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Section IV (Cont) Check mark the underlying hazardous constituents likely to be present. <br /> _Pentachlorodibenzo-furans Tetrachlorodibenzofurans _Vemolate <br /> Pentachloroethane _1,1,1,2-Tetrachloroethane Vinyl chloride <br /> _Pentachloronitrobenzene _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 �Tirpate _Cadmium <br /> _Phorate Toluene _Chromium(total) <br /> Phthalic acid Toxaphene —Cyanide(total) <br /> Phthalic anhydride Tdallate _Cyanide(amenable) <br /> _Physostigmine Tribromomethane(Bromoform) _Fluoride <br /> —Physostigmine salicylate _2,4,6-Tribromophenol _Lead <br /> Promecarb _1,2,4-Trichlorobenzene 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 <br /> Propoxur Trichloromonofluoromethane _Silver <br /> _Prosulfocarb e2,4,5-Trichlorophenol Sulfide <br /> _Pyrene _2,4,6-Trichlorophenol Thallium <br /> _Pyridine _2,4,5-Trichlorophenoxyacetic acid _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 only 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. 1 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 <br /> Title <br /> Company Lif' sr(olce. <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 />