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Clean Harbors Environmental Services, Inc. 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 Catifomia waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions of Part 1. If the waste Is non-hazardous or not restricted then complete only the applicable portions In Part I and sign I date the Form at the bottom of page. Otherwise complete Part 1,11,and III,and signldate 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 HoIQw Road,Tracy CA 95376 PROFILE NUMBER: DOP022OB-1 IS THIS WASTE NON-HAZARDOUS?®NO, []YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: _005870881 JJK -CA WASTE CODE(S): 151 IS THIS WASTE:RESTRICTED? ®YES ONO(if NO,stop here and sign1date 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)BOTH Check the appropriate boxes in Parts 11 and 111.If only one applies,then III(A)is not required.For multiple certifications/notifications,the appropriate choices from Part 11(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 1 notification noted in Part 11. 11. 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 166268.7(a)(2) f 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 Title 22,Section 66266132 or RCRA Section 3004(dl(42 U.S.C. Section 6924(d)).1 believe that the information 1 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. ❑ 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/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(d)f42 U.S.C. Section 6924(d)).I believe that the information f 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 (A) {91 (Cl IDI appropriate Check 1.2.or 3 from Corresponding bores handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66258.29 a-m1 and Treatment Standard (Part 111 Effective Date Treatability Group(s)6626e.1(Wa)(1.141 (Front 22 CCRI 1.❑ ❑1 ❑2 ❑3 1126/90 Aqueous wastes containing metals[66268.291a)&66268 190(a)(111 1 66268.107 Table II CCW 2.0 0 0 ❑3 516191 Auto ahredderwaste[6626829(e)&66268.1001x)13)1 2 66268.106 Table-A CCWE 3.❑ 01 ❑2 ❑3 1x1191 Hazardous waste foundry sand(66268.291e)&66268.100(al(6)l 4 66268.105 Table 141 CCWE 4.❑ ❑1 ❑2 ❑3 1 151 Fly ash,bottom ash.retortash or baghouse waste(66268.29Ih)&66268.140011811 7 66268.106 Table I•D CCWE 5.❑ ❑1 02 ❑3 1,1191 Baghouse waste from foundries[66268.29(1)&66266.140(al(9)I 8 66268.106 Table I•E CWE 6.0 ❑1 02 03 31193 Asbestos containing waste identified In section[66268.291m)&66268.100010311 12 66268.114 7.❑ ❑1 ❑2 ❑3 Other{Specify); 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 submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and Information,and that no omiss€ort or err t.1 v0rrant tha k I am an authorized representative of the generator. Scott A.Graham Shipping Coordinator 10/29/2018 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 1 of 1