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C W logy US Ecololm Inc.Land DisRgsal Restriction Form Generator: Universal Sar ica Recydi int EPA ID Number: CALOOD355717 Waste Stream or Profile Number: I Manifest Doc.No. Line No. Waste Is a: ❑ Wastewat r(<1%TSS and TOC) 23 Non-wastewater ® Debris Notification Frequency; ® Or a Time ❑ Required with Each shipment Shipment EPA Waste Codes(from 40 CFR 269.40) D001 t UHC°s(Underlying Hazardous Constit ents 40 CFR 268.481)? Yes Q No If yes,list: Does a subcategory apply per 40 CFR 268.40? ❑✓ Yes No If yes,list: High TOC ignilable Charai teristic Liquids Constituents requiring treatment in I DDI-S,F039,debris,and alternate soils? Yes ® No If yes,list: ; ® See Profile for analysis(if any) A, ❑ Restricted Waste Meets Tres ant standards(40 CFR 268.7(a)(3)) The restricted waste Identili J above meets the treatment standards in 40 CFR 268.40 or Alternative LDR treatment standards for contaminated golf 40 CFR268.49 and can be landfill disposed without further treatment. if applicable,under 268.49, contaminated soil ®does m ®does not contain listed hazardous waste and®does or ❑does not exhibit a characteristic of hazardous u aste and complies with the soil treatment standards as provided by 268.49(c)or the universal treatment standards. I certify under penalty of WA that I personally have examined and am familiar with the waste through analysis and testing or through knowledge of the waste to support this cartffi ation that the waste complies with the treatment standards specified In 40 CFR Part 268 Subpart D.I believe that the Information i submitted is trise,accurate and complete.I am aware that there are significant penalties for submitting a false certification,including the possibility of a fine and Im nmant B. Restricted Waste Treated To rreatment Standards 140 CFR 268.7(b)(1)&268.7(b)(2)) The treatment residue,or -act of such residue,or the restricted waste Identified above has been tested to assure that the treatment residues or extract meet all applicable treatmeni ndards in 40 CFR 268.40 and/or performance standards in 4D CFR 268.45. 1 certify under penalty of lay that i personally have examined and am familiar with the treatment technology and operation of the treatment process used to support this caftfia don. Based on my Inquiry of those Individuals immediately responsible for obtaining this information,I believe that the treatment process has beer operated and maintained properly so as to comply with the treatment standards specified in 40 CFR 268.40 without impermissible dilution of the prohibited waste. I am aware there are significant penalties for submitting a false certification,including the possibility of fine and imprisonment. C, ❑ Restricted Waste Soil treatet to alternative standards(40 CFR 268.7(b)(4)) 1 certify under penalty of lau that I have personally examined and am familiar with the treatment technology and operation of the treatment process usedto support this cartifica bn and believe that It has been maintained and operated properly so as to comply with treatment standards specified In 40 CFR 268.49 without lmperm Ib1e dilution of the prohibited waste&lam aware that there are significant penalties for submitting a false certification, Including the possibility of a Ine and Imprisonment D. ❑ Restricted Waste Decharecte ized But Requires Treatment For UNC(40 CFR 268.7(b)(4)IN)) I certify under penalty of I"that the waste has been treated in accordance with the requirements of 40 CFR 268.40 or 268.49 to remove the hazardous characteristic.This declarearisted waste cor(tains Underlying Hazardous Constituents that require furtheir treatment to meet treatment standards,I am aware that there are signift i nt penalties for submitting a false certification,including the possibility of a fine and imprisonment. E. ® Restricted Waste Subject To reatment(40 CFR 2683(e)(2)} The restricted waste ldendfi 14 above must be treated to the applicable treatment standards in 40 CFR 268.40,or treated to comply with applicable prohibitions set forth in Part 8.32 or RCRA Section 3004(d)and 268.49(c). If applicable,under 268.49,thisi contaminated sod does or does not certain Mad hazardous waste and does or 0 does not exhibit a characteristic of haxardus W ssW and Is subject to the soil treatment standards as provided by 268.49(c)or the universal treatment standards. F. ❑ Hazardous Debris Subject To rreatment(40 CFR 268A5) This hazardous debris ident'rfi 4 above must be treated to the alternative treatment standards In 40 CFR 268.45. I i 1 certify and warrant that the Inform ition that appears on this form,and appended documents,is true and correct.I have correctly Indicated how my waste is to be managed In actor ante with 40 CFR 268.My certification Is based on personal examination of the information submitted,or is based on my Inquiries of those indhril uals responsible for obtaining the information, Authorized Signature: Title: Agent Date: 04/08/20 H n bcateizoty list, Part 26,8.48 and Revised=15 1