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-LAND DISPOSAL NOTATION AND CERTIFICATION FORM � P19e of f Generator Name: 4 r f'P C ;3 EPA ID # 4T -9 v U 1 1 _ �4 State Manifest No.: Z C,-7 ! 3 �{ 1.If waste is a wastewater(see 40 CFR 268.2)place W next to the applicable code(s) 2,If waste is subject to any California List restriction enter the letter from below pext to each restriction that is applicable. —HOG, _PCBs, _MA!s,,.ITht Acid n 3.CODES WITH SUBCATEGORIES(place appropriate letter from section 9 before each code that applies)(See 40 CFR 268 for details) _D001 Hi-TOC _ D003 Unoxp Ord.Emg _K006 Hydrated _ P047 SaltsP092 Hi InU1RMERC Res. DOOi<1 o*%TOC-CWA D003 Other Reactives _K006 Anhydrous _ P047 Nonsalts _�U151 Lo RMERC Res. D001<101J,TOC-NONCWA D006 Batteries K069 Calcium Sulfate — P065 Lo Inc.Res. U151 Lo Not RMERC Res. _0002 Non-CWA D008 Lead acid batteries _K069 Not Calcium Sulfate _ P065 Lo RMERC Res. _U151 Hi Hg _D002 CWA D009 Organic Hg>260ppm _K071 Rmerc Res. _P065 No:1ncJRMERC Res. _U240 2.4 D _D003 Reactive Cyanide u U009 Inorg.Hg>260 K071 Not Rmerc Res. P065 Hi IncJRMERC Res, U240 2,4 esters d Salts _ 0003 Reactive Sulfide _0009 Hg<260 K106 Lo Rmerc Res. —P092 Lo Inc.Res. _D003 Explosive F025 Light ends K106 Not Rmerc Res. _ P092 Lo RMERC Res. D003 Water Reactives _F025 Spent filter _K106>260 ppm Hg _P092 Not IncfRMERC Res. The subcategory for D018-D043 waste is'treated in nonCWAlnonSDWA facility'unless the following box is chocked:�]`treated in CWAISDWA facility" 4.COMMON CODES(Place appropriate letter from section 9 before each code that applies) _D004 _D005 _0006 D007 D008 _0009 D010 _DOI 1 DO12 _D013 _DO 14 _DO1 S _17016 DO17 _D018 C D02D _D021 _D022 _D023 —_D024 _0025 _D026 _D027 —D028 D029 _D030 _D031 _0032 _J D033 D034 �C D036 _D037 _D038 —D039 _D040 _DO41 _DO42 _D043 i F001 __F002 _F003 _F004 _F005 _0002 U003 L 0007 UO44 _UO61 _U072 _U080 _U108 _U117 _U122 _Ul23 _U136 _U154 _U188 _U213 - U220 —U226 _l P012 —P030 _P051 _P098 P105 —P205 —F006 —F007 _F008 _F009 _Fol 0 _FO 11 _F012 FO 19 —F039 _K ADDITIONAL CODES(Enter all codes not identified above which are associated with waste) 7.HOW MUST THE WASTE BE 5.USEPA HAZARDOUS WASTE 6.TREATMENT STANDARDS FOR NON-PHASE II STATES(INDICATE 11HE APPLICABLE MANAGED?ENTER THE LETTER CODE(S) TREATMENT STANDARD 268.41,268.43 OR SPECIFIED TECHNOLOGY BELOW) FROM BELOW To identify F039,or UHCs managed in non-CWA,us the"F039AJnderlying Hazardous Constituents Form"provided(CWM-2004)and check here: 1f no UHCs are present upon generation check here:C Check here 4 disposal facility will check for all UHCs -(Le.no UHC form required) To list additional EPA waste code(s),use the supplemental sheet and check here:C1 In lieu of supplemental sheet you may use multiple copies of this farm. a.SOLVENT CONSTITUENTS(FOOt-FOOS)Check here if disposal facility will check for all spent solvents_ Acetone _Benzene n-Butyl alcohol _Carbon disuf ide Carbon.Tetrachloride —Chlorobenzene C-Cresol —Cresois(m&p} Cyclohexanone _o-Dichlorobenzene _2-Ethaxyethanol Ethyl acetate _Ethyl benzene _Ethyl ether _Isobutanol _Methanol _Methyiene chloride _Methyl ethyl ketone _Methyl isobutyl ketone _Nitrobenzene 2-Nitropropane Pyridine _Tetrachloroethylene _Toluene _1,1,1 Trichloroethane —1,1,2-Trichicroethane —1,1,2-Trichlaro,1,2,2-trifluorWhane _Trichloroethylene Trichloromonofluoromethane _Xylenes 9. (States authorized by EPA to manage the LDR program may have regulatory citations different from the 40 CFR citations fisted below.Where these regulatory citations differ,your certification will be deemed to refer to those-state citations instead of the 40 CFR Citations.) A.Or J RESTRICTED WASTETIEOUIRES TREATMENT This waste must be treated to the applicable treatment standards set forth in 40 CFR Part 268 Subpart D.268.32,or RCRA Section 3004(d) — For Hazardous Debris:"This hazardous debris is subject to the alternative treatment standards of 40 CFR Part 268.45." B.1 RESTRICTED WASTE TREATMENT TO PERFORMANCE STANDARDS -I certify under penalty of law that I have personally examined and am familiar with the treatment technology and operation of the treatment process used to support this certification and that.based on my inquiry of those individuals immediately responsible for obtaining this information.I believe that the treatment process has been operated and maintained properly so ar comply with the performance levels specified in 40 CFR Part 268,Subpart D,and all applicable prohibitions set forth in 40 CFR 268.32 or RCRA section 30041dI_without impermissible dilution of the prohibited waste.I am aware that there are significant penalties for submitting a false certification,including the possibility of fine and imprisonment." 8.2 RESTRICTED WASTES FOR WHICH THE TREATMENT STANDARD IS EXPRESSED AS A SPECIFIED TECHNOLOGY(AND THE WASTE HAS BEEN TREATED 131!THAT TECHNOLOGY) 'I certify under penalty of law that the waste has been treated in accordance with the requirements of 40 GFR 268.42.1 am aware that there are significant penalties for submitting a false certification,including the possibility of fine and imprisonment.' 8.3 GOOD FAITH AND ANALYTICAL CERTIFICATION-FOR INCINERATED ORGANICS "I certify under penalty of law that I have personalty examined and am familiar with the treatment technology and operation of the treatment process used to support this certification and that.based on my inquiry of those individuals immediately responsible for obtaining this information,I.belteve that the nonwastewater organic constituents have been treated by incinerad, in units operated in accordance with 40 CFR Part 264,Subpart O,or 40 CFR Part 265,Subpart O,or by combustion in fuel substitution units operating in accordance with applicable technical requirements,and I have been unable to detect the nonwastewater organic constituents despite having used bast good faith efforts to analyze for such constituents.I am aware that there are a significant penalties for submitting a false certification,including the possibility of fine and imprisonment," BA DECHARACTERiZED WASTE REQUIRES TREATMENT FOR UNDERLYING HAZARDOUS CONSTITUENTS 1 certify under penalty of taw that the waste has been treated in accordance with the requirements of 40 CFR 268.40 to remove the hazardous characteristic.This aecharacterized waste contains underlying hazardous constituents that require further treatment to meet universal treatment standards.I am aware that there are significant penalties for submitting a false certification.including the possibility of fine and imprisonment." C. RESTRICTED WASTE SUBJECT TO A VARIANCE This waste is subject to a national capacity variance,a treatability variance,or a case-by-case extension.Enter the effective date of prohibition in column 7 above. For hazardous debris:"This hazardous debris is subject to the alternative treatment standards of 40 CFR Part 268.45.- D. Fi8.45-D. RESTRICTED WASTE CAN BE LAND DISPOSED WITHOUT FURTHER TREATMENT "1 have determined that this waste meets all applicable treatment standards set forth in 40 GFR Part 268 Subpart 0,and all applicable prohibition levels set forth in Section 268.32 or RCF Section 3004(d),and therefore,can be land disposed without further treatment.A copy of all applicable treatment standards and specified treatment methods is maintained at the treatme storage and disposal facility named above.'7 certify under penalty of law that I have personally examined and am laminar with the waste through analysis and testing or thorough knowledge Of the waste 10 support this certification that the waste compiles with the treatment standards specified in 40 CFR Part 268 Subpart D and an applicable prohibitions set forth it 40 CFR 268.32 or RCRA Section 3004(d).I believe that the information I submitted is true,accurate and complete.I am aware that there are significant penalties for submitting a false cenifroatkxi.including the possibility of a fine and ImprisanmenL" E. WASTE IS NOT CURRENTLY SUBJECT TO PART 268 RESTRICTIONS This waste is a newly Identified waste that is not currently subject to any 40 CFR Part 268 restrictions. I hereby certify that al 'nforrnation in this and all assogaled documents is complete and accurate,to the best of my knowledge and information, Signature