TE 4 Land Disposal Restriction Form.pdf

NOTIFICATION FOR WASTE RESTRICTED FROM LAND DISPOSAL

GENERATOR NAME:

MAILING ADDRESS:

US EPA NUMBER: MANIFEST NUMBER:

MANIFEST

LINE #

RCRA

WASTE

CODE

SUBCATEGORY

CODE

TREATABILITY

CODE

F-LISTED

CONSTITUENT

CODE

CALIFORNIA

LIST WASTE

CODE

UNDERLYING

HAZARDOUS

CONSTITUENT CODE

DIRECTIONS FOR COMPLETING THE LDR NOTIFICATION

1. Record on the notification the generator name, mailing address, US EPA ID number, and manifest number.

2. Record the manifest line item number.

3. List all RCRA waste codes for each manifest line item.

4. Record the subcategory code (from page 3), if applicable. If the waste does not have a subcategory code, record N/A in the block.

5. Record the treatability group code (from page 4).

6. If the waste is a F001 - F005 solvent, record all applicable F-Listed Constituent Codes (from page 4).

If the waste is not a F001 - F005 solvent, record N/A in the block.

7. If the waste is a California List Waste, record the appropriate code (from page 4). If the waste is not a California List Waste, record N/A in the block.

8. If the waste is a D001 ignitable (except High TOC), D002, or D012 - D043, record all applicable underlying hazardous constituent codes (from pages 5 and 6). If the waste is not a D001 ignitable (except High TOC), D002, or D012 -D043, record N/A in the block.

DRMS FORM 1851, MAR 96 (EF) Page 1 of 6

LDR CERTIFICATION

Select the most appropriate certification. Sign and date this form.

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 fine and imprisonment. (40 CFR 268.7(a)(2)(ii))

I certify under penalty of law that I personally have examined and am familiar with the waste and that the lab pack does not contain any wastes at Appendix IV to part 268. I am aware that there are significant penalties for submitting a false certification including possibility of fine or imprisonment. (40 CFR 268.7(a)(8))

I certify under penalty of law that the waste has been treated in accordance with the requirements of 40 CFR

268.42. I am aware that there are significant penalties for submitting a false certification, including the possibility of fine and imprisonment. (40 CFR 268.7(b)(5)(ii))

I certify under penalty of law that the waste has been treated in accordance with the requirements of 40 CFR 268.40 to remove the hazardous characteristic. This decharacterized waste contains underlying hazardous constituents that require further treatment to meet universal treatment standards. I am aware that there are significant penalties for submitting a false certification, including the possibilty of fine and imprisonment.

(40 CFR 268.7(b)(5)(iv))

I certify under penalty of law that the debris have been treated in accordance with the requirements of 40 CFR

268.45. I am aware that there are significant penalties for making a false certification, including the possibilty of fine and imprisonment. (40 CFR 268.7(d)(3)(iii))

Signature : Title: Date:

DRMS FORM 1851, MAR 96 (EF) Page 2 of 6

WASTE CODE SUBCATEGORIES

CODE 1 2 3 4 5

D001 HIGH TOC IGNITABLE ALL OTHER IGNITABLES

MANAGED IN

NON-CWA/NON-CWA

EQUIVALENT/NON-

CLASS I SDWA SYSTEMS

ALL OTHER IGNITABLES

MANAGED IN

CWA/CWA

EQUIVALENT/CLASS I

SDWA SYSTEMS

D002 CORROSIVE WASTES

MANAGED

IN NON-CWA/NON-CWA

EQUIVALENT/NON-CLASS I

CORROSIVE WASTES

MANAGED

IN CWA/CWA

EQUIVALENT/

D003 REACTIVE CYANIDES REACTIVE SULFIDES EXPLOSIVES WATER REACTIVES OTHER REACTIVES

D006 CADIUM CONTAINING

D008 LEAD ACID BATTERIES

D009 HIGH MERCURY-ORGANIC

(NONWASTEWATER)

HIGH MERCURY -

INORGANIC

LOW MERCURY

(NON-WASTEWATER)

MERCURY

CONTAINING

P047 4,6 DINITRO-O-CRESOL 4,6 DINITRO-O-CRESOL

SALTS

P065 NON-INCINERATOR OR

NON-

RMERC RESIDUES

INCINERATOR OR RMERC

RESIDUE > OR EQUAL

TO

RMERC RESIDUE <260

MG/KG

TOTAL MERCURY

INCINERATOR

RESIDUE <260

MG/KG TOTAL

ALL

WASTEWATERS

P092 NON-INCINERATOR OR

NON-

RMERC RESIDUES

INCINERATOR OR RMERC

RESIDUE > OR EQUAL TO

260 MG/KG TOTAL

RMERC RESIDUE, <260

MG/KG TOTAL

MERCURY

INCINERATOR

RESIDUE <260

MG/KG TOTAL

ALL

WASTEWATERS

U151 HIGH MERCURY RMERC RESIDUES, <260

MG/KG

TOTAL MERCURY

NON-RMERC RESIDUES,

<260 MG/KG TOTAL

MERCURY

ALL WASTEWATERS

U240 2,4-DICHLOROPHENOXYAC

ETIC

ACID

2,4-DICHLOROPHENOXYA

CETIC

ACID SALTS AND ESTERS

F003 and/or F005

SOLVENT WASTE

CONTAINING ONLY

F-LISTED SOLVENTS

CARBON DISULFIDE,

CYCLOHEXANONE AND/OR

F005 SOLVENT WASTE

CONTAINING

2-ETHOXYETHANOL

AS THE ONLY LISTED

F001-5

F005 SOLVENT WASTE

CONTAINING

2-NITROPROPANE

AS THE ONLY LISTED

F001-5

DRMS FORM 1851, MAR 96 (EF) Page 3 0f 6

F-LISTED CONSTITUENT CODES

CODE CONSTITUENT CODE CONSTITUENT

1 Acetone 15 Methanol

2 Benzene 16 Methylene Chloride

3 N-Butyl Alcohol 17 Methyl Ethyl Ketone

4 Carbon Disulfide 18 Methyl Isobutyl Ketone

5 Carbon Tetrachloride 19 Nitrobenzene

6 Chlorobenzene 20 Pyridine

7 Cresol (B,M, or P Isomers) 21 Tetrachloroethylene

8 Cresylic Acid 22 Toluene

9 Cyclohexanone 23 1,1,1 Trichloroethane

10 o-Dichlorobenzene 24 1,1,2 Trichloroethane

Ethyl Acetate

1,1,2 Trichloro- 1,2,2 Trifluoroethane

12 Ethyl Benzene 26 Trichloroethylene

13 Ethyl Ether 27 Trichloromonofluoromethane

14 Isobutyl alcohol 28 Xylenes Mixed Isomers

CALIFORNIA LIST WASTE CODES

CODE CONSTITUENT

A Liquid Hazardous Waste Containing > Or = To 50 PPM PCBs

B Hazardous Waste Containing > Or = To 1000 Mg/L HOCs

C Liquid Hazardous Waste Containing > Or = To 134 Mg/L Nickel

D Liquid Hazardous Waste Containing > Or = To 130 Mg/L Thallium

TREATABILITY GROUP CODES

CODE CONSTITUENT

WW Wastewater

NWW Nonwastewater

DRMS FORM 1851, MAR 96 (EF) Page 4 of 6

UNIVERSAL TREATMENT STANDARDS - UNDERLYING HAZARDOUS CONSTITUENTS

CODE CONSTITUENT CODE CONSTITUENT CODE CONSTITUENT

Acenaphthylene 48 2-Chloronapthalene 95 Diphenylamine

Acenaphthene 49 2-Chlorophenol 96 Diphenylnitrosamine

Acetone 50 3-Chloropropylene 97 1,2-Diphenylhydrazine

Acetonitrile 51 Chrysene 98 Disulfoton

Acetophenone 52 o cresol 99 Endosulfan I

2-Acetylaminoflourene 53 m-cresol 100 Endosulfan II

Acrolein 54 p-cresol 101 Endosulfan sulfate

Acrylamide 55 Cyclohexanone 102 Endrin

Acrylonitrile 56 1,2-Dibromo-3-Chloropropane 103 Endrin aldehyde

Aldrin 57 Ethylene dibromide (1,2-Dibromomethane) 104 Ethyl acetate

4-aminobiphenyl 58 Dibromomethane 105 Ethyl cyanide (Propanenitrile)

Aniline 59 2,4-D (2,4-Dichlorophenoxyacetic acid) 106 Ethyl benzene

Anthracene 60 o,p'-DDD 107 Ethyl ether

Aramite 61 p,p'-DDD 108 bis(2-Ethylhexyl) phthalate alpha-BHC 62 o,p'-DDE 109 Ethyl methacrylate beta-BHC 63 p,p'-DDE 110 Ethylene oxide delta-BHC 64 o,p'-DDT 111 Famphur gamma-BHC 65 p,p'-DDT 112 Fluoranthene

Benzene 66 Dibenz(a,h)anthracene 113 Flourene

Benz(a)anthracene 67 Dibenz(a,e)pyrene 114 Heptachlor

Benzal chloride 68 m-Dichlorobenzene 115 Heptachlor epoxide

Benzo(b)fluoranthene 69 o-Dichlorobenzene 116 Hexachlorobenzene

Benzo(k)fluoranthene 70 p-Dichlorobenzene 117 Hexachlorobutadiene

Benzo(g,h,i,)perylene 71 Dichlorodifluoremethane 118 Hexachlorocyclopentadiene

Benzo(a)pyrene 72 1,1 Dichloroethane 119 HxCDDs All Hexachlorodibenzo-p-dioxins)

Bromodichloromethane 73 1,2-Dichloroethane 120 HxCDFs (All Hexachlorodibenzofurans)

Methyl bromide (Bromomethane) 74 1,1-Dichloroethylene 121 Hexachloroethane

4-Bromophenyl phenyl ether 75 trans-1,2-Dichloroethylene 122 Hexachloropropylene n-Butyl alcohol 76 2,4- Dichlorophenol 123 Indeno (1,2,3-c,d) pyrene

Butyl benzyl phthalate 77 2,6-Dichlorophenol 124 Iodomethane

2-sec-Butyl-4,6 Dinitrophenol (Dinoseb) 78 1,2-Dichloropropane 125 Isobutyl alcohol

Carbon disulfide 79 cis-1,3-Dichloropropylene 126 Isodrin

Carbon tetrachloride 80 trans-1,3-Dichloropropylene 127 Isosafrole

Chlordane (alpha & gamma isomers) 81 Dieldrin 128 Kepone p-Chloroaniline 82 Diethyl phthalate 129 Methacrylonitrile

Chlorobenzene 83 2-4-Dimethyl phenol 130 Methanol

Chlorobenzilate 84 Dimethyl phthalate 131 Methapyrilene

2-Chloro-1,3-butadiene 85 Di-n-butyl phthalate 132 Methoxychlor

Chlorodibromomethane 86 1,4-Dinitrobenzene 133 3-Methylcholathrene

Chloroethane 87 4,6-Dinitro-o-cresol 134 4,4-Methlene bis(2-Chloroaniline) bis(2-Chloroethoxy)methane 88 2,4-Dinitrophenol 135 Methylene chloride bis(2-Chloroethyl) ether 89 2,4-Dinitrotoluene 136 Methyl ethyl ketone

Chloroform 90 2,6-Dinitrotoluene 137 Methyl isobutyl ketone bis(2-Chloroisopropyl) ether 91 Di-n-octyl phthalate 138 Methyl methacrylate p-Chloro-m-cresol 92 p-Dimethylaminoazabenzene 139 Methyl methansulfonate

2-Chloroethyl vinyl ether 93 Di-n-propylnitrosamine 140 Methyl parathion

Chloromethane (Methyl Chloride) 94 1,4 Dioxane 141 Napthalene

DRMS FORM 1851, JUN 95 (EF) Page 5 of 6

UNIVERSAL TREATMENT STANDARDS - UNDERLYING HAZARDOUS CONSTITUENTS

CODE CONSTITUENT CODE CONSTITUENT CODE CONSTITUENT

142 2-Napthylamine 167 Phorate 192 2,4,6-Trichlorophenol

143 o-Nitroaniline 168 Phthalic acid 193 1,2,3-Trichloropropane

144 p-Nitroaniline 169 Phthalic anhydride 194 1,1,2-Trichloro-

1,2,2-trifluoroethane

145 Nitrobenzene 170 Pronamide 195 tris-(2,3-Dibromopropyl) phosphate

146 5-Nitro-o-toluidine 171 Pyrene 196 Vinyl chloride

147 o-Nitrophenol 172 Pyridine 197 Xylenes-mixed isomers

148 p-Nitrophenol 173 Safrole 198 Antimony

149 N-Nitrosodiethylamine 174 Silvex (2,4,5-TP) 199 Arsenic

150 N-Nitrosodimethylamine 175 2,4,5-T (2,4,5-Trichlorophenoxyacetic Acid) 200 Barium

151 N-Nitroso-di-n-butylamine 176 1,2,4,5-Tetrachlorobenzene 201 Beryllium

152 N-Nitrosomethylethylamine 177 TCDDs (All Tetrachlorodibenzo-p-dioxins) 202 Cadmium

153 N-Nitrosomorpholine 178 TCDFs (All Tetrachlorodibenzofurans) 203 Chromium (Total)

154 N-Nitrosopiperidine 179 1,1,1,2-Tetrachloroethane 204 Cyanides (Total)

155 N-Nitrosopyrrolidine 180 1,1,2,2-Tetrachloroethane 205 Cyanides (Amenable)

156 Parathion 181 Tetrachloroethylene 206 Fluoride

157 Total PCBs 182 2,3,4,6-Tetrachlorophenol 207 Lead

158 Pentachlorobenzene 183 Toluene 208 Mercury-NonWastewater from RETORT

159 PeCDDs (All Pentachlorodibenzo-p-dioxins) 184 Toxaphene 209 Mercury - All others

160 PeCDFs (All Pentachlorodibenzofurans) 185 Bromoform (Tribromomethane) 210 Nickel

161 Pentachloroethane 186 1,2,4-Trichlorobenzene 211 Selenium

162 Pentachloronitrobenzene 187 1,1,1-Trichloroethane 212 Silver

163 Pentachlorophenol 188 1,1,2-Trichloroethane 213 Sulfide

164 Phenacetin 189 Trichloroethylene 214 Thallium

165 Phenanthrene 190 Trichloromonofluoromethane 215 Vanadium *

166 Phenol 191 2,4,5-Trichlorophenol 216 Zinc *

* Vanadium and Zinc are not "underlying hazardous constituents" in characteristic wastes, according to the definition at 268.2(i)

DRMS FORM 1851, MAR 96 (EF) Page 6 of 6