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California Land Disposal/Restriction Information NotfcationlCertiflcation Form This form is submitted in accordance with the requirements of 22 CCR 66268 711a) Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate Cal.fomia 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 on,y the applicable portions in Part I and sign 1 date the Format the bottom of page Otherwise complete Part 1,II,and III and signidate the Form at the bottom of page. L GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence 1.ivermore Nntional Lahnraton, PHONE 925422-1925 SITE LOCATION: Cnrral 111nllow Rd,Tracy,CA 95376 PROFILE NUMBER: LLNI:1.01.4-t iS THiS WASTE NON-HAZARDOUS 7®NO, ❑YES(if YES,stop here and sogn/date form at the bottom of page) GENERATOR'S EPA ID#: C 12890090002 MANIFEST# 0194a5547111K CA WASTE CODE(S) 141 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 III If only one applies,then III(A)is not required For multiple certifications/notifications,the appropriate choices from Part 11(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 in Part III(A) 1-3 you are making the certification 1 notification noted in Part 11. I1. 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:=::�22 CCR 566268.7(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 22,Section 66268.32 or RCRA Section 3004(d)142 U.S.C.Section 6824(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 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) 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 Tide 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6824(d)).i believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significant penalties forsubmitting a false certification,including the possibility of fine or imprisonment. 111.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check {AI [Bl [C) (DI appropriate Check 1,7,or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted waste J22 GCA 66268,29 a-m)and Treatment Standard (Part Il) Effective Date Treatability Groupls)6068.100(al(1-14) lFrom 22 CCR) 1.❑ 131 ❑2 ❑3 1261951 Aqueous wastes containing metals 1E6268.29fai&66268.100(a)l 111 1 66268.147 Table II CCW 2.❑ Ell ❑2 133 518,91 Aum shredder waste[66268 29(cl&66268.160(a)(3)l 2 66268.106 Table•A COVE 3,❑ ❑1 02 ❑3 Mal Hazardous waste foundry sand 166268.29(e)&66268.1DO(a)(5)1 4 615268.106 Table 1 8 CCWE 4.❑ Eli ❑2 03 Vial Fly ash,bottom ash,retort ash or baghouse waste 166268 291h)&66266.100(a)(Bil 7 66268.106 Table I CCWE 5.❑ ❑1 02 ❑3 VIM Saghouso waste from foundries 166268291s&66268.100ia)(9)) 8 66268.106 Table I-E CWE 8.❑ ❑1 ❑2 ❑3 3AG3 Asbestos containing waste identified in section 166268.29(mi&66268.100(a)(138 12 662681 W 7,❑ ❑1 ❑2 03 Otherispeeify): 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 AUTHORIZZATIONiCERTIFICATION 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 ami ions ar xist. ,rant that I am an authorized representative of the generator. 517.OTT A.GRA IIAR1 Shi in r Coordinator 10122!2.019 ut .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 02 of 02