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SI E ENS 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 fOlowing wastes restricted under the land disposal restrictions for which applicable treatment standards are set forth in CCR Idle 22,Section 66268.40(40 CFR 268-40) Manifest Num. OOO25272h`1J-K Generator Name_ rJ.W. C. -5TOC7TON EPA# CkD()g2579251 RCRA HAZARDOUS WASTE INFORMATION U.S.F.PROFILE List all Subcategory WASTEWATER'[ California List a ction CCCRR TTWe 22,Sec 65268.45 HaDebris Subject To NUMBER/MANIFEST D,F,K,U&P NONWASTEWATER Per CGR Title 22,Seale LINE ITEM NUMBER Codes (IF ANY) WW NWW 66268.32 -75TTT4 El 9b . 1 VOLAE VOLAE ❑ ❑For ❑ ❑ ❑Far. ❑ ❑ ❑•. ❑For. ❑ ❑ ❑Far. E E ❑ ADDITIONAL INFORMATION FOR D001, D002, D012-43, F001-5 Sc F039 WASTE STREAMS: (check one) ❑ There are no underlying hazardous constituents (UHCs) present ❑ There are underlying hazardous constituents(UHCs) preserrt which do not meet treatment standards per CCR Title 22,Section 66268.48 Use the attached UTS Table and check the approrpriate constituents resent in the waste stream DETERMINATION BASED UPON : (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 DEFINITIONS: WASTEWATER = per CCR Tide 22,Semon 66260-10,WASTE THAT CONTAINS LESS THAN 1%BY WEIGHT TOTAL TOXIC ORGANICS (TOCs)AND 1-%By WEIGHT TOTAL SUSPENDED SOLIDS(TSS). 'CALIFORNIIA LIST=THE FOLLOWING HAZARDOUS WASTES ARE PROFIIBITED FROM LAND DISPOSAL- per CCR Title 22,Section 66268.32 Liquid hazardous waste with a pH less Than or equal to 2-0 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 • inducting free liquids associated with any sol-idslsludge,containing metals at concentrations greater than or equal to the Liquid hazardous waste, following: ARSENIC 500 lL MERCURY 20 rng[L CADMIUM 100 fL NICKEL 134 fl- CHROMIUM 500 /L SELENIUM 100 m9rL IE4D 500 THALLIUM 130 IL Liquid hazardous waste,that contains HO-C's in total concentration greater than or equal to 1,000 rrKjIL- Non-liquid RCRA hazardous waste contahiin HOC'S in total concentration greater than or equal to 1,000 m9JL CERTIFICATION I certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing or through knowledge of the waste to support this certification. I believe that the inform -on I have submitted is true,accurate and complete. I am aware that there are significant penalties for submitting a false certification,inthe ibiiity orf a fine and imprisonmentZ2Q �} IQ' V f. t� COMPANY NAME AUTIIORLZED SIGNATURE DATE