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California Land Disposafflestriction Information Notifcation/Certification Form This form is submitted in accordance with the requirements of 22 CCR 66258,7(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/date the Farm 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 Lawrence Livermore National Lahnrntory PHONE: 925422-1925 SITE LOCATION: Corral llollow Ktl Tracv CA 95376 PROFILE NUMBER DOP11131-1 IS THIS WASTE NON-HAZARDOUS?©NO, ❑YES(if YES,stop here and sigrl/date form at the bottom of page) GENERATOR'S EPA ID#: CA2890090M2 MANIFEST# U19445632.GIK CA WASTE CODE(S): 151 IS THIS WASTE RESTRICTED? ©YES ONO(if NO,stop here and sigrf/date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE; 0(B)GENERATOR KNOWLEDGE OF THE WASTE:;OR ❑(C)BOTH Check the appropriate boxes in Parts 11 and III. If only one applies,then III(A)is not requ-red.For multiple certificationstnotifiications,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 D.sposal Restrictions. By selecting an item in Part 111(A), 1-3,you are making the certification/notification noted in Part It. 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) XX 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS 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 ride 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C.Section 6924(4)).1 believe that the information/submitted is true,accurate and complete 1 am aware that there are significant penalties forsubmitting a false cerdrication,including the possibility of 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) I 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)).I believe that the information I submitted is true,accurate and complete.1 am aware that there are significant penalties forsubmitting a false certification,including the possibility of rine or imprisonment. III.LDR NOTIFICATION/CERTIFICATION INFORMATION REQUIRED BY 22CCR Chad (A) If11 CC) IDI appropriate Check 1,2,or 3 from Corresponding boxes handling information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a-m)and Treatment Standard (PartIq Effective Date Treatability Group(s)66268.1001ali1.14) (From 22 CCR) 1.❑ ❑1 02 ❑3 1126M Aqueous wastes containing metals 166268.29ial&66268.1001a)(111 1 66266.107 Table It CCW 2.❑ ❑1 02 03 5!8191 Auto shredder waste(66268.29(c)&66268.100(a)t3i1 2 66268.106 Tabte-A CCWE 3.❑ ❑1 02 03 111191 Hazardous waste foundry sand(66268.291al&66268.100(a115)) 4 66268.166 Table 1-B CCWE 4,❑ ❑1 02 03 111191 Fly ash,bottom ash,relort ash or baghouse waste 166268.29ihl&66268.100(s)(8)1 7 66268.106 Table 1.0 CCWE 5.❑ 01 02 03 Vti91 Baghouse waste from foundries 166268.29fil&66268.100(alt9)f B 66268.106 Table 1•E CWE S.121 ❑1 ❑x 2 ❑3 311193 Asbestos containing waste identified In section[66268.291m)&66268.1001al(131] 12 66268.114 7.❑ 01 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 omi1".-S or D ,e rt.I warrant that I am an authorized representative of the generator. SCOTTA.GRAIIAhl Shipping 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 11102 Page 10 of 11