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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(a) Chapter 18 wh;ch 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 1 date the Form at the bottom of page. Otherwise complete Part I,II,and III,and sign/date the Form at the bottom of page, I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME l.awrerlce Livtnnurc National l.atloratory PHONE: 925422-1925 SITE LOCATION: Corral IInItow_Rd,"I'racy,,C,19537fr PROFILE NUMBER: DOP0120-1 IS THIS WASTE NON-HAZARDOUS 7 ONO, ❑YES(if YES,stop here and sign/date form at the bottom of page) GENERATOR'S EPA ID#: CA289009I1102 -MANIFEST* 01944563211K CA WASTE CODE(S): 331,281.141 IS THIS WASTE RESTRICTED? OYES ®NO(if NO,stop hers and sigrWate form at the bottom ofpage) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICAUPHYSICAL 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 applies,then III(A)is not required.For multiple certifications/notifications,the appropriate choices from Part It(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 II. 11. 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 St CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=�22 CCA§66268.7(a)(2) 1 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 66268.32 or RCRA Section 30041d)(42 U.S.C.Section 6924(d)j.I believe that the information I submitted is true,accurate and complete.1 am aware that there are signiricant penallies forsubmitt/ng a false certification,including the possibility of rine or imprisonment ❑ 3.>NOTIFICATION St CERTIFICATION: NDN-RCRA WASTE THAT HAS BEEN TREATED AT AN OFFSITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS:=�22 CCR 966268.7(b)(5) i certify under penalty of law that 1 personalty 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)).1 believe that the information i submitted is true,accurate and complete.1 am aware that there are signirrcant penalties forsubmitting a false certification,including the possibility of fine or imprisonment III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) (BI (Cl {D1 appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted waste(22 CCR 6626829 a-m)and Treatment Standard (Pert If) Effective bete Treatability Groupls)66268,1001a1(1.141 (From 22 CCR) 1.❑ 01 02 ❑3 1/26190 Aqueous wastes containing metals(66268.291x)&66268.100(aill)I 1 66268.107 Table II CCW 2.❑ 01 02 03 518191 Auto shredder waste 166266.291c)&66268.1001a)13)) 2 66268.106 Table-A CLINE 3.❑ ❑1 02 ❑3 111191 Hazardous waste foundry sand 166268.29(e)&66268.100ia1(5i1 4 66268.106 Table 1•0 CCWE 4,❑ ❑1 02 03 111191 Fly ash,bottom ash,retort ash or baghouse waste 166268.291h)&66268.100(8)(8)1 7 66268.105 Table lZ CCWE 5.❑ 1 ❑1 ❑2 03 111191 Baghouse waste from foundries 166268.29(4)&65268.100(a)(9)1 8 66268.106 Table I•E CWE 6.❑ 01 ❑2 03 311193 Asbestos containing waste identified in section(66268.291m)&66268.100(a)(131] 12 66268.114 7.❑ ❑1 02 03 Other ISpecifyl: 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 r e r�.I warrant that I am an authorized representative of the generator. SCOTT A.GRAHAM Shi in Coordinator 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,11/72 Page 9 of 11