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California[_and Disposal/Restriction Information NotificationiCertifl:cation 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 1. 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,II,and III,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 95376 PROFILE NUMBER: DOP0104-1 IS THIS WASTE NON-HAZARDOUS?®NO, []YES(if YES,stop here and sign4date form at the bottom ofpage) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 005871009JJK CA WASTE.CODE(S): 172.223 IS THIS WASTE RESTRICTED? []YES ®NO(if NO,stop here and sigrl/date Corm 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 It and Ill.If only one applies,then 11I(A)is not required.For multiple certificationsinotifications,the appropriate choices from Part II(1-3)maybe marked in Part III(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions. Sy selecting an Item in Part III(A), 1-3,you are making the certification l notification noted in Part II. It. TYPE OF LDR NOTIFICATION 1 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§66268.7(a)(2) 1 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 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 30040)(42 U.S.C. Section 6924(d)).1 believe that the information 1 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 AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=:�22 CCR §66268.7ib)(5) /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 Title 22,Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66269.32 or RCRA Section 3004(d)(42 U.S.C. Section 5924(d)).l believe that the information 1 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. III.LDR NOTIFICATION 1 CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (B► IC1 IDI appropriate Check 1.2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-m)and Treatment Standard (Part Ill Effactive Date Treatability Group(e)662SE1.t001e)(1.141 IFrom 22 CCA) 1.❑ ❑t 02 ❑3 1126190 Aqueous wastes containing metals[66268.29(ai&66268.1001a111i1 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 ❑3 5!8191 Auto shredder waste 166268.2910&66268.100(all3il 2 66268.106 Table•A CCWE 3.❑ 13, ❑2 ❑3 111191 Hazardous waste foundry sand[66268.29(el&65268.100(a)1511 4 66268.106 Table 1.8 CCWE 4.❑ ❑1 ❑2 ❑3 111!91 Fly ash,bottom ash,retort ash or baghouse waste[66260.29(h)&66268.1001a1I8il 7 66268.106 Table I D CCWE 5.❑ 01 ❑2 03 1!1191 Baghouss waste from foundries 166268.291ii&66268.1001a1(9)1 8 66268.106 Table I•E CWE 6.❑ ❑1 ❑2 ❑3 311193 Asbestos Containing waste identified In section(6626B.291mi&66268.100(a)(1311 12 66268.114 Ll7.❑ Of ❑2 ❑3 OtheriSpecifyl: 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 fissions ara rs ' t.I warrant that I am an authorized representative of the generator. B rile Slinin er Shipping Coordinator 414119 Aut onzed Signature Printed Name Title Date 1. 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 10 of 13