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I1 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 111,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Latvrencc I.iircrtnnre National Lahnratory PHONE. 921422-1925 SITE LOCATION Currin Ilot low ILL"1'racv.CA 95376 , PROFILE NUMBER: DOP0044-1 IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YES,stop hem and sigMdate fort at the bottom of page) GENERATOR'S EPA ID#: C\28911090002 MANIFEST#: 019445545.1,11: CA WASTE CODE(S).223,181,352_ IS THIS WASTE RESTRICTED? ❑YES ©NO(if NO,stop here and sign/date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEM ICALIPHYS ICAL ANALYSIS OF THE WASTE. ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR E!(C)BOTH Check the appropriate boxes in Parts II and III.If only one app les,then III(A)is not required For multiple certifications/notifications,the appropriate choices from Part II(1-3)maybe marked in Part III(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions By se=ecling an item in Part III(A), 1-3,you are making the certification i notification noted in Part It. It. TYPE OF LDR NOTIFICATION f CERTIFICATION Fil> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT si. ANDARDS:=22 CCR§66268 7(a)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE i 1 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=oL 22 CCR§66268.7(a)(2) f 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 i<tle 22,Division 4.5 Chapter 18 Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22 Section 66168.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d))•1 believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certilication,including the possibility of 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 CCR §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 18 Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 US,C.Section 69241d)),I believe that the information I submitted is true,accurate and complete.1 am aware that there are signit<cant penalties for submitting a false certification,including the possibility of fne or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22C CR Check [A) (6) (C) lot appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a•ml and Treatment Standard (Pert Ill Effective rate Treatability Growls)66268,108islo-141 {prom 22 CCR) 1.❑ ❑1 02 03 1125'90 Aqueous wastes containing metals 166268.291a)&66268.1001a)(111 1 66268.107 Table If CCW 2.❑ ❑1 02 03 5r8r91 Auto shredder waste 166268.29(c)&66268,100(a:1311 2 66168.106 Table•A CCWE 3.❑ ❑1 02 ❑3 111191 Hazardous waste foundry sand 166266.29(e)&66258.100ia)1511 4 66268.106 Table 1-B CCWE 4.❑ ❑1 02 03 111!91 Fly ash,bottom ash,ruion ash or baghouse waste(66268.291h)&66268.100(a)(113 7 66260.106 Table 10 CCWE 5.❑ ❑1 ❑2 03 111[91 8aghouse waste from ioundr es 166268.29Ii)&66266 100 a 1911 8 66260.106 Table I•E CWE 6.❑ ❑1 [:12 03 311x93 Asbestos containing waste identified in section 10268.29(ml&66268.100(a)(1311 12 66268.114 7.0 01 02 ❑3 Other(Specify): 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 omi 'ons or a rs exist.I warrant that I am an authorized representative of the generator SCOTT A.GRAHAM Ship in Coordinator IQ!?5119 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 11102 Page 05 of 12