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Clean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information Notification/Certification Form This form is submitted in accordance with the requirements of 22 CCR 66268,7(a) 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 waste is non -hazardous or not restricted then complete only the applicable portions in Part I and sign/ date the Format the bottom of page Otherwise complete Part 1 It. and III, and sign./date the Form at the bottom of page. (For RCRA wastes, use Clean Harbors RCRA FORMS) 1. GENERAL INFORMATION REGARDING GENERATOR & WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory —Site 300 _ _ PHONE- 925422_125 SSE LOCATION Corral Hollow Road. Tracy. CA 953, 76 PROFILE NUMBER DOP0054-1 IS THIS WASTE NON -HAZARDOUS ? ©NO, ❑YES (if YES, stop hen: and sigrildate font of the bo(tom of page) GENERATOR'S EPA ID# CAD289 009 0002 - _ MANIFEST # 005 870 090 JJK - _ _ CA WASTE CODE(S) 331 IS THIS WASTE RESTRICTED? ❑YES ®NO (if NO stop here and sigivdate form at the bottom ofpage) THIS NOTIFICATION 8 CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICAUPHYSICAL ANALYSIS OF THE WASTE: F) (B) GENERATOR KNOWLEDGE OF THE WASTE, OR ©(C) BOTH 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 in Part III(A), 1-3, you are making the certification / notification noted in Part II IL TYPE OF LDR NOTIFICATION / CERTIFICATION © 1. > 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 certity 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 tovith 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 We, accurate and complete 1 am aware that Stere are significant penalties for submitting a false certification, Including the passibility of fine or imprisonment i ❑ 3. > NOTIFICATION & CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS: 0 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 arid 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 tnie, accurate and complete I am aware that there are significant penalties for submitting a false certification, including the possibility of a fine or imprisonment Ill. LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED BY 22CCR )A) ---- Chock 1,2, or 3 from 19) (c) Corrospondng Check appropriate boxes handling Information Prohibition Subcategory of Restricted Waste (22 CCR 66268 29 a m) arid Treatment Standard (From 22 CCA) lean ill Effective Dale Troolabitity Groups) 66268 100(x)(1.14) Aclueo s wastes conlaovnif metals PG20 291a) a 062M 100(ax 111 1 66268 107 Table It CCW 110 Cl 1 112 ❑ 3 1 r2G190 2 Q --- _ - (311 [122 ❑3 518191 -- E Auto Ovedder wasia 166" 29(c) & 5USS 100(a)(3)I 2 66268 106 Tablo-A CCWE 3 ❑ ❑ I 02 ❑3 111091 Hazantnrs virile kx" sand 166268 29(e) & 66268 100(a)(S)t 4 66168 106 Table 1 e CCWE Fly ash bottom ash, retort ash or baghousa waste 166268 29(h) & 66268 100(a)(8)l 7 66258 106 Table I.0 CCWE a ❑ ❑ 1 02 03 111191 i 5 ❑ Eli ❑2 03 111M Doghouse wails from foundries 166266 29(,) & 66268 100(a)(9)l 8 66268 106 Table I E CWE ' ? ❑ F ❑ 1 ❑1 ❑3 311/93 Asbestos amlarxng waste idcnkbcd m seuion 166268 29(m) S 66268 100(a)(13)] 12 66268 114 -- ❑ 01 ❑2 03 Qum Ispeoly) 1� Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above ------- R. GEN—ATOR AUTHORIZATIONICERTIFICATION I hereb cell fy at all I rmatlon submitted In th s and all associated documents is true, complete, and accurate to the best of my knowledge and information, and that n _mis ns or cr exist I warrant ih am an authorized representative of the generator Sean Garvey Shipping Coordinator February 26. 2014 j uttlorized Signature Printed Name Title Date THIS DOCUMENT. WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION. SUPPORTING DATA MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS AS PER 22 CCR 9bUbb y mev iifuc RECEIVED Page 3 of 10 JUL 14 2014 ENVIRONMENTAL HEALTH DEPARTMENT