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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboratary Manifest No. 01944553611K Pursuant to 40 CPR 5268.7(a).1 hereby notify that this shipment contains waste restricted under 40 CFR Parr 268 Land Disposal Restrictions(LD1) A. GENERAL WASTE NOTIFICATION Form EPA Waste Cozies Waste Constituent Notification Line Profile No. & LDR Subcategories(if any) NWW WW Check the "Axone"box or No. List codes or nese Attachrneut I List Legend Cortstittieert#or use Attachment 2 1.002 I Transfer ❑ ❑Chick if Attachment I has been used ®None ❑Check if Attachment 2 has been used 2 ® ❑ ❑Check if Allacliment 1 has been used ❑None ❑Check il'Anachment 2 has been used 3 ® ❑ Check if Attachment I has been used ❑None ❑Check il'Attachment 2 has been used 4 ® ❑ ❑Chick d'Altudimenl 1 bas been used ❑None ❑Check if Attachment 2 has been used 5 ® ❑ ❑Check if Attachment I has been used ❑None ❑Check il'Attachruent 2 has been used 6 ® ❑ ❑Check il'Allachnrent I has been used ❑None ❑Clieck if Attachment 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION (� 1 his hazardous debris.as identified above on Line No(s) is sub[cu to the ultemativr treatment statidards of 40 CFR 6268 45 The waste contains the follow ing contaminants subject to treatment(check all than apply) ❑1omcity characteristic debris ❑Debris contaminated with listed waste ❑Cyanide reactitic debris C. CONTAMINATED SOIL NOTIFICATION S CERTIFICATION n I Ise.;urntuminated stnl_as identified above on Lille trots) is subject to the alternative treatment standards 01.10 CI-R§268 494,c) C ornplele the following: "I cerul'y render penaln of low that I personally hme examined this contaminated still& It [❑docs: ❑does riot] contain listed hazardous waste &: [❑docs ❑does not[ exhibit a characteristic of hazsudous waste & [❑is subj"t to + ❑complies with] sod trealment standards as prat ided by §N68 49(c) or lite universal lreatinent standards" %ore Corrstiments sr(h}eci m treamient are air constauents ltsled in 40('FR.Y 268 48 t mversat iwal tent Stwrdardi that are reasonabh expected it he present it an)-given vrhoic of conlanratated sort except flttartdr sekPimit stdfrdes vanatlnrni{t-tit &are txr.-sail a1 coice,uratrons greater than reir times the universal treanneni standard D. LAB PACK(INCINERATION)NOTIFICATION& CERTIFICATION n HILLS lab Pack,as identified abets e un l me Nols) [s subject to the alternative treatment standards of40 CI-R 1268 42(c) "I cerut% under penalty (4'1;1%% that I personall) hale examined& um familiar tiiuh the waste&I that the lab pack cuntams ant) ss:Lstec that hole 111--t been excluded under Appendix IV to 40 Cf It fart 2t,8 & that this hili pack will he sent nu a combustion facility ui comPlnrnLC wnh the alttm.nite Ircalntent standards I'm lab packs at 40 C FR§268 42(c) 1 ant aware that there arc srknificatit penattici for submitting a false t ertiticallon.including the pussibilax of fine or imprisonment" E. EXTENSIONS& VARIANCES n This uastc_as identified above on Line No(s). is not prohibited from land disposal&is subject to a deadline extension or variance e g.,trealabiln) %ariance.CasC-b}-CaSC Vaenslon Describe below anT exieision or variance that applies to!tris haste&nwhtde appitcable dates Uradlei Simenger ,4hippmg Coordinator 10 8r7 ;�� 2019 Generator's Authoriz SI gnaturc Name&'I itle(Printed or T) ed) Dale UWALKER Lha�:.111;AT10%112;.2