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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 appropriate California waste code(s)and applicable non-RCRA hazardous waste listings From CCR 66258 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,11,and III,and sign/date the Form at the bottom of page I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Llttvrcnce[-ivermore National Laborntnry PHONE, 925422-1925 SITE LOCATION. Corral Hollow Rd,Tracv,(A 95376 PROFILE NUMBER- D01100417-1 IS THIS WASTE NON-HAZARDOUS? x❑NO, ❑YES(if YES,stop here and signtdate form at the bottom of page) GENERATOR'S EPA 1130 CA2890090002 MANIFEST#: 0058708R3.13K CA WASTE CODES) 512.513 IS THIS WASTE RESTRICTED? ❑YES ©NO(if NO,stop here and sigrVdate 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 111.if only one applies,then III(A)is not required.For multiple certifications/notifications the appropriate choices from Part ti(1-3)maybe 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 II. II. 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) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=*22 CCR§66268.7(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 speciAed in CCR Title 2Z Division 4.5,Chapter 18,Articles 4 and 11 and alf applicable prohibitions set forth in CCR Trt/e 22 Section 66268.32 or RCRA Section 30041042 U.S.C.Section 69241d)).I believe that the information 1 submitted is true,accurate and complete.I 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§66268.7(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 cerdrrcation that the waste complies with the treatment standards specified in CCR Tt/e 22, 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)).1 believe that the information/submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a Ane or imprisonment. 111.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (Al ia? ic) ID) appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 65208.29 a•ml and Treatment Standard I?art III Effective Date Treatability Grouplsl 66268.1001x)(1-14) iFrom 22 CCR? 1 ❑ 01 02 03 1126/90 Aqueous wastes containing metals 166268.29(a)&66268.100(al(1q 1 56268,107 Table II CCW 2.❑ ❑1 02 (33 518191 Auto shredder waste 166268 291c)&66268 100(411711 2 66266.106 Table•A CCWE 3 ❑ ❑1 02 ❑3 1/1191 Hazardous waste foundry sand(68268 29(el&66268.1001a)(5)I 4 66268 106 Table 1-e CCWE 4 ❑ ❑1 ❑2 03 Mist Fly ash,bottom ash,retort ash or baghouse waste 166268.291h)&66268 10018){811 7 66268 wit Table I-D CCWE s ❑ ❑1 [32 03 111191 baghouse waste from foundries(66268.29(ii&66268 10010911 8 66268 106 Table I.E CWE 6.❑ ❑1 02 ❑3311193 Asbestos containing waste identified in section 166268.29(m)&66268.100(a)(13)l 12 66268 114 7.[1 01 02 03 Other(specify) 13 Copies of applicable treatment standards and waste analysis data(where ava fable)are mainta ned at the facility identified on the manifest referenced above IV. GENERATOR AUTHORIZATiONiCERTIFICATION I hereby certify that all informa ion submitted in this and all associated documents:s true complete.and accurate to the best of my knowledge and.nformation,and that no omis ions or r rs 1.I warrant that I am an authorized representative of the generator. SCOTT A.GRAHAM Shippinu Coordinator 11/01118 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 06 of 11