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California Land Disposafflestriction 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 listings from CCR 66268 29 are noted below.Complete all portions of Part 1. If the waste is non-hazardous or not restricted then compete only the applicable portions in Part 1 and sign 1 date the Form at the bottom of page. Otherwise complete Part I,11, and III,and sign/date the Form at the bottom of page 1. GENERAL INFORMATION REGARDING GENERATOR 8 WASTE STREAM GENERATOR'S NAME Lttivreuce l.iverninre Nttlional Lnhoralnry _PHONE: 925--122-1925 SiTE LOCATION. Corral hollow RJ,Tracy,CA 95376 PROFILE NUMBER DOIIOII14-1 IS THIS WASTE NON-HAZARDOUS 7❑NO, :1 YES(if YES,stop here and sign/date,form at the bottom ofpagejl GENERATOR'S EPA ID#- CA28911090002 MANIFEST* 019445632.1.1K CA WASTE CODE(S): 172,223- IS 72,223IS THIS WASTE RESTRICTED? ❑YES (D NO(if NO,stop here and sign/date 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 II and III.If onj'y one applies,then III(A)is not required.For multiple certifications/notifications,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 1 notification noted in Part Il. U. 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:=:t�22 CCR §66268.7(a)(2) I certify under penalty oflaw 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 specirred in CCR Title 22,Division 4.5,Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66266.32 orRCRA 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 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 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 orRCRA Section 3004(d)(42 U.S.C.Section 6924(d))I 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 Chock {AI (a) (C) tot appropriate Check 12.or3from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66258.29 a-m)and Treatment Standard (Part IQ Effective Data Treatability Groupfs)66268.100(st(1.14) IFrom 22 CCR) 1.❑ ❑1 02 03 1126/90 Aqueous wastes containing metals[66268.291a)&66268.100(a1111] 1 66268.107 Table II CCW 2.❑ 01 02 03 518191 Auto shredder waste[66268.291c)&66268.1001ai1311 2 66268.108 Table-A CCWE 3.❑ ❑1 02 ❑3 1!1!91 Hazardous waste foundry sand 166268.29(o)&66268.100(all5il 4 66268.106 Table 1.6 CCWE 4.❑ ❑1 02 03 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268,291h)&66268.1001alt8)) 7 66268.106 Table 1.0 CCWE 5.❑ ❑t 02 03 Vim Saghouse waste from foundries[66268.29(1)&66168.100(a)(911 8 66268.106 Table I-E CWE 6.❑ 01 ❑2 03 311193 Asbestos containing waste identified in section[66268.29(m)&66268.100Ia)(1311 12 66268.114 7N;4 ❑ ❑1 02 C13 Other(Specifyi: 13 plicable 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 omissi ns or errors ex' t.I warrant that I am an authorized representative of the generator. SCOTT A.GRAHANI Shipping Coordinator _ 6/22/2420 Authorized Signature Printed Name Title Date THISDOCUMENT, 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 8 of 11