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California Land Disposal/Restriction information Notification/Certification Form This form is submitted in accordance with the requirements of 22 CCR 56268 7(a) Chapter 18 wKch 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 rioted 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 i date the Form at the bottom of page. Otherwise complete Part I,11,and 111,and sign/date the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE: 725422-1925 SITE LOCATION. Corral Iiolloty Rd,Tracv,CA 95376 PROFILE NUMBER i OP00a4-1 IS THIS WASTE NON-HAZARDOUS 7 0NO. ❑YES(if YES,stop here and signldate form at the bottom ofpage) GENERATOR'S EPA ID#' CA28900901HI2 MANIFEST#: 0194a5fr32.1.1K CA WASTE CODE(S):-352,223 IS THiS WASTE RESTRICTED? ❑YES ONO(if NO,stop here and signldate form at the bottom ofpage) 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 apples,then Ill(A)is not required.For multiple certificationstnotiflcations,the appropriate choices from Part II(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 I notification noted in Part It. II. TYPE OF LDR NOTIFICATION I 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 MEET'S THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=�22 CCR 966268.7(a)(2) 1 certify under penalty of law that l 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)(42 U.S C.Section 6924(d))./believe that the information I submitted is true,accurate and complete.l am aware that there are significant penalties for submitting a false certification,including the possibility ofa fine or imprisonment. ❑ 3.>NOTIFICATION&CERTIFICATION: NDN-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) /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)(42 U.S.C.Section 69241d))./believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility ofa fine or imprisonment. 111.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (B) (Cl 101 appropriate Check 12.or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCA 66268.29 a•ml and Treatment standard (Part III Effective Date Treatability Groups)66258.1801a)(1-141 (From 22 CCR) 1.❑ ❑1 02 ❑3 1126190 Aqueous wastes contain ng metals:66268.291a;&66268.1001aH111 1 66268.107 table 11 CCW 2.0 01 ❑2 03 5.1191 1 Auto shredder waste(66268.29(cl&66268.100(a 104 2 66268.106 Table-ACCWE 3.0 01 02 03 11.11911 Hazard.us waste foundry sand;66268.291ei&66268 1001a;45il 4 66268.106 Table 1.9 CCWE 4.❑ 01 02 03 1.1191 Fly ash,bottom ash,retort ash or baghouse waste 166268.29(h)&66268.100(a)(8)l 7 66268.106 Table I•D C(WE 5.❑ 01 02 ❑3 111191 Baghousewaste from foundries'66268.2901&66268,1w10911 8 66266.106 Tablel•E CWE 6.❑ ❑1 ❑2 03 M193 Asbestos containing waste identified in section 166268 29(m)&66268,1001a)(131) 12 66268.114 7,0 ❑1 I]2 ❑3 Otherr5pecifyi; 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 exi5.I vyarrant that I am an authorized representative of the generator ?r SCOTT A.GRAIIANI Shipping Coordinptor 6/22/2020 Authorized 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 4 of 11