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Epp rt U TAII ABILITY <br /> Land Disposal Restriction Notification <br /> Generator Name: CVS #09261 EPA Number. CAR000235200 <br /> Generator Address: 100 West Lodi Avenue Lodir CA <br /> Manifest Tracking Number. 010685501FLE <br /> Instructions <br /> Column 1 : List the Manifest Line number or Manifest Line item. <br /> Column 2: Identify all U .S. EPA hazards Waste Cortes that fly to this shipment <br /> Column 3: Choose the appropriate trealability group. Non=Wastewater (NWW) or Wastes (WW). <br /> Column 4: Enter the appropriate Subcategory (per 40 CFR 288,40), 0 appkCable and also enter 'Contaninated Soil` or "Debris' if the waste vall be <br /> treated using one of the afiernatkre treatment technologies provided by 268 49 (c)-soil, or 268.45= debris. <br /> Column 5: Enter the letter of the appropriate paragraph from belcrrr(sea Appendix 1 for other options if needed) <br /> Column 6: For F001 -1`005, please enter the Reference Number(s) located below for the cwstiluents in year waste stream subject to treatment_ <br /> Column 7. For 17039, D001-0043, Debris& Contaminated Soil: please fist the Reference humus listed in Appendix 2 for any Underlying Hazardous <br /> Constituents. <br /> Check One <br /> __--_ _ . <br /> Regulated s Underlying Hazardous <br /> Manifest Lir Number US. EFA Hazardous <br /> �y Haav Must This Constituents i Constituents <br /> ar Manifest Line Item Waste Codes Sub-Cal Waste for DLKI1-[3043, <br /> _ NV+I � VAN <br /> Managed? For 17001 -17005 Debris or Sad <br /> 1 - 100201 D941 ' Yes ; Ignitable A <br /> 11 Charectenstit <br /> 3 Waste <br /> 2 - 100198 DOOl IU002 Yes 3 Hilt TOC Ignitable A <br /> Liquid <br /> 3 - 102964 D009 aYes High Mercury A <br /> 1 <br /> , <br /> Inorganic � l <br /> 4 - 101351 13001 ` Yes ; <br /> High TOC Ignitable A <br /> Liquid <br /> 5 100196 D007rpo10 I `fes I A <br /> 6 - 101079 P001 Yes S i A <br /> Column 5 Waste Management Codes <br /> A THIS RESTRICTED WASTE REQUIRES TREATMENT TO THE APPLICABLE STANDARD_ This waste must be treated to <br /> the applicable performance basal treatment standard set forth in 40CFR Part 268 Subpart C, 268,32, Subpart D, 2€,8.40 or <br /> RCRA Section 3W4(d) prior to land dispose, <br /> Column 6 170011 +006 Reference Numbers <br /> Column 7 D0014D443 Reference Numbers <br /> I hereby certify that all information subscribed at this and afI associated documents is complete and accurate to the best of my knowledge and <br /> information. <br /> Generator Signature: ° Title: ! <br /> Date: <br /> Printed Name: <br /> ti <br />