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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/date the Form at the bottom of page. Otherwise complete Part 1,II,and III,and sign/date the Form at the bottom of page 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laborttory PHONE; 925422-1925 SITE LOCATION Corral Ilnllow itd.-rrslcv.CA 9=376, PROFILE NUMBER- D0110046-1 IS THIS WASTE NON-HAZARDOUS?El NO, ❑YES(if YES,stop here and sign/date farm at the bottom of page) GENERATOR'S EPA ID#: CA289(I0900(12 MANIFEST#: i11944S-.s45.I,IK CA WASTE CODE(S):512_ IS THIS WASTE RESTRICTED? []YES EINO(if NO,stop here and sigrildate format the bottom of page) 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 II and Ill,If only one applies,then III(A)is not required. For muttlple certificationslnotifications,the appropriate choices from Part It(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 III(A), 1-3,you are making the certification/notification noted in Part II. 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 966268.7(a)(2) l 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 U.S.C.Section 6924(d)l.1 believe that the information l submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a 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) 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(dl(42 U.S.C.Section 6924(d)l./believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Cheek iA) (e) ICL {Dt appropriate Check 112.or3from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 66269.29 a•m1 and Treatment Standard {part 11) Effective Date Treatability Groupe)66268.100(altl-141 (From 22 CCRJ 1.❑ ❑1 02 03 1126/90 Aqueous wastes containing metals 166268 291.1&66268.100tal{111 1 66266.1117 Table 11 CCW 2.0 ❑1 ❑2 03 518191 Auto shredder waste 166768,291c1&66268.104(al(31) 2 66268.106 Table-A CCWE 3.❑ 01 ❑2 ❑3 11191 Hazardous waste foundry sand[66268.29101&66268.100{.11511 4 65268.106 Table 1 e CCWE 4.❑ ❑1 ❑2 03 111A)l Ry ash,bottom ash,retortash or baghouse waste 166268.29(h)&66269.10010}(811 7 66268.106 Table 1-0 CCWE 5.❑ ❑1 ❑2 ❑3 111191 eaghouse waste from foundries 166268.29(i)&66266.100109)1 8 66268.106 Table I-E CWE 6.❑ 01 02 03 31193 Asbesim containing waste identified insertion(66268.29im)&66268.100(a1(1311 12 66260.114 7.❑ 01 02 03 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 omis Pions or Ors exist.I warrant that I am an authorized representative of the generator. SCOTT A.GRA IiAN1 Shipping Coordinator 110/25119 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 06 of 12