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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboratory Manifest No. 00571016 JJK Pursuant to 40 CFR 5268.7(a).l hereby notify that this shipment contains waste restricted under 40 CFR Part 268 Land Disposal Restrictions(LDR), A. GENERAL WASTE NOTIFICATION Form EPA Waste Cosies Waste Constituent Notification Line Profile No. &LDR Subcategories(if any) NWW WW Chuck the "Nome"bos or No. List codes or use Attachment 1 List Legend Constituent#or use Attachment l D003 I. EWSF ® ❑ Check if Attachment l has been used ®None ❑Check if Attachment 2 has been used 2 ❑ ❑ El Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been used 3 ❑ ❑ ❑Check if Attachment I has been used ❑ None ❑Check if Attaclunent 2 has been used 4 ❑ ❑ Check if Attachment t has been used ❑None ❑Check if Attachment 2 has been used 5 ❑ ❑ Check ifAttachment I has been used ❑None ❑Check if Attachment 2 has been used 6 ❑ ❑ Check if Attachment I has been used ❑None ❑Chuck if Atlaclunent 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION F1 This hazardous debris.as identified above on Line No(s), is subiect to the alternative treatment standards of 40 CFR 5268 45 The waste contains the following contaminants subject to treatment(check alt that apply): ❑ Toxicity characteristic debris ❑Debris contaminated with listed waste ❑Cyanide reactive debris C. CONTAMINATED SOiL NOTIFICATION&CERTIFiCATiOiN n This contaminated soil,as identified aboveon Linc No(s). is subject to the alternative treatment standards of 40 CFR§268 49(c). Complete the fallowing: "I certify under penally of law that I personally have examined this contaminated soil&it[[:Jdocs/[]does not]contain listed hazardous waste &[[:]does I❑dors not] exhibit a characteristic of hazardous waste&[Elis subject to 1[]complies wills] soil treatment standards as pr vidLd by 5268.49(c)or the universal treatment standards". ,Vote: Constituents subject to treaunent are airv constituents listed in ate CFR§268,48 Unirersal Treaunew Standards that are reasonahly expected to be present in any given voharre of contaminated soil, except fluoride.selenium,snrllides. varaditon&zinc.ce are present at concentrations greater thair ten limes the universal Ireatnent standard. D. LAB PACK(INCINERATION)NOTIFICATION&CERTIFICATION F1 This lab pack,as identified above on Line No(s), is subject to the alternative trwtmcnt standards of 40 CFR 5268.42(c). "I certify under penalty of law that I personally have examined&am familiar with the waste&that the lab pack contains only wastes that have not been excluded under Appendix IV to 40 CFR Part 268 &:that this lab pack will be sent to a combustion iacility in compliance will)the alternative treatment standards for lab packs at 40 CFR y268.42(c). l am aware that there are significant penalties for submittinE a false certification,including the possibility of fine or intprisonmenl". E. EXTENSIONS&VARIANCES F1 This waste,as identifier!above on Linc No(s), is not prohibileKd from land disposal&is subject to a deadline extension or variance, e,g.,trealability variance,case-by-case extension. Describe below aav extension or variance that applies to dris waste&include applicable dates: 14 Scott A.Graham,Shipping Coordinator 04 1 25 1 2019 cneratoFs Alllhori7i.ed Signature Mame&Title(Printed ora ed) Dale b1%ALKElLCI)R N J-Inch l ION.t t±,v%