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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 PartI. If the waste is non-hazardous or not restricted then complete only the applicable portions In Part I and sign I date the Fort at the bottom of page. Otharmse comp3ete Part I,II,and III,and sign/date 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 SITE LOCATION: 7000 East Avenue Livermore.CA 94550 PROFILE NUMBER: DOP0031-1 IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop here and sigrVdate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 005870998_JJK —CA WASTE CODE(S) 261 751 IS THIS WASTE RESTRICTED? ®YES ❑NO(if NO,stop here and sigrVdate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAL/PHYSICAL ANALYSIS OF THE WASTE: ®(B)GENERATOR KNOWLEDGE OF THE WASTE:OR ❑(C)BOTH Check the appropriate boxes in Parts II and Ill.If only one applies,then IIIA)is not required.For multiple certifications/notifications,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 11. 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(aXl) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=*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 specired 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 3004(W42 U.S.C.Section 69240A I believe that the Information Isubmitted is true,accurate and complete.I am aware that there are significant penalties for submitting a false certifrcatlon,Including the possibility of 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 §6626B.71b)(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 Title ZZ Section 66268.32 or RCRA Section 30041042 U.S.C.Section 69240.1 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. Iii.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (Al IBI ICI (DI appropriate check 1.2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-ml and Treatment Standard (Part til Effective Date Treatability Group(sl 66268 100(01 141 (From 22CCRI 1.❑ ❑1 ❑2 ❑3 112W 90 Aqueous wastes containing metals 166M.291a1&66268 100(all lit 1 i 66268.107 Table 11 CCW 2.❑ ❑1 02 ❑3 518191 Auto shredder waste 1166268.291c1&66268.1(0(a)(311 2 66268.106 Table-A CCWE 3.❑ 01 ❑2 ❑3 111191 Hazardous waste foundry sand I66268.29(el&66268.1001a)[511 4 66268.106 Table 1 B CCWE 4,❑ ❑1 ❑2 ❑3 111191 Fly ash,bottom ash,retort ash or baghouse waste(66268.291h)&66268,100(al(e)l 7 65268.106 Table 1 D CCWE 5.❑ ❑1 ❑2 ❑3 111191 Baghouse waste from foundries[66268.29(iI&66268.1001a1(911 8 66268.106 Table I E CWE 6.❑ ❑1 ❑2 ❑3 311193 Asbestos containing waste Identified in section(66268.291m1&6626a.1001a)11311 12 66268.114 7•❑ []1 02 103 0tiler[Specifyl: 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 errors exist.I warrant that I am an authorized representative of the generator. 1 T Authorized Si nature 1 Printed Nam ' T Title,� Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MIDST 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__!--of 1