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Clean Harbors Environmental Services, Inc. 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 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-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.(For RCRA wastes,use Clean Harbors RCRA FORMS) I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawr.ence Liverm re National Labolato PHONE: 925-422-1925 SITE LOCATION: Corral Hollow Road,Tracy CA 95376 PROFILE NUMBER: DOP0028-L IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(it YES,stop here andsign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: _005870808 JJK _CA WASTE CODE(S): 223 IS THIS WASTE RESTRICTED? ❑YES ®NO(if NO,stop here and sign/date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMiCALIPHYSICAL ANALYSIS OF THE WASTE; ❑(i3)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 certificationslnotifications,the appropriate choices from Part 11(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 III(A), 1-3,you are making the certification I notification noted in Part Il. 11. TYPE OF LDR NOTIFICATION 1 CERTIFICATION ❑ 1-> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE I I TREATMENT STANDARDS:=>22 CCR§66268.7(ax1) ❑ Z>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 penalty of law that 1 personally have examined and am familiar with the waste through analysis and tasting 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)).l believe that the information 1 submitted is true,accurate and complete.I am aware that there are significant penalties for submitting a false certification,including the possibility of 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) /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 Tide 22,Division 4.5, Chapter 18,Articles 4 and f 1 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))./believe that the information I submitted is true,accurate and complete./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 (AI IBI ICI (�1 appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste 422 CCR 66268.29a-m)and Treatment Standard (Part Ill Effective Cote Treatabllrty Group(s)662M.100fall 11.141 (From 22 CCRI 1 ❑ ❑1 02 ❑3 1/26,90 Aqueous wastes containing metals 166268.291al&66268.1001ali 111 1 66268.107 Table II CCW 2 Ej 1 01 ❑2 03 58131 Auto shredder waste,66268.29ic1&66258.1001ali311 2 66268.106 Table-A CC%VE 3 ❑ O1 ❑2 03 11111 Hazardous waste foundry sand(66268.29fel&66268.100(a)(511 4 66268.106 Table 1.8 CCWE 4.❑ Eli 02 ❑3 111191 Fly ash.bottom ash,retort ash or baghouse waste 166268.29(h)&66268,100(allfill 7 66266.106 Table 10 CCWE 5 ❑ ❑1 ❑2 ❑3 1!1191 Baghouse waste from foundries 166268.29ii)&66268.100(alt9ll 8 06268.106 Table I E CWE 6 ❑ 01 02 ❑3 V1,93 Asbestos cumaining waste identified in section(66268.291m)&66268.100{alll3fl 12 66268.114 7,❑ 01 ❑2 03 other ISpecofyl: 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 AUTHORI7_ATIIONICERTiFICATION I hereby certify that all Information submitin this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omissions or erro. I trait at 1 am an authorized representative of the generator. 1t A.OMham Shi inn Cooraina'or 0.4101201[3__ Auth lgnalure Printed Name Tide 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 1 of 1