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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboratory Manifest No. 005871056 JJK Pursuant to 40 CFR§269.7(a).I hereby notify that this shipment contains waste restricted under 40 CPR Pari 268 Land Disposal Restrictions(LDR). A. GENERAL WASTE NOTIFICATION Form EPA Waste Codes Waste Constituent Notification Line Profile No. &LDR Subcategories(if any) NAVW WW Check the "None"box or No. List codes or use Attachment I List Legend Constituent N or use Attachment 2 D003 I EWSF ® ❑ Check if Attachment l has been used ®None ❑Check if Attachment 2 has been used 2 ❑ ❑ Check if Attachment 1 has been used ❑None ❑Check if Attachment 2 has been used 3 ❑ ❑ Check if Attachment 1 has been used ❑None ❑Check if Attachment 2 has been used 4 ❑ ❑ Check if Attachment l has been used ❑None ❑Check if Attachment 2 has been used 5 ❑ ❑ Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been used 6 ❑ ❑ Check if Attachment 1 has been used ❑None ❑Check if Attachment 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION n This hazardous debris,as identified above on Line No(s). is subiect to the alternative treatment standards of 40 CFR 6268.45. The waste contains the following contaminants subject to treatment(check all that apply). ❑ Toxicity characteristic debris ❑Debris contaminated with listed waste ❑Cyan i dc reactive debris C. CONTAMINATED SOIL NOTIFICATION&CERTIFICATION n This contaminated soil,as identified above on Line NOW, is subject to the alternative treatment standards of 40 CFR§268.49(c) Complete the following: "1 certify under penalty of law that I personally have examined this contaminated soil&it[[]does!❑docs not]contain listed hazardous waste& [[]does/❑docs not] exhibit a characteristic of hazardous waste& ([]is subject to/[3complies with]soil treatment standards as provided by §268.49(c)or the universal treatment standards". Nate: Constituents subjecl to treatment are any constituents listed in 40 CFR§268 48 Universal Treatment Standards that are reasonably expected to be present in any given volume of contaminated soil, except fluoride,selenium,sulfides, vanadium&Vnc, &are present at concentrations greater than ten times the universal treatment standard. D. LAB PACK(INCINERATION)NOTIFICATION&CERTIFICATION F1 This lab hack.as identified above on Line No(s), is subject to the alternative treatment standards of 40 CI;R§268.42(c). "I certify under penalty of law that I personally have examined&am familiar Keith the waste&that the lab pack contains onl) wastes that have not been excluded under Appendix IV to 40 CFR Part 268 &that this lab pack will be sent to a combustion facility in compliance with the alternative treatment standards for lab packs at 40 CFR§268.42(c). 1 am aware that there are significant penalties for submitting a false certification.including the possibility of fine or imprisonment". E. EXTENSIONS&VARIANCES n This waste.as identified above on Line No(s). is not prohibited from land disposal&is subject to a deadline extension or variance e.g.,treatability variance,case-by-case extension. Describe below any extension or variance that applies to this waste&include applicable dates: Scott A.Graham,Shipping Coordinator 07 1 23 1 2019 Generator's Authorized Signature Name&Title(Printed or T cd) Date aWALUR-!.a0.NOTIFICATION 1123 93