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California Land Disposal/Restriction Information Notification/Certification Farm 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 66268 29 are noted below Complete al portions of Part I. If the waste is non-hazardous or not restricted then compete only the applicable portions in Part I and sign 1 date the Form at the bottom of page Otherwise complete Part I, II,and III,and sign/date the Form at the bottom of page. 1. GENERAL,INFORMATION REGARDING GENERATOR 8 WASTE STREAM GENERATOR'S NAME L:ttvrence Liverfnore national l.nharntary PHONE: 925422-1925 SITE LOCATION: Corral liollow RV 'Tracv 0,195376 PROFILE NUMBER DOP0131-1 IS THIS WASTE NON-HAZARDOUS?©NO, ❑YES(if YES,stop here and signldate form at the bottom of page) GENERATOR'S EPA ID#: Cf<2890090003 MANIFEST#: 005A7088311K CA WASTE CODE(S):151, IS THIS WASTE RESTRICTED? i]YES El NO(if NO,stop here and signldate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE, 0(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 certificationslnotitications,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 III(A), 1-3,you are making the certification/notification noted in Part II. IL TYPE OF LDR NOTIFICATION I 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) XX 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 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 28 Division 4.5 Chapter 18,Articles 4 and 11 arida/I applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 30041d)(42 U.S.C.Section 69241d)J./believe that the information/submitted is true,accurate and complete.lam aware that there are significant penalties for submitting a false cart/fleation,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 566268.7(b)(5) 1 certify under penalty of law that/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 Tide 22 Section 66268.32 or RCIM Section 3=(0142 U.S.C.Section 6924W.I 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 Ill.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check iA) IB) ICI IDI appropriate Check 1,2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66266-29 a-m)and Treatment Standard (Part III Effective Date Treatability Growls)66268.1001a)11.141 (From 22 CCRI 1.t] ❑1 ❑2 03 1126190 Aqueous wastes containing metals 166268.29(al&66268,100(a)t Ill 1 66266.107 Table 11 CCW 2.❑ ❑1 ❑2 ❑3 518!91 Auto shredder waste[66268.291c)&66268.1001a113)l 2 86268.106 Table-A CCWE 3.❑ ❑1 02 03 111!91 Hazardous waste foundry sand 166268.29(e)&66268.100(s)(5)1 4 68268,106 Table 1-8 CCWE 4.❑ ❑1 02 03 111191 Fly ash,bottom ash,retort ash or baghouse waste[66268 29(h)&66268.100(a)(811 7 66268,106 Table I•D CCWE 5.❑ ❑1 ❑2 03 N1191 Baghouse waste from foundries 166268,29(i)&66268.100(alt9)I 8 66268.106 Table I-E CWE 6.0 ❑1 ❑2 ❑3 311!93 Asbestos containing waste Identified In section 166268.29(m)&66268.100(1)(13)1 12 66268.114 7.❑ ❑1 02 03 Other Ispecifyl: 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 syprinitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and informal on,and that no omis 'ons or a t.I rrant that I am an authorized representative of the generator. SCOTT A.GRA IIAINI Shipping Coordinalor 11/01/18 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 11 of 11