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California Land Disposal/Restriction information Notification/Certification Form This form is submitted in accordance with the requirements of 22 CCR 66268.7(8) Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate California waste code(s)and applicable non-RCRA hazardous waste(.stings 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 signidate the Form at the bottom of page. I. GENERAL INFORMATION REGARDING GENERATOR 8 WASTE STREAM GENERATOR'S NAME Lawrence Livermore Nalional Laboratory PHONE: 925.422-1925 SITE LOCATION: Corral 1lollnw ltti,,Tracy,G%95376 PROFILE NUMBER: DOP0046-I IS THIS WASTE NON-HAZARDOUS?©NO. ❑YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID* CA2M)(190002 MANIFEST* 019445632111C CA WASTE CODE(S): 512 IS THIS WASTE RESTRICTED? []YES ONO(if NO,stop here and sigrWate format the bottom of page) 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 111 if only one applies,then Ill(A)is not required. For multiple certifications/notifications,the appropriate choices from Part 11(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 l notification noted in Part II. 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 MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=:.22 CCR§66268.71021 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 45 Chapter 78,Articles 4 and 77 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.I 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:=�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 78,Articles 4 and 77 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)J.1 believe that the information 1 submitted is true,accurate and complete.1 am aware that there are significant penalties forsubmitting a false certification,including the possibility of a fine or imprisonment III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) IB1 (C) ID) appropriate Check 12,or 3 from Corresponding bases handling Information Prohibition Subcategory of Restricted Waste 122 CCR 6626829 a-m)and Treatment Standard (Part Ill Effective Data Treatability Grouplsl 66268.100(alll•14) (From 22 CCR) 1.❑ ❑1 02 03 1126/90 Aqueous wastes containing metals 166268.29(a)&66268.100(a)11I1 1 66268.107 Table 11 CCW` 2.❑ ❑1 02 ©3 518191 Auto shredder waste(66268.29(c1&66268.100(a)(31) 2 66268.106 Table-A CC WE 3.❑ 01 ❑2 03 1/1191 Hazardous waste foundry sand(66268.29(e)&66268.100(a)15)1 4 66268.106 Table 1.8 CCWE 4,❑ ❑1 02 03 1/1/91 Fly ash,bottom ash,relort ash or baghouse waste 16626B.29(h)&66268.100(a)(B)I 7 66268.106 Table I-D CCWE 5.❑ 1 01 02 ❑3 111/91 8eghouse waste from foundries 166268.2911)&66268.100(a)i911 8 66268.106 Table I-E CWE 6.❑ ❑1 02 1-]3 311193 Asbestos containing waste Identified in section[66268.291m)&66268.100(a)(131] 12 66268.114 7.❑ ❑1 02 03 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 exis I warrant that I am an authorized representative of the generator. SCOTT A.GRAIIANI Shippino Coordinator 6/22/2020 Au prized Signature Printed Name Title Date IL- THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY CH 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 5 of 11