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California Land DisposallRestriction Information Notification/Certification Form This form is submitted in accordance with the requirements of 22 CCR 66268.7(a) Chapter 18 which restricts land disposal of certain hazardous wastes. The apprapdate California waste code(s)and applicable non•RCRA hazardous waste listings from CCR 66268 29 are noted below Complete aii pertions of Part I. If the waste is non-hazardous or not restricted then complete only the applicable port.ons n Part I and sign i date the Form at the bettam of page Otherwise complete Part I, II and 111, and sign/date the Farm at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME I.assrence Litermorc N:itional Laharatory PHONE: 925422-1925 SITE LOCATION: Corral Hollow Rd,Tniev.CA 9376 PROFILE NUMBER i10P0010-I IS THIS WASTE NON-HAZARDOUS? x❑NO, ❑YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA IDM CA2890090002 MANIFEST#: 005870883.1.111: CA WASTE CODE(S)- 134,132 IS THIS WASTE RESTRICTED? DYES ONO(if NO,stop here and sign1date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAUPHYSICAL ANALYSIS OF THE WASTE; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts it and III.If only one applies,then IIIA)is not required.For multiple certifications/notifications,the appropriate choices from Part 11 (1-3)maybe marked in Part IIIA)to indicate how waste is to be managed to conform with Land Disposal Restrictions By selecting an item in Part III(A), 1-3,you are making the certification 1 notification noted in Part II. [I. TYPE OF LDR NOTIFICATION I CERTIFICATION ❑ 1.> NOTIFICATION ONLY; WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=*22 CCR§66268.7(a)(1) -0 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=:>22 CCR 966268.7(a)(2) 1 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 speciried in CCR Title 2x Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22 Section 66268.32 or RCR4 Section 30041d)(42 U.S.C.Section 6924(d))./believe that the information/submittedis true accurate and complete.1 am 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:=*22 CCR 966268.7(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 certirrcation,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 22,Section 65258.32 or RCRA Section 3004(d)142 U.S.C.Section 6914(d)).I believe that the information/submitted is true,accurate and complete./am aware that there are significant penalties for submitting a false certification,including the possibility of a Ane or imprisonment. III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) 1111 Icl (D) appropriate Check 1.2,or 3 from Corresponding boxes handling Information Prohibition suboategary of Restricted Waste 122 CCR 66268.29 a-m)and treatment Standard ]Part Ill Effective Date Treatability Groupls)66268.1001ai11.14) (From 22 CCR) 1.❑ ❑1 02 C13 1126190 Aqueous wastes containing metals[66268.29(01&66268.100{&1(1)1 1 66268.107 Table II CCW 2.❑ Eli ❑2 03 518491 Auto shredder waste I66268.29ic)&66268.1001al(311 2 66268.106 Table-A CCWE 3.❑ ❑1 02 03 1/1191 Hazardous waste foundry sand[66268.291e)&66268.1001a)(5)1 4 66268.106 Table 1-11 CCWE a,❑ ❑1 02 03 1!1191 Fly ash,bottom ash,retort ash or baghoase waste 166268.29(h)&66268.1001a)(8)) 7 66260,106 Table I•D CCWE s.❑ ❑1 02 (:13 111191 Baghouse waste from foundries[66268.29ti)&66268 1001x)19)1 8 662611.106 Table I-E CWE 6.Cl ❑1 02 03 311193 Asbestos containing waste identified in section[66268,29(m)&66268.100(e)(13)1 12 662611A14 7.❑ ❑1 ❑2 03 Other Mpecifyl: 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 AUTHORIZATIONICERT[FICATION hereby certify that all information submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omissions or err r Xarrant that I am an authorized representative of the generator SCOTTA.CRAIIAM Shipping Coordinator 11101118 Au prized Signature Printed Name Title 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 11102 Page 02 of 11