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Callfonua Land Disposal/Restriction Information
<br />Notification/Certification Form
<br />This form is submitted In accordance with the requirements of 22 CCR 66268 7(a) Chapter 18 which reslr cts land disposal of certain hazardous wastes The
<br />appropriate California waste code(s) and applicable non RCRA hazardous waste IlsUngs from CCR 66268 29 are noted below Complete all portions of Part I If the
<br />waste is non -hazardous or not restricted then complete only the applicable portions in Part I and sign f date the Form at the bottom of page Otherwise complete Part
<br />1 II, and III, and sign/date the Form at the bottom of page
<br />I. tsCNCKAL INhUKMAIIVN KtUHKUINU UEIVtKAlUK4 WAJIC JIKCHM
<br />GENERATOR'S NAME Lawrence I.Jivermorc National Laboratory - PHONE 925-422-1925
<br />SITE LOCATION Corral llollow Road, Trac, Ca 95376 PROFILE NUMBER DOP0120-1
<br />IS THIS WASTE N0/1 -HAZARDOUS ? MNO, ❑ YES (if YES, stop here and sign/date form at the bottom ofpage)
<br />GENERATOR'S EPA ID# - C12890090002 MANIFEST # - 005865488 JJ i. CA WASTE CODE(S) 741, 331, 181, 141, 541, 281, 221
<br />IS THIS WASTE RESTRICTED? ®YES ❑NO (!f NO, stop here and slgn/date form at the bottom c,f page)
<br />THIS NOTIFICATION & CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION
<br />❑(A) CHEMICALIPHYSICAL ANALYSIS OF THE WASTE, M (B) GENERATOR KNOWLEDGE OF THE WASTE, OR ❑(C) BOTH
<br />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
<br />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 item in Part III(A) 1-3 you
<br />are making the certification f notification noted in Part II
<br />IL TYPE OF LDR NOTIFICATION / CERTIFICATION
<br />❑ 1. > NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT
<br />STANDARDS: a 22 CCR §66268 7(a)(1)
<br />IN
<br />2. > NOTIFICATION & CERTIFICATION: WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS, NO ADDITIONAL
<br />TREATMENT REQUIRED:.: 22 CCR 466268 7(a)(2)
<br />l certify under penalty of law that l personafly have examined and am familiar with the waste through analysis and testing through knowledge of
<br />the waste to support this certification, that the waste complies with the treatment standards specified in CCR Title 22, Division 4.5, Chapter 18,
<br />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
<br />69240). l believe that the information I submitted is true, accurate and complete. I am aware that there are significant penalties for submitting a
<br />false certification, including the possibility of a fine or imprisonment
<br />3. > NOTIFICATION & CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO
<br />MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS::;, 22 CCR §66268.7(b)(5)
<br />l certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing through knowledge of
<br />the waste to support this certification, that the waste complies with the treatment standards specified in CCR Title 22, Division 4.5, Chapter 18,
<br />Articles 4 and 11 and al/ applicable prohibitions set forth In CCR Title 22, Section 66268.32 or RCRA Section 3004(d)(42 U. S C Section
<br />6924(d)l. / be/leve that the information / submitted is true, accurate and complete. 1 am aware that there are significant penalties for submitting a
<br />false certification, including the possibility of a fine or imprisonment.
<br />111. LDR NOTIFICATION / CERTIFICATION INFORMATION REQUIRED BY 22CCR
<br />IV. GENERATOR AUTHORIZATION/CERTIFICATION _
<br />I hereby certify that all information sibmitted in this and all associated documents is true, complete, and accurate to the best of my knowledge and information, and
<br />that no omissions ore ors exist I warrant that I am an authorized representative of the generator
<br />_ SCOTT A. GRAHAM _ _ Shipping Coordinator 06/06/13
<br />A, ; rued Signature Printed Name Title Date
<br />THIS DOCUMENT. WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMEN i A CUHY VI- I HIS I:EK l WIUA I JUN, ANU ALL
<br />SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS A� 2 Rev 11/02
<br />FtF, , EPage 09 of 11
<br />ja 14 2014
<br />ENVI;ONMENTAL HEALTH
<br />.�a..r.rtn.1-�TAA� nM -T
<br />Check
<br />(Al
<br />lel
<br />(Cl
<br />(D)
<br />appropriate
<br />Check 1,2, at 3 from
<br />Conosponding
<br />boxes
<br />handling Information
<br />Prohibition
<br />Subcategory of Restricted Waste 122 CCR 66288.29 a•ml and
<br />Troatment Standard
<br />(Part 11)
<br />❑1 ❑2 ❑3
<br />Effective Date
<br />Treatability Oroupisl 66268.1001a111 141
<br />if rom 22 CCR!
<br />1 ❑
<br />1126/90
<br />Aqueous wastes containing metals 166268.29(a) & 66268 1001a111)) 1
<br />66268 107 Table it CCW
<br />i 2 ❑
<br />❑1 ❑2 03
<br />518191
<br />Auto shredder waste 166268 29(c1 & 6026B 1000011 2
<br />66268 106 Table A CCWE
<br />3 ❑
<br />El ❑2 ❑3
<br />111191
<br />Hazardous waste foundry sand (66268 29(e) & 66268 10001150 4
<br />66268 106 Table I B CCwE
<br />4 ❑
<br />❑ 1 ❑2 03
<br />01/91
<br />Fry ash, bottom ash, retort ash or baghcuse v.asio 166268 29Ihi & 66268 100(al( i1 7
<br />66268 106 Table 1.0 CCWE
<br />5 ❑
<br />❑ 1 ❑2 ❑3
<br />1/1191
<br />Baghouse wasto from foundries 166268 2910 & 66268 1001a)(91! 6
<br />66268 106 Table tE CWE
<br />6 ❑ 01 ❑2 ❑3 311193 Asbestos containing viaste Identified in section 166268 29(m) & 66268 101 /2 68268 114
<br />7 ❑ 0 ❑2 ❑3 at Specify) 13
<br />Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above
<br />IV. GENERATOR AUTHORIZATION/CERTIFICATION _
<br />I hereby certify that all information sibmitted in this and all associated documents is true, complete, and accurate to the best of my knowledge and information, and
<br />that no omissions ore ors exist I warrant that I am an authorized representative of the generator
<br />_ SCOTT A. GRAHAM _ _ Shipping Coordinator 06/06/13
<br />A, ; rued Signature Printed Name Title Date
<br />THIS DOCUMENT. WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMEN i A CUHY VI- I HIS I:EK l WIUA I JUN, ANU ALL
<br />SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE (5) YEARS A� 2 Rev 11/02
<br />FtF, , EPage 09 of 11
<br />ja 14 2014
<br />ENVI;ONMENTAL HEALTH
<br />.�a..r.rtn.1-�TAA� nM -T
<br />
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