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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 1 date 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 Liyerinore National Laboratory PHONE: 925422-1925 SITE LOCATION: Corral Ilollow Rd Tracy CA 95376 PROFILE NUMBER D01300119-11 IS THIS WASTE NON-HAZARDOUS?❑NO, ❑YES(if YES,stop here and sigrddate form at the bottom of page) GENERATOR'S EPA ID#: CA28900%002 MANIFEST#: 019445545.11.111: CA WASTE CODE(S): 134 IS THIS WASTE RESTRICTED? ❑YES 21NO(if NO,stop here and sigrVdate form at the bottom ofpage) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAUPHYSICAL 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(A)is not required For multiple certifications/notifications,the appropriate choices from Part 11(1-3)maybe 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/notification noted In Part II. II. TYPE OF LDR NOTIFICATION I 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:a 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 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 rtle 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.I am aware that there are significant penalties for submitting a false certification,including the possibility ofa 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 §66268.7Ib)(6) /certify under penalty of law that/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(dl(42 U.S.C.Section 6924(d))./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 ofa fine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check {A) let (C) tot appropriate Check 12,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-mi and Treatment Standard /Part 11) Effective Data Treatability Grouplsl 66268.1001a)11.14) (From 22 CCR) 1.❑ ❑1 ❑2 ©3 126M Aqueous wastes containing metals[66268,29fal&66268.1001a1(I Il 1 66268.107 Table II CCW 2.❑ ❑1 02 ❑3 518191 Auto shredder waste 166268.29(c)&66268.1DOW134 2 66268.106 Teble-A CCWE 3.❑ ❑1 02 ❑3 111,91 Hasardous waste foundry sand(66268.29(e)&66268.1001all511 4 66268.106 Table 1 B CCWE 4.❑ ❑1 [12 03 111191 Fly ash,bottom ash,reton ash or baghouse waste 156268.291 h1&66268.1001a)I8:1 7 66268.106 Table I-]CCWE 5.❑ ❑1 ❑2 03 111191 Baghouse waste from foundries[66268.291i)&66268.10Dlal(911 8 66268.106 Table 1 F CWE 6.❑ 01 02 03 1 771193 Ashestoscontaining waste identified insection 166268.29(m)&C52681AIa'l1311 12 66268.114 7.❑ 01 ❑2 03 Other[Specify): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facil;ty identified on the manifest referenced above IV. GENERATOR AUTHORIZATIONICERTIFICATION hereby certify that all infotion submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and information and that no omis ' ns or error xist.I warrant that I am an authorized representative of the generator. SCOTT A.GRAI1AM Shipping Coordinator 10125/19 A 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 11/02 Page 01 of 12