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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. If the waste Is non-hazardous or not restricted then complete only the applicable portions In Part I and sign I date the Form at the bottom of page. Otherwise complete Part I,II,and III,and signidate the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOF'S NAME Lawrence Livermore National Laboratory PHONE: 925-422-1925 SITE LOCATION: Corral Hallow Rd.Tracy,CA 95376 PROFILE NUMBER: DOP0117-1 IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 005871009JJK- CA WASTE CODE(S): 141 IS THIS WASTE RESTRICTED? ❑YES ®NO(if NO,stop here and sigrildate 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 certificationslnotifications,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 1 notification noted In Part II. If. 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 566268.7(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 Title 22,Division 4.5, Chapter 16,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 orRCRA Section 3004(d)142 U.S.C. Section 69240)).l believe that the information f 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. ❑ 3.>NOTIFICATION&CERTIFICATION: N0N•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 §66268.71b)(5) /certify under penalty of law that l 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 66268.31 or RCRA Section 3004(d)(42 U.S.C. Section 6924(dd.l believe that the information I submitted is true,accurate and complete.I 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 Check (Al 181 ICI (D) appropriate Check 1.2.or 3from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCR 66260.29 a-ml and Treatment Standard (Part Ill Effective Data Treatability Rroupls)66268.100(al(1 141 (From 22CCRi 1.❑ ❑1 ❑2 ❑3 1726190 Atlueous wastes containing metals 166268.29(al&66268.10o(aH1)l 1 66268.107 Table II CCW 2.❑ 131 ❑2 ❑3 5091 1 Auto shredder waste 166268.291cl&6620.1001a)(3)] 2 OMAN Table-A CCWE 3.❑ ❑1 ❑2 03 1fi191 Hazardous waste foundry sand(66268.29(e)&66268.1DD(a)1511 4 66266.106 Table 1-B CCWE 4,❑ ❑1 02 ❑3 10191 Fly ash,bottom ash,retort ash or baghouse waste I66268.29(h)&6626am aia)(a)I 7 66268.106 Table I-D CLW! 5.❑ ❑1 ❑2 ❑3 111(91 Baghouse waste from foundries 166268.29(i)&66268.100(al(9)I a 66266.106 Table I-E CWE 6.❑ ❑1 ❑2 ❑3 31t193 Asbestos containing waste identified in section 166268.291m)&66268.100(6)(13)1 12 66268.114 7.0 1 ❑1 ❑2 03 Other(Specifyi: 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 or errq nt that I am an authorized representative of the generator. Bradley Slinin er Shloping Coordinator 4/4119 Au orized Signature Printed Name Title Data 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 11 of 13