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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 appl cab'e non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all port-ons of Part I If the waste is non-hazardous or not restricted then complete only the applicable portions in Part I and s.gn!date the Form at the bottom of page. Otherwise complete Part 1 Il,and III,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME I.nnTence Liwrmnre National Lahnralory, PHONE: 925422-1925 SITE LOCATION Corral lln0urr Rt! Tract CA 95376 PROFILE NUMBER i OP0120-I IS THIS WASTE NON-HAZARDOUS?ONO. YES(if YE$ stop here and sigrl/date form at the bottom of page) GENERATOR'S EPA ID#• CA2890090002 MANIFEST#. 0087081`1311K CA WASTE CODE(S):331,223,141 IS THIS WASTE RESTRICTED? ❑YES ONO(ifNO,stop here and signldate form at the bottom ofpage) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE:OR Ci(C)BOTH Check the appropriate boxes in Parts II and III. If only one applies.then III(A)is not required For multiple Certifications,not.ficat ons,the appropriate choices from Pari II(1-3)may be marked in Part 111(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 II. II. TYPE OF LDR NOTIFICATION 1 CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE i 1 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) 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 rt/e Z? Division 4.5,Chapter 18,Articles 4 and 11 andallepplicableprohibitions set forth in CCR Tide 22,Section 66268.32 or RCRA Section 30041d)(42 U.S.C.Section 6924(d)j./believe that the information/submitted is true,accurate and complete.lam aware that there are significant penalties for submitting a false certification,including the possibility ofa 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 oflaw 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 Title 2Z Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 0241d)).l belleve that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment Ill.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (81 ICI (D) appropriate Check 1,2,or 3 from Corresponding bares handling information Prohib'tion Subcategory of Restricted Waste 122 CCR 66268.29 a-m)and Treatment Standard {Part III Effective Date Treatability Groups)66268.100{atll-141 (From 22 CCRI 1.❑ ❑1 02 03 1/26190 Aqueous wastes containing metals(66268.291a)&66268.1001a1(t)1 1 66268.147 Table 11 CCW 2.❑ 01 02 03 519191 Auto shredder waste(66268.291c)&66260,100in)(3I1 2 66268,106 Table-A CCWE 3.❑ ❑1 ❑2 03 1+1191 Hazardous waste foundry sand 166268.29(x)&66268.100(a)1511 4 66268.106 Table 1-B CCWE 4.❑ ❑1 02 ❑3 111191 Fly ash-bottom ash,retort ash or baghouse waste 166268.29(h)&66268,100lali8)I 7 66268.106 Table 1•0 CCWE 5.❑ Ell ❑2 03 111191 Baghouse waste from foundries[66268.29(1)&66268.100(a)[9)] 8 66268.106 Table I-E CWE 6.❑ 1:11 ❑2 ❑3 3M93 Asbestos containing waste identified in section[66268.291mi&66268.100(0)(1311 12 66268.114 7.0 01 02 03 otherl5pecifyl 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 information submitted n this and all asscsiated documents is true,compete,and accurate to the best of my knowledge and information,and that no omiss[ ns or a 1st warrant that I am an authorized repesentative of the generator SCOTT A.GRAFI. Nl Shippina Coordinator 11/01/18 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 10 of 11