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SIEMENS <br /> Siemens Water Technologies Corp. <br /> LAND DISPOSAL. RESTRICTION NOTIFICATION FORM <br /> Pursuant to CGR Title 22,Section 66268-7(40 CFR 258-7(a), I hereby notify that this waste shipment contains one or more <br /> of the following wastes restricted under the land disposal restrictions for which applicable treatment standards are set forth <br /> in CCR True 22,Section 65268.40(40 GFR 268.403) <br /> Manifest Num. 0002 5'? Generator Name: — EPA# ? <br /> RCRA HAZARDOUS WASTE INFORNL4TION <br /> U.S.F.PROFILF List all Subcategory WASTEWATER"I Ga{ifomia List" hazardous Debris SuteetTo <br /> NUMBER!MANIFEST U,F,K,U 8 P NONWASTEWATER Per CCR Titie 22,Section CCR Title 22,Sec 66268.45 <br /> LINE ITEM NUMBER Codes (IF ANY) WW NWW 66268.32 <br /> AP158384, 9b.Ir NONE NONE F1 DFor. 3� <br /> ❑ D D For <br /> ❑ ❑, D <br /> For.- <br /> For-- <br /> ADDITIONAL <br /> orForADDITIONAL INFORMATION FOR D00I, DO02, D,012-43, F001-5 & F039 WASTE STREAMS: (check true) <br /> There are no underlying hazardous constituents (UHCs)present <br /> J There are underlying hazardous constituents (UHCs) present which do not meet treatment standards per CCR Trtle 22,Section <br /> 86268.48 <br /> (Else the attached UTS Table and check the appropriate constituent(s) present in the waste stream) <br /> pETERI-ENATION BASED UPON : (check ane) <br /> I[j Knowledge of the process generating the waste and the raw materials used and the reaction products <br /> Results from analytical testing Anahytical results attached Q YES ❑ NO <br /> TERM DEFIlYITIONS: <br /> • WASTEWATER = per GCR T6,--22,Section 66260.10,WASTE THAT CONTAINS LESS THAN 1%BY WEIGHT TOTAL TOXIC ORGANICS <br /> iTOCs)AND 1%BY WEIGHT TOTAL SUSPENDED SOLIDS(TSS). <br /> -CALIFORNIA LIST=THE FOLLOWING HAZARDOUS WASTES ARE PROHIBITED FROM LAND D)SPOSAL per CCR True 22,Section 6626B_32 <br /> Liquid hazardous ware with a pH less than or equal to 2.0 <br /> Liquid hazardous waste containing PCB's at concerrtrabon of greaterthan or equal to 6C ppm <br /> Liquid hazardous waste, including free frquids associated with any solids?--Judge,containing free cyanide at concentrations greater than or equal tc <br /> 1,000 mg/L <br /> Liquid hazardous waste, indcti <br /> ung free fiquids associated with arty soFidslsludge,containing metals at concentrations greaterthan or equal Yc the <br /> folknving: <br /> _ ARSENIC 500 H191 putc-URY 20 rricItL <br /> CADMIUM 100 T21L NECKEL 134 fl- <br /> CHROMIUM 500 mglL SELENIUM 100 m91L <br /> LEAD 500 M9L THALLIUM 130 T91L <br /> . Liquid hazardous waste,that contains HOC's in tonalconcentration greater than or equal to 1,000 rrrgVL <br /> Nan-f-cid RGRA hazardous waste containin HOC's in total concentration renter than ore cat to 1,000 1L <br /> CERTIETCATIONI <br /> I certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing or through knowledye <br /> of the waste to support this certification_ 1 believe that the inform tion 1 have submitted is tree,accurate and complete. 1 am aware that there <br /> are significant penalties for submitting a false certification,i I ing the to sibility of a Line and imprisonment (/}� <br /> COMPANY NAME AUTHORIZED SIGNATURE DATE <br />