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Clean Harbors Environmental Services, inc. California Land Disposal/Restriction Information Notification/Certification Form 'his form is submitted in accordance with the requirements of 22 CCR 66268 7(2) Chapter 18 which restricts land disposal of certain hazardous wastes The appropriate California waste code(s) and applicable non-RCRA hazardous waste listings from CCR 66268 29 are noted below Complete all portions of Part I If the ,•raste is nonhazardous or not restricted then complete only the applicable portions in Part I and sign if date the Form at the bottom of page Otherwise complete Part 1 II. and III, and sign/date the Form at the bottom of page (For RCRA wastes, use Clean Harbors RCRA FORMS) i. GENERAL INFORMATION REGARDING GENERATOR & WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory - Site 300 _ _ PHONE. 925.422.1925 SITE LOCATION Corral Hollow Road. Tracy CA 95376 _ _ PROFILE NUMBER DOP0044-1_ IS THIS WASTE NON -HAZARDOUS ? ®NO, [)YES (if YES, slop here and signldate form at the bottom ofpage) GENERATOR'S EPA ID# CAD289 009 0002 _-__ MANIFEST q 005 870 090 JJK CA WASTE CODE(S) 181, 223, 1 IS THIS WASTE RESTRICTED? DYES ❑NO (if NO, stop here and sig/Udate form at ilia bottom ofpage) THIS NOTIFICATION & CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICAUPHYSICAL ANALYSIS OF THE WASTE, ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE, OR Check the appropriate boxes in Parts It and III If only one applies then III(A) is not required For multiple certifications/notifications. the appropriate choices from Part 11 (1-3) may be marked in Part III(A) to indicate how waste is to be managed to conform with Land Disposal Restrictions By selecting an Item 1n Part III(A) 1-3, you are making the certification / notification noted in Part 11 IL TYPE OF LDR NOTIFICATION /CERTIFICATION ®(C) BOTH — r1. > NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: 22 CCR §66268 7(a)(1) ❑ 2. > NOTIFICATION & CERTIFICATION: WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS, NO ADDITIONAL TREATMENT REQUIRED: ;. 22 CCR §66268 7(a)(2) I certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification, that the waste complies with the ireatment standards specified in CCR Title 22, Division 4 5 Chapter 18 Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22, Section 66268 32 or RCRA Section 3004(d)(42 U S C Section 6924(d)) 1 believe that the information i submitted is true accurate and complete 1 am aware that there are signdicant penalties for submitting a false cellrBcabon, including the possibility of a fine or imprisonment. ❑ 3. > NOTIFICATION & CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFFSITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS: = 22 CCR §66268.7(b)(5) I certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification that the waste complies with the treatment standards specified in CCR Title 22, Division 4.5. Chapter 18, Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22 Section 66268 32 or RCRA Section 3004(d)(42 U S C Section 6924(d)) i believe that the information I submitted is true. accurate and complete I am aware that there are significant penalties for submitting a false certibcation, including the possibility of a fine or imprisonment. — 111. LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED BY 22CCR Check appropaale boxes (A) (a) Check 1,2, or 3 from handling information Prohibition tc) Subcategory or Restncted Waste (22 CCR 66268 29 am) and (D) Corresponding �I Treatment Standard (Part II) Effective Dale Treatablhty Group(s) 66268 100(aX144) tFrom 22 CCR) ' 1 ❑ ❑ 1 02 ❑3 126190 AquDous wastes containing metals 166268 29(a) 8 66268 1000)(1)( 1 - -- - — 66268 lOr Tad" II CCW ❑ [If ❑2 03 518191 Auto shredder waste 166268 29(c) B GG268 11>D(aX3)1 2 88268 106 Table -A CCWE 3 ❑ ❑ 1 02 03 1nl91 Hazardous waste foundry sand 166268 29fo) 8 66_%8100(a)(5)I 4 66268 106Tab4c 1-6 CCWE a ❑ ❑ 1 02 03 111191 Fly ash boltum ash retort ash or baghaise waste 1662268 29(h) 8 66268 100(aXa)I 7 68268 106 Table I D CCWE > ❑ ❑ 1 ❑Z 03 Mist Baghouso waste from foundries )66268 29(1) 8 66268 I0(lia)(9)I 8 66268 106 Table I E CWE ❑ ❑ 1 02 03 311193 Asbestos caniainrtlg wdsia Teem rod o seom (66266 29(m) 866266 100(n)(13)I _ 12 66268 114 ❑ ❑ 1 02 03 Othcr ISpae;ly} 13 Copies of applicable treatment standards and waste analysts data (where available) are maintained at the facility Identified on the manifest referenced above GEN lfz, all ormation submitted in this and all associated documents is true, complete, and accurate to the best of my knowledge and information, and ns or r exist I warrant that I am an authorized representative of the generator __ / Sean G rye Shi in Coordinator _ February 26,201Q gnature Printed Name Title Date THIS DOCUMENT, WIi1N ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. -A COPY OF THIS CERTIFICATION AND ALL i AN SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS AS PER 22 CCR §66268 7 Rev 11102 Page 2 of 10 _ RECEIVED JUL 14 2014 ENVIRONMENTAL HEALTH DEPARTMENT