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LAND DlS -;U: ' L NL) t ,i i(1'A , lUN AJN .i i,till il-ICAfi0 N FORM Generator Name: - t fiL\- '.`q�ni(esf D«. No. : Q J 11 Profile Number: State Macifest No.:_JS ely 7 This form is submitted to LUoild f�<Se �I es , Inc. in accordance ai;h 40 CFR Part arM8,which restricls the land disposal of certain ha dous was:cs. 1. IDENTIFICATION OF THE WI.STE I have identified my waste and marked the appropriate box(cs) below to indicate how my waste must be managed to conform to the land disposal restrictions. (� A. Is this waste a non-wasicixater or a wastewater ? Check ONE: �,Noa•Wastewater C Wastewater B. Identify ALL USEPA hazardous waste numbers that apply to this waste shipment (as defined by 40 CFR 161). For each waste number, identify the corresponding subcategory (check NONE or write in the description from :0 CFR 268. 11, .42 or .43) ustfa SUBCATEGORY use PAsuacatnulT i,ataattts w.:uDocs ea STC a0. .eat DtsOlmlcM vaaR YO. aOnE D[stluf PTS CM b I i l To list additional USEPA waste number(s) and subratcgory(s), use the supplemental sheet provided (CWM.2001.B). If the supplemental page is used check here: 0 11. HOW MUST THE WASTE BE MANAGED ' Check the box(es) that indicate the Land Baa status of the waste. For any waste(s) that meets part of the treatment standard and requires additional treatment, you must mark (1) Box A (tbe.waste requires treatment) and (2) Bo: B.1 or B.2, or D (the waste satisfies part of the treatment standards). F A. RESTRICTED WASTE REQUIRES TREATMENT 1 am the initial generator of a rosined rote (i.e..solvent/dfoea,California fist,oe wheduled waste)Mich mut be treated to the applicable trenment standard set forth in e0 CFR Pan :.A Subpart D and all appliabk pmhjy itil"set forth in W CFR:68.32 or RCRA Section 3004(d)prior to:and dispotaL Thin requirement applies to EPA hacardmra waste aumber(s) F040(• AND/OR the follcwing California Lust corshtuentc (check An that apply): IJ AM, \(caskyCys nide; f-'HOG, p(Ba. A copy o/all applicable treatment suu ndasand sTectficd trealrn<ar methods u tuuuirwd at t"treatment.uonge�M deposal facility,naflee�atadK. 8.1 RESTRICTED WASTE TREATED TO PERFOR-MkVCE STANDARDS The EPA baurdous waste numbers) has been treated in eomptianm with the applrab:e pciformana uaneards,Febfcd m 60 CFR Pan 3fA SuDpan D. Svppomnt eau o i7idabk to be pia+did as requested by the receiving fanlity. 1 cenlfv under;eralry of!caw that 1 haeme personally crammed and am familiar with the treatment technology and opention of Ise treatment protects used to Support tha certification and Out.based upon my iaqutry of than indmel"Is immediately responsible for obtaining thus information,I believe that the treatment protea hu been openied and maintained properly an An to cempry.nub the performance kve!s spMrAd in 40 CTR pan UA Subpan D and all applKaMe prohibitions tot forth to 40 CFR:.68-32 or RCRA Seniod 300e(d)without dilution of the prohibited waste. 1 am aware that there are ugmrinnt Nnalltu for submnnng a hne nrdcatx^including the peenbility of a fine and impnaonmena.• B2 RESTRICTED WASTES FOR WHICH THE TREATMENT STANDARD IS EXPRESSED AS A SPECIFIED TECHNOLOGY AND THE WASTE HAS BEE'i TheATED BY TfiE SPECIFIED TECKNOLOGl) 'I nn,t) under ivcnalty C(r char the wince Lae been treated is accordance with the requirements of b CFR 2(A.e2. I am aware that there are vvutreant penaihu for submitting a fab"andintioes,including the poeubtliry W rine and impriwoment' Thu treatment hu been performed for*EPA hazardous wuia number(,) C. RESTRICTED WASTE SUWCT TO A VARL\NCE The waste identified abM in tublett to a national opacity nri,nm,a treaubility nname,or a cs cbyu encnsion which cgtrts on This vanana applies to FPA hacardo,r waste number(,) If dispoul omit is a uaoriil or rurfaa vnpoutdmenr,the unit mint mete the wmmum t"haolopul mgv,remenu. (.tipv Wastes dunned for deepwe0 Inlect,on art subject to a ep4mic act of varianaa See ingnactions or b CFR Pan 148.) E] D. RESTRICTED WASTE CAN BE LAND DISPOSED"TTHOUT FURTHER TREATMENT I am the initial generator o(tae folk�ing EPA hazardous wane sumber(i) I have delermmed that the was mem W applicable treatment mndards tat forth in 40 CFR Pan Ya Subpart D.and all applicable prob,bdioe kvcls eel forth in Section UJI.32 or RCRA Senior 300e(d),nod therefore.m be Land diapoaed without further treatment. A copy o(W npplkabk hutment standards and specified treatment mcLbOd, u maintained! at the treatment.uonge and digx" facility named abet. 'I an,ty under pcnalry o(law that I persaulty,have examined and am familiar vilh the weate Ihrflu()1 arta lria and taring or through bnow'Rdge of IA<wuu to nuppon for rentrinteon that IM wuta complies with the ImAIRKnl standards rpeerfed ie 40 CFA Pan US Subpart D and all ArVicable prohibitions tar forth on 40 CFR UA32 er RCRA section 300a(d). 1 odic caul the Information I submitted a true,acevnte and torn to 1 am aerare that thea art siptdcanr penalties for mbmimng fabe esm6catron.including the "aboliry of a fine and imprisonment' I hcrcby certify that all information submitted in this and all associated d«umenu u complete and accurate, to the best my knowledge and information Signature fir' L� Tilfe2 /KWI Date t