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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 Califomia waste code(s)and applicable non-RCRA hazardous waste'ist(ngs from CCR 66268 29 are noted below. Comp,ele all portions of Part I. If the waste is non-hazardous or not restricted then complete only the applicable portions in Part I and sign I 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 Lawrence Livermore National Laboratory PHONE: 925422-1925 SITE LOCATION Corral Ifollow Rd Tracy CA 95376 PROFILE NUMBER: 5,195-2551 IS THIS WASTE NON-HAZARDOUS 7®NO. ❑YES(if YE$ stop here and signldate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#- 005870814 JJK CA WASTE CODE(S) 181` 1S THIS WASTE RESTRICTED? ❑YES ENO(if NO,stop here and signldate 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 II and Ill. It only one applies then III(A)is not required.For multiple certifications/nolificat:ons 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 IIIA). 1-3 you are making the certification I notification noted in Part It. If. TYPE OF LDR NOTIFICATION f CERTIFICATION ❑ 1.> 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 11 TREATMENT STANDARDS,NO ADDITIONAL FTREATMENT REQUIRED:=::b 22 CCR§66268.7(a)(2) 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 1 i 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 l 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 OFFSITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=1�22 CCR §66268.7(b)(5) I 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)), I 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 fine or imprisonment. Ill.LDR NOTIFICATION i CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (8) (C) 10) appropriate Check 1,2,or 7 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-m)and Treatment Standard {Part iq Effective Date Treatability Groups)66268.100(x)(1.14) (From 22 CCR) 1 ❑ ❑t 02 03 V26190 Aqueous wastes containing metals[66268 29(a)&66268.100(a':1); 1 66266 107 Table 11 CCW 2 I3 ❑1 02 03 518191 Auto shredder waste(66268 29(c)&66268.100(a)(3)I 2 66268.106 Table-A CCWE 3 ❑ 01 02 03 1!1191 Hazardous waste foundry sand[66268 29(e)&66268 100(a)(5)I 4 66268 106 Table 1•B CCWE 4 ❑ ❑1 02 03 111191 Fly ash,bottom ash.retort ash or baghousa waste[66268 29(h)&66268 100(a)(8)) 7 66268,106 Table I-D CCWE 5 ❑ ❑1 02 ❑3 111191 Baghouse waste from foundries[66268.29(1)&66268.100(a)(9)) 8 66268.106 Table I-E CWF 6 ❑ ❑1 02 03 311193 Asbestos containing waste identified in section(66268.29im)&66268.100(a)(13)1 12 66268-114 7 ❑ 01 ❑2 ❑3 Other(Spec4y): 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 omissi ns or errop I warrant that I am an authorized representative of the generator. SCOTT A.GRAHAM Shinning Coordinator 05/2112018 Authorized 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 13 of 13