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California Land Disposal/Restriction Information Notification/Certification Form This form is submitted in accordance w-th the requirements of 22 CCR 56268.7(a) Chapter 18 which restricts land disposal of certain hazardous wastes The appropriate Caafomia waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66258,29 are noted below.Complete all portions of Part I If the waste s 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,ll,and III,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore N21ional Labornf0 PHONE: 925422-1925 SITE LOCATION Corral linllow Rd.Tracv.01.95376 PROFILE NUMBER: DOP0131-1 IS THIS WASTE NON-HAZARDOUS?®N0, Ej YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#; 005870814.1.1K CA WASTE CODE(S):151, IS THIS WASTE RESTRICTED? ®YES ❑NO(if NO,stop here and sign/date Corm 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:.n 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 certifcation I notification noted in Part It. II. TYPE OF LDR NOTIFICATION 1 CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=.22 CCR§66268 7(a)(1) XXX 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=22 CCR§66268.7(a)(2) i 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 orRCRA Section 3004(d)(42 U.S.C.Section 6924(d)).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 Tine 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 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 rile 22,Division 4.5, Chapter 18,Articles 4 and i f 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)).I 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 fine or imprisonment. III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (a) (C) (D) appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCR 65268.29 arm)and Treatment Standard (Part II) Effective Date Treatability Group(s)6626a.100(a)(1-14) lFrom 22 CCR) 1.❑ 01 ❑2 ❑3 1126!90 Aqueous wastes containing metals(66268 29(a)&66268 100(al(111 1 66268.10 Table fl CCW 2 ❑ ❑1 02 ❑3 1 5!0!91 Auto shredder waste(66268 29(c)&66268 100(a)(3)) 2 65258.106 Table-A CCWE 3 ❑ ❑1 ❑2 03 1!1191 Hazardous waste foundry sand(66268 29(e)&66268 100(a)(5:i 4 66268 106 Table 1•B CCWE 4 ❑ 01 02 03 111191 Fly ash,bottom ash,retort ash or baghouse waste(66268 29(hl&66268-10:(a.g8F 7 66268.106 Table bD CCWE 5 ❑ ❑1 ❑2 03 111191 baghouse waste from foundries(66268 29(1►&66268 100(a)(9ii 8 66260.106 Table I•E CWE 6 ❑ ❑1 ©2 03 3/1193 Asbestos containing wastedentrfied in section(66268 29(m)&66268 100(x}(13;( 12 66268 114 7 ❑ 01 ❑2 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 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 err .I rrant that I am an authorized representative of the generator. SCOTT A.GRAEIAi4I Shippine Coordinator 05121/2018 Au prized Signature Printed Name Title Date IL- 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 12 of 13