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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 California waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions of Part I. 1f the waste is non-hazardous or not restricted then complete only the applicable portions in Part I and sign 1 date the Farm at the bottoms of page. Otherwise complete Part I,II,and ill,and signldate the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence_Livermore National Laboratory_ PHONE: 925422-1925 SITE LOCATION: Corral Hollow Rd.Tracy,CA 95,376 PROFILE NUMBER: DOP0044-1 iS THIS WASTE NON-HAZARDOUS 7®NO, El YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#:. PA2Q9W90002 MANIFEST M __005871009JJK CA WASTE CODE(S): 223,352 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 III.If only one applies,then III(A)is not required.For multiple certifications/notifications,the appropriate choices from Part 11(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 1 notification noted in Part ll. II. TYPE OF LDR NOTIFICATION 1 CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TOrMEET 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) I certify under penalty of law that I 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 7i"de 22,Division 4.5, Chapter 18,Articles 4 and T 1 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 1 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 A5 TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=*22 CCR 166268.7(b)(5) 1 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 l I and all applicable prohibitions set forth in CCR Title 22,Section 66266[32 or RCRA Section 3004(d)(42 U.S.C. Section 69240)).1 believe that the information/submitted is true,accurate and complete./am aware that there are significant penalties(or submitting a false certification,including the possibility of a fine or imprisonment III.LDR NOTIFICATION 1 CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IA) 481 IC1 Il]! appmprlate Check 1,2.or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-m)and Treatment Standard (Pert IIi Effective Dale Treatability Group(s)66268.10G elil-141 iFrom 22 CCR) 1.❑ ❑1 ❑2 ❑3 1126190 Aqueous wastes containing metals 166268.29ial&65268.1001 a:tI)". 1 56268.197 Table rl CCW 2.❑ ❑1 ❑2 ❑3 5/8191 Auto shredder waste i66268.291cl&66268.1DOla)13)1 2 G6268.106 Tabre•A CCWE 3.❑ Eli ❑2 03 Vial Hazardous waste foundry sand 166268.29tel&66268.100ia)15;1 4 66268.106 Tab'e 1.6 CCWE 4.❑ ❑1 ❑2 ❑3 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29fh)&66268 14"I.::8'1 7 06268.108 Table I•G CCWE 5.❑ 131 ❑2 ❑3 111191 eaghouse waste from foundries{66268.29111&66268.100109:1 8 66258,106 Table I-E CWE 6.❑ ❑t ❑2 ❑3 311193 Asbestos containing waste identified in section(66268.29(ml&65268.17DIaa 1311 12 66268 114 7.❑ 01 ❑2 ❑3 Other ISpecifyl: 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the faci'ily Identified on the manifest referenced above. IV. GENERATOR AUTHORIZATION/CERTIFICATION I hereby certify that all information submitted in this and ail associated documents is true,complete,and accurate to the best of my knowledge and Information,and tTnK iissionns:ore exist.I warrant that I am an authorized representative of the generator. Bradley Slinin er ShIpRing Coordinator 44119 Authorized Sig azure 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. 11.102 Page 4 of 13