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California Land Disposal/Restriction Information NotificationfCertification 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 Califomia waste code(s)and applicable non-RCRA hazardous waste I stings 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"n Part I and sign I date the Form at the bottom of page. Otherwise complete Part I,ll,and 111.and sign/date the Form at the bottom of page. 1, GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Laurence Livermore National Lahoratory PHONE: 925422-1925 SITE LOCATION. Corral Hollow Rd.Tram C►95376 PROFILE NUMBER: DOP0046-1 IS THIS WASTE NON-HAZARDOUS 7 Z NO, ❑YES(if YES,stop here and sigrVdate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 00587(1814,1.IK CA WASTE CODE(S): 512 IS THIS WASTE RESTRICTED7 []YES ®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)CHEMICALiPHYSICAL ANALYSIS OF THE WASTE; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts 11 and III If only one applies,then 111(A)is not required For multiple certiftcationsinotifications,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 i notification noted in Part It. 11. 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§66258.7(a)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=:>22 CCR§66268 7(a)(2) 1 certify under penalty of law that I 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)(42 U.S.C.Section 6924(d)).t 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 OFFSITE 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 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(d)(42 U.S.C.Section 6924(d)).1 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 passibility of a fine or imprisonment. III.LDR NOTIFICATION i CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (9) (C) (D) appropriate Check 1,2,or 3 from Corresponding bones handling information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-m)and Treatment Standard (Part 11) Effective Date Treatability Group(s)66268.100(a)(1.141 (From 22 CCR) 1 ❑ ❑1 ❑2 ❑3 1126190 Aqueous wastes containing metals 166268 29(a)&66268101](8[(1)] 1 66265 107 Table II CCW 2 ❑ ❑1 ❑2 03 1 5!8191 Auto shredder waste[66268 29(c)d 66268.100(a)(3)] 2 66268.106 Tabla•A CCWE 3 ❑ ❑1 02 ❑3 111191 Hazardous waste foundry sand[66268 29(e)&66268 100(a)(5)] 4 6626a.106 Table 1.8 CCWE 4 ❑ ❑1 ❑2 03 V1191 Fly ash,bottom ash,retort ash or baghouse waste[66268.29ih)&66268 100(a)(a)) 7 66268.106 Table I-0 CCWE 5 ❑ ❑1 ❑2 03 VIM Raghowe waste from foundries[66268 29(1)8 66268 100(a)(9)[ a 66268.106 Table I•E CWE 6 ❑ Eli ❑2 ❑3 311193 Asbestos containing waste iWentiried in section(66266 29(m)&66268 100(ak13)] 12 66268.114 7 ❑ ❑1 ❑2 03 Other(Sperjfyl, 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 omissions or e o xi I warrant that I am an authorized representative of the generator. SCOTT A.GRAHAIN1 Shippine Coordinator 05/21/2018 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 11102 Page 06 of 13