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PET%oe)LEUhi RECYCLrNG 33COR 131 N. Hwy. 33 FH- (209) 892-67,2 r_d� P.O. Box 1167 PATTERSON, CA 95363 FAX y (209) 892.3892 errxalrn.0 - _CALIFORNIA LAND DISPOSAL RESTRICTION NOTIFICATION ------------------- __------------------_-_---_-_----------_-----_-------------- PART I: Generator Inform ion TR /RA 1 . Generator Name: 4 Or I CY EPA ID# Q -- 3 2. Profile Number Manifest- / 7i1 The waste(s) identified on the above referenced manifest and bearing the California waste number(s) idencified below is subject to the Land Disposal Restrictions of CCR, Title 22, Division 4.5 , Chapter IS - PART 11: waste Identification Calif waste - z Check the appropriate lines. More than one line may apply . 1 . RCRA regulated waste ( 1f, this line is checked, please complete other side ). _ 2. Waste Oil-Aqueous wastes with organics identified in CCR, Title 22 . 66268-112 Prohibition date effective 5/8/52- - _ 3. Non-RCRA metal-containing aqueous waste identified in CCR, Title 22 . 66268 , 107( x ). _ 4• Non-RCRA solvent waste identified in CCR . Title 22 , 676268 , 107( b ). Prohibition effective date 1/1/95. _ S. Non-RCRA metal-containing solid waste identified in CCR . Title 22 , 66268, 106( a )(3). Prohibition effective date 1/1/95 . 5. Non-RCRA aqueous and liquid waste containing any organic conoound identified by EPA ` � Test Methods 8080 , 8140 , 8150 , 6240 , and/or 8270; identified in CCR, Title 22 , 66268.112. Prohibition effective date 1/1/95- 7. Non-RCRA solid waste containing any organic compound identi'ied by EPA Test Methods 8080, 8140, 6150 , 8240, and/or 8270; identified in CCR, Title 22 , 66268.113. Prohibition effective date 1/1/95. _ S. Other Non-RCRA. California regulated waste, category includes lab packs, California-__ extremely small quantity generators , and household hazardous waste exempted in the Health and Safety Code Section 2517a -c - PART III : Handling Method Check the appropriate lines. More than one line nay apply . _ 1 . The RCRA waste identified above must be handled in accordance with the EPA Land Disposal Restriction Notification included on the reverse side of this form. 2. Recycling- _ 3- The waste identified above must be treated to meet the applicable standardz. in CCR, Title 22, Division 4-5 , -Chapter 18 , Article 1'_ . _ 4. The waste identified above meets the applicable treatment standard. 'I certify under penalty of law that 1 personally have examined and 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 CCR Title 22, Division 4 -5 , CZP7er 16, Article 11 - 1 believe that the information i submitted is true, accurate, and complete . 1 am aware that there are signiTicant penalties for submitting a false certification, including the possibility of a fine and imprisonment. ' _ S. The waste identified above is subject to a variance The expiration date of the i Find and insert the actual prohibition effective date from variance s Part 11 above . 6. The Non-RCRA waste identified above is not currently restricted ,from land disposal . PART IV . Generator Certification I hereby certify that all information supplied above and On all associated documents 15 true, Complete and accurate to the best of my knowledge and that no omissions or errors exist- / //Date /J Pri nc or Type name r 16 LL —"'