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LAND DISPOSAL RESTRICTION AND SUBPART CC WASTE <br /> DETERMINATION CERTIFICATION <br /> Generator Name : Lodi Memorial Hospital West Manifest Doc. # : 013525650FLE <br /> GeneratorUSEPAID# : CAL000107712 State Manifest # : <br /> INSTRUCTIONS : In Column 1 , identifyall USEPAhazardous waste codes that applyto this waste approval/shipment. In Column 2 , indicate the <br /> appropriate Treatability Group , Non-WasteWater (NVVW) or WasteWaster (VWV) for each waste code . In Column 3 , in <br /> accordance with Subpart CC , identifywhether or not your waste contains > 500 ppmw VOC (YES or NO) . In Column 4 , enter <br /> the appropriate Subcategory key # from Table - 41 If applicable , and also enter "Debris " in Column 4 if the waste is debris that <br /> will be treated using one of the alternative treatment technologies provided by26845 . In Column 5 , reference the appropriate <br /> Waste Management paragraph (s ) from Table -3 . In Column 6 , enter the Reference Number(s ) from Table - 1 for all regulated <br /> constituents associated with Subpart CC VOC 's , F001mF005 , F039 , D001 -D043 . If the waste is a California List waste , <br /> complete the boxes below and identify the Reference Number(s ) of the appropriate California Listconstituent(s ) identified in <br /> Table -2 . <br /> Check this box if using a continuation sheet. <br /> MANIFEST 1 . WASTE 2. NWW or 3. SUBPART CC 4. SUBCATEGORY 5 . WASTE 6 . REGULATED <br /> LINE ITEM # CODE( S) WW YES/NO MANAGEMENT CONSTITUENTS <br /> 1 DO11ID024 NVWV NO <br /> I hereby certify that all information submitted in this and all associated documents is complete and accurate to the best of myknowledge and <br /> information . <br /> Signature Title <br /> Print Name Date <br /> ECOFLO LDR Revision 7 December 17 , 2003 <br /> Page 1 of 1 <br />