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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 at 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,II, and 111,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Liyernlnre National Laboratory PHONE: 925422-1925 SITE LOCATION: Corral Ilollniv RJ Tracy,CA 95376 PROFILE NUMBER: DOI'0120-1 IS THIS WASTE NON-HAZARDOUS?©NO, ❑YES(if YES,stop here and signldate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 0194145.i453.1K CA WASTE CODE(S):331,641,141_ IS THIS WASTE RESTRICTED? ❑YES ONO(if NO,stop here and signldate form at 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 111,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 III(A)to indicate haw waste is to be managed to conform with Land Disposal Restrictions. By selecting an item in Part Ifi(A), 1-3,you are making the certification I notification noted in Part Il. It. TYPE OF LDR NOTIFICATION 1 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 I personally have examined and am familiar with the waste thraugh 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 77de 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(dJ),I belie ve that the information I submitted is true,accurate and complete.I 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 966268.7(b)(5) /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 6924fd)A 1 believe that the information I 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. Ill.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check JAI Ie1 IQ lot appropriate Check 1.2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste RZ CCR 66268.29 a-m)and Treatment Standard lPart II) Effective Date Treatability Group1s166269.100(a)h•14) (From 22 CCRI 1.❑ ❑1 ❑2 ❑3 1126'90 Aqueous wastes containing metals(66268.29(a)&66268.10ola)l1II 1 66268.107 Table II CCW 2.❑ ❑1 02 03 516191 Auto shredder waste(66268-29(c)&66268,1001a)(3)1 2 66268.106 Table-A CCWE 3.❑ ❑1 C17 03 1!1191 Hazardous waste foundry sand 165268.291a)&66268.1oa(13)15)I 4 [6268.106 Table 1.8 CCWE 4.❑ ❑1 ❑2 03 111191 Fly ash,bottom ash,retort ash or beghouso waste 156268.29Ih1&66268.1Do(a;;8;1 7 65268.106 Table 1-0 CCWE 5.❑ ❑1 02 03 1110131 Saghouse waste from foundries 166268.29(i)&56268.100(a)18)I 8 66268.106 Table I-E CWE 6.❑ ❑1 02 03 311F33 Asbestos containing waste identified in section[66258.29Im)&66268 1001a)(131: 12 66268.114 7.❑ 01 02 133 Otherispecily): 13 Copies of applicable treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above. 1V. 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 omissions or a ors exist.I warrant that I am an authorized representative of the generator. SCOTT A.GRAHAM Shipping Coordinator 10125/19 Au prized 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 11 of 12