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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 I date the Format the bottom of page Otherwise complete Part I,II,and III,and sign/date the Form at the bottom of page I. GENERAL_INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Luwrenee Livermore Nal(unstl Lnhorafory PHONE. 925422-1925 SITE LOCATION: Corral Hollow Rd,Tracy,CA 95376 PROFILE NUMBER: DOP0046-1 IS THIS WASTE NON-HAZARDOUS 7 ONO, ❑YES(if YES,stop here and signldate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST# 005870883.LIK CA WASTE CODE(S)- 512 IS THIS WASTE RESTRICTED? DYES El NO(if NO,stop here and signldate 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 Ill. If only one applies,then III(A)is not required. For multiple certificationstnotifications,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 Ill(A). 1-3, you are making the certification I notification noted in Part 11. II. TYPE OF LDR NOTIFICATION f 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(x)(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 specified in CCR rifle 22, Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22 Section&UN..32 or ITCRA Section 3004(d)(42 U.S.C.Section 8924(d)].1 believe that the information I submitted is true,accurate and complete./am aware that there are signiRcant penalties for submitting a false certification,including the possibility of a Ane 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 166268.7(b)(5) I certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this cerdfication,that the waste complies with the treatmentstandards specified in CCR Title 22 Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions sat forth in CCR Tide 22,Section 66268.32 or RCRA Section 3004 042 U.S.C Section 6924(4)/./believe that the information Isubmittedis true,accurate and complete./am aware that there are significant penalties for submitting a false certification,including the possibility of a line or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 72CCR Check LA) I61 (Cl {o) appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCA 66268.29 a-m)and Treatment Standard (Part 10 Effective Date Treatability Group(sl 66268.1001a11-14) [From 22 CCRI 1.❑ ❑1 ❑2 ❑3 1/26190 Aqueous wastes containing metals(66268.29(a)&66268.1001all1)) 1 66268.107 Table ll CCW 2.❑ ❑1 ❑2 03 518/91 Auto shredder waste(66260 291c)&66268.1001al(311 2 66260.106 Table•A CCWE 3.❑ ❑1 02 ❑3 1/1/91 Hazardous waste foundry send 166268.29(al&06288.100(0)[511 4 66268.106 Table 1•e CCWE 4.❑ Eli ❑2 ❑3 1/1191 Fly ash,bottom ash,retort ash or baghouse waste(66268.291h)&66258.1001a)(8)l 7 66268.106 Table I•D CCWE 5.❑ ❑t ❑2 03 1/1191 aaghouse waste from foundries[66268.29111&662611.100101911 8 00268.106 Table 1•E CWE 6.❑ ❑1 02 03 311193 Asbestos containing waste identified in section 166268.29(m)&66268.100(0)113)1 12 66268.114 7.0 ❑1 02 03 Other(specify): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified an the manifest referenced above IV. GENERATOR AUTHORIZATIONICERTiFICATION I hereby certify that all information gubmitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and #hat no omi ions!" ist. arrant that I am an authorized representative of the generator SCOTT A.CILkHAN1 Shipping Coordinator 11/01/18 uthorized 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 05 of ll