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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 l and sign 1 dale the Form at the bottom of page. Otherwise complete Part I,II,and III,and sign/date 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: Corral Hallow Rd.Tracy,CA 95376 PROFILE NUMBER: D P0080SJ-1 IS THIS WASTE NON-HAZARDOUS?®NO, []YES(if YES,stop here and signldate farm at the bottom of page) GENERATOR'S EPA 1D#: CA2890090002 MANIFEST#: 005871009JJK CA WASTE CODE(S): 223 IS THIS WASTE RESTRICTED? ❑YES ®NO(if NO,stop here and signldate 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 IIIA)is not required.For multiple certifications/notifications,the appropriate choices from Part 11(1-3)maybe 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/notification noted in Part 11, It. TYPE OF LDR NOTIFICATION/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§66268.7(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 lit/e 22,Division 4.5, Chapter 19,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66269.32 or RCRA Section 300141042 U.S.C. Section 6924(d))•I believe that the information l submitted is true,accurate and complete.l am aware that there are significant penalties for submitting a false certification,including the possibility of 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 966268.7(b)(5) /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 77119 22,Division 4.5, Chapter 19,Articles 4 and 11 and at/applicable prohibitions set forth in CCR Tri/e 22,Section 6626532 or RCRA Section 3004 042 U.S.C. Section 69240).I believe that the information/submitted is true,accurate and complete.i am aware that there are significant penalties tar submitting a false certification,including the possibility of fine or imprisonment III.LDR NOTIFICATION i CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) IB) (C) 101 appropriate Check 1,2,or 3 from corresponding boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a•ml and Treatment Standard (Part 11) Effective Date Treatability Group(s)66268.10U(al(1-141 (From 22 CCR] 1 ❑ ❑1 El ❑3 1126190 Aqueaus wastes containing metals(66268.291 a;&66268.1001 a)I1)1 1 66I68,107 Table 11 CCW 2 ❑ M ❑2 ❑3 516191 Auto shredder waste l66268.29ic)&66268.100?a 11311 2 66268.106 Table-A CCWE 3 ❑ ❑1 ❑2 ❑3 1/1191 Hazardous waste foundry sand 166268.29:e)&56268.1001a1;5)I 4 66268.106 Table 1 B CCWE 4 ❑ ❑1 ❑2 03 1n191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29(hl&66268.100(a)18)1 7 66268.106 Table FD CCWE 5 ❑ ❑1 ❑2 ❑3 111191 Baghouse waste from laundries 166268.2901&66260.100{a119)f 8 66268,106 Table I-E CWE 6,❑ ❑1 ❑2 03 311193 Asbestos containing waste Identified in section 166258.29(ml&66268.100(al(1311 12 66268.114 7.0 ❑1 ❑2 ❑3 Otheri$peciryl: 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 that no omissions ore rs exist.I warrant that I am an authorized representative of the generator. BradleyZ��5�i: Slin'n Shipping Coordinator 414119 Authorized Signalure Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL S'GNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE RETXNED BY THE GENERATOR FOR A LEAST FIVE.(5)YEARS A5 PER 22 CCR§66268.7 Rev.11102 Page__L_of 13