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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 Califomia 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 partions in Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part I,II,and III,and signldale 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 _-Lawrence Livermore National Laboratory PHONE: 925422-1925 SITE LOCATION: Corral Hallow Road.Tracy CAS95376 PROFILE NUMBER: DOP02208-1 IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: _005870992 JJK _CA WASTE CODE(S): 151 IS THIS WASTE RESTRICTED? ®YES El NO(if NO,stop here and sign1date form at the bottom of page) THIS NOTIFICATION 8 CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAUPHYSICAL ANALYSIS OF THE WASTE; ®(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts Il and 111.If only one applies,then III(A)is not required.For multiple certificationslnotifications,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 Ilt(A), 1-3,you are making the certification 1 notification noted in Part II. It. TYPE OF LOR 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 certify under penalty of law that If 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 I I and all applicable prohibitions set forth in CCR Title 22,Section 66268 32 or RCRA Section 3004(d1142 U.S.G. Section 6924(dll.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. ❑ 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 566268.7(b)(5) 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 19,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 6626832 or RCRA Section 3004(dl(41 U.S.C. Section 69241d1)./believe that the information/submitted is true,accurate and complete./am aware that there are significant penalties for submitting a false certification,including the possibility of a Ane or imprisonment. III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check JAI I81 (C1 lot appropriate Check 1,2,er 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22CCR 66268.29a-ml and Treatment Standard iPsrt II) Effective pate Treatability oroupls)66M.100la)(1.141 (From 22CCR) 1.❑ ❑1 ❑2 ❑3 1126190 Aqueous wastes containing metals 166268.29tal&66268.IQO(all 111 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 03 &WgI Auto shredder waste,;66268.291[c1&66268.100laN311 2 66268.106 Table-A CCWE 3.❑ 0 ❑2 1:11 111191 Hazardous waste foundry sand 166268.291e)&66268.1001a)I6)I 4 66268.106Table 1-B CCWE 4.❑ ❑1 ❑2 03 111191 Fly ash,bottom ash,retort ash or baghouse Wdate{66268.290)&66268.10pia1{B)I 7 66268.106 Table 1.0 CCWE 5,❑ El ❑2 ❑] 111191 Saghouse waste from foundries 166268 29(1)&66268.100;al19)1 B 66268.106 Table I E CWE 6.0 131 ®2 ❑ 311193 Asbestos containing waste identified in section 166268.29tm1&66268.1O01a1(1311 12 66268.114 7.❑ ❑1 02 ❑3 Other(Specifyi: 13 Copies of applicable treatment standards and waste analysis data(where available)are ma'ntained at the facility identified on the manifest referenced above. IV. GENERATOR AUTHORIZATIONICERTIFICATION 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 omissions or erroZIrrant that I am an authorized representative of the generator. Scott A.Graham Shipping Coordinator 03113/2019 Authorized Signature Printed Name Title Date THIS DOCUMENT, WITH AN OR'GINAL 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