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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 1, II, and III, and sign/date the Form at the bottom of page GENLKAL INFOKMATIUN KLGAKUING GLNtKA I UK tk WAS I t GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE. 925-422-1925 SITE LOCATION Corral Hollow Road, Tracy, Ca 95376 PROFILE NUMBER DOP0104-1 IS THIS WASTE NON -HAZARDOUS ? ®NO, ❑ YES (if YES, stop here and sigrVdate form at the bottom of page) GENERATOR'S EPA ID#. CA2890090002 MANIFEST #. 00586548811K CA WASTE CODE(S) 181, 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 II and III If only one applies, then III(A) is not required For multiple certifications/notifications, the appropriate chotces from Part II (1.3) maybe marked in Part 111(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. TYPE OF LUR NUTIFIGATIUN / GLRTIFIGA ❑ 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: z_> 22 CCR §66268.7ta)(2) / 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)142 U.S.C. Section 6924(d)). f believe that the information If 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) If 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 alf applicable prohibitions set forth in CCR Title 2Z, Section 66268.32 or RCRA Section 30041d)(42 U.S.C. Section 6924(d))• I 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. 111 I MO atnTl Cll`A TIAAI I PCOTICIn ATlnal lel Cil OaaATln al t]CnIIICCn OV 77Pr`O Check appropriate boxes IA) Check 1,2, or 3 from handling Information (Part 11) lel Prohibition Effective Date IC) Subcategory of Restricted Waste 122 CCR 66268.29 a -m) and Treatabli ty Oroup4l 66268.1001e)11-14) tot Corresponding Treatment Standard (From 22 CCRI 1 ❑ Of 02 03 1/28/90 Aqueous wastes containing metals 160268 291a) & 66268 1001a)111) 1 66268 107 Table 11 CCW 2 ❑ ❑ f 02 03 518/91 Auto shredder waste 166268.291c) & 66268 100411311 2 66268 106 Table -A CCWE 3 ❑ 01 02 03 1/1/91 Hazardous waste foundry sand 186268 29(s) & 66268 100(a)(5)1 4 66268 106 Table 1 8 CCWE 4 ❑ 01 02 ❑3 111/91 Fly ash, bottom ash, retort ash or baghouse waste (66268.29(h) & 66258 lootafl8)) 7 66268 106 Table 1.0 CCWE 5. ❑ ❑1 02 ❑3 111/91 Baghouse waste from foundries 166268 29(0 & 66268 100(a)(9)1 8 66268 108 Table 1-E CWE 6 ❑ ❑i 02 03 1 311/93 1 Asbestos containing waste identified in section (66268 291m) & 66268 100(al(1311 12 66268 114 7 ❑ ❑i 02 ❑3 Other ISpecdy) 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 that no omissions r errors L i warrant that I am an authorized representative of the generator SCOTT A. GRAHAM Shipping Coordinator 06/06/13 Authoriz lgnature Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS AS PER 22 CCR 6§ 8268 7 Rev 11/02 "'� R C E IV ® Page 08 of 11 JUL .14 2014 ENVIRONMENTAL HEALTH is