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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboralory Manifest No. 01944553611K Pursuant to 40 CPR 5268.7(a).1 hereby notify that this shipment contains waste restricted under 40 ChR Parr 268 Land Disposal Restrictions(LDR) 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 use Attachrneut I List Legend Cortstittierrt#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 i has been used ❑None ❑Check il'Anachment 2 has been used 3 ® ❑ Check if Atnuchrnent I has been used ❑None ❑Check il'Attachment 2 has been used 4 ® ❑ ❑Chick rf Attachmenl 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 ❑C12eck if Attachment 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION (� 1 his hazardous debris.as identified above on Line No(s) is subtecl to the ultemativr treatment standards of 40 CFR 6+268 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&CERTIFICATION n I Ise.;urntumrnated stnl_as Identified above on Lille'rots) is subject to the alternative treatment standards of•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 [❑does: ❑does not] contain listed hazardous waste &: [❑does ❑does not[ exhibit a characteristic of hazaudous waste & [❑is subject to + ❑complies with] sod trealment standards as prat ided by §N68 49(c) or the Lim%ersal lreatinem standards" %ore Corrstiments sr(h}eci io treamient are a,n constauents ltsled in 40('FR.Y268 48 t mversat iwal tent Stwrdardi that are reasonabh expected ter he present in an)'given vrhonc of conlanrrnated sort except flttartdr sekPimit stdfrdes vanatlnrni{t rrnc &are lxr.-sail a1 conce,uratrons greater than rear tnnes the universal treanneni standard D. LAB PACK(INCINERATION)NOTIFICATION& CERTIFICATION n HILS lab Pack,as identified abcn e tin I me Nols) is subject to the alternative treatment standards of40 CI-R 1268 42(c) "I cerut% under penalty of low than I personall) hale examined& um familiar tiiuh the waste& that the lab pack cuntams aril) ss:Lstec that hate ns:-t been excluded under Appendix IV to 40 0It fart 2t,8 & that this huh pack will he sent nu a combustion I'aC1110} uT comPlnrnLC wnh the altem.nne Ircalntent standards I'm lab packs at 40 C FR§268 42(c) 1 ant aware that there arc srknificallL penattici for submitting a false t ertrticallon.including the possibiln. 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 Vaension Describe below anT extension or variance that applies to!iris haste&nwhtde appitcable dates Uradlei Shninger ,4hipping Coordinator 10 8r7 ;�� 2019 ✓✓""Ge�enneer��at--o--r's Authoriz SI gnaturc Name&'I isle(Printed orT)ped) Date UWALKER Loa�:.111S AT10%11 2;.2