COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

California Land Disposal/Restriction Information Notification/Certification Form This form is submitted -n 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 app:;cable non-RCRA hazardous waste'istings from CCR 66268.29 are noted below Complete a-I portions of Part 1 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,11,and III, and signldate the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR 8 WASTE STREAM GENERATOR'S NAME I.awrence Livermore Nafional Lahornlorc PHONE: 426422-1921 SITE LOCATION: Corral I lullmr ltd Tr:lcy,CA 95376 PROFILE NUMBER. D0110028-1 IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop here and signldate form at the bottom ofpage) GENERATOR'S EPA ID#: CA2890091)(102 MANIFEST* 019445546,1.1K CA WASTE CODE(S). 223 IS THIS WASTE RESTRICTED? []YES EINO(if NO,stop here and signldate fern at the bottom of page) THIS NOTIFICATION 8 CERTIFICATION IS BASEL]ON THE FOLLOWING WASTE STREAM INFORMATION ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE; ❑(8)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes:n Parts II and III.If only one applies,then III(A)is not requited.For multip a 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 Ili(A) 1-3,you are making the certification 1 notification noted In Part 11. It. TYPE OF LDR NOTIFICATION t 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:=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 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004 002 U.S.C.Section 6924(d)).l believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significantpenalties for submitting a false certification,including the possibility of 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 466268.7ib)(5) 1 certify under penalty of law that l 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(d)(42 U S.C.Section 69241d)).1 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 of a fine or imprisonment. 111.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IA) IBl (C) (DI appropriate Check 12,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a•ml and Treatment Standard (Part II) Effective Date Treatability Group1s)66268.1001ati1.141 (From 22 CCR) 1.❑ ❑1 02 03 1126M Aqueous wastes containing metals t66268,291al&66268.1001a11111 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 03 518,91 Auto shredder waste[66268.291cl&66268.100(a)(3)1 2 66268.106 Table-A CCWE 3.0 1 ❑1 02 03 Mal Hazardous waste foundry sand[66269 Niel&66268.100ia1(5l[ 4 66268.106 Table 1,11 CLINE 4.❑ ❑1 02 03 111V Fly ash,bottom ash,relorl ash or baghouse waste 166268,29(hl&66268.1001,1181) 7 66268.106 Table I•D CCWE 5.❑ ❑1 02 ❑3 111191 Baghouse waste from foundries(66268.291i)&66268.100ial(911 8 66268.106 Table I-E CWE 6.Cl ❑1 02 03 311f93 Asbestos containing waste idenlified in seclion 166268.29(ml&66268.1001a)l 13)] 12 66268.114 7.❑ 01 ❑2 03 Other(Specify]: 13 Caples 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' s or erre List.I rant that I am an authorized representative of the generator. SCOTT A.GRAHAM Shipping Coordinator 10/25/19 Authorized 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 03 of 12