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Applicable Certifications TART M. Authorized Representative Crosby&Overton Profile Number Manifest and Linc Item Number associatcd with wasteshipment . 51192 000250269 JJ{ 9b.1 CHECK THE APPROPRIATE CERTIFICATION 1. Generator's Certification(263.7(a)(2)(ii))for waste that meets Treatment Standards I certify under penalty of law that I personally have examined asid am familiar with the waste through analysis and testing or through knowledge of the waste to support this certification that the waste complies with the treatment standards specified in 40 CFP,Part 268 Subpart D and all applicable prohibitions set forth in 40 CFR 26832 or RCRA 5etti.on 3004(d)- I believe that the information I submitted is true,accurate and complete. I am aware that there are si,o ific. t penalties for submitting a false ccrtifi:cation,including the possibility of a fine and imprisonment- 2- Waste Treated to Remove Characteristics(268.7(b)(5)(iv)) I certify under penalty of law that the waste has been treated in accordance with the requirements of 40 CFR 268.40 to remove the hazardous characteristic. This de-chazactetized waste contains undodyiiig hazardous constituents that require further treatment to meet universal treatment standards. I am await,that there are significant penalties for submitting a false certification including the possibility of fine and imprisonment 3. Debris Treated to meet Alternative Standards(268.7(d)(3)(m�) I certify lander penalty of law that the debris has been treated in accordance with the requirements of 40 CFR 268.45. I am aware that there are significant penalties for m3ldng a false cerboacatian including the possibility of fv.e and imprisonment 4- Lab Packs to be Treated by Incineration(Certification must be completed.)Appendix IV Lab Packs I certify under penalty of law that I have personally examnied and am£am5in with the waste and that the lab pack co tai ss only wastes which have not been excluded-tinder Appendix N to 40 CFR Part 268 or solid wastes not subject to regulation under 40 CFR Part 261- lam aware that there are significant penalties for submitting a false certiS-acation, including the possibility of flue or imprisarmment 5. Appendix V Lab Pack: I certify wader penalty of law that I personally have examined and am familiar with the waste tbrough analysis testmg or through,knowledge of$le waste and that the lab pack contains only organic waste specified im Appendix V to part 268 or solid wastes not subj ect to regulation under Part 261. 1 am aware that there are significant penalties for submitting a false certifica±ton,including the possibility of fine or imprisonment- Print Name Title 1 41YT Date 0 G-O 3 of 5