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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboratory Manifest No. 005865488 JJK Pursuant to 40 CFR §268 7(a), I herebX,notify that this shipment contains waste restricted under 40 CFR Part 268 Land Disposal Restrictions LDR A. GENERAL WASTE NOTIFICATION Form EPA Waste Codes Waste Constituent Notification Line Profile No. & LDR Subcategories (if any) NWW WW Check the "None" box or No. List codes or use Attachment I List Legend Constiluent # or use Attachment 1 I DOP0027-1 D008 ® EJ _— -__ Check if Attachment I has been used ® None ❑ Check if Attachment 2 has been used D040 __ 2 DOP0032-1 N El ❑ Check if Attachment I has been used ® None ❑ Check if Attachment 2 has been used D040, D008, D005 3 D0110036 _ ❑ Check if Attachment I has been used ® None ❑ Check if Attachment 2 has been used D001 IQ, D035, F005 4 DOP0054-1 ❑ Check if Attachment l has been used ® None ❑ Check if Attachment 2 has been used D011 5 DOP0096A-1 ❑ El Check if Attachment I has been used ® None ❑ Check if Attachment 2 has been used D002, D001 LQ, U228, D018, D035 D007, D005, P008 6 DOP0112-1 ® El Check if Attachment I has been used N None ❑ Check if Attachment 2 has been used B. IIAZARDOUS DEBRIS NOTIFICATION n This hazardous debris as identified above on Line No(s). is subiect to the alternative treatment standards of 40 Cl It 6268 45 The waste contains the following contaminants subject to treatment (check all that apply) ❑ Toxicity characteristic debris ❑ Debris contaminated with listed waste ❑ Cyanide reactive debris C. CONTAMINATED SOIL NOTIFICATION & CERTIFICATION n This contaminated soil, as identified above on Line No(s) is subject to the alternative treatment standards of •10 CFR §268 49(c) Complete the following: "I certify under penalty of law that 1 personally have examined this contaminated soil & it (❑does/ ❑docs not] contain listed hazardous waste & (❑does / ❑does not] exhibit a characteristic of hazardous waste & [❑is subject to / ❑complies with] soil treatment standards as provided by §268 49(c) or the universal treatment standards" Note Constituents subject to treatment are any constituents listed in 40 Ch'R ¢268.48 Universal Treatment Standards that are reasonably expected to be present in any given volume of contaminated soil, except fluoride, selenium, sulfides, vanadium & zinc, & are present at concentrations greater titan ten times the universal treatment standard D. LAB PACK (INCINERATION) NOTIFICATION & CERTIFICATION phis lab hack, as identified above on Line No(s) 6-11 is subject to the alternative treatment standards of 40 CFIZ §268 42(c) "I certify under penalty of law that I personally have examined & am familiar with the waste & that the lab pack contains only wastes that have not been excluded under Appendix IV to 40 CFR Part 268 & that this lab pack will be sent to a combustion facility in compliance with the alternative treatment standards for lab packs at 40 CFR §268 42(c) I am aware that there are significant penalties for submitting a false certification, including the possibility of fine or imprisonment" E. EXTENSIONS & VARIANCES n This waste. as identified above on Line No(s). is not prohibited from land disposal & is subject to a deadline extension or variance, e g, treatability variance, case-by-case extension Describe below any extension or variance that applies to this waste & include applicable dates Scott A. Graham, Shipping Coordinator 06 / 05 / 2013 Generator's Authorized Signatur Name &Title (Printed or Typed) DWALKEA LDP. RaMCATION 11 719{ ,ky'104, J U L 14 2014 ENVIRONMENTAL. HEALTH DEPARTMENT