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Clean Harbors Environmental Services, Inc. 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 1, If the waste is non-hazardous or not restricted then complete only the applicable portions in Part 1 and sign 1 date the Form at the bottom of page. Otherwise complete Part 1,II,and III,and sigrlldate the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS) I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE: 925-422-1925 SITELOCATION: Corral Hollow Road,Tracv CA 95376 PROFILE NUMBER: QOP022OB-1 IS THIS WASTE iVON-HAZARDOUS?®NO, ❑YES(if YES,stop here and sign/date form at the bottom ofpage) GENERATOR'S EFA ID#: CA2890090002 MANIFEST#: 005871035 JJK —CA WASTE CODE(S): 151 IS THIS WASTE RESTRICTED? ®YES C1 NO(if NO,stop here and sign1date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALiPHYSICAL ANALYSIS OF THE WASTE, ®(8)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 certiffcationslnotifications,the appropriate choices from Part It(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 I notification noted in Part Il. II. TYPE OF LDR NOTIFICATION i CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=:;,22 CCR§66268.7(ay1) ® 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:a 22 CCR§66268.7(a)(2) I 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 6626932 or RCRA Section 3004(d)(42 U.S.C. Section 6924(d)),I believe that the information 1 submitted is true,accurate and complete.f 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 22CCR ARTICLE 11 TREATMENT STANDARDS:=22 CCR 966268.7(b)(5) I 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 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Tide 22,Section 66268.32 or RCRA Section 3004(d)f42 U.S.C. Section 6924(d)).I believe that the information I submitted is true,accurate and complete./am aware that thereare significant penalties for submitting a false certi{cation,including the possibility of a fine or imprisonment. III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IA) l61 ic) io) appropriate Check 1,2,or 3from Carresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCA 66268.29 a-m)and Treatment Standard (Part Ill Effective Dote Trealabllity 13roup1s)66268,100tall1.141 (Pram 22 CCR) 1.❑ ❑1 ❑2 ❑3 1126190 Aqueous wastes containing metals[66288.291ai&66268.100(a)l l l l 1 66268.107 Table II CCW 2.❑ 01 ❑2 ❑3 518191 Auto shredder waste 166268.29(c)&66268.1001a1(3)I 2 66268.106 Table-A CCWE 3.❑ 01 ❑2 ❑3 111191 Hazardous waste laundry sand 166268.29(e)&66268AGO[olm 4 66268.106 Table 1-B CCWE 4.❑ 01 ❑2 ❑3 111191 Fly ash,bottom ash,retort ash or baghouse waste[66268.29ih)&66268.100(a)(811 7 66268.106 Table I•D CCWE 5.❑ ❑1 ❑2 ❑3 111191 1 Baghouse waste from foundries 166268.29(i)&66268.1001aH9)I 8 66268.106 Table I-E CWE 6.0 ❑1 ®2 ❑3 311W Asbaslas containing waste identifiad In section[66268.29(m)&66268.100(al(IM 12 66268.114 7.❑ ❑1 ❑2 ❑3 Dther(Specily): 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 informationsub 'tied in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omissions ore i I.1 nt that I am an authorized representative of the generator. Scott A.Graham Shi in Coordinator 06/18/2019 onz Aut ed Signature Printed Name Title Date 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 1 of 1