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California Land Disposai/Restriction Information NotifIcationlCertification Farm 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 i date the Form at the bottom of page Otherwise complete Part I,II,and III,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lstlsrcncc Livermore\:Hiurtal l.alelratory PHONE: 925422-I935 SiTE LOCATION: Corral hollow Rd Tracy,CA 95376 PROFILE NUMBER: DOP0010-1 iS THIS WASTE NON-HAZARDOUS?©N0, ❑YES(if YES,stop here and signldate form at the bottom ofpage) GENERATOR'S EPA ID#: CA28900911002 MANIFEST#: 019445n-4A.LIK CA WASTE CODE(S) 343.133,132 IS THIS WASTE RESTRICTED? ❑YES ANO(if NO,stop here and signldate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE:OR E..: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 i notification noted in Part II. It. 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) 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 i 1 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(042 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 certification,including the possibility ofa fine or imprisonment ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFFSITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=22 CCA §66268-7(b)(5) I certify under penalty of law that I 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 78,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))./believe that the information/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 W Ml (C) IDI appropriate Check 1.2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted waste(22 CCR 662611.29 a-ml and Treatment Standard (Part III Effective Date Treatability Group(s)66268 1001a)11•14) (From 22 CCR) 1.❑ [:11 ❑2 03 1126M Aqueous wastes containing morals 166268.29(a)&66268.100(11)1111 1 66268.107 Table It CCW 2.0 01 02 03 SON Auto shredder waste 166268.29(.1&66258.100(a11311 2 66260.106 Table-A CCWE 3.❑ Cl1 C12 ❑3 111191 Hazardous waste foundry sand;66268 291 e)&66268.1001a)(5)1 4 66268.106 Table 1.9 CCWE 4.❑ Eli 112 ❑3 111191 Fly ash,bottom ash,retort ash at baghouse waste(66268.291h)&66268.1001a)180 7 66268.106 Table I-D CCWE 5.❑ 1 ❑1 02 03 sitl91 Baghouse waste from foundries;66268.291i;&66268.10WaR911 8 66268.106 Table I-E CM 6.❑ ❑1 ❑2 03 311/93 Asbestos containing waste identified in section[66268.291ml&66268.100(al(13)1 12 66268.114 7.❑ j 01 02 03 OtherlSpecily)• 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above IV. GENERATOR AUTHORIZATiONICERTIFICATION 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 omiss( qs or error xis arrant that I am an authorized representative of the generator, SCOTT A.GRAIIIANI Shipping Coordinator 10125119 Au orized Signature Printed Name Title Date It- 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§65268.7 Rev 11102 Page 02 of 12