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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 portions of Part I. If the waste Is non-hazardous or not restricted then complete only the applicable portions in Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part I,11,and III,and sigrlldate the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME_ Lawrence Livermore National Laboratory PHONE: _925-422-1925 SITE LOCATION: Conal Hollow Rd.Tracy,CA 95376 PROFILE NUMBER: DOP0010-1 IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop here andsign/date form at the bottom of page) GENERATOR'S EPA ID#._CA289009.0002MANIFEST#: 0Q5871009JJK CA WASTE CODE(S): 134,223.343 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; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts II and 111.If only one applies,then III(A)Is not required.For multiple certificationslnotificadons,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 III(A),1-3,you are making the certification i notification noted in Part It. It. TYPE OF LDR NOTIFICATION f CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=*22 CCR§66268.7(axi) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED;-22 CCR 466268.7(a)(2) 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 litre 22,Division 4.5, Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 6626&32 or RCRA Section 3004(dl(42 U.S.C. Section 6924(d)).1 believe that the information l submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a line 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 466268.7(6)(5) /certify under penalty of law that/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)).1 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 Cheek IN IB► ici ID) appropriate Check 1,2,or 3 from Corresponding boxes handling Information Prah(bidon Subeetegary of Restricted waste 422 CCR 68258.29 a-ml and Treatment Standard iPart Ill Effective Date Treatability Group(s)GS268.1001e1{1.14) (From 22 CCR) 1.❑ Eli ❑2 ❑3 1!26190 Aqueous wastes containing metals[66268 291a)&66268.1001a)l111 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 ❑3 518!91 Autoshredderwaste[66268.29(cl&66268.100(a)13)I 2 66268.106 Table-ACCWE 3.0 El ❑2 ❑3 111191 Hazardous waste fou ndry sand 166268.291e1&66268.100(al(5)1 4 66268.106 Tablet-BCCWE 4.❑ ❑1 02 ❑3 111191 Fly ash,bottom ash,retort ash or baghouse waste(66268 291h)&66268.1001a)1811 7 66268.106 Table I.D CCWE 5.❑ 01 ❑2 ❑3 111!91 Baghouso waste from foundries 166268.29(i)&66268.1001al 1911 8 66268.106 Table I E CWE 6.❑ ❑1 ❑2 03 3!1193 Asbestos containing waste identified In section 166268.291m1&66268.1001a)(13)I 12 66268.114 7.❑ ❑1 ❑2 03 Other 18pecify); 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 AUTHORIZATIONICERTIFICATiON I 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 thaZnolss'llons or erro st.I warrant that I am an authorized representative of the generator. Bradley Slinin er Shipping Coordinator 414119 Authorized Signatu a 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 4 of 13