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Clean Harbors Environmental Services,Inc. California Land Disposal/Restriction Information Notification/Certification Form This form Is submifted 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 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 i 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: 925-422-1925 SITE LOCATION: Corral Hollow Road,Tracy_CA 95376 _ PROFILE NUMBER: DOP0080-1 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#: 005870822 JJK -CA WASTE CODE(S): 221 _ IS THIS WASTE RESTRICTED? []YES ®NO(if NO,stop here and slgnldate 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 II and III.If only one applies,then III(A)is not required.For multiple cerUttcationslnotificatians,the appropriate choices from Part II(1-3)may be marked In Part III(A)to indicate howwaste 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 It. If. TYPE OF LDR NOTIFICATION i CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=*22 CCR§66268.7(axi) ❑ 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 1 personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this cen'ificatlon,that the waste complies with the treatment standards specified in CCR 7r71e Z2,Division 4.5,Chapter 18,Articles 4 and I I and all applicable prohibitions set forth in CCR 77fle 22,Section 66268.3Z or RCRA Section 3004(d)(42 U.S.C. Section 69241d)).I 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 Fyne 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 966268.7(b)(5) /certify underpenalty of law that t 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 45,Chapter 18,Articles 4 and I 1 and all applicable prohibitions set forth in CCR Title 22,Section 66266132 or RCRA Section 3004(d)(42 U.S.C. Section 6924(d1).l believe that the information 1 submitted is true,accurate and complete./am aware that there are significant perlalties for submitting a false certification,including the possibility of a She or imprisonment III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) f81 ICI (D) appropriate Cheek 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted waste 122 CCR 66268.29 a-ml and Treatment Standard Wart Ill Effective Date TreatabiRry aroupls15626B.1O(Nall1-141 (From 22 CCRI 1.❑ ❑1 02 ❑3 1126190 Aqueous wastes containing metals 166268.291aI&66268.100181(111 1 66268.107 Table II CCW 2.0 ❑1 ❑2 ❑3 518191 Auto shredder waste 166268.29(ci&66268.100(a)(31) 2 56268.im Table-A CCWE 3.❑ ❑1 02 ❑3 111191 Hazardous waste foundry sand 166268.291e1&66268.1001a115)I 4 66268.106 Table 1 8 CCWE 4.❑ ❑1 ❑2 ❑3 111191 Fty ash,bottom ash,retort ash or baghouse waste[66268.291h)&66268.100(ai1811 7 66268.108 Table I D CCWE 5.❑ ❑1 02 [:13 1/1/91 Baghouse waste from foundries 166268.29111&66268.1001aiMI 8 66268.106 Table I-E CWE 6.❑ ❑1 ❑2 ❑3 311193 Asbestos containing waste Identified in section 166268.29(ml&65268.100ta111311 12 66268.114 7.❑ 171 ❑2 ❑3 Otherl5pecifyi: 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 informadon submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omission or errors 2, � at I am an authorized representative of the generator. 16/ Scott A.Graham Shiooino Coordinator 06/14/2018 Au z 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.11-02 Page i of 1