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_ 05/23/2011 NON 15: 56 FAX 209 667 1126 Blackmun equipment U013/029 <br /> RUE-03-200d(TUE) 04: 11 P. 0031003 <br /> Land Disoosal Natificafon and Certification Form (Cont.) <br /> Constituents of Concern (For F001 - F005-EPA Waste Codes Only) <br /> 9b.1100.2l9b.319b.4 991100.16111 9b.119b.?10b319b.4 r.,nanW,tK 9b,119b09b.319b.4;yallmadt <br /> x T Acetone Cyd[twwnom N11mmunna <br /> 13 u e Pmalno <br /> n.Bugl nlMhat EW Acolbro �,r7410chlamau Ytrme <br /> CartmP TOZahlondo Eft e-=rla Toluene <br /> Carhan Dtoullldo Ebryl Ether _�,�„1.'I.t Yrkhlalmlhona <br /> CNombar¢eno mabW Alrohol �_�__1,1 t•7ndtlamelnnna <br /> Clobd MW4lwmon Maumnat ___—1,17rTAchtota7,7,b7nlluoroaln�no <br /> cro04 p4wmam Ma"na ChlarWa ^7rlddotml Jaw <br /> Creezi,m4bmwr3 tAathM Ethyl KOW6 Tdch1momcnal4aromalhlMu <br /> oLreecl ,��� MolhylactuNlKetone XylbneaIToMq <br /> Underlying Waste Constituents for Characteristics Wastes <br /> (From 40 CFR 268,48, not applicable for Lab Packs) <br /> 9b.1 <br /> 913.2 <br /> 9b.3 <br /> 9b.4 <br /> Certifications <br /> 9b,1 9b.2 9h.3 9b.4 Waste Does No Meet Applicable Treatrlent Standards <br /> Wayo does not meet applioblo treatment standards In 4D CFR 288,40 or exceeds appllcoble prohibition <br /> r " lover of 40 CFR 289.32 or RCRA Sedan 3004(d). <br /> Was,Wasle pr Contomirgted soil nnoek roatmont Standard At Orlolnol Polntof GaneraUon <br /> I certify under penalty of law that 1 personally have eDamined and am familiar with the waste through <br /> G ❑ © <br /> znaly3ls and testing or through knowILdga eAhu waste 10 SUPPOrt this coruncation that the waste comptlet <br /> r with the treatment standards spedfied In 40 CFR part 268 subpart 0 and In CCR,Title 22,Division 4.5, <br /> Chapter 1 D,kUde 4. I believe that the Information I suhmItted is true,accurate,and complete• 113M <br /> aware that there are significant penalties for submltUn9 a false cartIncation,including the posslbllltyof a <br /> fine and lmpdsonmonL <br /> Contaminated Soils Certification(Mprk aapprlopriate answers In cer-MCStlon statement.l <br /> I certify under penalty of law that I personally have examined this contaminated soil and It[DOES/DOES <br /> M NOT]contain listed huardaus waste and IDon f DOES NOT]exhibit a characteristic of hatardow waste <br /> and requires treatment to meet the soli(realment standards as provided by 40 CFR 268.49(c)and CCR <br /> TIUe 22 g66260.49(c), <br /> I ab Park Alternate Treatment Standard Certification <br /> t caNfy under penalty of law that 1 parconony have examined and am farrilller with the waste and ttro lab <br /> © pack contains orgy wastes that have not been wccluded under appendix lV to 40 CFR part 268 andthat <br /> this lab packwln be sent to a combustion facility in compliance with the alternative treatment standards for <br /> lab packs at 40 CFR 2aBA2(c). I am aware thot there are significant penalties for submitting a false <br /> eertlncillon,Including the possibility of fine or ImprisonmonL <br /> I hereby certify that all Information supplied is complete and accurate to the best of my knowledge and Infnnnallon, <br /> Signature r—+� Printed Name: <br /> Title: Date: <br />