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Clean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information Notification/Certification Form This form rs 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 nonhazardous or not restricted then complete only the applicable portions in Part I and sign/ date the Format the bottom of page Otherwise complete Part ,. 11. 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 Lawrer)ce Livgrmore National Laboratory —Site 300 PHONE 925 422 1925 SITE LOCATION Corral Hollow Road, Tracy CA 95376 _ PROFILE NUMBER DOP0087-1 IS THiS WASTE NON -HAZARDOUS ? ®NO, ❑YES (if YES stop here and stgnrdate form at the bottom of page) GENERATOR'S EPA ID#. CAU289 009 W02 MANIFEST # 005 670 090 JJK -- CA WASTE CODE(S) 181 IS THIS WASTE RESTRICTED? [)YES EINO (rf NO stop here and sign/date form at the bottom of page) THIS NOTIFICATION b CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICAL /PHYSICAL ANALYSIS OF THE WASTE. ❑ (8) GENERATOR KNOWLEDGE OF THE WASTE, OR Eg(C) BOTH Check the appropriate boxes in Parts II and III If only one applies then IIIA) is not required For—m- ultiple certifcations/nohfications 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 Reslrchons By selecting an item in Part III(A) 1-3, you are making the certification I notification noted in Part II II. TYPE OF LDR NOTIFICATION / CERTIFICATION 1. > NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: a 22 CCR §66268 7(a)(1) ❑ 2. > NOTIFICATION 8 CERTIFICATION: WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS, NO ADDITIONAL TREATMENT REQUIRED. . 22 CCR §66268 7(a)(2) / certify under penalty of law that I personally have examined and am famihar with the waste through analysis and testing through knowledge of time waste to support this certification, that the waste complies with the treatment standards spocified 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(0(42 U S C Section 6924(d)) I behave that the information I submitted Is true, accurate and complete I am aware that then; are significant penalties for submitting a false rerbfication including the possibility of a fine or impnsonmeni ❑ 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 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 Secbon 66268 32 or RCRA Section 3004(4)(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 signit-rant penalties for submitting a false certificalion including the possibility of a fine of imprisonment :A Check appropriate boxes t ❑ ❑ ❑ 1 ❑1 (A) Check 1.2. or 3 from handling information (Part 11) 02 03 02 03 (B) Prohibition EReclrve Data - --- — -- (C) Subcategory of Restricted Waste (22 CCR 66268.26 a -in) and Treetabillty Groupls) 66268 1001a)I I.14) Aqueous wastes containing metals 166266 29(a) 6 GG268 100(a)(1)1 Auio shredder waste M268 2%c) d 66258 100(a)(3)1 `t 2 (n) Corresponding Treatment Standard (From 22 CCR) G6268 107 Tobe It CCW 66258106 TableA CCWE 1126M `,lent 3 ❑ D 02 03 MIDI Ha2ardous waste faxxuy sand 166M 29(a) b 66268 100(aH5)l 4 66268 1061able I B CCWE 4 ❑ 01 02 03 111191 Fly ash bottom ash retort ash or baghouse waste 16626829(hl b 66268 IMORS)l — Baghouso uvslo koro foundries 166268 2911) s 65268 100(aHg11 _ 7 a 66268 106 Table I D CCWE 662E8 106 Table I E CWE ,1 5 ❑ 01 02 03 1!1191 6 ❑ 01 02 03 311193 Asbostos conimrwrg wasic demlioo m saceon (66268 29(m) 6 6626A 100(aH 1319 12 86258 114 `- i ❑ 01 — _ ❑2 ❑3 Omer (Spmfyi 13 Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above IV I hereb certify eTT formation submitted In this and all a _laced documents is true. complete and accurate to the best of my knowledge and information, and that n m �, ms or ors exist I warrant that I am a orized representative of the generator _ Sean Garvey Shippna Coordinator February 26.. 2014 utho a ignature Printed Name Title Date THIS DOCUMENT, WITH AN ORIGI SIGNATURE MUST ACCOMPANY EACH WASTE SHIPMENT A COPY OF THIS CER'f1FICATION AND ALL SUPPORTING DATA. MUST BE RETA 'ED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS AS PER 22 CCR §66268 7 Rev 11102 Page 7 of 10 RECEIVED JUL 14 2014 ENVIRONMENTAL HEALTH DEPARTMENT