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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 1. 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,II,and III,and sign/date the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'SNAME l.anrcncc Ltcermore luttonal l.ohorntury PHONE: 925422-1925 SITE LOCATION: Corral Iinllaiy Rd.Traci-,CA 91376 PROFILE NUMBER. 1.LN1-LCl'2-1 IS THIS WASTE NON-HAZARDOUS 7®NO, ❑YES(if YES,stop here and sign/date fonn at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 019.45.547.1,11( CA WASTE CODE(S): 331 IS THIS WASTE RESTRICTED? []YES ®NO(if NO,stop here and sign/date 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 111.If only one applies,then IIIA)is not required For multiple certifications/notifications,the appropriate choices from Part II(1-3)maybe marked in Part III(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions By selecting an item :n Part IIl(A). 1-3.you are making the certification/notification noted in Part II. ll. TYPE OF LDR NOTIFICATION I CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT STANDARDS:a 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 966268.7(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 3004(d)(42 U.S C.Section 6924(d)).1 believe that the information l submitted is true,accurate and complete.l 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) 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)(42 U.S C. Section 6924(d)),1 belleve that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties fo r submitting a false certification,including the possibility of a fine or imprisonment III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) {BI ICI 1Dl appropriate Check 12.or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a mi and Treatment Standard (part 11) Effective Data Treatability Group(sl 66266100(altl-141 IFrorn 22 CCR) 1.❑ 01 ❑2 ❑3 1126,90 Aqueo,s wast^s containing metals 165268 2:i(a)&66266 19tt(a 11): 1 66268.107 Table 11 CCW 2.0 ❑1 ❑2 ❑3 5/"1 Auto shredder waste 166268.2%c)&66268100(a)(31: 2 66268.106 Tab,o-ACCWE 3 ❑ 01 ❑2 ❑3 171191 Hazardous waste foundry sand 166268.29fe1&66268 1D0la'15'I 4 66268.106 Tab'e 1 8 CCWE 4 ❑ ❑1 ❑2 ❑3 1.191 Fly ash,bottom ash,retort ash or batihouse wosto'66268 2g1hl&66268.1WaH&l 7 66268.106 Table 1-D CCWE 5 ❑ ❑1 ❑2 ❑3 1.191 Baghouse waste from foundries 166266.29(w&66268.100i a:l9)1 6 66268.106 Table I-E CWE 6 ❑ 01 02 ❑3 31193 Asbestos containing wasta identified in settion 166268 291--1)&66268 1001a)113i1 12 66268.114 7 ❑ 01 ❑2 ❑3 Other{Specifyf: 13 Copses of applicable treatment standards and waste analysis data(where avaitab e.)are maintained at the facility identified on the manifest referenced above 1V. GENERATOR AUTHORIZATIONICERTIFICATION t hereby certify that all information submitted in this and all associated documents is true,complete and accurate to the best of my knowledge a-id information and that no omissions or ors exist I warrant that I am an authorized representative of the generator SCOTT A.GRAHAM Sh in Cnnrdinntor _ t)?�22TU _ ._ 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 11102 Page 01 of 02