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Profile Number: <:JQ a'`)% h ' Nfanifest Number: <br />PARTWastesubject wLaridDis osafRestriction.' j• �a ,t :T <br />❑ Pursuant to 40CFR 268.7, 1 am notifying Statewide Environmental Services that under the above profile <br />number and manifest number, I am shipping to you a waste which is subject to the EPA Land Disposal <br />Restrictions, as checked below. <br />Mark one or mon as appicablo. <br />❑ 1.A wastewater identified by the EPA Waste Code/subcategory that I have checked in Part V; OR <br />❑ 2.A non -wastewater identified by the EPA Waste Code/subcatergory that I have checked in Part V; OR <br />❑ 3.A hazardous debris identified by the EPA Waste Code/subcatergory that I have checked in Part V. <br />Note: A wastewater is a waste that contains <1 % by weight Total Organic Carbon (TOC) and <1 % by weigh <br />Total Suspended Solid (TSS). 40CFR 268.2 (d)(f) <br />California List Notification, if applicable <br />❑ 4.A D001-13011 waste which (a) does (b)_does not meet the definition of a 'California List' waste <br />(see definition below). if (a), 1 have also checked the 'California List section of Attachment I, which I <br />am enclosing. Additionally, D018 -D043 apply if wastewater. <br />❑ 5.A nickel, thallium, FCB, or HOC 'California List' waste (see definition below). I have checked the <br />'California List' section of Attachment 1, which I am enclosing. Additionally D01 B -D043 apply if <br />wastewater. <br />Note: If any of the above California List Notifications were checked, identify ALL UNDERLYING HAZARDOUS <br />CONSTITUENTS in Section VI which can reasonably be expected to be present in the waste at a <br />concentration above the constituents - specific treatment standard listed in 40CFR 268.48. <br />Note: A 'California List' waste is (a) a hazardous waste containing Halogenated Organic Compounds (HOC) at <br />a concentration Z 1000 mg/kg or mg/I, or (b) a liquid hazardous waste having a pH < 2.0 and/or <br />containing any of the following materials at a concentration > that specified: PCBs, 50 ppm or lin mg/I) <br />free cyanides, 1000: As, 500; Cd, 100; Cr (VI), 500; Pb, 500; Hg, 20; Ni, 134; Se, 100; TI, 130. <br />❑ 6.A specific extension or variance (other than a 'capacity variance extension'), as I have checked on Line <br />B or C of Attachment II, which I am enclosing. <br />❑ 7.The waste already meets all relevent treatment standards. I have signed the required certification page <br />of Attachment 11, which I am enclosing. <br />❑ 8.Lab Pack. I have Signed the required certification page of Attachment 1, which I am enclosing. <br />Pursuant to 40 CFR 268.7, 1 am notifying Statewide Environmental Services that, under the above <br />profile number and manifest number, I am shipping to you a waste which is non-RCRA or <br />non -hazardous. The waste is not currently subject to EPA Land Disposal Restrictions because the waste <br />is non-RCRA or non -hazardous. <br />PART IV' Authonz <br />Signature: ' J ' <br />Print Or Type Name: <br />Tide: <br />