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Clean Harbors Environmental Services, Inc. California Land Disposal/Restriction Informatio= Notification/Certification Forn This farm is submitted in accordance with the requirements of 22 CCR 66268.7(a) Chapter 18 which restricts land disposal of certain hazardous wastes. Th appropriate Califomia waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions of Part I. If th waste is tion-hazardous or not restricted then complete only the applicable portions in Part I and sign I date the Form at the bottom of page. Otherwise complete Pa I,Il,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: DOP0065EL-1 IS THIS WASTE NON-HAZARDOUS 7®NO, DYES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 019445559_JJK _CA WASTE CODE(S):181 IS THIS WASTE RESTRICTED? [_—]YES ®NO(if NO,stop here and signldate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE: ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Paris II and III.If only one applies,then Ill(A)is not required.For multiple certifications/notifications,the appropriate choices from Pa 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,yG are making the certification/notification noted in Part II. II. 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(a)(1) ❑ 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 1 personally have examined and am familiar with the waste through analysis and testing through know/edgc 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 66258.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d1)./believe that the information l submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a line or imprisonment. ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SQ AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=:>22 CCR §66268.7(6)(5) I certify under penaltyof 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 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d)1.I believe that the information 1 submitted is true,accurate and complete.I am aware that there are significant penalties for submitting a false certification,including the possibility of fine or imprisonment. III.LDR NOTIFICATION i CERTIFICATION INFORMATION REQUIRED BY 221CCR Check (AI 161 (C) 10) appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-ml and Treatment Standard Wait Ill Effective Date Treatability Groupw 662f;8.100(al(1.141 (From 22 CCRI 1 ❑ O1 ❑2 03 1126W Aqueous wastes containing r letafs;66268 291ai&66268.100:an11] 1 66268.107 Table it CCW 2 ❑ Eli ❑2 ❑3 5WI Auto shredder wasto;6626a.29(c)&66268 100(a:13:1 2 66268,106 Table-A CCWE 3 ❑ ❑1 ❑2 ❑1 IM91 Hazardous waste foun6l ry sand:66268-291ei&66268 S00(al(511 4 66268,106 Table 1-B CCWE 4.❑ ❑1 ❑7 ❑3 111191 Fly ash,bottom ash,retort ash or bagh-use waste 166268.291ht&66268.100(a,181' 7 66268.106 Table 1.0 CCWr: 6 ❑ ❑s 02 ❑1 111+21 BoghOuse waste from foundries 166268.29111&66268 100(a)(9)) 8 66268.106 Table 6E CWE 6.❑ ❑1 I]2 ❑7 3153 Asbestos containing waste identified in section{66268.291 m)&66268.Xva1(131J 12 66268.114 7.❑ ❑1 ❑2 ❑- Other ispecifyl, 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 hereby certify that all.n#ormafton submitted:n this and a,l associated documents is true.complete and accurate to the best of my knowledge and Information and that no o� is's or ergsex! .I warrant that I am an authorized representative of the generator y- - --, 10 Z9 Zo/ ! . Scall A Graham 3-1il:l:ing Cyordi:iatar utF-iorized SI nature Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND AL SUPPORTING DATA, MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CCR§66268.7 Rev,11 0 Page 1 of 1