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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 .vasle 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 II, and III, and signidate 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 Lawrence Livermore National Laboratory – Site 300 _ _ PHONE _.925-422-1925__ SITE LOCATION Corral Hollow Road Tracy. CA 95376 _ _ _ PROFILE NUMBER _DOP0104-1 IS THIS WASTE NON -HAZARDOUS ? ENO, DYES (if YES, stop here and sign/date 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? []YES LJNO (if NO, stop here and sign/date form at the bottom ofpage) i HIS NOTIFICATION 8 CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION n(A) CHEMICAUPHYSICAL ANALYSIS OF THE WASTE D (B) GENERATOR KNOWLEDGE OF THE WASTE: OR N(C) BOTH Check the appropriate boxes in Parts 11 and Ili If only one applies then III(A) is not required For multiple certification- unifications the appropr ale choices from Part l (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 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) rl 2. > NOTIFICATION S 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 1 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 I submitted is true, accurate and complete t am aware that there are significant penalties for submitting a false cerPrication, including the possibility of a line or imprisonment [] 3. > NOTIFICATION 8 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 spocirted 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)) 1 believe that the information 1 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 Ill. LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED t3Y 22CCR Check appropnato boxes IA) Check 1.2, or 3 from handling Information (pan 8) lel Prohibition Effective Date IC) Subcategory of Restricted Waste (22 CCR 66268 29 a -m) and Treatability Grouplc) 66268.100(aJ17-14) lo) Corresponding Treatment Standard (From 22 CCR) 66268 107 Table II CCW 1 ❑ 3 ❑ — ❑ 1 ❑ 1 – 02 02 ❑3 03 126!90 Aqueous wastes eontame7g metals KC268 29(a) E 66268 1000](1)1 1 51&91 Auto s7veddor waste P268 29(c) d 66268 100(o)(311 2 662268 106 Table -A CCWE ? ❑ 01 02 03 111m1 Hazardous waste foundry sand 16626829(c) 8 662681 00(&X 5)1 4 I 66268 106'rablu 1-a CCWE .1 ❑ ❑ i 02 07 711191 Fly ash bottom ash retort ash w baghouse waste 166266 29(h) 8 65269 100(a)(S)l eaghouse waste from laundries 166268 29p) 9 66266 100(aHg)1- -- – 7 8 66266 106 Table t 0 CCWE ❑ 1 02 –_- E13 111191 66268 106 Table I E CWE F'00 03 311193 Asbesioscontaulmgwaste,dentil.Mmsedron16626829im)666268100(o)(73)I 12 66266114 0 ❑; — ❑J 01he' (Speuly) 73 Copies of applicable Ireatrnt standards and waste analysis data (where available) are maintained at the facility Identified on the manifest referenced above IV. GEN AT RIZATIONiCERTIFICATION I here ertlfy that information submitted in this and sociated documents is true, complete, and accurate to the best of my knowledge and information, and that missions - rr 's exist I warrant that I a authorized representative of the generator Sean Garvey Shipping Coordinator February 26,, 2014 Aut rued Signature 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 ENVIRONMENTAL HEALTH DEPARTMENT