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SYSTECH ENVIRONMENTAL CORPORATION <br /> NOTIFICATION OF HAZARDOUS WASTE RESTRICTED FROM LAND DISPOSAL <br /> This notification form shall be completed by the generator and shall accompany each shipment of waste subject to the Land Disposal <br /> Restrictions(40 CFR 268 Subpart C). Use a separate notification form for each US DOT description(i.e.Line 11 a,11 b, 11 c, 11 d)on <br /> the Uniform Hazardous Waste Manifest. Complete additional forms for each waste type represented by the US DOT description. <br /> • Complete all required information in Section 1. <br /> • Complete Section 11 to identify the contaminants subject to treatment for debris treated via alternative treatment standards. <br /> • Complete Section III if your shipment includes F001-F005 spent solvents. <br /> • Check mark all applicable Underlying Hazardous Constituents in Section IV. <br /> • Sign the certification in Section V,if applicable. <br /> SECTION <br /> GENERATOR'S NAME Ivif r Ir,ke Goth F-r, j <br /> EPA I.D.NUMBER CAO 0'7 Y d Y 2 9 Q/ <br /> WASTE PROFILE NUMBER VA 3/S573,3 <br /> DATE OF SHIPMENT 2-7 <br /> MANIFEST DOC.NUMBER <br /> MANIFEST LINE NUMBER (Check One) 1%11 a ❑ 11 b ❑ 11 c ❑ 11 d <br /> ❑ By checking this box and signing Section V,you are certifying that the waste identified on this notification is subject to the land <br /> disposal restrictions and meets the treatment standards specified in 40 CFR 268. Complete Sections I through V. <br /> This shipment includes hazardous waste that is subject to the land disposal restrictions of 40 CFR 268. The waste does not <br /> meet the treatment standards set forth in 40 CFR 268,Subpart D.Complete Sections I through IV. <br /> TREATABILITY GROUP (Check One) ❑ WasteWater �d Nonwastewater <br /> HAZARDOUS DEBRIS ❑This shipment contains hazardous debris that will be treated via the alternative <br /> treatment standards of 40 CFR 268.45. The contaminants subject to treatment <br /> are identified in Section 11,or <br /> ❑This shipment contains hazardous debris that will be treated to meet the <br /> treatment standards for the contaminating wastes in 40 CFR 268.40. <br /> This shipment includes F001 -F005 spent solvents. Complete Section Ill. <br /> ❑ This shipment includes F039 multisource leachate. Complete.Section IV. <br /> This shipment includes waste that displays a hazardous characteristic.(D001-13043). The generator must determine the <br /> Underlying Hazardous Constituents(UHCs)in the characteristic waste,where applicable. Complete Section IV. <br /> Note:The UHCs do not need to be determined for D001 (nonwastewaters)that will be treated by CMBST,RORGS or POLYM. <br /> EPA Hazardous Waste Codes (use a continuation page if necessary) ❑ Check box if continuation page is used. <br /> Code Subcategory Code Subcategory Code Subcategory <br /> (if applicable) (if applicable) (if applicable) <br /> �®45 <br /> Dool . n;ivlc i C ?►0f <br /> �ta3s <br /> ❑Analysis or TIS Knowledge: of waste was used to determine that the waste is restricted from land disposal. <br /> Waste analysis data attached,if applicable? ❑ Yes No <br /> ' l <br />