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LDR NOTIFICATION FORM Generator Name Lawrence Livermore National Laboratory Manifest No. 019445632 JJK Pursuant to 40 CFR§268.7(0.I hereby notify that this shipment contains waste restricted under 40 CFR Part 268 Land Disposal Restrictions(LDR). A. GENERAL WASTE NOTIFICATION Form EPA Waste CodesWaste Constituent Notification Line Profile No. &LDR Subcategories(if any) IY�VW WW Check the "None"box or No. List codes or use Attachment 1 List Legend Constituent#or use Attachment 2 D0111,130061 QOP0013-1 ❑ Check if Attachment 1 has been used ®None ❑Check if Attachment 2 has been used D002 2 DOP0015-1 El Check if Attachment I has been used ®None ❑Check if Attachment 2 has been used D008,D006,DOI l 3 DOP0036-1 ❑Check if Attachment t has been used ®None ❑Check if Attachment 2 has been used DO11,D008,D006 4 DOP0036A-1 ® ❑ ❑Check if Attachment I has been used ®None ❑Check if Attachment 2 has been used DOO1 LQ 5 DOPOO54-1 ® ❑ ❑Check if Attachment 1 has been used ®None ❑Check if Attachment 2 has been used D009 HM NIIIR 6 DOP0071-IA ® ❑ El Check if Attachment 1 has been used ®None ❑Check if Attachment 2 has been used B. HAZARDOUS DEBRIS NOTIFICATION n This hazardous debris,as idcntilied above on Line No(s). is subiect to the altemative treatment standards of 40 CFR 6268.45. 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 n 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 l personally have examined this contaminated sail& it[[:]does/❑docs not]contain listed hazardous waste& [❑does/❑docs not]exhibit a characteristic or hazardous waste& [[3is subject to/❑complies with] sail treatment standards as provided by §268.49(c) or the universal treatment standards". Nate: Constituents subject to treatment are any constituents 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&zinc,&are present at concentrations greater than ten times the universal treatment standard D. LAB PACK(INCINERATION)NOTIFICATION&CERTIFICATION This lab pack,as identified above on Line No(s). 7-9 is subject to the alternative treatment standards of 40 CFR§268.42(c). "I certify under penalty of law that I personally have examined&am familiar with the waste&that the lab pack contains only wastes that have not been excluded under Appendix IV 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). I am aware that there are significant penalties for submitting a false certification,including the possibility of fine or imprisonment". E. EXTENSIONS&VARIANCES n This waste,as identified above on Line No(s), is not prohibited from land disposal&is subject to a deadline extension or variance, e.g.,treatability variance,case-by-case extension. Describe below any extension or variance that applies to this waste&include applicable dates: Scott A.Graham,Shipping Coordinator 06 1 23 / 2020 Generator's Authorized Signature Name&Title Printed or Typed) Date D WALKEILLDRNOTIFICATION.11,11.93