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CALIFORNIA LAND DISPOSAL RESTRICTION NOTIFICATION AND CERTIFICATION fGerator Name rS(A,M I 'I)C^� !(ZIE ( +k� n u2° Menifest Number /3 �.Z ) Z 7 t ratorAddress / ( ( r/N� 4)Q' J L � l CWM Profile Number Q i -1737/ rnia Fiazardous Waste Codes) f This form Is submitted to Chemical Waste Management, Inc.In accordance with the requirements of CCR Title 22, Chapter 18,Article 1,which restricts the lane, t disposal of oertain hazardous wastes. I have marked the appropriate box (boxes A through D)below to ktdicate how my waste must be managed to oontwrr to the land disposal restrictions. A oopy of all applicable treatment standards and waste analysis data,where avallable, Is maintained at the Chernlcal Waste Management facility Mentt led on the manNest referenced above. I have entered the appropriate C Wfomia Waste Code and checked the appropriate box In' the table below to indicate the applicable non-RCRA hazardous waste listing from 22 CCR S 08268.29. Prohibition Corresponding State of California Implementation Treatment Standard Restricted Waste Description Listed In 22 CCR 1 66268.29 Date (from 22 CCR) 2 PCR w,,te, 01/27190 1 AAAo shredder waste Identified In section W-NIS 2Q(c). ry;/nA/9 1 4 Non-wastowntef sotyent waste Identified In section 66268.29(d). 01/01/96 ly" . .. ../.n../ Y Y:::..:. :4:. ..v.4.y .:..../. ay........:ry.:r:..: ........ P ..::Y:.: '�{' 8 Fly bottom ash,retort ash of bachoum waste Wentified in 66268.29(h). 0111711/91 66268.106(a)(41 10 Antienus an' 01/01/96 66268,112 .. :....n.:..,... ..n..... ....: ..v..... .. ...,..n., ,-:. .::- .. 13 Asbestos-oontaining waste Identified In section 6626829(m). 03/01/83 66268.i14 O A. RESTRICTED WASTE REQUIRES TREATMENT I am the generator of the waste identified above which must be treated to meet the applicable treatment standards set forth in CCR Title 22,Artide 4 or Article 11 of Chapter 18. Cl 8.1 RESTRICTED WASTE TREATED TO PERFORMANCE STANDARDS 7 certify under penalty of law that/have personalty examined and am familiar with the treabneat technology and operation of bre treatment process used to support this certification and that;based upon my Inquiry of those individuals immediately responsible for obtaining this Information,1 believe that tie treatment process has been operated and maintained property so as to comply whm the performance levels specified in Article 4 and Article 11 of Chapter 18, Division 4.5, The 22, CCR and all applicable prohibitions set forth in section 66268.32 orRCRA section 3004(d)[42 U.S.C.Section 6924(d)]**hN t Impermissible dilution of ore prohibited waste. I am aware that there are slgnitihcant penalties for submitting a false certification,including the possibility of a fine and imprisonment.' ❑ B.2 RESTRICTED ASBESTOS WASTE TREATED TO PERFORMANCE STANDARD. 'I warrant that I am an authorized representative of the generator. I certify under penalty of law that the waste complies with the treatment standards specified in CCR, Title 22, Division 4.5, Chapter 18, section 66268.114. 1 believe that the information I submitted is true, accurate, and complete. I -/ am aware that there are significant penalties for submitting a false certification, including the possibility of a fine and imprisonment.' 6d" C. RESTRICTED WASTE SUBJECT TO AN EXEMPTION 122 CCR 66268.7(a)(3)) The waste identified above is subject to a prohibition Implementation date of i- , - 9 L O D. RESTRICTED WASTE CAN BE LAND DISPOSED WITHOUT TREATMENT 'I certity 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,that the waste complies with tie treatment standards specified in CCR Tide 22, Division 4.5,Chapter 18,Article 4 and Article I f and all applicable prohibitions set forth in CCR Title 22, Section 66268.32 or RCRA Section 3004(d) [42 U.S.C.Section 6924(d)]. I am aware that there significant penalties for submitting a talse certification, Including the possibility of a fine and imprisonment.' I hereby certify tha infor n submitted in this and all associated documents is complete and accurate to the best of my knowledge and information. Signature: Date / S Authorized Representative Print Name: A ;vG Title: Note: Generator address and printed name of authorized representative required for Box B.2 Copyright 0 04/19/95: Chemical Waste Management, Inc. . Fd.QUI I W