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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 I 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 Liverm(ire_Nat[nttal 1.3hontfnry PHONE. 925422-1925 SITE LOCATION: Corral Ilollow_Rd,Tr:icv,CA 95376 PROFILE NUMBER: D011iI118051-1 IS THIS WASTE NON-HAZARDOUS 7 Z NO, ❑YES(if YES,stop her=and signldate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: o19s.155d5.1ai; CA WASTE CODE(S)-223_ IS THIS WASTE RESTRICTED? ❑YES (ENO(if NO,stop here and sigMdate 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 ❑(C)BOTH Check the appropriate boxes in Parts II and III.if only one applies,then III(A)is not required.For multiple certificationslnotifications,the appropriate choices from Part II (1-3)may be marked in Part I11(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions. By selecting an item in Part Iil(A), 1-3,you are making the certification 1 notification noted in Part 11, 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 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 3004141(42 U.S.C.Section 6924(dA/believe that the information 1 submitted is true,accurate and complete.Jr am aware that there are significant penalties 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 §66268.7(b)(5) 1 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 Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 30041042 U.S.C.Section 69241d)).i 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 fine or imprisonment III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check JAI IBI (Cl IDI appropriate Check 12,or 3 from Corresponding boxes handling infarmation Prohibition Subcategory of Restricted Waste 122 CCR 6525829 a-ml and Treatment Standard (Part ill Effective Date Treatability Group1s)66268.100(a)(1.14) 11'rom 22 CCRI 1.❑ ❑1 02 ❑3 1126190 Aqueous wastes containing metals I66268.29(a)&66268.1001a:-11}[ 1 66268.107 Table II CCW 2.❑ ❑1 02 03 5.1181 Auto shredder waste[66268-291c)&66268.100(a)13)1 2 66268.106 Table•A CCWE 3.0 Cl 1 ❑2 ❑3 111131 Hazardous waste foundry sand 166268.29(e)&66268.100(aIJ5): 4 56268.106 Table 1 B CCWE 4,❑ ❑1 02 03 Illl91 Fly ash,bottom ash,relort ash or baghouse waste[66268.29(hl&66268.1001a11e11 7 66268.106 Table 1•13 CCWE 5.❑ 01 ❑2 03 111,91 Baghousa wash from foundries 166268 291i&66268.1001al(911 8 65268.106 Table VE GAME 6.❑ ❑1 ❑2 ❑3 311133 Asbestos containing waste identified in sechon 166268.29(ml&66268.100I013)I 12 66268.114 7.❑ ❑1 ❑2 03 Other(Specify): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facl.ity 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' ns ore ars ist.l warrant that I am an authorized representative of the generator SCOTT A.GRAHAM Shimiine Coordinator I0?251[9 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. I V02 Page 08 of 12