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California Land Disposal/Restriction information Notification/Certification Farm 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-hazatdous or not restricted then complete only the applicable portions in Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part I,11,and III,and sign/date the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME_LawrenceLivermore National Laboratory PHONE: 925422-1925 SITE LOCATION: Corral I Inllew Rd,Tracv,CA 95376 PROFILE NUMBER: DOP0120-1 IS THIS WASTE NON-HAZARDOUS 7®NO, ❑YES(if YES,stop here and sigri/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 005870814 dJK CA WASTE CODE(S):331,541,2B1,141_ IS THIS WASTE RESTRICTED? ❑YES ©NO(if NO,stop here and sigrWate fort 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 certificationsinotifications,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 Ili(A), 1-3 you are making the certification I nolificafion noted in Part 11. II. TYPE OF LDR NOTIFICATION i CERTIFICATION ❑ .> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS: 22 CCR§66268.7(x)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 1i TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=�22 CCR§66268.7(a)(2) i certify under penalty of law that t 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 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 orRCRA Section 3004(d)(42 U.S.C.Section 6924(4)).t 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 a fine orimprisonment. ❑ 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 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 alt applicable prohibitions set forth in CCR Title 22,Section 66268.32 orRCRA 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 Erne or imprisonment 111.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (Al (a) (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 II) Effective Date Treatability Group(s)66268.100(a)(1-14) (From 22 CCR) 1 ❑ ❑1 02 03 1126190 Aqueous wastes_� Wlmmg metals[66268 29(a)&65268.100(aX1)] 1 66268.107 Table 11 CCW 2 ❑ Ell ❑2 ❑3 516!91 Auto shredder waste[66268 29(x)&66268.100(a)(3)] 2 6626x.106 Table-A CCWE 3 ❑ ❑1 02 03 111x91 Hazardo,a waste foundry sand[66266 29(e)&66268-100(x)(5)] 4 66268-106 Table I•B CCWE 4.❑ ❑1 02 ❑3 1x1,11 Fly aih,bollcm ash,retort ash or baghouse waste(6626B 29(h)&66268.100(a)(6)1 7 66268.106 Table I-D CCWE 5 ❑ ❑1 ❑2 ❑3 +.1191 Baghouse waste from foundries[66268 29(i)&66268,100(a)(9)] 8 66268.106 Table I-E CWE 6 ❑ ❑1 ❑2 03 Sat 53 Asbestos c ntain'ng waste identsfi,ed in section 166268 29(m)&66268 100(a)(13)1 12 56268 114 7 ❑ ❑l 02 0:3Other:Sperdy:: 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 om]ssio s or r ist.I rrant that I am an authorized representative of the generator- SCO TP A.GRAHAM Shipinine Coordinator 05/21t-7018 uthorized 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 11 of 13