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California Land DisposaURestriction 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 / 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,alvrence Livermore National l.aborstory PHONE 925-422-1925 SITE LOCATION. Corral Hollow Road, Tracy, Ca 95376 PROFILE NUMBER DOP0032A-1 IS THIS WASTE NON -HAZARDOUS ? ®NO, ❑ YES (if YES, stop here and sign/date form at the bottom of page) GENERATORS EPA ID# _CA2890090002 MANIFEST # 005865488 JJK CA WASTE CODE(S) 181_ IS THIS WASTE RESTRICTED? ❑YES ®NO (if NO, stop here and sigrVdate form at file 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 II 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 ll. TYPE OF LDR NOTIFICATION f 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: a 22 CCR 466268.7(a)(2) l 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 30041d)(42 U.S.C. Section 6924(0). l 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 466268.7(b)(5) 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 ail applicable prohibitions set forth in CCR Title 22, Section 66268.32 or RCRA Section 3004(d)(42 U.S.C. Section 6924td)). I believe that the information 1 submitted is true, accurate and complete. I am aware that there are significant penalties for submitting a false certification, including the possibility of a r1ne or imprisonment. Ill. LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED BY 22CCR Check appropriate bones (Al Check 1,2, or 3 from handling information (Part III IBI Prohibition Effective Dale ICI Subcategory of Restricted Waste 122 CCR 66268 29 a m) and Treatability Gtoup(s) 65268.100(a)(1.14) (0) i Corresponding Treatment Standard (From 22 CCR) I ❑ ❑t 02 ❑3 1126190 Aqueous wastes containing metals 166268 291at & 66268.100(e)(1)) 1 66268 107 Table It CCW 2 ❑ ❑ 1 ❑2 ❑3 518/91 Auto shredder waste (66268 291cl & 66268 1001all311 2 66268 106 Table�A CCWE 3 ❑ 01 02 ❑3 1!1;91 Hazardous waste foundry sand 186288 291el & 66268 1001a)1511 4 68288 106 Table 1-8 CCWE 4 ❑ El ❑2 03 1/1/91 Fly ash, bottom ash, retort ash or baghouse waste 166268.291h1 & 66268 100(a)I811 7 66266 106 Table I D CCWE 5 ❑ 01 ❑2 ❑3 1/1191 Baghousa waste from foundries 166288 2914 & 66268 101 a 66268 106 Table I E CWE 6 ❑ ❑ 1 ❑2 ❑3 3/1/93 Asbestos containing waste Identified In section (66268.291ml & 66268 100(a)(13)1 12 1 66288 114 7 Cl 01 ❑2 03 Other (Specify) 13 Copies of applicable treatment standards and waste analysis data (where available) ate maintained at the facility identified on the manifest referenced above 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 erre exist I yvarrant that I am an authorized representative of the generator 00, SCOTT A. GRAHAM Shipping Coordinator 06/06/13 Auth SignaturePrinted Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANYO THIS CERTIFICATION, AND ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEASfFi1MVft1VC&QP 7 Rev 11/02 JUL 14 2014 ENVIRONMENTAL HEALTH DEPARTMENT Page 04 of 11