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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 any the applicable portions in Part I and sign 1 dale the Form at the bottom of page Otherwise complete Part I,11,and III,and sign/date the Form at the bottom of page I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laborntory PHONE 925422-1925 SITE LOCATION Corral Ifollow Rd,Tracy,CA 95376 PROFILE NUMBER. DOP022OR-1 IS THIS WASTE NON-HAZARDOUS 7®NO, ❑YES fif YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#:_01944553111K 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)CHEM ICAUPHYS ICAL ANALYSIS OF THE WASTE; ®(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts 11 and III If only one applies,then III(Al is not requ'red.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 I notification noted in Part II. it. TYPE OF LDR NOTIFICATION t CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 22 CCR§66268 7(a)(1) XX 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=22 CCR§66268.71a)(2) 1 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 CCA Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S C.Section 6924(d)).1 believe that the information 1 submitted is true,accurate and complete. I am aware that there are significant penalties for submitting a false certitrcation,including the possibility of fine or imprisonment, ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITS;TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=*22 CCR §66266.7(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 certirrcatlon,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(042 U.S.0 Section 6924(dll.I believe that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties forsubmitting a false certification,including the possibility of a rine or imprisonment III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Cheery Ml (a) ICI lot appropriate Check 1.2,ora from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste l22 CCA 662SB29 a-m)and Treatment Standard (Part Ill Effective Date Treatability Groupfsl 66268.100(a)(1.14) lFrom 22 CCR) 1.❑ ❑1 132 ❑3 1126190 Aqueous wastes containing metals 166268.29{al&66268.100(a)(i 11 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 03 51"ll Auto shredder waste I66268.291[cl&66268,100(a 10)) 2 66268.106 Table.A CCWE 3.❑ ❑1 ❑2 ❑3 111191 Hazardous waste foundry send(66268.29(e)&66268,100(e)(5)I 4 66268.106 Table 1.0 CCWE 4.❑ 01 ❑2 ❑3 111091 Fly ash,bottom ash,retort ash or baghouso waste 166268.29(h)&66268.100MIS)l 7 66268.106 Table I•D CCWE l 5.❑ ❑7 ❑2 ❑3 111191 Baghousa waste from foundries(66268.2910)&66268.100(a)1911 8 66268.106 Table I•E CWE 6.10 1 ❑1 02 03 31183 Asbestos containing waste identified in section 166268.29(m)&66268.1001a)(1311 12 56268,114 7.0 1 ❑1 ❑2 ❑3 Other(Specifyl: 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified an 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 omit ' ns or e .I rranl that I am an authorized representative of the generator. SCOTT A.GRAHAM ShipVing Coordinator 09/23/19 Au orized 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 01 of 01