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California Land Disposal/Restriction 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 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 III,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE: 925-471-1925 SITE LOCATION: Corral Ifolloly Rd.'Cracv,CA 95376 PROFILE NUMBER DOP0029-1 IS THIS WASTE NON-HAZARDOUS 7®NO, ❑YES(if YES,stop here and signldate farm at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 005670814.1.IK CA WASTE CODE(S): 223 IS THIS WASTE RESTRICTED? ❑YES 0 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)CHEMICALIPHYSICALANALYSIS 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/notifications,the appropriate choices from Part II(1-3)may be marked in Part Ill(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 It. I1. TYPE OF LDR NOTIFICATION I CERTIFICATION E 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:a 22 CCR§66268.7(a)(2) 1 certify underpenalty of taw that 1 personalty 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 9 7 and all applicable prohibitions set forth in CCR Title 22,Section 66258.32 or RCRA Section 3004(d)f42 U.S.C.Section 6924(d)).l believe that the information l submitted is true,accurate and complete.t am aware that there are significant penalties for submitting a false certification,including the possibility of a Arne or imprisonment. ❑ 3.>NOTIFICATION&CERTIFICATION: NDN-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 underpenally 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 9 I and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d)).1 believe 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 Arne or imprisonment. III.LDR NOTIFICATION i CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (AI IB) (C) (D) appropriate Check 1,2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66268 29 a-m)and Treatment Standard (Part 11) Effective Date Treatabllity Group(s)66268.100(a)(1.14) (From 22 CCR) 1 ❑ ❑1 02 ❑3 1126190 Aqueous wastes containing metals'66258 29(a)&66268 lCuta)(1)l 1 6626a 107 Table II CCW 2 ❑ ❑t 02 03 5!8!91 Auto shredder waste 166268.29(cl&66268.tDD(al(3:1 2 66266.106 Table-ACCwE 3 ❑ ❑1 02 ❑3 1lL51 Hazardous waste foundry sand(66268 291 e)&66268.1 00(a 1f 5)) 4 66268 106 Table 1•0 CCWE 4 ❑ ❑1 ❑2 ❑3 1.1.91 Fly ash,bottom ash,retort ash or baghouie waste(66268.291 h)&66268.100(a)(8)] 7 66268 106 Table 1•D CCWE 5 ❑ ❑1 02 03 MAI Baghouso waste from foundries 166268 29i,)&66268 100(a':9)1 8 66268 106 Table i,E CWE 6 ❑ ❑1 02 ❑3 3!1.'�3 Asbestos containing waste identified in section(66208 29?m)&66268 100(a)(13)1 12 66268 114 7 ❑ 01 02 03 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 W. 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 oma ions ar ist. arrant that I am an authorized representative of the generator. SCOTT A.GRAHANI Shippine Coordinator 05/21/2018 A razed 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 04 of 13