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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 1 If the r,asle 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 I. If. and III, and sign/date the Form at the bottom of page (For RCRA wastes, use Clean Harbors RCRA FORMS) 1. GENERAL INFORMATION REGARDING GENERATOR & WASTE STREAM I) GENERATORS NAME Lawrence Livermore National Laboratoiy_-Site 300PHONE 925-422-1925 SITE LOCATION Corral Hollow Road. Tracy, CA 95376 PROFILE NUMBER SJ95-2554 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 # 0056 g 090 JJK _ CA WASTE CODE(S) 181 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 THE FOLLOWING WASTE STREAM INFORMATION D(A) CHEMICAUPHYSICAL ANALYSIS OF THE WASTE; D (B) GENERATOR KNOWLEDGE OF THE WASTE, OR ED (C) BOTH Check the appropriate boxes in Parts II and IIi If only one applies then III(A) is not required For multiple certrficationslnoltfications the appropriate choices from Part !1 (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 / not,ficahon noted in Part 11 11 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 & 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 familiar with the waste through analysis and testing through knowledge of the waste to support this certification, that the waste complies with the trealment standards specified to 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 I 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 OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS: , 22 CCR §66268 7(b)(5) 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 certcation, that the waste complies with the treatment standards specified in CCR Title 22 Division 4 5, Chapter 18, Articles 4 and I 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(4)) I believe that the information I submitted is true, accurate and complete I ain awaie that there are significant penalties for submitting a false certification including the possibility of a fine or impnsonment ED Chock nppropriate boxes (A) Chack 1,2, of 3 from handling Information (Part 8) (a) Prohibition Effective Date IC) subcategory of Restricted Wuste 122 CCR 66268 29 a m) and 1 Treatability Groupls) 66268 100(a)(1-141) to) Corresponding Treatment Standard IFrom22 CCRI 66268 107 Table II CCY/ 1 ❑ ❑ 1 02 ❑S 1/26190 Aqueous wastes containing metals IG6268 29(a) & 615268 1Mail l 11 1 ❑ ❑ 1 112 03 5!8191 Auto stlredder waste (6626a 29(c) 6 68268 100(8X3)) 2 hazardous walla foundry sand 16525829(e) 8 66268 100(a)(S)l 4 66268 106 Table A CCWE Il .i Cl ❑ 1 -- 02 03 111191 66268 1W Table 1-9 CCWE ! 0 1 07 03 1/1191 Fly ash bottom ash retort ash or baghwse wnste (6626a 29(h) &68266 1ng(aNe)J 7 6628 106 Table 1-0 CCWE : 5 ❑ ❑ 1 02 03 ❑ 1 02 03 111191 -- 311193 6agnouse waste from laundries 166268 29(1) & 66268 100(a)(9)l 6 66268 106 Tablr )�E CWE G ❑ Asbestos cents no ng waste identified in swoon t6G26829(m) It 66-1.68 100(eX 13)1 12 66268 114 ❑ 01 - ❑2 03 We((Specly) tl 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, cerLfy that info ion submitted in this and all as ted documents is true, complete, and accurate to the best of my knowledge and Information, and that n om ssions err ex t I warrant that I am an onzed representative of the generator Sean Garvey -- — Shipping Coordinator February 26.. 2014 inn ivo 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 §66266 7 Rev 11102 RECEIVED Page i O .of 10 JUL 14 2014 ENVIRONMENTAL HEALTH DEPARTMENT