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California Land Disposal/Restriction Information NotificationlCertifcation 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 I. If the waste is non-hazardous or not restricted then complete only the applicable portions in Part I and sign l dale the Form at the bottom of page. Otherwise complete Part I,11,and III,and sign/date the Form at the bottom of page. L GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore Nafionnl L.ihoratary PHONE: 925422-1925 SITE LOCATION: Corral hollow Rd Trttcv,CA 95376 PROFILE NUMBER: 1101110010-I IS THIS WASTE NONHAZARDOUS?2)NO, ❑YES(if YES,stop here and sigNdate form at the bottom of page) GENERATOR'S EPA ID#: rA2890090002 MANIFEST#: 019445632.LIK CA WASTE CODE(S): 133.343 IS THIS WASTE RESTRICTED? ❑YES ®NO(if NO,stop here and sigNdate form at the bottom of page) THIS NOTIFICATION 8 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 It and III If only one applies,then III(A)is not required.For multiple certiffcationslnotifications,the appropriate choices from Part II(1-3)may be 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/notification noted in Part II, IL TYPE OF LDR NOTIFICATION/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:a 22 CCR§66268.7(a)(2) /certify under penalty of law that I 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 66269.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(d)).I believe that the information/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. ❑ 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 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 i 7 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 I submitted is true,accurate and complete./am aware that there are significant penalties for submitting a false certification,including the possibility of fine or impfisonment Ill.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (Al lel Ic) (D) appropriate Check 1.2.or 3 from Corresponding banes handling Information Prohibition Subcategory of Restricted waste(22 CCR 66268.29 a-m)and Treatment Standard {Part It) Effective Date Treatability Group(s)66268.100(al(1.141 (From 22 CCRI 1 ❑ ❑1 02 ❑3 1/26!90 Aqueous wastes conte ping metals[66268.29(a)&66268.100tall Ill 1 66268.107 Table 11 CCW 2.❑ ❑1 02 ❑3 51&91 Auto shredder waste 166268.291c)&66268.100(al(311 z 66268.106 Table-A CCWE 3.❑ 01 02 ❑3 11.1191 Hazardous waste foundry sand[65268.291e)&66268.100fa)(5)] 4 66268.106 Table 1-8 CCWE 4.❑ 01 02 ❑3 11191 Fly ash,bottom ash,retort ash or baghouse waste;66268.29(h)&66268.100(all8)I 7 66268.106 Table I-D CCWE 5.❑ 01 02 03 1!V91 Baghouse waste from foundries 166258.29(i)&66268.1001a)(9)1 8 66268,106 Table I-E CWE 6.❑ ❑1 02 ❑3 311193 Asbestos containing waste idem fred_n section 166268.29(m)&66268.1001all1311 12 66268.114 7.❑ 01 02 ❑3 Other[Specifyr 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 a rArsoxist warrant that I am an authorized representative of the generator SCOTT A.GRAHAM Shi in CDordinnfor 6/22/2020 Aut 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 11:02 Page I of II