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California land Disposal/Restriction 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 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 1 date the Form at the bottom of page. Otherwise complete Part I, II,and Ill,and sigrildate the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Ltitvrence Livermore\atiannl I_ahoratnry PHONE. 725422-1925 SITE LOCATION: Carrel Ilollow Rd,Trace,CA 75376 PROFILE NUMBER. D0110029-1 IS THIS WASTE NON-HAZARDOUS?©NO, ❑YES(if YES,stop here and signidate form at the bottom of page) GENERATOR'S EPA ID#: CA2870090002 MANIFEST#: 005870583.1.1h CA WASTE CODE(S). 223 IS THIS WASTE RESTRICTED? ❑YES ®NO(if NO,stop here and sigrl/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 III(A)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 11 II. 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:=,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 certrrication,that the waste complies with the treatment standards specified in CCR Title 2Z Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 2Z Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d))./believe that the information/submitted is true,accurate and complete.lam aware that there are significant penalties for submitting a false certification,including the possibility of 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 i 1 TREATMENT STANDARDS:a 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 certification,that the waste complies with the treatment standards specified in CCR Title 2Z Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title ZZ Section 66268.32 orRCRA Section 3004042 U.S.C.Section 6924(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 fine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IAI (B) (Cl lot 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 11) Effective Date Treatability Group(s)66266.100ia111.14) [From 22 CCR) 1.❑ ❑1 02 03 1/26190 Aqueous wastes containing metals(66268.291x)&66268.100(all Ill 1 66268.107 Table II CCW 2.❑ ❑1 02 03 518191 Auto shredder waste 166268.291x1&66268.100(a)(3)1 2 66268.106 Table-A CCWE 3.❑ 01 02 03 111191 Hazardous waste foundry sand(66268.29(-)&66268.100ia)IS)I 4 66269,106 Table 1•8 CCWE 4.0 01 02 ❑3 1!1191 Fly ash,bottom ash,ratart ash or baghouse waste 166268.291hI&66268.100(a11611 7 66268.106 Table I-D CCWE 5.❑ ❑t 02 03 1/1/91 Doghouse waste from foundries[66269.291i)&66268 100(a)(911 8 66268.106 Table I-E CWE 6.❑ ❑1 ❑2 03 311/93 Asbestos containing waste identified in section 166268.29im1&66288.100la111311 12 66268.114 7.0 El ❑2 03 other{specify): 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 AUTHORIZATIONICERTIFICATION I hereby certify that all information submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and informat on and that no omissions or errors exis I warrant that I am an authorized representative of the generator. SCOTT A.GRAIIAyNI Shipping Coordinator 11/01/18 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 03 of 11