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Section IV (Cont.) Check mark the underlying hazardous constituents likely to be present. _Pentachlorodibenzo-furans _Tetrachlorodibenzofurans _Vernolate Pentachooroethane _1,1,1,2-Tetrachloroethane Vinyl chloride OPentachloronitrobenzene _1,1,2,2-Tetrachloroethane —Xylenes(total) —_Pentachlorophenol _Tetrachloroethylene Antimony _Phenacetin _2,3,4,6-TetrachlorophenolArsenic _Phenanthrene Thiodicarb _Barium _Phenol Thiophanate-methyl Beryllium _o-Phenylenediamine _Tirpate _Cadmium _Phorate Toluene _Chromium(total) Phthalic acid Toxaphene _Cyanide(total) _Phthalic anhydride Triallate _Cyanide(amenable) Physostigmine Tribromomethane(Bromoform) _Fluoride _Physostigmine salicylate e 2,4,6-Tribromophenol _Lead Promecarb ,_1,2,4-Tdchlorobenzene _Mercury(retort residues) Pronamide ^1,1,1 -Trichloroethane _Mercury(all others) Propanenitrile(Ethyl cyanide) _1,1,2-Trichloroethane _Nickel Propham _Trichloroethylene Selenium ^Propoxur Trichloromonofluoromethane _Silver —_Prosulfocarb _2,4,5-Trichlorophenol Sulfide —Pyrene 2,4,6-Trichlorophenol Thallium _Pyridine _2,4,5-Trichlorophenoxyacetic acid _Vanadium _Safrole (2,4,5-T) Zinc _Silvex.(2,4,5-TP) _1,2,3-Trichloropropane _1,2,4,5-Tetrachlorobenzene _1,1,2-Trichloro-1,2,2-trifluoroethane Tetrachlorodi-benzo-p-dioxins Triethylamine tris(2,3-dibromopropyl)phosphate Section V Certification for wastes that meet the treatment standard as required by 40 CFR 268.7 (a)(3). Note: Complete and sign this section only if your are certifying that the waste meets the treatment standards specked in 40 CFR 268,Subpart D at the original point of generation. I certify 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 the treatment standards specified in 40 CFR part 268 Subpart D. I 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. Authorized Signature Print Name lam✓ Title /�- Company ,rote►- aICe, Date Systech has prepared this form for the convenience of its customers to comply with the notification requirements under the Land Disposal Restrictions(LDR)Program in 40 CFR Part 268. Systech believes that it addresses all of the notification requirements imposed by the LDR regulations as they apply to our customers. The regulations impose on the generator the responsibility for proper LDR notification. Therefore,the generator should ensure that he has complied with all of the LDR notification requirements when using this form. NOTIFICATION REVISION OCT.98(TSll1r)