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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 I. It the waste is non-hazardous or not restricted then complete only the applicable portions In Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part I,11,and 111,and sign/date the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS) I. GENERAL INFORMATION REGARDING GENERATOR 8 WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laborato PHONE: 925422-1925 SITE LOCATION: Corral Hollow Road Tracy CA 95376 PROFILE NUMBER: DOP0220B-1GM IS THIS WASTE NON-HAZARDOUS?®NO, El YES(if YES,stop here and signidate form at the bottom of page) GENERATOR'S EPA IDM CA2890090002 MANIFEST ff: 005870952 JJK -CA WASTE CODE(S): 151 IS THIS WASTE RESTRICTED? ®YES []NO(if NO,stop here and sign/date form at the bottom of page) THIS NOTIFICATION 8 CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAUPHYSICAL 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 certificatianslnotifications,the appropriate choices from Part 11(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 11. 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(a)(1) 2.>NOTIFICATION&CERTIFICATiION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=>22 CCR§66288.7(a)(2) l 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 22,Section 6626832 or RCRA Section 3004(d)(42 U.S.C. Section 6924(d)).I believe that the information 1 submitted is true,accurate and complete l 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 §66268.7(b)(5) I certify underpenalty 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 Ttle 22,Section 66268.32 or RCRA Section 3004(dY42 U.S.C. Section 6924(d)J./believe that the information/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 {Ai lel {Cl {p1 appropriate Chack 1.2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66269.29 a•ml and Treatment Standard (Part til Effective Date Treatability Groupie)66269.100(a)(1.141 {From 22CCR) 1.0 ❑1 ❑2 ❑3 1126190 Aqueous wastes containing metals(66268.29(a)&66268.100(a)(111 1 66268.107 Table It CCW 2.❑ ❑1 02 ❑3 519191 Auto shredder waste 166268.291cl&66268,100faHM 2 66266.106 Table-A CCWE 3.❑ ❑1 02 03 111191 Hazardous waste foundry sand(66268.29(e)&66269.100ia)15)1 4 662611106 Table 1 B CCWE 4.❑ ❑1 02 ❑3 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29(hl&66268.1WICB13 7 66260-106 Table I D CCWE 5.❑ ❑1 ❑2 ❑3 111191 1 eaghouse waste tram foundries 166268.291i)&66268.100(all9)I a 66268.106 Table i E CWE 6.El ❑1 02 03 311193 Asbestos containing waste identified in section 166268.291m)&66268.100fa1(1311 12 66268.114 7.[3 Eli [32E33 Other(Specify): 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 sybmitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omissions or X st . rrant that I am an authorized representative of the generator. ' �� Scott A.Graham Shipping Coordinator 01/24/2019 AU&nlfe-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.11,02 Page- 1 of 1