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Section IV (Cont.) Check mark the underlying hazardous constituents likely to be present. _Pentachlorodibenzo-furans _Tetrachlorodibenzofurans __Vemolate ®Pentachloroethane ^1,1,1,2-Tetrachloroethane ®Vinyl chloride —Pentachloronitrobenzene 1,1,2,2-Tetracfiloroethane _Xylenes(total) ®Pentachlorophenol _Tetrachloroethylene _Antimony _Phenacetin _2,3,4,6-Tetrachlorophenol Arsenic _Phenanthrene Thiodicarb Barium _ —Phenol Thiophanate-methyl _Beryllium o-Phenylenediamine Trpate _Cadmium _Phorate Toluene Chromium(total) _,Phthalic acid Toxaphene _Cyanide(total) _Phthalic anhydride Triallate _Cyanide(amenable) _Physostigmine _Tdbromomethane(Bromoform) Fluoride _Physostigmine salicylate _2,4,6-Tribromophenol _Lead _Promecarb _1,2,4-Trichlorobenzene _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-Tdchloropropane _1,2,4,5-Tetrachlorobenzene —1,1,2-Tdchloro-1,2,2-trifluoroethane _Tetrachlorodi-benzo-p-dioxins Triethylamine ds(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 specified in 40 CFR 268,Subpart D at the original point of generation. I certify under penalty of law that 1 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. 1 believe that the information 1 submitted is true,accurate,and complete. 1 am aware that there are significant penalties for submitting a false certifii n,including the possibility of a fine and imprisonment. Authorized Signatur Print Name Title ft ) Company J-hter0, ce, 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(TSW)