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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 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, Il, and 111, and sigNdate the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR & WASTE STREAM GENERATOR'S NAME Lawrence LiyermoreNational Laburatory PHONE 925422-1925 SITE LOCATION (corral Hollo" Road, Tracy, Ca 95376 PROFILE NUMBER. DOP0046-1 IS THIS WASTE NON -HAZARDOUS ? ®NO. ❑ YES (if YES, stop here and sigri/date form at the bottom ofpage) GENERATOR'S EPA ID# CA2890090002 MANIFEST # 005865488 JJK CA WASTE CODE(S) 512_ IS THIS WASTE RESTRICTED? ❑YES ®NO (if N0, stop here and sign1date 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 II and III If only one applies, then III(A) is not required For multiple certifications/notifications, the appropriate choices trom Part 11 (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 Rem in Part III(A). 1-3, you are making the certification / notification noted in Part 11 11. TYPE OF LDR NOTIFICATION / CERTIFICATION II❑ 1.> NDARDSATII 22 CCR ONLY: WASTE6268 S1THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT ❑ 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 /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. l am aware that there are significant penalties for submitting a false certification, including the possibibry of a fine or imprisonment. ❑0 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) 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 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. tIi f nR Nr)TIFicATInN I CFRTIFICATION INFORMATION REQUIRED BY 22CCR Check appropriate boxes (A) Check 1,2. or 3 from handling Information Wait II) IBI Prohibition Effective Date (Cl Subcatogory of Restricted Waste 122 CCR 66268.29 a -ml and Treatability Oroup(el 66258 10813)(1.14) to) Corresponding Treatment Standard (From 22 CCRI 1 ❑ ❑1 ❑2 ❑3 1126190 Aqueous wastes containng metals 166288 29(0) & 56268 100(a)(11) 1 11 107 Teblo 11 CCW 2 ❑ ❑i ❑2 113 518191 Auto shredder waste (88288.2910 & 66268 10013113)1 2 66268 106 Table -A CCWE 3 ❑ 01 02 ❑3 1/1191 Hazardous waste foundry sand 166268 29(al & 66268 100(0)(5)1 4 66268 106 Table 1 B CCWE 4 ❑ ❑1 ❑2 03 1/1191 Ry ash, bottom ash, retort ash or baghouse waste 166288 29Ih1 & 66288 100(a)(811 7 66268 106 Tab'e 1 0 CCWE 5 ❑ Eli ❑2 ❑3 1/1191 Bagh;use waste from foundries 166268 291) & 65268 100(01911 8 86268 106 Table I E CWE 6 ❑ 0 02 ❑3 311193 As bos tos contain]ng we sic Identified In section (88268 29(m) & 66208 100Wf 13)) 12 1 66268 113 7 ❑ 01 ❑2 ❑3 Othe, ISpecifyl 13 Copses of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above FV. GENERATOR AUTHORIZATiONXERTiFICATION 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 a ors st I warrant that I am an authorized representative of the generator I SC TT A. GRAHANI Shipping Coordinator 06/06/13 Auth Signature Printed Name Title Date THIS DOCUMENT, WiTH AN ORIGINAL SIGNATURE, MUST ACCOMPANY tE THIS CtRiII—IGAIIUN, ANU ALL SUPPORTING DATA MUST BE RETAINED BY THE GENERATOR FOR A LEAST� lMr%tV 68 Rev 11/02 Page 06 of 11 JUL 14 2014 ENVIRONMENTAL WEALTH [1ERARTMENT