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Clean Harbors Environmental Services, Inc. California Land Disposal/Restriction Informabon 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 11, and Ili, and sign/date the Format 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 DOP0065-1 IS THIS WASTE NON -HAZARDOUS ? ONO ❑YES (if YES. stop here and sign/date form of the bottom of page) GENERATOR'S EPA ID#. CAD289 009 0002 MANIFEST # 005 870 D90 JJK_ _ _ CA WASTE CODES) 181, IS THIS WASTE RESTRICTED? ❑YES ElNO (if NO, stop here and sign/date form at the bottom of page) THIS NOTIFICATION & CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE, OR ©(C) BOTH one applies, then III(A) is not required For multiple certifications/notifications, the II (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 Iil(A). 1-3, you are making the certification / notification noted in Part II It. TYPE OF LDR NOTIFICATION / CERTIFICATION Cj 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 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 I 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 certification, including the possibility of a fine or imprisonment ❑ 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: , 22 CCR §66268 7(b)(5) I certify under penalty of law that / 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 certification, including the possibility of a fine or imprisonment III LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED BY 22CCR IV GENERATOR AUTHORIZATION/CERTIFICATION I heretr defy 'm submitted submitted in this and all elated documents is true, complete. and accurate to the best of my knowledge and information, and that n mis . ns or s exist I warrant that I am uthorized representative of the generator 1 Sean Garvey hi i Coordinator ebruary 26, 2014 ____ uth ed Slgnatu a Printed Name Title Dale THIS DOCUMENT, WITH AN OfiI I L SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT A COPY OF THIS CERTIFICATION. AND ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS AS PER 22 CCR §66268 7 Rev 11102 Page 4 of 10 RECEIVED JUL .14 2014 ENVIRONMENTAL HEALTH DEPARTMENT ---'--- ---- ii Chock (A) (Q)--- IC) IDi Corresponding appropriate boxes Check 1. 2, or 3 from handling Information Prohibition Subcategory of Restricted Waste (22 CCR 66268 29 o -m) and Treatment Standard (Pan 11) Effective Data Treatability Group(s) 66268.100(ag1 14) Aqueous wasles comanmg maials 168268 29(a) 8 66268 100(9)(1)I 1 (From 22 CCR) 1 ❑ ❑1 ❑2 ❑3 11`16K30 _ - 60268107 Table II CCW ❑ ❑ 1 02 03 518191 Auto shredder waste 166268 29(c) & 66268 10D(a;(3)1 2 66268 106 Table.A CCWE 3 ❑ ❑ 1 02 03 111191 Hazardous waste foundry sand 166268'.'%*) 9 66268 1oo(ax5)1 4 66266 108 Table 1.6 CCWE t 130 1 02 [13 111191 Fly ash bottom ash rebut rill or baghouse waste I6it268 29(h) & 61`1268 100(a)18)) 7 68268 106 Table I -D CCWE Mist 66268 106 Table t -E CWE 5 O 01 02 ❑3 Daghouse waste from foundries 166268 290 & 66M 100(a)(9)l 8 r, ❑ 01 02 ❑3 311193 Asbestos conlonng waste dmified in sea on 156.158 29(rn) & 66268 100(a)(13)1 12 66268 114 11 ❑t ❑2 03 other (Specify) 13 Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above IV GENERATOR AUTHORIZATION/CERTIFICATION I heretr defy 'm submitted submitted in this and all elated documents is true, complete. and accurate to the best of my knowledge and information, and that n mis . ns or s exist I warrant that I am uthorized representative of the generator 1 Sean Garvey hi i Coordinator ebruary 26, 2014 ____ uth ed Slgnatu a Printed Name Title Dale THIS DOCUMENT, WITH AN OfiI I L SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT A COPY OF THIS CERTIFICATION. AND ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS AS PER 22 CCR §66268 7 Rev 11102 Page 4 of 10 RECEIVED JUL .14 2014 ENVIRONMENTAL HEALTH DEPARTMENT