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Clean Harbors Environmental Services, Inc. California Land D)sposaVRestriction Info(mabon Notification/Certification Form This form is submitted In accordance with the requiremenls 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 Form at the bottom of page Otherwise complete Part 1 II, and III, and signidate 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 Nalional Laboratory - Site 300 __- PHONE 925-422.1925 SITE LOCATION Corral Hollow Road. Tracy. CA 55376 PROFILE NUMBER DOP0086-1 IS THIS WASTE NON -HAZARDOUS ? EINO, []YES (If YES stop here and sign1date form at the bottom of page) GENERATOR'S EPA ID# _CA0289 009 D002 _ _ MANIFEST # _00 870 090 JJK_ _ CA WASTE CODE(S) 331 IS THIS WASTE RESTRICTED? ❑YES NO (if NO, stop here and sigNdate form at the bottom orpage) THIS NOTIFICATION & CERTIFICATION IS BASED ON rHE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE. ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE, OR [0(C) BOTH Check the appropriate boxes in Parts 11 and III if only one applies, then Ilf(A) is rint reriutred Fnr multiple certifications/notficatlons the appropriate choices from Part II (1-3) maybe 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 cerbncalion t nobfication noted in Part II it. TYPE OF LDR NOTIFICATION / CERTIFICATION ❑X 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 penally 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(4)(42 U S C Section 6924(d)) I believe that the Information 1 submitted is true, accurate and complete 1 am aware that there are significant penalties for submitting a false certification including the possibility of a fine or impnsonment ❑ 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: 3� 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 Secha16924(d)) I believe that the 1 information l submitted is true accurate and complete i am aware that there are significant penalties for submitting a false certification including the jj possibility of a fine or imprisonment BY -- _ - Chock Check — ----- ------- (A) 181 (C) IDI Co,in"ridmg appropriate boxes Check 1.2, or 3Irani handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a m) and Treatment Standard �i (Part 11) Effective Date Trealabllily Group(s) 66268 00(a)(1-14) _ _ _ (From 22 CCR) t ❑ O 1 ❑2 _ 03 126190 Aqueous wastes eontwo g mewls 166268 20(a) 8 66268 100(a)( I)) 1 66268 107 Table II CCW ❑ ❑ 1 ❑2 ❑3 518791 Auto s)uedder waste 166268 29(c) & 66268 100(a)(3)1 _- _ 2 6626a 101. Tabla-A CCWE ❑ 1 02 n3 111191 _ Hazardous waste foundry sand 166268 29a) & 66268 100(a)(5)1 a 66268 106 Table l-8 CCWE 3 ❑ a ❑ ❑ f 02 03 111191 Fly ash bottom ash relort ash or baghouse waste (66268 29(h) 8 66266 100(a)(8)I 7 GG268 106 Table I D CCWE j =, ❑ Eli ❑2 ❑3 111191 Saghmm waste from ro%ndnm iss266 29(x) 8 66268 100(o)(9)I a 66268 106 Table I C CWC 6 ❑ ❑ 1 ❑2 03 3!1193 Asbestos conle ning woste .dunI&ad in section 166268 29(m) & 66268 100(ox 13)1 12 66268 114 -- ❑ Or 0 [332 3 Other (Specify) 13 Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest references aoove IV. GENERATOR AUTHORIZATIONICERTIFICATION 1 here certify at all I'rmation submitted in this and all associated documents is true, complete, and accurate to the best of my knowledge and information, and V that omtss ns or s exist I warrant that I am n authorized representative of the generator Sean Garvey ._ Shppinq ggordlnator February ed ignatire 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 §66268 7 Rev 11/02 RECEIVED Page _6 -_of -10 JUL 14 2014 ENVIVA()N aENTAL HEALTH DEpARTNIENT