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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(x) Chapter 18 which restricts land d sposal of certain hazardous wastes The appropriate California waste code(s)and applicable non•RCRA hazardous waste listings from CCR 66268.29 are noted be'ow 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 Farm at the bottom of page. Otherw se compete 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 Lawrence Livermore rational Lahorsitore PHONE. 925.422-1925 SITE LOCATION: Corral Hollow Rd Tracv,CA 95376 PROFILE NUMBER. DOP0086-1 IS THIS WASTE NON-HAZARDOUS?©NO, ❑YES(if YES,stop here and signidate form at the bottom of page) GENERATOR'S EPA IDM VA2890090002 MANIFEST M 00587088311K CA WASTE CODE(S): 343.331 IS THIS WASTE RESTRICTED? DYES ©NO(if NO,stop here and sign/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;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 chokes 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 i notification noted in Part 11 It. 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(0)(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 I 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 lite ZZ Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 68268.32 or RCRA Section 3004(dJ(42 U.S.C.Section 691410.1 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 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 certification,that the waste complies with the treatment standards specified in CCR Tt/e 1Z Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66768.32 or RCRA Section 3R 41d)(42 U.S.C.Section 69241d)J.l believe that the information Isubmitted is true,accurate and complete.lam aware that there are significant penalties forsubmitting a false certification,including the possibility of fine orimprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IA) IRI (Cl IDI appropriate Check 12,ora from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-m)and Treatment Standard Mart ll) Effective Date Treatability Grouplsl 66268.1001a)(1-14) (From 222 CCRI I.❑ (:I1 02 03 1/26/90 Aqueous wastes containing metals 166268.291x)&66268.100(a)I11I t 66268.107 Table II CCW 2.❑ ❑1 02 03 518!91 Auto shredder waste 166269.291c1&66268.100tall3ll 2 66268.106 Table-A CCWE 3.❑ ❑1 02 03 111191 Hazardous waste foundry sand 166268.291@1&66268.100ta1(5)l 4 66268.106 Table 1-6 CCWE 4.❑ ❑1 ❑2 ❑3 1/1/91 Ry ash,bottom ash,retort ash or beghouse waste(66268.29(hi&66268.1001108)] 7 66269.106 Table I•D CCWE 5.❑ ❑1 02 • ❑3 1/1191 Saghcusa waste from foundries t66269.29(i)&66268.100(a]t9)] 8 66269.106 Table I-E CWE 6.❑ ❑1 02 03 311193 Asbestos containing waste identified in section 166268.291m)&66268.100(a)113)] 12 66269.114 7.❑ 01 02 ❑3 Other t5pecifyl: 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 s bmitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information and that no omissions or r t t.I arrant that I am an authorized representative of the generator. SCOTT A.GRAIIIAM Shipping Coordinator 11/01/18 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 11102 Page 08 of 11