COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

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 Cafrfomia 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 / 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. GENERAL INFORMATION REGARDING GENERATOR & WASTE STREAM GENERATOR'S NAME I.awrence Livermore National Laboratory PHONE _925422-1925 SITE LOCATION Corral Itollow Road, Tracy, Ca 95376 PROFILE NUMBER DOP0029-1 IS THIS WASTE NON -HAZARDOUS ? ®NO, ❑ YES (if YES, stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID# CA2890090002 MANIFEST # 005865488 JJK CA WASTE CODE(S) 223_ IS THIS WASTE RESTRICTED? ❑YES ®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 ❑(A) CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE, ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE, OR ❑(C) BOTH Check the appropriate boxes in Parts 11 and III if only one applies, then III(A) is not required For multiple certifications/notifications, the appropriate choices from Part 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 / notification noted in Part II 11. 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) 11 ❑ 2. > NOTIFICATION & CERTIFICATION: WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS, NO ADDITIONAL TREATMENT REQUIRED: _> 22 CCR §66268.7(a)(2) l 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 Title 22, Section 66268.32 or RCRA Section 3004fd)f42 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. ❑ 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) l 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 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)). l believe that the information / 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 imprisonment. III I nR NOTIFICATION / CERTIFICATION INFORMATION REUUMEU I3Y ZZ(;L:R Cheek appropriato boxes (A) Check 1,2, or 3 (Yom handling information (Part II) fill Prohibition Effective Date IC) Subcategory of Restricted Waste (22 CCR 66268.29 a ml and Treatability Group(s) 66268.1001a)(1-14) IDI Corresponding Treatment Standard /From 22 CCAI 1 ❑ ❑1 0 ❑3 1/26/90 Aqueous wastes containing metals (66268 29(a) & 66268 1001o)ll)1 1 66268 107 Table n CCW 2 ❑ El 02 ❑3 5!8191 Auto shreddor waste 186288 29(c) & 66268 10018)(3)) 2 68268.108 Table A CCWE 3 ❑ ❑l ❑2 03 1/1/91 Hazardous waste foundry sand 168268 29(e) & 66268 1001a)1511 4 e626a 106 Table 1-8 CCWE 4 ❑ 01 D ❑3 1/1191 Fly ash, bottom ash, retort ash or baghouse waste 166268.29(hl & 66260 1001a)(8)1 7 66268 106 Table 1-0 CCWE 5 ❑ 01 ❑2 ❑3 1/1/91 Baghouse waste from foundries 166268 29(1) & 68268 100iel(911 8 66266 106 Table I -E CWE 6 ❑ 0 ❑2 03 3/1193 Asbestos containing waste identified in section 166268.29(mi & 66288 1QO;a!(13)1 12 66268 114 7 ❑ ❑ 1 112 ❑3 other Ispecily). 13 Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above N. GENERATOR AUTHURIZAIIUN/UtRIIFIUAIIUN 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 exist I warrant that I am an authorized representative of the generator SCOTT A. GRAIIAM ShippinLy Coordinator 06/06/13 Aut rized Signature Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY H 51 Stilt'MtN I . A I:UYT Ur I rIIJ t�tK 6t-il,A l lUN. ANU ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A ffLEAS �7 Rev 11/02 Page 03 of 11 JUL .14 2014 ENVIRONMENTAL HEALTH DEPARTMENT