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California Land Disposal/Restriction Information Notification/Certification Form This form is subm tt2d ;n 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 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 app'icable portions in Part I and sign I date the Form at the bottom of page. Otherwise complete Part 1,11,and III,and signidale the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE: 925422-1925 SITE LOCATION. Corral 11allow Rd.Tracv.CA 95376 PROFILE NUMBER: DOPO0874 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#: 00587081411K CA WASTE CODE(S): 331 IS THIS WASTE RESTRICTED? AYES Z NO(if NO,stop here and sign/date form at the bottom ofpage) 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 III(A)is not required For multiple certifications/notifications,the appropriate choices from Part II(1-3)may be marked:n 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 II. II. 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(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 penally of taw 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 t t and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 orRCRA Section 3004(4)(42 U.S.C. Section 6924(d)). l believe that the information 1 submitted is true,accurate and complete.t 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 penally 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 12 and all applicable prohibitions set forth in CCR Title 22,Section 66268:32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(4)).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 possibility of a rine or imprisonment. III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (a) (C) (D) apprapdato Check 1,2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-m)and Treatment Standard (Part II) Effective Date Treatability Group(s)69268.100(a)(1.14) (From 22 CGA) 1 ❑ ❑1 ❑2 ❑3 1r26190 Aqueous wastes containing metals 166268.29(a)&66268.100(a)i11: 1 66268 107 Table 11 CCW 2.❑ 111 ❑2 03 Simi Auto shredder waste(66268 29(c)&66268.100(a){3)1 2 66268 106 Table•A CCM 3.❑ ❑1 ❑2 ❑3 111!91 Hazardous waste foundry sand(66268.29(e)&65268.100(a)(5)) 4 66268106 Table 141 MW 4 ❑ ❑1 02 03 111191 Fly ash,bottom ash,relon ash or baghouse wails(66268 29(h)&66268-100(a)(fl l 7 56268 106 Table I-V CCWE 5 ❑ ❑1 02 (:13 111191 Baghouse waste from foundries 166268 2911)&66268 100(a)(9)l B 66268.106 Table I•E CwE 6.❑ ❑1 02 ❑3 311193 Asbestos containing waste identified in section(66268 29(m)&66263 100(aN 13)I 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 faci1ty 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 a Pdt.I ant that I am an authorized representative of the generator. SCOTT A.GRAfIA,NI Shi in Coordinator 05121/2018 !zed 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 09 of 13