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LDR NOTIFICATION FORM Generator Name Lawrence Livermore /National Laboratory Site 300 Manifest No. 005 870 090 JJK Pursuant to 40 CFR '268.7(x), 1 hereby notify that this shipment contains waste restricted under 40 CFR Part 268 Land Disposal i qfmn� (L61110 A. GENERAL WASTE NOTIFICATION7REt ill tv Form Line No. CH Profile No, EPA Waste CodesWaste & LDR Subcategories (if any) List codes or use Attachment 1 MVW WW Constituent Notification Check the "None" box or 1 p List Legend Constituent # or ttsJU 4,1,2U1 D002 1 DOP001-1 ❑ ❑ ENVIRONMENTAL ❑ Check if Attachment I has been used ® None ❑ Check if Attachm D008, DOl 1 2 DOP0036-1 ❑ ❑ Check if Attachment 1 has been used 0 None ❑ Check if Attachment 2 has been used D008 3 DOP0048-1 ® ❑ ❑ Check if Attachment I has been used (D None ❑ Check if Attachment 2 has been used D001 LQ, F003, F005 4 DOP0054A-1 ❑ ❑ ❑ Check if Attachment I has been used ® None ❑ Check if Attachment 2 has been used D008 5 DOP0077-1 ❑ ❑ ❑ Check if Attachment 1 has been used ® None ❑ Check if Attachment 2 has been used DOI i 6 DOP0096A-1 ® ❑ ❑ Check if Attachmdnt I has been used ® None ❑ Check if Attachment 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION ® This hazardous debris, as identified above on Line NOW. 2 is subject to the alternative treatment standards of 40 CFR §268.45. The waste contains the following contaminants subject to treatment (check all that apply). ® Toxicity characteristic debris ❑ Debris contaminated with listed waste ❑ Cyanide reactive debris C. CONTAMINATED SOIL NOTIFICATION & CERTIFICATION ❑ This contaminated soil, as identified above on Line No(s). is subject to the alternative treatment standards of 40 CFR §268.49(c). Complete the following: "I certify under penalty of law that I personally have examined this contaminated soil & it [[]does/ []does not] contain listed hazardous N%asw & [❑docs I ❑docs not) exhibit a characteiisuc of hazardous caste & [Elis subjed to / ❑complies witli) soil treatment standards as provided by §268.49(c) or the universal treatment standards". Nae. Constituents subject to treatment are any constituents listed in 40 CFR §268.48 Universal Treatment Standards that are reasonably expected to be present in any given volume of contaminated soil, except fluoride, selenium, sulfides, vanadium & zinc, & are present at concentrations greater than ten times the universal treatment standard. D. LAB PACK (INCINERATION) NOTIFICATION & CERTIFICATION ❑ This lab pack, as identified above on Line No(s). is subject to the alternative treatment standards of 40 CFR §268.42(c). "I certify under penally of law that I personally have examined & am familiar with the waste & that the lab pack contains only wastes that have not been excluded under Appendix IV to 40 CFR Pan 268 & that this lab pack will be sent to a combustion facility in compliance with the alternative treatment standards for lab packs at 40 CFR §268.42(c). I am aware that there are significant penalties for submitting a false certification, including the possibility of fine or imprisonment". E. EXTENSIONS & VARIANCES ❑ This waste, as identified above on Line No(s). is not prohibited from land disposal & is subject to a deadline extension or variance, e.g., treatability variance, case-by-case extension. Describe below any extension or variance that applies to this waste & include applicable dates: Sean Garvey, Shipping Coordinator 02 _2 2014 Generator's Authorized Signal Name &Title (Printed or Typed) Date DWALI:ER Lq NOTIFICATION II 2199 / / ED iEALTH