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Califorri,. Land DisposaIlRestriction 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 waste is non -hazardous or not restricted then complete only the applicable portions in Part I and sign I date the Form at the bottom of page. Otherwise complete Part I, ll, and ill, and sign/date the Form at the bottom of page. I. GENERAL NG GENERATOR & WASTE GENERATOR'S NAME Lawrence Livermore Nationel Laboratory PHONE: 9254122-1925 SITE LOCATION: Corral Hollow Road Tracy Ca 95376 PROFILE NUMBER DOP0010-1 IS THIS WASTE NON -HAZARDOUS 7 RNO, ❑ YES (if YES, stop here and signidate form at the bottom of page) GENERATOR'S EPA ID#. CA2890090002 MANIFEST* 00586.5488 JJK CA WASTE CODE(S): 222, 134, 343_ IS THIS WASTE RESTRICTED? []YES ONO (f NO, stop here and sigrVdate form at the bottom of page) THIS NOTIFICATION & CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A) CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE; ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE, OR [I (C) BOTH Check the appropriate boxes in Parts II and iIi It only one applies, Nen m(A) IS not mqulrea. rur mulupiB iociumAuvrlonlvu11-1-1o, — wFF • F " ^• , - 11 (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 ❑ i.> 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: z.�> 22 CCR 566268.7(a)(2) 1 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(d)142 U.S.C, Section 6924(d)), I 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. ❑ 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 l 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 77t/e 22, Section 66268.32 or RCRA Section 3004fd)(42 U.S.C. Section 6924(dJ). l believe that the information / 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. n wTlnal 1e1ErlOaaATlr't1U OCf11 IIQEiI RV iii�rrl Ill. LDR 1401 IrICA 11UN r VER I IMes I MN n 411) Prohibition Effective Date ICI Subcategory of Restricted Waste 122 CCR 66268.29 ii -m) and Treatability Groupisl 68268.100(91(1-14) ID) Corresponding g tan Treattment t Stan (From 22 CCRI Check appropriate bones IA) Check 1,2, or 3 from handling Information (Part III 1 ❑ ❑ 1 ❑2 ❑3 1126190 Aqueous wastes containing metals 168268 29(a) & 66268 1001a11111 1 66268.107 Table 11 CCW 2 ❑ El ❑2 ❑3 518!91 Auto shredder waste 166268.29(c) & 66268.100(a11311 2 66268.108 Table A CCWE 3 ❑ 01 02 03 1/1/91 Hazardous waste foundry sand 166288.29101 & 66288 100(a)(5)1 4 66268.106 Table 1-8 CCWE 4 ❑ ❑t ❑2 ❑3 Ill/9/ Fly ash, bottom ash, retort ash or beghouse waste 166268 291h1 & 66288 100(al(811 7 66268.108 Table 1-0 CCWE 5 ❑ ❑1 ❑2 ❑3 111/91 Baphouse waste from foundries 166268. Mil & 66268 100(e119)) 8 66268 106 Table I CWE 6 ❑ ❑1 ❑2 ❑3 311193 Asbestos containing waste identified In section 166268 291m( & 66268 100101(13)1 12 66268 114 7 ❑ ❑1 02 ❑3 Other (Specify) 13 Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above IV. GENERATOR I hereby certify that all information submitted in this and all associated documents is true, complete, and accurate to the best of my knowledge and information, and that no omissions or errors eltisl I warrant that I am an authorized representative of the generator Signature Printed Name THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY E SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST Title JUL .14 2014 ENVIRONMENTAL HEALTH NVIRONMETALHEALTH DEPARTMENT Date CERTIFICATION, AND ALL Rev. 11/02 Page 01 of 11