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California Land Disposal/Restriction Information Notification/Certification Form This form is submitted in accordance with the requirements of 22 CCR 66266 7(a) Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate California waste code(s)and applicable non-RCRA hazardous waste list ngs 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 app icable portions in Part I and s gn i date the Form at 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 8 WASTE STREAM GENERATOR'S NAME I.:nrrence l.ivermoreN.itinii.ti Lahortllnry PHONE: 925422-1925 SITE LOCATION Corra]l[nllnty ltd.Tr11cv.CA 9-376 _ PROFILE NUMBER DOP0104-1 IS THIS WASTE NON-HAZARDOUS?ZNO, ❑YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#- CA2890090002 MANIFEST#• 00',87088311K CA WASTE CODE(S) 352,223 IS THIS WASTE RESTRICTED? []YES ©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)CHEMICAUPHYSICAL 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 11(t-3)may be marked in Part il1(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 It. II. TYPE OF LDR NOTIFICATION 1 CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 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 166268.7(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 Title 2Z Division 4.5,Chapter IS Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 2Z Section 66268.32 orRCRA Section 3004(d)(42 U.S.C.Section 69241d))./believe that the information I submitted is true,accurate and complete.1 am aware that there are signilrcanl 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 566268.7(b)(5) I certify under penalty of law that l 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 22, Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title Z2,Section 66268.31 or RCR,4 Section 3004(d)J42 U.S.C.Section 6924(d)J./believe that the information Isubmittedis 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 (A1 IBi ICI 101 appropriate Check 1.2,ora from Corresponding boxes handling Information Prah'bition Subcategory of Restricted Waste(22 CCR 66258 29 a-m)and Treatment Standard Mart Iq Effective Date Treatabil.ty Groupls)66268.1001a)[1-141 lFrom 22 CCR) 1 ❑ ❑1 ❑2 ❑3 1+26190 Aqueous wastes containing metals 166268.291al&66268.1001all1)1 1 66268.107 Table 11 CCW 2 ❑ Eli ❑2 03 5+8f91 Auto shredder waste(66268.291c)&66268.1001a)[311 2 66268.106 Table-A.CCWE 3 ❑ ❑1 02 03 1+691 Hazardous waste foundry sand(66268 291e)&66268.1001a)(5)] 4 66268.106 Table 1•8 CCWE 4 ❑ ❑1 02 03 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29(h)&66268.100181(8ll 7 66268,106 Table 1•0 CCWE 5 ❑ ❑t 02 ❑3 111;91 Baghouse waste from foundries[662611.29(i1&66266 100(ali9)( 8 66268,106 Table I•E CWE 6 ❑ 11]1 02 ❑3 311193 Asbestos containing waste identified in sect:an[66268.291m)&66268.1001al(1311 12 66268,114 7 ❑ ❑1 02 03 OtherlSpecify); 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 hereby certify that all informat,�n sub fitted in this ar.d all associated documents is true,complete,and accurate to the best of my knowledge and information and that no omissi! r er ar .I w rant that I am an authorized representative of the generator SCOTT A.GRAI IIA M Silint)iII2 Coordinator 11/01/18 Au razed Signature Prnted 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 15)YEARS AS PER 22 CCR§66268 7 Rev I V02 Page 09 of 11