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California Land Disposal/Restriction Information NotificationiCertification Form This farm is submitted in accordance with the requ rements of 22 CCR 66268 7(a) Chapter 18 which restricts and 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�n Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part I,II, and III,and signidate the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National lahoratory PHONE; 925422-1925 SITE LOCATION Ctirrnl ilnlloty RJ Tracv CA 95376 PROFILE NUMBER DOP0086-1 IS THIS WASTE NON-HAZARDOUS 7 El NO, ❑YES(if YES,stop here and sign1date,farm at the bottom of page) GENERATOR'S EPA ID#- CA2890090(NI2 MANIFEST#- 019d45545.1,iK CA WASTE CODE(S): 343_ IS THIS WASTE RESTRICTED? ❑YES ONO(if NO,stop here and sigrddate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEM ICALIPHYSICAL 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)1s not required.For multiple certificationsinotifications,the appropriate chokes from Part 11(1-3)may be marked in Part III(A)to indicate how waste is to be managed to conform with Land Disposal Restrict-ons. By seled'ng an item in Part II1(A), 1-3 you are making the certification 1 notification noted in Part It. 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:=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 22r Section 66268.32 or RCRA Section 3004(dl(42 U.S.C.Section 6924fd)1.I believe that the information I submitted is true,accurate and complete./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 OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=;�22 CCR §66268.7(b)(5) l certify under penalty of law that t 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)t42 U.S.C.Section 69240)).1 believe that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties forsubmitting a false certification,including the possibility of a fine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (Al to) ICI loi appropriate Check 1.2.or 31rom Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(22 CCA 66268.29 a•ml and Treatment Standard (Part Ill Effective pate Treatability Group(s)66268.1001a11i-141 (From 22 CCR{ 1.❑ ❑1 ❑2 03 1126!90 Aqueous wastes containing metals 166268291a&66268.100(a)(111 1 66268.107 Table 11 CCW 2.❑ ❑1 ❑2 03 518191 Auto shredder waste 166268.29(cl&66268.10a(a)(311 2 66268.106 Table-A CCWE 3.❑ ❑1 ❑2 03 1n191 Hazardous waste foundry sand 166268,291e)&66268.100(aN5H 4 66268.106 Table 1.0 CCWE 4.❑ ❑1 ❑2 03 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29(h)&66266.100(a)[8)1 7 66268.106 Table I•D CCWE 5.IJ ❑1 ❑2 ❑3 111191 Baghouse waste from foundries 166268.2901&6626BA001a)19)1 8 66268.106 Table i-E CWE 6.❑ ❑1 ❑2 ❑3 311193 Asbestos containing waste identified in section 16626B.291ml&6626B 1001413H 12 66268.114 7.0 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 aurisions or errors exist.I warrant that I am an authorized representative of the generator. SCOTT A.GRAFiANI Shipping Coordinator 10/25/19 u orized 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 t)9 of 12