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California Land Disposal)Restrir-tirm Ir.`a ma(lori Notification/CEltifimilon 5orm This form is submitted in accordance with the requirements of 22 CCR 66268.7(a) Chapter 18 which restricts land disposal of certain hazarrou- appropriate California waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions ui Part' E waste is non-hazardous or not restricted then complete only the applicable portions in Part i and sign 1 dale the Form at the bottom of page Otherwise Lomp'L 1,it,and ill,and sign/date the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence LivermoreNational Laboratory PHONE: 925422-1925 SITE LOCATION: Corrat Hollow Rd.Tracy,CA 95376 PROFILE NUMBER: DOP0080-1 IS THIS WASTE NON-HAZARDOUS?®NO, El YES(if YES,stop here and signAdate form at the bottom of page) GENERATOR'S EPA ID#: CA2690090002 MANIFEST M 44 871010JJK CA WASTE CODE(S): 221 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: I1 ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE:OR ❑(i,)10TH Check the appropriate boxes in Parts II and Ill.If only one applies,then III(A)is not required.For multiple certifications/notifications,the appropr+atF choices from P.- II(1-3)may be marked in Part IIIA)to Indicate how waste is to be managed to conform with Land Disposal Restrictions. By selecting an ite yi in Fart III(A) 1-1 y are making the certification f notification noted in Part II. II. 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(x)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS.NO AhUiTIONAL { TREATMENT REQUIRED:a 22 CCR 466268.71a1121 �t I certify under penalty of law that I personally have examined and am famillar with the waste through analysis and testerr g thr+wgi knowledge of the waste to support this certilicadon,that the waste complies with the treatment standards specified In CC+7 tale 1 Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth In CCR Trtie 2Z Section 66268.32 or RVT4 Sc-dor 30041d)(42 U.S.C.Section 6924fd)).I believe that the Information 1 submitted Is true,accurate and complete.l am aware•',af Aivre e significant penalties for submitting a false ceriifrcadon,including the possibility of fine or Imprisonment ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACI J Y SO A u MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=-22 CCR 366268.71b1(5) 1 certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and test'n_r through knowledge of the waste to support this cw f)cedoa,that the waste compiles with the treatment standards specifled In a'61 Tide ZZ Divislon 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth In CCR Tide ZZ Section 66768.32 or RC R...'ecdon 30041d)(42 U.S.C.Section 6924(dJ),1 believe that the information 1 submitted is true accurate and complete./am aware.lw!There attr significant penalties far submitting a false certiffcatfon,including the possibility of a fine or imprisonment III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) IBI lei rpt appropriate Check 12.or 3 from f rvreeporr. boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29a ml and 1 -ar,t Stards d (Part Til Effective Onto Treatabtlity erouplsl 66268.1txxel(I.141 ,m 22C H- 1.❑ ❑1 ❑2 03 V26190 Aqueous wastes containing metals 166268.2%ai&66268.100(a1(1)l 1 66208 101 Te'to II CCW --- - 2.❑ 1 ❑1 ❑2 ❑3 508191 Auto shredder waste 166268.291c1&66268.100(a)(3)1 2 66268.106 Ter to-A crw.. 3.❑ ❑1 ❑2 ❑3 1f7191 Hazardous waste laundry send[66268291@)&66268.160(a1(5ll 4 66ma.1r6Ta',1e 1 9 CC%V9 4.❑ ❑1 ❑2 ❑3 11 V 91 Fly ash,bottom ash,retort ash at baghouse waste[66268.29(h)&66268.100(ell8ll 7 662GH.1Gd Ta!is I-r)CC-.YE 5 ❑ ❑1 ❑2 ❑3 101191 Baghouse waste born foundries 166268.29(1)&B626SAWa1I91] 8 66:69.101 Table I-E CIV' 6 ❑ Cl 1 ❑2 ❑3 311t93 Asbastow,ntsinIng waste;do nit Red to section r66263.2%mi&66268.100(11113)1 12 1 66253.114 7 ❑ 01 02 ❑3 1 0that ispecito 13 Copies of applicable treatment standards and waste analysis data{where ava.lable)are maintained at the facility identified on the manifest rafervnred ab( f� IV. GENERATOR AUTHORtZATIONICERTIFICATION I hereby certify that all Information submitted In this and all assoclated documents-s true,complete,and accurate to the best of my knowledge and information :,r J i that no omissions or erro a '5t. I warrant that I am an authorized representative of the generator. Bradke Slin'n er Sh'ppinq Coordinator 414119 Authorized Signature Printed Name Title Dale THIS DOCUMENT, WITH AN ORIGINAL S GNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFIC A„ION, AND SUPPORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CCR§66268.7 Re 1lit 2