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California Land Disposal/Restriction Information Notification/Certification Farm This form is submitted in accordance with the requirements of 22 CCR 66268.7(x) Chapter 18 which restricts land disposal of certain hazardous wastes The appropriate California waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268 29 are noted below Complete all portions of Part I If the waste is non-hazardous or not restricted then complete only the applicable portions in Part I and sign i date the Form at the bottom of page. Otherwise complete Part I,11,and Ill,and signidate the Form at the bottom of page I. GENERAL INFORMATION REGARDING GENERATOR 8 WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE. 925422-1925 SITE LOCATION Corral Ifollow Rd,Tracy,CA 95376 PROFILE NUMBER DOP0009-1 IS THIS WASTE NON-HAZARDOUS 7❑x NO ❑YES(if YE$ stop here and sigrl/date form at the bottom of page) GENERATOR'S EPA ID#I CA2890090002 MANIFEST* 00587088311K CA WASTE CODE(S): 141 iS THIS WASTE RESTRICTED? []YES ©NO(if NO,stop here and sign/date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE, ❑(B)GENERATOR KNOWLEDGE OF THE WASTE:;OR ❑(C)BOTH Check the appropriate boxes in Parts II and III If only one applies,then III(A)is not required. For multiple certifications/notifications,the appropriate choices from Part II(1-3)may be marked in Part Ill(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions. By selecting an item in Part 11](A), 1-3,you are making the certification I notification noted in Part 11. if. TYPE OF LDR NOTIFICATION t CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: �22 CCR§66268 7(a)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:a 22 CCR§66268.7(a)(2) I certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification,that the waste complies with the treatment standards specified in CCR Title 22, Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 2Z Section 66268.32 or RCRQ Section 3004(d1(42 U.S.C.Section 6924(d1/.I believe that the information Isubmittedis true,accurate and complete.lam aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:.--:5 22 CCR 166268.7(b)(5) I certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certifrcadon,that the waste complies with the treatment standards specified in CCR Tide 22, Division 4.5,Chapter 18,Articles 4 and I I and all applicable prohibitions set forth in CCR Trtte 22,Section 66268.32 or RCR4 Section .?VO4(d)j42 U.S.C.Section 6924fd11.I believe that the information I submitted is true,accurate and complete.lam aware that there are significant penalties for submitting a false certification,including the possibility of a Arne or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (Al la) (C) IDI appropriate Check 1,2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-m)and Treatment Standard (Part 14 Effective Date Treatabil,ty Groups)66268.1001a)(1.14) (From 22 CCR) 1 ❑ ❑1 02 03 VM90 Aqueous wastes containing metals[66268.291al&66268.100[a)t111 1 66268,107 Table II CCW 2.❑ Eli ❑2 ❑3 818191 Auto shredder waste[66268.291c)&S626S.l00(a:13)I 2 66258.106 Table-A CCWE 3.❑ Eli ❑2 . 03 if 1/91 Hazardous waste foundry sand 166268.291e1&66260.100(a)(5)l 4 66268.106 Table 1-8 CCWE 4.❑ Eli ❑2 ❑3 111/91 Fly ash,bottom ash,retort ash or baghouse waste[66268.29(hl&66268.100(a)1811 7 66268.106 Table I-D CCWE 5.❑ ❑1 ❑2 03 111191 Baghouse waste from foundries 166268.2911)&66268,100la)19)1 8 66268.106 Table 1-E CWE 6.❑ ❑1 02 03 311193 Asbestos containing waste identified In section;66268.29(m1&66268.1001aH131t 12 66268.114 7.❑ 01 ❑2 03 OtherlSpecifyl: 13 Copies of applicable treatment standards and waste analysis data+.where available)are maintained at the facility identified on the manifest referenced above IV. GENERATOR AUTHORI ATIONICERTIFICATION hereby certify that all information bmitted in tHs and all associated d--cuments is true.complete,and accurate to the best of my knowledge and information,and that no omissions or rD IXP I. arrant that I am an autl•crized representative of the generator SCOTTA.GitAI[AN1 Shippine Coordinator 11/01/18 Authorized Signature Printed Name Tit'e Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE. MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CCR§66268 7 Rev 11i02 Page 01 of 11