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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 appl cable 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 appl'cable portions in Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part I,11, and 111,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR 8 WASTE STREAM GE=NERATOR'S NAME Lawrence Live rtnore Nifional I.ahoralon- PHONE: 925427-1925 SITE LOCATION: Corral Ilollnw Rd.Tracv,CA 95376 PROFILE NUMBER 5.195-2551 IS THIS WASTE NON-HAZARDOUS?ANO, ❑YES(if YES,stop here and signldate form at the bottom of page) GENERATOR'S EPA ID#- CA28911090002 MANIFEST* 019115515111 CA WASTE CODE(S):181_ IS THIS WASTE RESTRICTED? DYES 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 Ili If only one applies,then III(A)is not required.For multiple certificationstnotifications,the appropriate choices from Part II(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 1 notification noted in Part 11. II. TYPE OF LDR NOTIFICATION 1 CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=5 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(x)(2) /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 IS 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))•I believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certifrcatron,including the possibility of line 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 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(d)f42 U.S.C.Section 69241d)).l believe that the information/submitted is true,accurate and complete.I am aware that there are signirrcant penalties forsubmitting a false certification,including the possibility of a fine or imprisonment 111.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check JAI IBI (Cl (DI appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste(Z2 CCR 6626829 a-m)and Treatment Standard (Part III Effective Data Treatability Group(s)66268.100(x)(1•14) (From 22 CCRI I.Cl ❑1 ❑2 ❑3 1126190 Aqueous wastes containing metals 166268.29(x)&66260.100(a)i111 1 66268.107 Table II CCW 2,❑ ❑1 ❑2 0 51'8/91 Auto shredder waste 166268.29(c)&66268.1001ali311 2 66268.106 Table-A CCWE 3.❑ ❑1 ❑2 ❑3 111191 Hazardous waste(oundry sand I66268.29(e)&66268.1001a)15)1 4 66268.146 Table 1.0 CCWE 4.❑ ❑1 02 03 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29(h)&66268.100(at(all 7 66268.146 Table 1-13 CCWE 5.❑ ❑1 ❑2 03 111191 Baghouse waste from foundries 166168 291i)&66268.1001a)1911' 8 66268.106 Table I-E CWE 6.❑ [31 ❑2 ❑3 311193 Asbestos containing waste identified in section(66268.29im)&66268.100taHi3)1 12 66268.114 7.❑ 01 ❑2 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 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 omissions or erro exist.I warrant that I am an authorized representative of the generator. SCOTT A.GRAHAM Shinning Coordinator 10/25/19 Authorized Signature Printed Name Title Date THtS 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 12 of 12