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Califo... a Land DisposaliRestriction 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 6626829 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, 11, and 111, and sign/date the Form at the bottom of page I. GENERAL INFORMATION REGARDING GENERATOR & WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Lsboratory PHONE. 925422-1925 SITE LOCATION Corral Hollow Ro2d, Tracy, C2 95376 PROFILE NUMBER DOP0151-1 IS THIS WASTE NON -HAZARDOUS 7 ®N0. ❑ YES (if YES, stop hen= and sign/date form at the bottom of page) GENERATOR'S EPA ID# CA2890090002 MANIFEST # 005865488 JJh CA WASTE CODE(S) 151 IS THIS WASTE RESTRICTED? ®YES ONO (if NO, stop here and sigrVdate form at the bottom of page) THIS NOTIFICATION & CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A) CHEMICAUPHYSICAL 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/notitica[ions, the appropriate choices from ran 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 are making the cerbficalion / notification noted in Part 11 IT rc ur LUft reu I IrII+A I jurei V Cit 1 Ir I VH I lure ❑ 1. > NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: 0 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 §66268.7(a)(2) I terrify under penalty of law that I 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 69241d)). l believe that the information l 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. ❑ 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: 0 22 CCR §65268.7(b)(5) l certify under penalty of law that / persona#y 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 69241d)) I 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 appropriate bones (AI Check 1,2, or 3 ham handling information (Part 111 IB) Prohibition Effective Data (CI Subcategory of Restricted Waste 122 CCR 66268.29 a -m) and Treatability Groupisl 6626e.100(a)11-141 ID) Corresponding Treatment Standard (From 22 CCR) 1 ❑ ❑1 ❑2 ❑3 1/26190 Aqueous wastes containing metals 166268 2911) & 66268 1001e)(11) 1 66268 107 Table II CCW 2 ❑ ❑ 1 ❑2 ❑3 5/8191 Auto shredder waste (66268 291c) & 66258 100io)13J) 2 66288 106 Table A CCWE 3 ❑ ❑ 1 02 ❑3 1/1191 Hazardous waste foundry sand 166268 291e1 & 66268 100(o)I51) 4 66288 106 Table 1 B CCWE 4 ❑ 0 ❑2 ❑3 1/1/91 Fly ash, bottom ash, retort ash or baghouse waste (66268 291h) & 65268 1001e11B)) 7 66268 108 Table I D CCWE 5 ❑ ❑ 1 0 D 1/1/91 Baghouse waste from foundries 166268 29bi & 66258 100(a)(91) 8 66268 106 Table 1 E CWE 6 ❑ 01 02 ❑3 3/1/93 Asbestos containing waste ,dentihed In section 166268 29(ml & 66268 100(a)113)J 12 66268 114 7. ❑ ❑1 02 03 other Ispecilyl 13 Copies of applicable treatment standards and waste analysis data (where available) are maintained at the facility identified on the manifest referenced above IV GFNFRATOR 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 omissionssr errors exist Lwarrant that I am an authorized representative of the generator SCOTT A. GRAIIIAM Shipping 'oordinstor _ 06/06/13 Autho d Signature Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A, IhIS UtRilrlc;AliuN, ANU ALL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST �'U'FIEIVS6 Rev 11/02 Ieeeeee Page 11 of 11 JUL 14 2014 ENVIRONMENTAL HEALTH NVIRONMENT LHEALTH DEPARTMENT