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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 porbons of Part I. If the waste is non -hazardous or not restricted then complete only the applicable portions in Part I and sign I date the Format the bottom of page Otherwise complete Part 1 II, 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 Lawrence Liygrmore National Laboratory — Site 300 PHONE _ 925-422-192. _ SITE LOCATION..Corral H to low Road. Tracy. CA 95376 PROFILE NUMBER DOP0131-1 IS THIS WASTE NON -HAZARDOUS 7 ©NO, ❑YES (if YES, slop here and sigr✓date form at the bottom of page) GENERATOR'S EPA ID# CAD289 009 0002 _ MANIFEST # 008 870 090 JJK _ _ — CA WASTE CODE(S) 151 IS THIS WASTE RESTRICTED? DYES ©NO (if NO. stop here and sign/date form at the bottom of page) THIS NOTIFICATION & CERTIFICATION IS BASED ON TI IE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICALIPHYSICAL ANALYSIS OF THE WASTE, ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE, OR O(C) BOTH Check the appropriate boxes to Parts If and III If only one applies then 111(A) is not required For multiple cerliricationstnohrications 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 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 i CERTIFICATION (� 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: 0 22 CCR §66268 7(a)(1) j ❑ 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 Tide 22, Division 4 5. Chapter 18, Articles 4 and 11 and all applicable prohibitions set forth in CCR Tale 22, Section 66268 32 or RCRA Section 3004(d)(42 U S.0 Section 6924(d)) I believe that the information 1 submitted is true, accurate and complete I em aware that there are significant penalties for submitting a false certification. including the possibility of fine orimpnsonment ❑ 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: a 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 I 1 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)) 1 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 ICATION INFORMATION R Check appropriate boxes (A) Check 1,2, or 3 110 handling information (Part ll) IB) Prohibition Effective Data (C) Subcategory of Restricted Waste (22 CCR 66266.29 a m) and Treatability Groupie) 66266 100(a)(1.14) to) Corresponding Treatment Standard (From 22 CCR) ❑ ❑1 02 ❑3 1/26/90 Aqueous wasins conta;rxng malals 16626929(a) 9.66268 100(a)l1)1 1 66200 107 Toole II CCW 2 ❑ ❑ 1 02 03 5/8791 Auto stvedder wave 166268 29(c) & 66268 100(aj(3)1 Hazardous waste foundry sand 166788 29(c) & 66268100(aH5)I 2 4 66268 106 Taolo-A CCWE 86268 106 Taw 1-8 CCWE 3 ❑ ❑ 1 02 03 111/91 a ❑ ❑ 1 02 03 11151 Fly osh bottom ash retort ash or baghouse, waste 166268 29(h) & 66268 tt>a(eHe)1 7 66268 106 Table I D CCWE 5 ❑ ❑ 1 02 ❑3 11151 Bagtlouse waste from loundees (06266 2910 & 06266 100(aH9)1 6 66268 106 Table I -E CWE 6 ❑ Ell ❑2 ❑3 311193 Asbestos eontawvng wasle Klenitfied .n sockon 166 68 29(m) & 66268 100(axl!)1 -- 12 66266 11.1 ❑ 01 02 ❑3Othar(Specdy; -------13 — - Copses of applicable treatment standards . I and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above Ij IV TION/CERTIFICATION here certtiy t tall int(SeAist. �ahon submitted in This and all assoclat documents is true, complete, and accurate to the best of my knowledge and information, and that n omisso s or err I warrant that I am an autho_Limllfrepresentative of the generator -----V9 epn,. arve _ Shipping Coordinator February 26, 2014 LAuthb ed Signature Printed Name Title Date — THIS DOCUMENT WITH AN ORIGINAL MNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA MUST BE RETAINED BY THE GENERA TOR FOR A LEAST FIVE (5) YEARS AS PER 22 CCR §66268 7 Rev 11102 RECEIVED `""'3 JUL 14 2014 ENVIRONMENTAL HEALTH DEPARTMENT