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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 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 complete only the applicable portions in Part I and sign 1 date the Form at the bottom of page. Otherwise complete Part 1,II,and III,and sign/date the Form at the bottom of page.(For RCRA wastes,use Clean Harbors RCRA FORMS) I. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laboratory PHONE: 925-422-1925 SITE LOCATION: Corral Hollow Road,Tracy.,California 95376 PROFILE NUMBER: DOP0031-1 IS THIS WASTE NON-HAZARDOUS? ®NO, El YES(if YES,slop here and sigrlfdate form at the boffom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: _005870832 JJK CA WASTE CODE(S): 751 IS THIS WASTE RESTRICTED? El YES ®NO(if NO,stop here and sigrVdate form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMICALIPHYSICAL ANALYSIS OF THE WASTE; ❑(8)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts II and 111.If only one applies,then III(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 1 notification noted in Part II. If. 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(aXl) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=�22 CCR§66268.7(a)(2) 1 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 rtle 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 3004042 U.S.C. Section 6924(d)).1 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 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 966268.7(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 rale 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 1 submitted is true,accurate and complete.f am aware that there are significant penalties for submitting a false certification,including the possibility of a fine or imprisonment. III.LDR NOTIFICATION I CERTIFICATION INFORMATION REQUIRED BY 22CCR Check (A) 181 i0 IDI appropriate Check 1.Z at 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste 122 CCR 66268.29 a•mi and Treatment Standard (Part Ill Effective Dais Trsatability Urouptsl 66268.1001a)(1.141 (From 22 CCR) 1.❑ Eli ❑2 ❑3 1126190 Aqueous wastes containing metals 166268.29101&66268.1001a)l1)1 1 66268.107 Table II CCW 2.❑ ❑1 ❑2 ❑3 51"1 Auto shredder waste 166268.29tc)&66268,10010)13)1 2 66268.106 table-A CCWE 3.❑ ❑1 ❑2 03 111191 Hazardous waste foundry sand(66268.29(e)&56268.100(a)(5)) 4 66268.106 Table 1•B CCWE 4.❑ 01 ❑2 ❑3 111191 Fly ash,bottom ash,retort ash or baghousa waste(66268.291h)&662 68.1001 a 118)1 7 66268.106 Table VD CCWE 5,❑ ❑1 ❑2 ❑3 111191 Baghouse waste from foundries t66268.290)&66268.1001a)(9)1 8 66268.106 Table I•E CWE 6.❑ ❑1 ❑2 ❑3 1 311193 Asbestos containing waste identified In section 166268.29(m)&66268.1001all13)I 12 66268.114 7.El ❑1 ❑2 ❑3 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 n this and all associated documents is true,complete,and accurate to the best of my knowledge and information,and that no omission or erro .I rran at I am an authorized representative of the generator. Scott A.Graham Shiopina Coordinator Authorized Signature7 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§66266.7 Rev.11102 Page 1 of 1