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�. SIEMENS Siemens Water Technologies Corp. LAND DISPOSAL RESTRICTION NOTIFICATION FORM Pursuant to CCR Title 22,Section 66268.7(40 CFR 268.7(a),I hereby notify that this waste shipment contains one or more of the following wastes restricted under the land disposal reshictions for which applicable treatment standards are set forth in CCR Title 22,Section 66268.40(40 CFR 268.40) Manifest Num. 003214613 'j lc Generator Name:UNIFIED WESTERN GROCERS - EPA#CAD982508251 RCRA HAZARDOUS WASTE INFORMATION U.S.F.PROFILE List all Subcategory WASTEWATER'1 California List'" Hazardous Debris Subject To NUMBER!MANIFEST D,F,I(,U&P NONWASTEWATER Per CCR Title 22,Section CCR Title 22,Sec 66268.45 LME REM NUMBER Codes (IF ANY) WW NWW 66268.32 P165407E NONE NONE ❑ ® ❑For. 343 ❑ ❑ ❑ ❑For. E ❑ ❑•. ❑For. ❑ jz: ❑ ❑ ❑For. ❑ ADDITIONAL INFORMATION FOR D001, D002, 0012-43,11OOL-5 ffi F039 WASTE STREAMS: (check one) ❑ There are no underlying hazardous Constituents(UHCs)present ' ❑ There are underlying hazardous constituents (UHCs)present which do not meet treatment standards per CCR True 22,Section 66268.4$ Use the attached LITS Table and check the appropriate constituent(s) present in the waste stream) DETERMINATION BASED rPON: (check one) ❑ Knowledge Of the process generating the waste and the raw materials used and the reaction products ❑ Results from analytical testing Analytical results attached ❑yES ❑ NO TERM.DEFDiTPIONS: `WASTEWATER = per CCRTitIe22,Secbon66260.10,WASTETHAT CONTAINS LESS THAN I"%BY WFJGHTTOTAL TOXIC ORGANICS (TOCs)AND 1%BY WEIGHT TOTAL SUSPENDED SOLIDS(TSS). 'CALIFORNIA LIST=THE FOLLOWING HAZARDOUS WASTES ARE PROHIBITED FROM LAND DISPOSAL per CCR Tide 22,Section 66268.32 Liquid hazardous waste with a pH less than or equal to 20 • Liquid hazardous waste containing PCB's at concentration of greater than or equal to 50 ppm . Liquid hazardous waste, including free liquids associated with any solids/sludge,containing free cyanide at concentrations greater than or equal to 1,000 mg/L • Liquid hazardous waste,encs dig free liquids associated with any sods/sludge,containing metals at concentrations greater than or following: 9 equal to the ARSENIC 500 2 MERCURY 20 CADMIUM 1110 /L NIGXEL 134 CHROMIUM 500 2 MIL SELENIUM 100 Jn9fL THALLIUM 130 /L • Liquid hazardous waste,that mrAains HOC's in total concentration greater than or equal to 1,000 mg& NorF4 uid RCRA hazardous waste containin HOC'S in total Concentration greater than or egi sal to 1,000 fMIL CERTIFICATION certify render penalty of law that I personally have examined and am familiar with the waste through analysis and besting or through knowledge zf the waste to support this certification. I believe that fhe information I have submitted is true,accurate and complete. I am aware that there ire significant penalties for submitting a false certification,insluing the possibility of a fine and imprisonment U/ , 4:d dg vN G�o�rS 7 -- :OMPA NAME AUTH RIZED SIGNATURE DATE