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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboratory Manifest No. 019445567 JJK Pursuant to 40 CFR§268.7(a),I hercbX notift that this shi ment contains waste restricted under 40 CFR Part 268 Land Disposal Restrictions(LDR). A. GENERAL WASTE NOTIFICATION Form EPA Waste Codes Waste Constituent Notification Line Profile No. & LDR Subcategories(if any) NWW WW Check the "Norte"box or No. List codes or use Atiaclutrent I List Legend Constitueut#or use Attachment 1 D003 I EWSF ® ❑ Check if Attachment I hos been used I None ❑Check if Attachment 2 has been used 2 ❑ ❑ ❑Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been used 3 ❑ ❑ ❑Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been used 4 ❑ ❑ ❑Check if Attachment 1 has been uscd ❑None ❑Check if Attachment 2 has been used 5 ❑ ❑ ❑Check if Attachment 1 has been used ❑None ❑Check if Attachment 2 has been used 6 1:1 ❑ ❑Check if Attachment I has been used ❑None ❑Check if Attachment 2 has been uscd B. HAZARDOUS DEBRIS NOTIFICATION This hazardous debris,as identified above on Linc No(s). I is subicct to the a]tcmativc treatment standards of 40 CFR 5268.45. The waste contains the following contaminants subject to treatment(check all that apply): ®Toxicity characteristic debris ❑Debris contaminated with listed waste ❑Cyanide reactive debris C. CONTAMINATED SOIL NOTIFICATION&CERTIFICATION F-1 This contaminated soil,as identified above on Line No(s)• is subject to the alternative treatment standards of 40 CFR§268.49(c). Complete the following: "I certify under penalty of law that 1 personally have examined this contaminated soil & it[❑docs!❑does not]contain listed harnrduts waste & [❑docs/❑docs not] exhibit a characteristic of hazardous waste & [[]is subject to l[]complies with] soil treatment standards as provided by §268.49(c) or the universal treatment standards". ,Vote: Constintems subject to treatment are any constilnents listed in 40 CFR§268.48 Universal Treatment Standards that are reasonably expected to be present in any given volume of contaminated soil, except fluoride, selenium, sulfides, vanadium&:inc,&are present at concentrations greater than ten times the universal treatment standard. D. LAB PACK(INCINERATION)NOTIFICATION&CERTIFICATION n This lab pack,as identified above on Line No(s), is subject to the alternative treatment standards of 40 CFR§268.42(c). "I certify under penalty of law that 1 personally have examined&am familiar with the waste&that the lab pack contains only wastes that have not been excluded under Appendix [V to 40 CFR Part 268 & that this lab pack will be sent to a combustion facility in compliance with the alternative treatment standards for lab packs at 40 CFR§268.42(c). 1 am aware that there arc significant penalties for submitting a false certification,including the possibility of fine or imprisonment". E. EXTENSIONS&VARIANCES {�This waste,as identified above on Linc No(s), is not prohibited from land disposal&is subject to a deadline extension or variance, e.g.,trentability variance,case-by-cast extension. Describe below airy extension or variance that applies to this waste&inchide applicable dates: Scott A.Graham,Shipping Coordinator 10 ! 30 1 2019 Generator's Aatharizcd Sianature Name&Title(Printed or T cd) Date DWILL KIMLM40TlFICATIOV 13.2174