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California (_and 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 applicab'e 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 applicable portions in Part I and s gn i 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. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National LahoraWry PHONE: 925422-1925 SITE LOCATION: Corral Hollow Road,Tracy,Ca 95376 PROFILE NUMBER. DOP00A0-I IS THIS WASTE NON-HAZARDOUS?®NO, ❑YES(if YE$ stop here and signldate form at the bottom of page) LGENERATOR'S EPA ID#: CA1890090002 MANIFEST#: 0194.15586.I,fK CA WASTE CODE(S): 221 E RESTRICTED? ❑YES ®NO(if NO,stophere and signldate form at the bottom of page) TION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: AUPHYSiCAL ANALYSIS OF THE WASTE, ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts 11 and III.If only one applies,then III(A)Is not required.For multiple certificationslnoffications,the appropriate choices from Part 11(1-3)may be marked in Part 111(A)to indicate how waste is to be managed to conform with Land Disposal Restrictions. By selecting an item in Part II[(A), 1-3,you are making the certification I notification noted in Part II. It. TYPE OF LDR NOTIFICATION I CERTIFICATION F7STANDARDS�:=:, > NOTIFICTION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE 11 TREATMENT 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§662683(a)(2) 1 certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing through kno wledge 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 6924(d)).I 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 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:a 22 CCR §66268.7(b)(5) I certitlunder penalty of law that!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 16,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 69240))•1 believe 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 fine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (AI (B) (Cl (DI appropriate Check 1,5,or 3 from Coh esponding boxes handling Information Prohibition Subcategory of Restricted waste 122 CCA 66268.29 a-m)and Treatment Standard (Part Ili Effective Date Trestabillry Group(s)66268.100(+)(1-14) (From 22 CCRi 1.❑ ❑1 ❑2 ❑3 1126190 Aqueous wastes containing metals[66268.291al&66268.100{a](111 1 66268.107 Table 11 CCW 2.❑ ❑1 ❑2 ❑3 518191 Auto shredder waste 166268.29(c)&66268.100(al(3)I 2 66268.106 Table•A CCWE 3.❑ ❑1 ❑2 ❑3 IMS1 Hazardous waste foundry sand 1662681910)&66I68.100(ali511 4 66268.106 Table 1•B CCWE 4.❑ 01 ❑2 03 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268,29(hl&66268.100(a)(a)1 7 66268.106 Table I•D CCWE S.❑ ❑1 ❑2 ❑3 111191 Baghouse waste from foundries 166268.2911&66268.10(11a)19)I 6 66269.106 Table I-E CWE 6.❑ 01 ❑2 03 311193 Asbestos containing waste Identified in section(66268.29(m)&66268.100(013)1 12 66268.114 7,0 ❑1 ❑2 E13 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 errors exi .1 warrant that I am an authorized representative of the generator. SCOTT A.GRAHANT Shipping Coordinator 11/14/2019 Au onzed 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_L_of I