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Clean Harbors Environmental Services, Inc. California Land Disposal/Restriction Information Notification/Certification Form This farm 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 porlions of Part I. It 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) 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Liv rmore National Laboratory PHONE: 925-422-1925 SITE LOCATION: Corral Hollow Road Trapy CA 95378 PROFILE NUMBER: DOP0028-L IS THIS WASTE NONHAZARDOUS 7®NO, [:I YES(if YES,stop here and signldate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 005870801 JJK -CA WASTE CODE(S): 22 IS THIS WASTE RESTRICTED? []YES ®NO(if NO,stop here and sigrVdale 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 III.If only one applies,then III(A)is not required.For multiple certificationsinotifications,the appropriate choices from Part II(1-3)maybe marked In Pert Ili(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 II. It. 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(ax1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=:�22 CCR 966268.7(a)(2) 1 terrify 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 6924(d)).I believe that the information I submitted is true,accurate and complete.I am aware that there are significant penaltles 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(6)(5) 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 Tile 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S C. Section 6924(d))•I 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. 111.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Cheek (AI lel (Cl IDI appropriate Check 1.2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted waste 122 CCA 66268.29 a-ml and Treatment Standard [Pert III Effective Data Treatability Gfoup(sl 65268.1001e111.141 (From 22 CCR) 1 ❑ ❑1 ❑2 01 1x76/90 Aqueous wastes containing metals;66268 291al&66268.100(all111 1 66266.107 Table 11 CCW 2 ❑ ❑1 ❑2 ❑3 51591 Auto shredder waste 166268.29(ci&66268.tM10311 2 66268.106 Table•A CCWE 3.❑ 01 ❑2 ❑- vial Hazardous waste foundry sand 166268,291e1&66258.100(al(5)] 4 66268.106 Table 1.0 CCWE 4.❑ ❑1 02 ❑3 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.291h1&66268.100fa11811 7 66268.106 Table I.D CCWE 5.❑ ❑1 ❑2 ❑3 VIM Baghouse waste from loundres 166268.29ril&66268.1001a1(9)1 8 66268,106 Table I•E CWE 6.❑ 131 ❑2 ❑'. 1.1193 Asbestos containing waste identified in section 166268.29{m1&66268.100(a)(1311 12 66268.114 7 ❑ 01 ❑2 ❑3 Othertspecifyl: 13 Copies of appiicab'e 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 rn this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omissions or st.I rant that I am an authorized representative of the generator. Scott A.Graham Shippinp Coordinator 04/04/2018 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.11102 Page 1 of 1