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California Land DisposaURestriction Information Notification/Certification Form This form is submitted in accordance with the requirements of 22 CCR 65268 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-hazafdous 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 1,11,and III,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore.National Lahoratory PHONE 925-122-1925 SITE LOCATION Curral_ilf)llnw Rd,Trace.CA 95376 PROFILE NUMBER. U0110090S.1-I IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop here and sigrVdate form at the bottom of page) GENERATOR'S EPA ID#: CA28911090002 MANIFEST#: 005870883.1.IK CA WASTE CODE(S): 223 IS THIS WASTE RESTRICTED? OYES i]NO(if NO,stop here and sigr✓date form at the bottom ofpage) THIS NOTIFICATION 8 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 lil(A), 1-3,you are making the certification 1 notification noted in Part 11. It. TYPE OF LDR NOTIFICATION 1 CERTIFICATION E: 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STAN DARDS: 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) /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 7it/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 30WId)(42 U.S.C.Section 6924(d))./believe that the information I submitted is true,accurate and complete 1 am aware that there are significant penalties for submitting a false certii<cation,including the possibility ofa fine or imprisonment ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS SEEN 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 I personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this cerifffcation,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=Section 66268.32 or RCRA Section 3004M(42 U.S.C.Section 69241d))./believe that the information/submitted is true,accurate and complete./am aware that there are significant penalties for submitting a false cerdrication,including the possibility ofa fine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IA) 18) (C) (D) appropriate Check 1.2.or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 6626029 a-ml and Treatment Standard (Part III Effective Date Treatability Groupls)66266.100[a)I1-141 (From 22 CCR) 1.❑ ❑1 ❑2 03 1126190 Aqueous wastes containing metals[66268.29(a)&66268.100(a)11II 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 ❑3 518191 Auto shredder waste 166268.291cl&66268.1004113)1 2 66268.106 Table-A CCWE 3.❑ ❑1 02 03 111191 Hazardous waste foundry sand[66268.291e)&66268.100ta)15)l 4 66268.106 Table 1•B CCWE 4.❑ ❑1 ❑2 1—]3 111191 Fly ash,bottom ash,retort ash or baghousa waste 166268.29(h)&66269.100(a)16)I 7 66266.106 Table 1-D CCWE s.❑ ❑1 02 03 111191 Baghouse waste from foundries 166268.29111&66268.100(.)(9)) 8 66268.106 Table I-E CWE 6.❑ ❑1 02 ❑3 311193 Asbestoa containing waste identified in section[66268.29[mi&66268.1001all1311 12 66268.114 7.❑ 01 ❑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 inform 'on submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omi ions or or st.I warrant that I am an authorized representative of the generator SCOTT A.GRAHAM Shipnine Coordinator 11/01/I8 Authorized 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. 11/02 Page 07 of 11