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California Land DisposaVRestriction 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 ate 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 Format 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_ Lawrence Livermore_N.ational Lahoratin PHONE 925422-1925 SITE LOCATION Corral Hollow Road, Tracy, Ca 95376. PROFILE NUMBER DOP0080-1 IS THIS WASTE NON -HAZARDOUS ? ®NO ❑ YES (if YES, stop here and signldate form at the bottom of page) GENERATOR'S EPA ID# CA2890090002 -_ MANIFEST # 005865488 JJK CA WASTE CODE(S) 221_ IS THIS WASTE RESTRICTED) ❑YES ®NO (d NO, stop here and sign1date form at the bottom of page) THIS NOTIFICATION & CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICALJPHYSICAL ANALYSIS OF THE WASTE, ❑ (B) GENERATOR KNOWLEDGE OF THE WASTE, OR ❑(C) BOTH Check the appropnate 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 t notification noted in Part II It. 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) ❑ 2. > NOTIFICATION & CERTIFICATION: WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS, NO ADDITIONAL TREATMENT REQUIRED: ? 22 CCR §66268.7(a)121 1 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 30041d)(42 U.S C. Section 6924(d)1. I believe that the information l 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 Anowledge 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)f42 U.S. C. Section 69241d11. l believe that the information I 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 III. LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED BY 22CCR _ Check IAI IBI ICI IDI appropriate Chock 1,2, or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a ml and Treatment Standard (Part III Effective Date TrealablGly Grouplsl 66268.100(a)(1.14) (From 22 CCRI 1 ❑ 01 02 ❑3 1126190 Aqueous wastes conta.n ng metals 166268 291al & 66268 1001a1(111 1 66268 107 Table II CCW i — 2 ❑ El ❑2 ❑3 5'8'91 Auto shredder waste 166268 291c1 & 66268 100Iall311 2 66268 106 Table A CCWE 3 ❑ 01 ❑2 03 111191 Hazardous waste foundry sand 166268 291o1 & 66268 100(a)(511 4 66268 106 Table 1 B CCWE 4 ❑ ❑1 02 03 1/1!91 Fly ash, bottom ash, retort ash or baghouse waste 166268 291h) & 68268 1D0Ia11811 7 66268 106 Table I D CCWE 5 ❑ 01 02 ❑3 1/1191 Baghouse waste from foundries [66268 29n! & 66268 1001a11911 8 66268 106 Table I E CWE 6 ❑ i ❑1 02 ❑3 311,93 1 Asbestos containing waste idenuhed in section 168268 29(m) & 68268 1001all1311 12 66268 114 7 ❑ ❑I ❑2 ❑3 Other(Speafyl 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 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 ithat no omissions or errqvs exist I warrant that I am an authorized representable of the generator _ SCOTT A. GRAHAM _ Shiprint=_ Coordinator 06/06/13 Auth d Signature Printed Name Tir-al Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY TETHIS CERTIFICATION, AND ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAS FI P R 8 7 Rev 11/02 J U L .14 2014 Page 07 of 11 ENVIRONMENTAL HEALTH DEPARTMENT