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Clean Harbors Environmental Services, Inc. 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 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-hazardous or not restricted then complete only the applicable portions In Part I and sign/date the Form at the bottom of page. Otherwise complete Part I,II,and ill,and sign/date the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS) I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE: 925422-1925 SITE LOCATION: Corral Hollow(toad.Tracy CA 95376 PROFILE NUMBER: DOP022OB-1 IS THIS WASTE NON-HAZARDOUS 7®NO, El YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090D02 MANIFEST#: _005870880 JJK _CA WASTE CODE(S): 151 IS THIS WASTE RESTRICTED? ®YES El 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/noUFtcations,the appropriate choices from Part II(1-3)maybe 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/notification noted In Part 11. ll. TYPE OF LDR NOTIFICATION t CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 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 966268.7(a)(2) l 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 77de 22,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 6924(dll.l believe that the information I submitted is true,accurate and complete.l 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) l 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 Title 22,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(dl(42 U.S.C. Section 69241d)).I believe that the information/submitted is true,accurate and complete.l am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. III.LDR NOTIFICATION l CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IN 1131 (C) ID) appropriate Check 1.2 or 3 from Corresponding hexes handling information Prohibition Subcategory of Restricted Waste(22 CCR 65268.29 e•m)and Treatment Standard 1part ii) Effective Date Treatability Gfoup(s)66268.lWa)(1-14) (From 22 CCR) 1.❑ ❑1 ❑2 03 1126x90 Aqueous wastes containing metals[66268.29(al&66268.11)gIaW 11 1 66268.107 Table 11 CCW 2.❑ 01 02 ❑3 Sim1 Auto shredder waste(66268.291c)&66268.100(a)(3)] 2 66268.106 Table-A CCWE 3.❑ 01 ❑2 ❑3 111191 Hazardous waste foundry sand 166266.29(e)&66268.100(a)15]] 4 66268.106 Table 1.13 CANE 4.❑ ❑1 ❑2 03 111x91 Fly ash,bottom ash,retort ash or baghouse waste 166268.291h)&66268.100(a)(B)i 7 66268.106 Table I•D CCWE 5.❑ Eli ❑2 ❑3 111191 baghouse waste from foundries[66268.29(i)&65268.100(0911 8 66266.106 Table I•E CWE 6,0 ❑1 32 ❑3 311193 Asbestos containing waste Identified in section(66268.29(ml&66268.1001a)(13)) 12 66268.114 7.0 01 02 03 OtherlSpecily): 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 su milted In this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omissions or e .I rrant that I am an authorized representative of the generator. Scott A.Graham hi in Coordinator 10/29/2018 Authorized Signature Printed Name Title Dale 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 1 of 1