LDR Form

Step 1 of 4

25%

1.) General Information

Comments

Generator(Required)

US EPA ID No.(Required)

Manifest No.(Required)

Manifest Line No.(s)

EPA Waste Code No.(s)(Required)

Waste Category(Required)

Non-wastewater

Wastewater

Waste Subcategory, if applicable

2.) Treatment Standards

A. F001 - F005 Solvent Waste (check each constituent present in the waste)

Regulated Constituent(Required)

Acetone

Benzene

n-Butyl alcohol

Carbon tetrachloride

Carbon disulfide

Chlorobenzene

Cresol-mixed isomers (Cresylic acid) (sum of o-,m-p-cresol concentrations)

Cresol (m- and p-isomers)

None Apply

Regulated Constituent(Required)

o-Cresol

Cyclohexanone

o-Dichlorobenzene

Ethyl acetate

Ethyl benzene

Ethyl ether

Isobutyl alcohol

Methanol

Methylene chloride

Methyl ethyl ketone

Methyl isobutyl ketone

None Apply

Regulated Constituent(Required)

Nitrobenzene

Pyridine

Tetrachloroethylene

Toluene

1,1,1-Trichloroethane

1,1,2-Trichloroethane

1,1,2-Trichloro-1,2,2 trifluoroethane

Trichloroethylene

Trichloromonofluoromethane

Xylenes (total)

None Apply

B. D001 Treatment Standards (check, if applicable)

Waste Description

High TOC ignitable characteristic liquids subcategory based on 40 CFR 261.21(a)(1) greater than or equal to 10% total organic carbon

Ignitable characteristic waste, except for the 261.21(a)(1) high TOC subcategory, that are managed in non-CWA / non-CWA- equivalent / non-Class l SDWA systems

C. Corrosive Waste Treatment Standards (check, if applicable)

Waste Description

Corrosive characteristic wastes that are managed in non-CWA / non-CWA equivalent / non-Class l SDWA systems

D. California List Prohibited Wastes (check, if applicable)

Prohibited Wastes

HOC's - 1000.0 mg/L

PCB's - 50.0 mg/L

Arsenic - 500.0 mg/L

Mercury - 20.0 mg/L

Nickel - 134.0 mg/L

Thallium - 130.0 mg/L

Acid - ≤2 pH

E. Hazardous Debris (check, if applicable)

Hazardous Debris

This waste is hazardous debris and is subject to the treatment standards in 40 CFR 268.45.

3.) F039, D001, D002, or D012 through D043

(write the underlying waste constituents below)

F039, D001, D002, or D012 through D043(Required)

US EPA Waste Code(s)

Regulated Constituent Present in Waste

4.) Certifications

(Check one)

Certifications(Required)

Waste does not meet applicable treatment standards in 40 CFR 268.40; or exceeds applicable prohibition levels of 40 CFR 268.32 or RCRA Section 3004(d).

Waste is subject to exemption from land ban treatment standards due to national capacity variance; or case-by-case extension under 40 CFR 268.5; or approved petition under 40 CFR 268.6 or 268.44.

Consent(Required)

Waste can be land-disposed without further treatment. It meets all applicable treatment standards in 40 CFR 268.40 and it does not exceed the prohibition levels upon generation. (Note: Additional certification must be signed.)

I certify under penalty of law that I personally have examined and am familiar with the waste through analysis and testing or through knowledge of the
waste to support this certification that the waste complies with the treatment standards specified in 40 CFR Part 268 Subpart D and all applicable prohibitions set forth in 40 CFR 268.32 or RCRA section 3004(d). I believe that the information I submitted is true, accurate and complete. I am aware that there are significant penalties for submitting a false certification, including the possibility of a fine and imprisonment

Signature(Required)

Certify(Required)

I hereby certify that all information supplied above, and attached, is complete and accurate to the best of my knowledge and ability to determine that no omissions or errors exist.(Required)

Email(Required)

Signature(Required)

Title(Required)

Date

MM slash DD slash YYYY

CAPTCHA

Land Disposal Notification and Certification

1.) General Information

2.) Treatment Standards

3.) F039, D001, D002, or D012 through D043

4.) Certifications