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American Ecology Corporation Land Disposal Restrictlon Form
<br />GENERATOR.J�qc L0q15tx 5 U,4 SFW.Aavl Lcgdji(s 41' EPA LD. NUMBER; 1!�4LQ%DJ3A79
<br />WASTE STREAM or PROFILE NUMBER:070i377 ID MANIFEST DOC. N0.00625: 3A LINE NO.9 N' f
<br />WASTE IS A: ❑ WASTEWATER �UON-WASTEVYATER ❑ DEBRIS
<br />NOTIFICATION FREQUENCY: ❑ ONETIME REQUIRED WITH EACH SHIPMENT
<br />EPA WASTE CODES (from 40 CFR 268.40): -DC0
<br />UNDERLYING HAZARDOUS CONSTITUENTS (from 40 CFR 268,48):
<br />A. ❑ Restricted Waste Meets Treatment Standards (40 CFR 268,7(a) (3))
<br />The restricted waste Idenlliled above meals the treatment standards In 40 CPR 268,40 or Alternative LDR treatment
<br />standards for contaminated soil 40CFR268.49 and can be landfill disposed without further treatment. i have attached all
<br />supporting analytical data, where available.
<br />I certify under penalty of law that I personally have examined and am familiar with the waste through analysis
<br />and testing or through knowledge of the waste to support this certification that the waste complies with the
<br />treatment standards apeclfled In 40 CPR Part 268 Subpart D. I believe that the Information I submitted Is true,
<br />accurate and complete, I am aware that there are significant penalties for submitting a false certification,
<br />Including the posalbility of a fine and Imprisonment,
<br />B, ❑ Restricted Waste Treated To Treatment Standards (4.0 CFR 288,7(b) (1) & 268,7 (b) (2))
<br />The treatment residue, or extract of such residue, or the restricted waste Identified above has been tested to assure that the
<br />treatment residues or extract meet all applicable treatment standards In 40 CFR 266.40 and/or performance standards In 40 CFR
<br />268.45. 1 have attached all supporting analytical data, where avallabie,
<br />I certify under penalty of law that I personally have examined and am familiar with the waste through analysis
<br />and testing or through knowledge of the waste to support this certification that the waste compiles with the
<br />treatment standards specified in 40 CPR Part 268 Subpart D. I believe that the Information I submitted Is true,
<br />accurate and complete. I am aware that there are significant penalties for submitting a false certification,
<br />Including the possibility of a fine and'Imprisonment
<br />C, ❑ Restricted Waste With Technology Based Treatment Standards (40 CFR 268,7(b) (4))
<br />1 certify under penalty of law that I personally have examined and am familiar with the treatment technology and
<br />operation of the treatment process used to support this certification and that based on my Inquiry of those
<br />Indlvlduals Immediately responsible for obtaining this Information. I believe that the treatment process has
<br />been operated and maintained properly so as to comply with the treatment standards specified In 40 CFR 268,40,
<br />without Impermissible dilution of the prohibited waste. I am aware that there are significant penalties for
<br />submitting a false certification, Including the possibility of a fine and Imprisonment,
<br />E),
<br />❑ Restricted Waste Decharacterized But Requires Treatment For UHC (40 CFR 268.9)
<br />1 certify under penalty of law That the waste has been treated In accordance with the requirements of 40 CFR 268.40 to remove
<br />the hazardous characteristic. This decharacierized waste contains Underlying Hazardous Constituents (UHC) that require
<br />further treatment to meet the universal treatment standards. I am aware that there are significant penalties for submitting a false
<br />certlflcallon, including the possibility of a fine and Imprisonment.
<br />E. Restricted Waste Subject To Treatment (40 CFR 268,7(a) (2))
<br />The reslricleci waste Identified above must be treated to the applicable treatment standards In 40 CFR 268,40, or treated to
<br />comply with applicable prohibitions set forth In Part 268,32 or RCRA Section 3004(d). I have attached all supporting analytical
<br />data, where available,
<br />F. Hazardous Debris Subject To Treatment (40 CFR 268,45)
<br />This hazardous debris Identified above must be treated to the aiternallve Irealmenl standards In 40 CFR 268.45.
<br />G. ❑ Restricted Waste Subject To A Variance or Extension (40 CFR 268,7(a) (4))
<br />This restricted waste Identified above Is sub)ecl to a case by case exempllon under 40 CFR 268.5, an exemption under 40 CFR
<br />268.6 or a nationwide capacity variance under Subpart C of 40 CFR 268, and Is not prohibited from land disposal. LDR
<br />prohibitions become effective on (date) for this restricted waste. The corresponding treatment slandard(s) are
<br />promulgated In 40 CFR 268.40. 1 have attached all supporting anelyllcal data, where available,
<br />H, ❑ Restricted Waste Managed In A "Lab Pook" (40 GFR 268,7(a) (9))
<br />I certify under penalty of law that I personally have examined and am familiar with the waste and that the lab
<br />pack contains only waste that have been excluded under appendix IV to 40 CFR Part 268 and that this lab pack may
<br />be sent to a combustion facility In compliance with the alternative treatment standards for lab packs at 40 CFR
<br />268.42(c). I am aware that there are signlficant penalties for submitting a false certification, including the
<br />possibility of a flne and Imprisonment,
<br />I certify and warrant that the information that appears on this form, and appended documents, Is true and correct.
<br />I have correctly Indicated how my waste is to be managed In accordance with 40 CFR 268, My certification is
<br />based on personal examination of the Information submitted, or Is based on my Inquiries of those Individuals
<br />responsible for obtaining the Infori
<br />Authorized Signature Title Date ` J
<br />r
<br />UHC list from 40 CFR Part 268,48 available upon request r
<br />SEP 08 2015
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