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LDR NOTIFICATION FORM Generator Name Lawrence Liverniore!Vational Laboratort Manifest No. 005870918 11K Pursuant to 40 CFR 268 7(a),1 hereby notify that this shipment contains w isle restricted under 40 CFR Pail 268 Land Disposal Restrictions(LDR) A. GENERAL WASTE NOTIFICATION Form EPA Waste Codes Waste Constituent Notification Line CII Profile No. &L D R Subcategories(if any) N%VW %N'Nk' Check the 'Wnne"ho or No. List codes or ttse Attaclunent! List Legend Constituent#or use.-I ttachment 2 F0o5 I DOP0054EX-1 D001 L i ❑ ❑Check if Attachment i has been used ❑None ®Check if Attachment 2 has been used 2 ❑ ❑ ❑Check if Attachment 1 has been used ❑None ❑ChLck if Allachmcnt 2 has been used 3 ❑ ❑ ❑Check if Attacluncnt I has been used ❑None ❑Check if Attachment 2 has been used a ❑ ❑ Check if Attachment 1 has been used ❑None ❑Check if Attachment 2 has been used 5 ❑ ❑ ❑Check tt'Attachment l has been used ❑None ❑Check if Attachment 2 has been used 6 ❑ ❑ Check if Attachment I has been used ❑None ❑Check il'Allachnicut 2 has heen used B. HAZARDOUS DEBRIS NOTIFICATION n This hazarlous debris,as identified above on Linc Nuts). is subiect to the alternative treatment standards of40 CFR*268,45. The waste contains the following contaminants subject to treatment(check all that apply): ❑Toxicity characteristic debris ❑Debris contaminaled Willi listed waste ❑Cyanide reactive debris C. CONTAMINATED SOIL NOTIFICATION&CERTIFICATION n This contaminated soil,as identtfied above on Linc NoW. is subject to the altemative treatment standards of 40 CFR§268.49(c), Complete the fnllnwing: "I cenify under penalty of law that I personally lave examined this contaminated soil&it[❑does ❑docs not[contain listed hazardous waste&[[Idocs i []does not] exhibit a characteristic of hazardous waste&[❑is subject to t ❑complies will%] soil treatment standards as provided by §?68.49(e) or die universal treatment standards". ,lute: Constituents soh1ect to treatrnenl are aptY constinients listed in di)CFR,%26,4.48 Uniwwsal Troalmem Standards that are reasonabh c rpected to he presem in arc gitfw volunie njcaxulamrirratealsoil, rrceplJlrrw tde, .relerriar»e snlJidL:s. vairadiurn a4,inc, &are preseirt at concentrations greater than tart tines the universal treatment suordan•d. D. LAB PACK(INCINERATION)NOTIFICATION&CERTIFICATION n This lab pack_as identirred above on Linc No(s) is subject to the alternative Inaluncnt standards of40 CFR§268.42(c). "I certify under penally of law that 1 personally have examined d:am familiar with the waste&that the lab pack contains only wastes that have not been excluded under Appendix IV to 40 CFR Pan 268 &that this lab pack will he sent to a combustion facility in compliance with the alternative treatment standards for lab packs at 40 CFR§268.42(c) I am aware that there are significant penalties for submitting a false certification,including the passibility of fine or imprisonment". E. EXTENSIONS&VARIANCES F1 This waste,as identified above on Line:No(s) is not prohibited from land disposal&is subject to a deadline extension or variance, e.g.,treatability variance,case-by-case extension. Describe Mow am-rxteonsitn or variance that applies to this waste&include applicahlo dates. st-un:I. Graham Shipping coordinator 01 / 15 / 2019 Generator's Authorizer{Si natureName&Title(Printed or Typed) Date ua%LKER LoiLnonn r;rwv 11 a'.44