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Section IV (Cont.) Check mark the underlying hazardous constituents likely to be present. <br /> _Pentachlorodibenzo-furans _Tetrachlorodibenzofurans Xemolate <br /> _Pentachooroethane _1,1,1,2-Tetrachloroethane Vinyl chloride <br /> _Pentachioronitrobenzene _1,1,2,2-Tetrachloroethane Xylenes(total) <br /> _Pentachlorophenol ,_Tetrachloroethylene Antimony <br /> _Phenacetin _2,3,4,6-Tetrachlorophenol Arsenic <br /> _Phenanthrene Thiodicarb Barium <br /> _Phenol Thiophanate-methyl _Beryllium <br /> o-Phenylenediamine Trpate _Cadmium <br /> _Phorate Toluene _Chromium(total) <br /> Phthalic acid Toxaphene _Cyanide(total) <br /> _Phthalic anhydride Triallate !Cyanide(amenable) <br /> —Physostigmine Tribromomethane(Bromoform) _Fluoride <br /> _Physostigmine salicylate a 2,4,6-Tribromophenol _Lead <br /> Promecarb —1,2,4-Tdchlorobenzene Mercury(retort residues) <br /> _Pronamide ®1,1,1 -Trichloroethane _Mercury(all others) <br /> _Propanenitrile(Ethyl cyanide) —1,1,2-Trichloroethane Nickel <br /> Propham Trichloroethylene =selenium_Selenium <br /> —Propoxur Trichloromonofluoromethane _Silver <br /> Prosulfoce2 <br /> rb ,4,5-Trichlorophenol _Sulfide <br /> _Pyrene _2,4,6-Trichlorophenol Thallium <br /> _Pyridine ®2,4,5-Trichlorophenoxyacetic ad =Vanadium <br /> Vanadium <br /> _Safrole (2,4,5-T) _Zinc <br /> _Silvex.(2,4,5-TP) ®1,2,3-Tdchloropropane <br /> _1,2,4,5-Tetrachlorobenzene —1,1,2-Tdchloro-1,2,2-trifluoroethane <br /> _Tetrachlorodi-benzo-p-dioxins Triethylamine <br /> tris(2,3-dibromopropyl)phosphate <br /> Section V Certification for wastes that meet the treatment standard as required by 40 CFR 268.7 (a) (3). <br /> Note: Complete and sign this section oI if your are certifying that the waste meets the treatment standards specified in 40 CFR <br /> 268, Subpart D at the original point of generation. <br /> I certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing or through <br /> knowledge of the waste to support this certification that the waste complies with the treatment standards specified in 40 CFR part 268 <br /> Subpart D. I believe that the information I submitted is true,accurate,and complete. I am aware that there are significant penalties <br /> for submitting a false certification,including the possibility of a fine and imprisonment. <br /> Authorized Signature <br /> Print Name -���"-,e'.�l �/I <br /> Title <br /> Company Ztgter talo <br /> Date <br /> Systech has prepared this form for the convenience of its customers to comply with the notification requirements under the Land Disposal <br /> Restrictions(LDR)Program in 40 CFR Part 268. Systech believes that it addresses all of the notification requirements imposed by the <br /> LDR regulations as they apply to our customers. The regulations impose on the generator the responsibility for proper LDR notification. <br /> Therefore,the generator should ensure that he has complied with all of the LDR notification requirements when using this form. <br /> NOTIFICATION REVISION OCT.98(TSV1) <br />