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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 appl cable 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 Lahoratory PHONE: 925422-1925 SITE LOCATION Corral liollory RilTraCv.CA_95376 PROFILE NUMBER: DOP0065-1 1S THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES. stop here and sigrl/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST* 005870814,iJK CA WASTE CODE(S): 141 IS THIS WASTE RESTRICTED? ❑YES ©NO(if NO,stop here and sigrl/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 11 and III If only one appl es,then III(A)is not required.For multiple certifications/notifications,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/notification noted in Part II. It. TYPE OF LDR NOTIFICATION 1 CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 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 566268.7(a)(2) I certify under penalty of taw 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 4.5,Chapter 18,Articles 4 and i 1 and all applicable prohibitions set forth in CCR Tille 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C. Section 6924(d)),t 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 possibility of a line 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) 1 certify underpenalty 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)).l believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certiffcalion, including the possibility of a fine or imprisonment. III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (8) (C) (o) appropriate Check 1,2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted waste(22 CCR 66266 29 a-m)and Treatment Standard (Part II) Effective Date Treatabillty Group(s)66268.100(x)(1-14) (From 22 CCR) 1 ❑ ❑1 02 03 1126M Aqueous wastes containing metals(66268 29(a)&66268 100(a)(1)) 1 66268 107 Tab%it CCW 2 ❑ ❑1 02 03 510191 Auto shredder waste[66268.29(c)&66268.100{a)(3)1 2 66268.106 Table-ACCwE 3 ❑ 01 ❑2 03 111191 Hazardous waste foundry sand 166268 2919)&66268.100(a)(5Il 4 6626a-106 Table 1•B CCWE 4 ❑ ❑1 ❑2 03 111191 Fly ash bottom ash,relod ash or baghouse waste(66268 29(h)&66268 100(al(B)I 7 66268.106 Table I-n CCWE 5 ❑ ❑1 ❑2 ❑3 111191 Baghouse waste from foundries 166268 29(.)&66268 1130;a}(9)1 8 66268106 Table bE CWE 6 ❑ ❑1 ❑2 ❑3 311f93 Asbestos containing waste identified in section(66268 29;m)&66268 100(a)(13)1 12 66268,114 7 ❑ 01 ❑2 ❑3 Other(Speafy) 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above. [V. GENERATOR AUTHORIZATIONICERTIF[CATION I hereby certify that all informatio submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omis ions or a exi I warrant that I am an authorized representative of the generator. SCOTT A.GRAEIANI Shinnine Coordinator 05/21/2018 ALAamVTSignature 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 08 of 13