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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 I,11,and III,and sign/dale the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME f.a►rrence l.iccrmure N;uinnal[.abnrntun' PHONE: 925.122-1925 SITE LOCATION: Corral Ilollow Rd,Tracy,CA 9537G PROFILE NUMBER: DOP0104-1 IS THIS WASTE NON-HAZARDOUS 7❑x NO, ❑YES(if YES,stop here and sign/date,form at the bottom of page) GENERATOR'S EPA IEW C'A2890090002 MANIFEST* (11914554511K CA WASTE CODE(S):352,223_ IS THIS WASTE RESTRICTED? ❑YES NO(if NO,stop here and sign1dafe form at the bottom of page) THIS NOTIFICATION 8 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 III.If only one applies,then III(A)is not required,For multiple certifications/notifications,the appropriate choices from Part II(1-3)maybe 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 III(A), 1-3 you are making the certification/notification noted in Part II, 11. 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.i NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=>22 CCR§66268.7(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 I 1 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 30041d)(42 U.S.C.Section 6924(d))./belie ve that the information/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. ❑ 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 966268.7(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 i 1 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 30041d)(42 U.S.C.Section 6924(d)).1 believe that the information 1 submitted is true,accurate and complete.I am aware that there are significant penalties for submitting a false certification,including the possibility of fine or imprisonment. Ili.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check tilt ie) {C) rot appropriate Check 1.2,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted waste(22 CCR 66268.29 a-m)and Treatment Standard {Part Ill Effective Date Treatability Groups)66268.100(,)11-141 if'rom 22 CCR) I.Cl ❑1 ❑2 03 W&90 Aqueous wastes containing metals 166268.29(a)&66268.100(aH1ll 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 03 sr6M Auto shredder waste(66268.29(c)&66268.1001a)(3)1 2 66268.106 Table-A CCWE 3.❑ ❑1 ❑2 03 l/lel Ha2ardaus waste laundry sand 166268.29(e)&66268.100(a)(5)1 4 66268.106 Table 1-B CCWE 4.❑ ❑1 02 03 Illei Fly ash,bottom ash,retort ash at baghouse waste 166268.29(h)&66268.100ia)(8)) 7 66268.106 Table I-D CCWE 5.❑ ❑1 ❑2 03 Viel Saghouse waste Tram laundries 166268.29(1)&66268 1 X.a 11911 8 66268.106 Table I•E CWE 6.❑ ❑1 ❑2 ❑3 311 e3 Asbestos containing waste identilled in section(66268 29trt)&66268.1001ali13)I 12 66268.114 7.❑ ❑1 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 AUTHORIZATION/CERTIFICATION I 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 sions or err sexist.I warrant that I am an authorized representative of the generator SCOTT A.GRA I[X%I Shinnine Coordinator 10/25/19 _ Authorized Signature Printed Name T:tte 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 10 of 12