kswdedge of the waste la suppn Mie centhem,Mat the waste c"Pfes with me treatment standards spored In 40 CFR Pad 286 Subpart D.I believe that iha infor nsfion I submkled is IF .anowede and cwnplen.I am aware mel Mere are signlfxem nemeses Ira%Wmf ig a false CMificattin,IMlud'ay the pesstility 01 a time and Imprisonment.' E. WASTE NOT CURRENTLY SUBJECT TO PART 268 RESTRICTIONS This waste is a newly identified waste Mal is nM currently subject to airy 40 CPR Pan 268 zeslddrons. I Hereby caniy mal an i/nbFrmano�n h�Oil/s a�ct�+ eta menta is comped amenamels,b the banal of my knowledge act Inbrmenan. a Tired«y &gwCC _ Date�� GENERATOR COPY FORMavEs-tae i