COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

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 .vaste is non -hazardous or not restricted then complete only the applicable portions in Part I and sign / date the Form at the bottom of page Otherwise complete Part 1 II. and III, and sign/dale the Form at the bottom of page. (For RCRA wastes, use Clean Harbors RCRA FORMS) n. VCIyCKAL IrirummA I IV 1V KCbAKU11111.3 UCfVtKA I UK & INA) I t J I KtAM GENERATOR'S NAME Lawrence Livermore National Laboratory -Site 300 PHONE 9254122-1925 SITE LOCATION- Corral Hollow Road. Tracy, CA 95376 PROFILE NUMBER: DOP0080-1 IS THIS WASTE NONHAZARDOUS ? ENO, El YES (if YES, stop here and sigrWate form at the bottom of page) GENERATOR'S EPA ID# _ CAD289 009 0002 _, MANIFEST # 005 870 090.JJK CA WASTE CODE(S). 223 IS THIS WASTE RESTRICTED? DYES ENO (if NO. stop here and sigrvdate form at the bottom of page) THIS NOTIFICATION t±, CERTIFICATION IS BASED ON TFIE FOLLOWING WASTE STREAM INFORMATION: ❑(A) CHEMICAUPHYSICAL ANALYSIS OF THE WASTE, ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE. OR E(C) BOTH Check the appropriate boxes in Parts 11 and III If only one applies then III(A) is not required For multiple cenirfcations/not 5cations 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 se ecting an Item in Part III(A), 1-3. you are making the certification I notification noted in Part 11 11. TYPE OF LDR NOTIFICATION / CERTIFICATION ❑X 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: -j 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 7iHe 22, Division 4.5, Chapter 18, Articles 4 and 11 and all appkcable prohibitions set forth in CCR Title 22, Section 66268 32 or RCRA Section 3004(d)(42 U.S. C. Section 6924(co). 1 befieve that the I information 1 submitted is true. accurate and complete i am aware that there are significant penalties for submitting a false certification, includ)ng the I possibility of a fine or imprisonment IV. GENERATOR AUTHORIZATION/CERTIFICATION I hereb cert hat el ' ormation submitted in this prid all associated documents is true, complete, and accurate to the hest of my knowledge and information, and that t on dons or mors exist I warrant that I an authorized representative of the generator Sean Garvey Shioping Coordinator February 28. 2014 ignatura Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL 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 6268 7 Rev 11/02 hECL.IVED Page 5 of 10 JUL .14 2014 ENVIRONMENTAL HEALTH IJEPARTMENT ❑ 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) it i certify under penalty of law that / personally have examined and am familiar with the waste through analysis and testing through knowledge of the j waste to support this certircation, that the waste complies with the treatment standards specified in CCR title 22, Division 4 5, Chapter 18, Articles 4 and I i and all applicable prohibitions set forth in CCR Tittle 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 I am aware that there are significant penalties for submitting a false certificalia), including the possibility of a rine or imprisonment IIIA. LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED BY 22CCR Iappropriala , (wars Check 1,2, or 3 from handling Information Prohibition Subcategory of Restricted Waste (22 CCR 66268 29 a m) and Corresponding Treatment Standard (Part 11) Effective Date Treatability Group(s) 66268.100(aX i.14) (From 22 CCR) 1 ❑ O 1 O2 03 11266 Aqueous wastes coniarnrq metals 166268 29(a) 8 66268 100(aK 1)) 1 Auto shedder waste 186268 29(c) d 66268 100(a)(3)1 — -- 2 Hazardous waste foundry sand 166268 29(o) E 66266 700(69511 — 4 68768 107 Table it CCW 0 01 02 03 516191 662W 106TaWo-A CCWE 3 0 O 1 02 03 111191 66266 106 Table t B CCWE a 0 01 02 03 1n191 Fly ash boeam ash retort ash or bagtauso waste 166268 29(h) 6 66268 100(a)(8)l 7 66266 106 Tabie I D CCWE s O 01 02 03 111191 Bagtwtge westo from (aundnes IG6268 29f0 a G62a'8 100(aX9)1 6 68768 106 Table I F LWE 01 02 03 31193 Asbestos contanev2 woae identified in sodron (66268 29(m) 8 66258 100(6)(13)1 12 66268 1 M r 0 01 02 03 1 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 hereb cert hat el ' ormation submitted in this prid all associated documents is true, complete, and accurate to the hest of my knowledge and information, and that t on dons or mors exist I warrant that I an authorized representative of the generator Sean Garvey Shioping Coordinator February 28. 2014 ignatura Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL 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 6268 7 Rev 11/02 hECL.IVED Page 5 of 10 JUL .14 2014 ENVIRONMENTAL HEALTH IJEPARTMENT