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Califoillra 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 Califomia 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, II, and III, and sign/date the Form at the bottom of page I. GENEKAL INI-UKMAI IUN KLUAKUING UtNtKAI UK a arra 1 c a 1 r%CAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE 925422-1925 SITE LOCATION Corral Ii0110w Road,.Tracy, Ce 95376 PROFILE NUMBER DOP0028-1 IS THIS WASTE NON -HAZARDOUS ? ®NO, ❑ YES (if YES, stop hen; and sigrVdate form at the bottom of page) GENERATOR'S EPA ID# CA2890090002 MANIFEST #. 005865488 JJK CA WASTE CODE(S) 223, IS THIS WASTE RESTRICTED? OYES ®NO (d NO, stop here and sigrl/date form at the bottom of page) THIS NOTIFICATION & CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICAUPHYSICAL ANALYSIS OF THE WASTE, ❑ (13) GENERATOR KNOWLEDGE OF THE WASTE. OR ❑(C) BOTH Check the appropriate boxes In Parts iI and III If only one applies, then III(A) Is not requlreG rot mualple cenmcauvnsJnuuuLatwl w, 1110 CL FJI VF I CIG .I ..w ' a,. II (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 L.DR NOTIFICATION I CERTIFICATION ❑ 1. > 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: _-D 22 CCR §6626B.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(d)(42 U. S.C. Section 6924(d)). / believe that the information l submitted is true, accurate and complete. l 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/ 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)(42 U.S.C. Section 6924(d)). / believe that the information / submitted is true, accurate and complete. / am aware that there are significant penalties for submitting a false certification, including the possibility of a fine or imprisonment. u r nC-i—AY10- IAIcr1RAd A-rinM OEQI IIRED RV 29CCR !if. LLJM IMV I111%,M I!V I vcn I lr la,r•rrv.� v,.,�.�..�...,�.�.... 181 Prohibition Enectlee Date .�� ... ____.. ICI Subcategory of Restricted Waal* 122 CCR 66268.29 a ml and Treatability Group(sl 66268 100121(l.14) - IDI Corresponding TreattmmennttStandard ard IFrom 22 CCRI Chock appropriate boxes JAI Check 1,2, or 3 from handling Information (Part II) 1 Cl ❑1 02 ❑3 1126190 Aqueous wastes containing metals (66268 29(a) & 66268 1001a)(1)1 1 56268 107 Table II CCW 2 ❑ 01 ❑2 ❑3 518191 Auto shredder waste 166268 2910 & 86268 1001all3l) 2 66268 108 Table A CCWE 3 ❑ ❑1 02 03 1/1191 Hazardous waste foundry sand (66268 291e1 & 65266 1DOW1511 4 88268 106 Table 1 e CCWE 4 ❑ 01 02 03 111191 Fly ash, bottom ash, retort ash or baghouse waste 166268 291h1 & 56268 100(a1I8l) 7 66268 106 Table I D CCWE 5 ❑ ❑1 ❑2 ❑3 111/91 flaghouse waste from foundries 188288 2801 & 66268 loola)(9)) 8 86268 106 Table I -E CWE 6 ❑ ❑l ❑2 ❑3 311193 Asbestos containing waste identified in section (66268 291ml & 66266 1D0iel(1311 12 66268 114 7 [1❑1 ❑2 ❑3 Other ISpecify) 13 Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above n - IV. GENERATOR AUTHORIZATION/CERTiFICATION 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 sexist I warrant that i am an authorized representative of the generator SCOTT A GRAHAM Shippine Coordinator 06/06/13 Authorized Signature Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY IP A PY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST S Rev. 11102 Page 02 of 11 JUL .14 2014 ENVIRONMENTAL HEALTH DEPARTMENT