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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 If the waste is non-hazardous or not restricted,then complete only the applicable portions in Part I and sign/date the Form at the bottom of page. Otherwise complete Part I,II,and ill,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National 1.aboralory PHONE: 92c,422-1925 SITE LOCATION: Corral(follow Road.Tracy,CA 95376 PROFILE NUMBER: n0110109P-1 IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop here and sigrl/date form at the bottom ofpage) GENERATOR'S EPA ID#: CA2 9002 MANIFEST#: 019445553.iJK _ _CA WASTE CODE(S)- 223 IS THIS WASTE RESTRICTED? []YES ®NO(if NO,stop here and sigNdate 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 It and III.If only one applies,then III(A)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 111(A),1-3,you are making the certification i notification noted in Part 11. It. TYPE OF LDR NOTIFICATION f CERTIFICATION yY ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 22 CCR§66268.7(a)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TRFr4TMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=22 CCR§66268.7(a)12) 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 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d)).i believe that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties forsubmitring 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 22 CCR ARTICLE 11 TREATMENT STANDARDS:=*22 CCR §66268.7(b)(5) /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 rtle 22,Division 4.5,Chapter 16,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 believe that the information I submitted is true,accurate and complete. lam aware that there are significant penalties forsubmitting a false certification,including the possibility of fine or imprisonment III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Beck I JAI (8) (Cl to) appropriate Check 1.2.or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCH 6626839 a-ml and Treatment Standard (Part 11) Effective Date Treetabllity Grouplsl 66126111.11001a)11-141 (From 22 CCRI i.❑ 01 ❑2 ❑3 1126!90 Aqueous wastes containing metals 166268.29(a)&66268.100(a)(1)l 1 66268.107 Table II CCW 2 ❑ 01 02 ❑3 sisal Auto shredder waste 166268.291e)&66268.100(a)(3)1 2 66268.106 Table-A CCWE 3 ❑ ❑1 ❑2 ❑3 1.1 i81 Hazardous waste foundry sand(66268.29[e)&66268.100(a;(5)) 4 66260.106 Table bH CCWE 4 ❑ 01 ❑2 ❑3 1r1f91 Fly ash,bottom ash,retort ash or baghouse waste f66268.291h)&66268.100(a)(8)I 7 66268.106 Table I-D CCWE 5 ❑ 01 ❑2 ❑3 111,51 Baghouse waste from foundries 166268.29ii)&66268.1001a)(9)1 6 66268106 Table I-E CWE 6 ❑ ❑1 ❑2 03 371Ft3 Asbestos containing waste identified in section[66266 29(m)&66268.100(a)(13)I 12 66268.114 7.❑ ❑l ❑2 ❑3 OtherlSpecify): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above. (V. GENERATOR AUTHORMATIONICERTIFICATION 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 ore e i I w ,Vlnt that I am an authorized representative of the generator. AAr SCOTT A.(.RAHAM Shippigg Coordinator11/0512019 A anted SignatW 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