COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

:lean Harbors Environments[Services, Inc. California Land Disposal/Restriction Information Notification/Certification Form 'his 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 vaste 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 11,and III,and sign/date the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS) GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE: 925-422-1925 S1TE LOCATION: Corral Hollow Road,Tracy CA 95376_ PROFILE NUMBER: DOP0028-L IS THIS WASTE NON-HAZARDOUS 7®NO, []YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA289 0 02 MANIFEST#: _005870803 JJK _CA WASTE CODE(S): 223 IS THIS WASTE RESTRICTED? ❑YES ®NO(if NO,stop here and signidate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE:OR ❑(C)BOTH heck the appropriate boxes in farts It and III,If only one applies,then III(A)is not required.For multiple cerfificationslootifications,the appropriate choices from Part 1 (1-3)maybe 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 Ill(A),1-3,you are making the certification I notification noted in Part II. il. 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(aXi) ❑ 2.>NOTIFICATION &CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=22 CCR 566268.7(a)(2) 1 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 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C. Section 6924fd)).1 believe that the information 1 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. ❑ 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 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 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004f042 U.S.C. Section 6924(d)).l 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 or imprisonment Ill.LDR NOTIFICATION l CERTIFICATION INFORMATION REQUIRED BY 22CCR Check 1A) to) ICI IDI appropriate Check 1,2.or 3 from Corresponding buses handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a m)and Treatment Standard Wart ill Effective Date Treatability Groupls)66268.1001x)(1.141 (From 22 CCR) 1.0 ❑1 ❑2 ❑3 1126.90 Aqueous wastes containing metals(66268.291a)&66268.100-,dl;1ll 1 66268.107 Table ilCCW 2.❑ Eli ❑2 ❑3 51.91 Auto shredder waste 166268.29(c)&66268.100ia)(311 2 66268.106 Tabla-A CAVE 3.❑ ❑1 ❑2 ❑3 11r91 Hazardous waste foundry sand 166268.29ie1&66268.100(a1151i 4 66268.106 Table 1-8 CCWE 4.❑ ❑1 ❑2 ❑3 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29(h)&66268.100(06)) 7 66268 106 Table I•D CCW;. 5.❑ ❑1 02 1:13 IMS1 baghouse waste from foundries 166268,2910&66268.1001a)(911 a 66268.106 Table i-E CINE 6.❑ ❑1 02 ❑3 31193 Asbestos containing waste idenisfied in section 166268-29(ml&66268.100fa Ill3)1 12 66268.114 7.0 01 02 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 omissi ris or a .a nt that I am an authorized representative of the generator. Scotl A.Graham Shi lnq CDcrdina'ar L4I 3 2 1 Au .odzed 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 1 of 1