&EPA
United States       Office of Enforcement and  EPA 315-R-99-003
Environmental Protection   Compliance Assurance   November 1999
Agency



Environmental Management


Review (EMR) National Report:


Lessons Learned  in Conducting


EMRs at Federal Facilities

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SEPA
This document was prepared by EPA's Federal Facilities Enforcement Office (FFEO)
in the Office of Enforcement and Compliance Assurance. The study was directed by
James Edward and Sarah Hart.  Technical research, writing, editing, and document
design/layout support was provided by SAIC under EPA contract No. 68-C6-0027.

For additional copies of this document, please contact:

The Federal Facilities Enforcement Office (2261 A)
U.S. Environmental Protection Agency
401 M Street, S.W.
Washington, DC 20460

Tel:  (202)564-2510
Fax: (202)501-0069

Copies of the document also can be obtained on-line at the FFEO Web site:
http://www.epa.gov/oeca/fedfac/fflex.html

In addition, updates to the document will be available on-line.

Acknowledgment

The Federal Facilities Enforcement staff gratefully acknowledges the contributions of
EPA's Program Offices and the Regions in reviewing and providing comments on this
document.

Limitations of This Document

This document is written to serve as a basic reference.  Due to the rapidly changing
area of environmental law, the reader is advised to consult the current version of the
relevant statute or regulation for the most accurate information. Where the actual text
of a statute,  regulation, executive order, policy, guidance or other document differs
from the description of such documents contained in this document, the actual text of
the statute, regulation, executive order, policy, guidance or other document should be
followed. This document does not constitute rule making by the Agency and may not
be relied upon to create a right or benefit, substantive or procedural, enforceable at law
or in equity, by any person.  The Agency may take  action at variance with this
document and its internal implementation procedures.

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                                TABLE OF CONTENTS

Section 1 - Overview	 -3-
       1.0   Introduction	 -3-
       1.1    The Future of EMRs	 -4-
       1.2   Purpose of this Report 	-5-
       1.3    EMRs and Their Role in Compliance Assistance Activities  	 -5-
       1.4   EMRs and the CEMP  	 -6-
       1.5    EPA Position Statement on EMSs and ISO 14001  	-8-
       1.6   Lessons learned 	-8-

Section 2 - EMR Background	 -11-
       2.0   Policy Development	 -11-
       2.1    EMS Standards & Guidelines	-12-
       2.2   Benefits of an EMR  	 -13-

Section 3 - EMR Pilot Program Methodology Assessment and Lessons Learned	 -17-
       3.0   Goals of the EMR Pilot Program	 -17-
       3.1    Different Regional Approaches to EMRs	 -18-
             3.1.a  EPAPhase 3 Audit Protocol Approach	 -21-
             3.1.b  EPAPhase 3 AuditProtocol/CEMP approach	 -21-
       3.2   Lessons Learned	 -21-
             3.2.a  The IVRP did not result in enforcement actions or penalties at any
                    facility receiving an EMR during the pilot program	 -21-
             3.2.b  Difficult to Stay within the Selected EMR Scope	 -21-
             3.2.c  Ample preparation time is critical  	 -22-
             3.2.d  Avoid surprises 	 -22-
             3.2.e  Conduct pre-site visit meetings with site representatives	 -23-
             3.2.f  Post-EMR evaluations help build a better EMR program	 -23-
             3.2.g  Inform interview personnel  of the EMR process as soon as possible .  . -23-
             3.2.h  Neutral on-site escorts can facilitate candid discussions 	 -23-
             3.2.i   Mixed EMR team with management and technical expertise worked
                    best	 -24-
             3.2.J   Produce report in a timely manner  	 -24-
             3.2.k  Note that an EMR is a snapshot in time  	 -24-
       3.3    Federal facility comments/feedback on the Pilot Program	 -24-
       3.4   How Lessons Learned Resulted in Changes in the EMR Policy	 -25-
                                                                                     27-
Section 4 - Summary of Federal Facility EMR Findings  	
       4.0    Overview of findings and recommendations in EMR reports	 -27-
              4.0.a  Strengths of facility EMSs 	 -27-
              4.0.b  Main areas for improvement of the facility EMSs  	 -28-
       4.1    Recommendations implemented by facilities	 -31-

Section 5 - Conclusion	 -33-
Appendices	 -35-

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APPENDIX A - EMR Case Studies	 -37-
APPENDIXB - Final EMRPolicy	 -47-
APPENDIX C - Process steps for a sample EMR 	 -59-
APPENDIX D - EMR Tools and Related Compliance Assistance Resources	 -61-

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                                      SECTION 1

                                     OVERVIEW
  This section provides background information on EMRs, explains the purpose of this
  report, and provides the primary EMR Pilot Program lessons learned.
1.0    Introduction

Since its inception in 1970, the Environmental
Protection Agency (EPA) has used a variety of
methods  to  help  regulated  organizations
understand  and comply with environmental
regulations.  During the agency's formative
years,  the  regulated  community primarily
sought explanations  of the relatively new
regulations, as organizations reacted to changes
in the regulatory environment.   However,
during the  past  decade,  it has  become
inefficient for organizations to simply react to
regulatory   changes   and   issues  of
noncompliance.
 An EMR is "a review of an individual
 facility's program and management
 systems to determine the extent to which
 a facility has developed and
 implemented specific environmental
 protection programs and plans which, if
 properly managed, should ensure
 compliance and progress towards
 environmental excellence."

        EPA's Final EMR Policy
        December 1998
In increasing numbers,  public  and private
sector organizations changed their focus from
reactive to proactive, choosing to  prevent
pollution at the source. With fewer resources
available to them,  facility managers used
improved   tools  to   address  complex
environmental issues and to help ensure their
site's long-term  environmental  compliance.
Many environmental managers chose to revise
their  management  systems to  proactively
address environmental issues. In conjunction
with this paradigm shift, EPA increased the
types and numbers of compliance assistance
activities offered.  One new tool added to
EPA's compliance  assistance  tool  kit for
federal  facilities was  the Environmental
Management Review (EMR).  This report is
intended to give federal facility managers new
insights into the EMR process, describe how a
review can benefit managers, and  provide
information  on the results of  and  lessons
learned from  EMRs  conducted at federal
facilities during EPA's EMR Pilot Program,
which  began in May  1996 and ended  in
September 1998.

As defined in EPA's Final EMR Policy for
Federal Facilities., an EMR is "a review of an
individual facility's program and management

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systems to determine the  extent to which  a
facility has  developed  and  implemented
specific environmental  protection programs
and plans which, if properly managed, should
ensure  compliance  and   progress  toward
environmental excellence."  The majority of
the EMRs conducted during the pilot program
did not review a facility' s entire environmental
management system (EMS); rather, the focus
was  generally on selected portions  of  the
facility's systems.  The facility staff and the
EPA Region determined  how much  of the
system was to be reviewed during each EMR.

1.1    The Future of EMRs

Given  the increased  interest in the pilot
program, EMRs are slated to be an integral
part  of EPA's  compliance  and technical
assistance  toolbox at  federal  facilities  for
years to come.   Agencies appreciated  the
technical assistance, the ways in which EMRs
heightened  environmental  awareness   at
facilities,  and how  the EMRs focused on
addressing  environmental  issues   via   a
systematic  approach. EPA and the regulated
community alike  recognize that  it is more
efficient to identify and address environmental
matters before they become compliance issues.
While  compliance inspections will continue,
EPA  will   also  emphasize  working
cooperatively with federal facilities,  using
management  system-based approaches, to
reduce the facilities' environmental impacts in
the most effective manner possible.

EMRs  are  not   regulatory   inspections.
However,  when  a  facility  volunteered to
participate in the EMR program, it also agreed
to abide by the program's Incidental Violations
Response   Policy   (IVRP).    This  policy
recognized that there may be circumstances
when an EMR incidentally uncovers violations
either through document review or while on
site.  The IVRP described how violations
would be treated  if they were incidentally
uncovered at a federal facility participating in
the EMR program.  Although some of the
participants raised concerns about the policy,
there were no enforcement actions  taken  or
    Agencies Receiving an EMR
     During the Pilot Program
Air Force
Army (2)
Army Corps of
Engineers(2)
Army National Guard
Bureau of Indian
Affairs
Bureau of Prisons
Coast Guard (2)
Department of
Agriculture
Department of Energy
Department of the
Treasury
Environmental
Protection Agency (3)
Federal Aviation
Administration
Federal
Emergency
Management
Agency
Fish & Wildlife
Service (2)
National
Aeronautics &
Space
Administration
National Park
Service
Navy (2)
U.S. Postal Service
(3)
U.S. Mint
Veteran's Health
Administration
fines assessed as a result of EMRs conducted
during the pilot program.

EPA encourages agencies to participate in the
EMR program. The primary audience for this
report   is  the  federal  facility  managers
responsible for ensuring compliance  with
applicable environmental regulations. The first
step in becoming a participant is to contact the
appropriate EPA Regional Federal  Facility
Coordinator.  Appendix D provides contact

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information for those coordinators.

1.2    Purpose of this Report

To comply with Executive Order (EO) 12088
(Federal   Compliance  with   Pollution
Standards),  EPA's  national  and  regional
federal  facility programs  supply  technical
assistance to federal facilities to ensure cost
effective   and  timely  compliance  with
environmental  regulatory requirements.  EPA
initiated a pilot program in 1996 to determine
if EMRs were a useful tool for EPA staff to
add to their compliance assistance toolbox for
federal facilities.

EPA Regions 1, 6, and 10 conducted EMRs for
several  years  prior to the pilot  program.
Twenty-nine  reviews  were  conducted at
federal facilities in seven EPA regions during
the nationwide two and  a half  year pilot
program.  Twenty different federal agencies
participated. The pilot program enabled EPA
personnel to apply the lessons learned from
conducting EMRs and, in  turn, modify  the
program to better suit  the  needs  of future
participants.
          Examples of Compliance
            Assistance Activities
      Activity

       EMR

       PPOA

  Compliance Audit
     Focus Areas

Management Activities

Processes & Materials

   Compliance with
   Environmental
     Regulations
                         1.3
       Provides background  information on
       EMRs;
       Describes the essence of the EMR
       Pilot Program;
       Highlights the lessons learned from the
       program; and
       Forecasts the future of EMRs and their
       role  in EPA's compliance assistance
       program.

       EMRs and Their Role in Compliance
       Assistance Activities
This report:
EPA compliance assistance information and
activities  seek  to  ensure that the regulated
community  understands   its   regulatory
obligations.   An   effective  compliance
assistance program helps protect public health
and the environment by making it easier for
regulated  entities to comply with applicable
regulations.   EPA's compliance  assistance
tools   often   include  compliance  audits,
pollution prevention opportunity assessments,
and EMRs.

Compliance audit  teams  review a facility's
activities and processes and determine if any
of the activities or their by-products meet the
applicable  environmental  regulatory
requirements.   The subsequent audit report
identifies the compliance gaps.

During  a  pollution  prevention opportunity
assessment (PPOA),  the technical assistance
providers   review  a  facility's  processes,
focusing  on  material inputs  and  wastes
generated, and work with the facility personnel
to develop a list of  projects that reduce or
eliminate waste at the source.

Alternatively, an EMR focuses on the ways in
which a federal facility manages its activities

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to  decrease  or   eliminate   the   site's
environmental impact, and how environmental
considerations  are  formally woven into its
processes and activities.  It focuses on the
system of policies and procedures the facility
consistently  uses to  address environmental
issues   and  maintain  compliance  with
environmental regulations. The team reviews
documents and interviews facility personnel to
better understand the existing environmental
management  system (EMS),  analyzes the
system to identify and describe its strengths
and areas for improvement, and recommends
ways  to enhance the effectiveness  of the
system.  While the areas of focus may differ,
all  three  of these compliance assistance
activities  benefit the federal  community by
assisting facility  environmental  management
efforts.

1.4    EMRs   and   the    Code   of
       Environmental  Management
       Principles

The  Code of Environmental  Management
Principles for Federal Agencies  (CEMP),
developed by EPA in response  to Executive
Order (EO) 12856 (Federal Compliance with
Right-to-Know Laws and Pollution Prevention
Requirements), is a collection of five broad
principles  (management  commitment,
compliance   assurance  and  pollution
prevention, enabling systems, performance and
accountability,   and  measurement   and
improvement)  and underlying  performance
objectives that federal agencies can use as a
guide to move toward effective environmental
management.

Environmental  management systems  can be
based on  and compared to different sets of
standards  or guidelines.  As the list below
demonstrates, a variety of EMS standards or
guidelines exist worldwide. Some of these are
used to develop systems for federal facilities
throughout the United States:

•      Generic  Protocol   (Phase   3)  for
       Conducting Environmental  Audits  at
       Federal Facilities
•      Code  of Environmental Management
       Principles  for  Federal   Agencies
       (CEMP)
•      International   Organization   for
       Standardization (ISO) 14001
•      International Chamber of Commerce's
       (ICC) Business Charter for Sustainable
       Development
       Chemical   Manufacturer's
       Association's Responsible  Care
       Guidelines
•      Protocols   for   Conducting
       Environmental   Management
       Assessments of DOE
       Organizations

EMR  participants  should take  steps  to
ascertain which standard or guideline should
be used during the system review. The facility
needs  its parent  agency  or  personnel  at
headquarters  to determine if  one  guideline
would be better than the rest. Federal facilities
should also  keep in  mind that 16 agencies
endorsed the CEMP, which may  make the
CEMP the best choice for use in developing an
EMS. Lastly, each facility should determine
which one of the guidelines best matches the
site's existing management system structure.

 Each standard or guideline examines a system
from a slightly different point of  view and
emphasizes different parts  of a management
system. Later in this report (Section 2.1), there
is an outline on the approach for three of the

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primary standards.  For example, the Generic
Protocol  (Phase   3)   for  Conducting
Environmental Audits at Federal Facilities1
touches on but does not  focus on a system's
ability to  address emergency management
issues, however, the  Implementation Guide
for the Code of Environmental Management
Principles for Federal Agencies2 has an entire
section devoted to emergency preparedness.
Differences such as  this do not make one
standard superior  to another; they  simply
provide examples of the various lenses through
which one can view an EMS.

In early  September and October  1996, the
International Organization for Standardization
published the first five standards in the ISO
14000 series of environmental management
system standards. On September 1, 1996, ISO
officially  published  ISO   14001,
"Environmental  Management  Systems   -
Specification with  Guidance for Use."  The
ISO 14001  standard specifies requirements for
establishing   an  environmental   policy,
determining environmental aspects & impacts
of   products/activities/services,  planning
environmental  objectives   and  measurable
targets, implementing and operating programs
to meet objectives & targets, establishing a
program  for   checking   and   correcting
environmental   programs,   and   conducting
management system reviews.
       1 This document (EPA Document No.
300-B-96-012 A&B) can be obtained by
contacting the U.S. EPA Federal Facilities
Enforcement Office at 202-564-2461.
       2 This document (EPA Document No.
315-B-97-001) can be obtained by contacting the
U.S. EPA Federal Facilities Enforcement Office at
202-564-2461.
Standards and Guidelines By Which
      U.S. EMSs Are Developed

 Federal Facilities Phase 3 Protocol for
 Conducting Environmental Audits at
 Federal Facilities
 CEMP
 ISO 14001
 International Chamber of Commerce's
 (ICC) Business Charter for Sustainable
 Development
 Chemical Manufacturer's Association's
 Responsible Care Guidelines
 Protocols for Conducting
 Environmental Management
 Assessments of DOE
Currently, federal facility EMRs are based on
either the Generic Protocol (Phase 3) for
Conducting Environmental Audits at Federal
Facilities or the CEMP.  Thus, EMR teams
used either one of the two  standards or a
combination of the two to guide them through
the review process. Section 2.1 of this report
provides details on the linkages between the
two standards, and Section 3.1 describes the
different methods and standards used by the
EPA regions.

1.5    EPA Position Statement on EMSs
       and ISO 14001

On March  12, 1998, EPA published in the
Federal Register (63 FR 12094) its Position
Statement on EMS and ISO  14001.  In that
Position Statement, EPA encourages:

•      The use  of  EMSs  that  focus  on
       improved performance, compliance,
       source  reduction,   and  system

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       performance;
       Organizations    to   maintain
       accountability  for  the performance
       outcomes  of  their  EMSs  through
       measurable objectives and targets;
•      The development of EMSs through an
       open  and  inclusive  process  with
       relevant stakeholders;
•      Dissemination  of information on the
       actual performance  of EMSs to the
       public and government; and
•      The  review  of EMSs  to  achieve
       superior environmental performance.

The Position Statement quotes verbatim from
the  North   American  Commission   on
Environmental Cooperation  (CEC)  Council
Resolution #97-05 which states that, "adoption
of EMSs  based on ISO  14001 may  foster
improved  compliance  and performance, but
does not constitute or guarantee compliance or
in any way prevent governments from taking
enforcement action where  appropriate." At
this time, EPA does not base any regulatory
incentives solely on the use of EMSs,  or
certification to ISO 14001.

The  Federal  Register notice also  solicits
comment on the categories of information and
data that will be gathered through ISO 14001
pilot   projects,   including   environmental
performance,    compliance,   pollution
prevention,  environmental   conditions,
costs/benefits to implementing facilities, and
stakeholder participation and the effect that
such participation has on the public credibility
of EMS implementation.

1.6    Lessons Learned

During the course of the pilot program, many
lessons were learned about the EMR process
itself, and common strengths and weaknesses
of  environmental  management  systems  at
federal  facilities.  The information below
highlights what is explained in greater detail
throughout the rest of this report.

EMR Process Lessons Learned

•      The IVRP did not result in enforcement
       actions or penalties  at any facility
       receiving  an EMR during  the pilot
       program,
•      It is difficult to stay within the selected
       EMR scope,
       Ample preparation time is critical,
•      Avoid surprises,
•      Conduct  pre-site visit meetings with
       site representatives,
       Post-EMR evaluations help build  a
       better EMR program,
•      Inform personnel to be interviewed of
       the EMR process as soon as possible,
       Neutral on-site  escorts can facilitate
       candid discussions,
•      Combine  management  and  technical
       expertise in an EMR team  for best
       results,
•      Produce reports in a timely  manner,
       and
       Note that  an EMR is a snapshot in time.
Common  EMS  strengths among federal
facilities

•      Personnel    acknowledge their
       environmental responsibilities and are
       committed   to   protecting  the
       environment;
•      Field  staff routinely review facility
       environmental performance;
       Agencies participate in cooperative

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       environmental  programs  with  other
       organizations; and
•      Environmental   considerations   are
       incorporated  into  most  planning
       processes.

Common  EMS  areas  for  improvement
among federal facilities

•      Agencies and facilities lack adequate
       environmental staff and formal, annual
       training plans and mechanisms to track
       individual  training   needs   and
       accomplishments;
•      Facilities lack  formal  environmental
       management programs;
       Facilities    lack   facility-specific
       environmental   policies,  goals,
       objectives, or targets;
       Facilities lack commitment to  going
       beyond  compliance;  facilities  seek
       only to meet compliance requirements;
•      Work being done does not match job
       descriptions   and   performance
       evaluations;
•      Lessons   learned   (positive   and
       negative) are not shared with  other
       federal  facilities,  let  alone  with
       facilities within the same  agency;
•      Line and staff personnel are not  asked
       for  their opinion during the policy
       development process;
       Tenant organizations  are not  held
       responsible for adhering to a  site's
       EMS; and
•      Management is not aware of the work
       being done to  minimize  the  site's
       impact on the environment.

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                                       10

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      Rackvround
                                      SECTION!
                                 EMR BACKGROUND
  This section discusses the development of the Final EMR Policy, shows the relationships
  between different EMS standards and guidelines, and describes the benefits and the future
  ofEMRs.
2.0    Policy Development

Following a six-month development effort, the
EMR Workgroup, which included staff of the
Federal Facilities Enforcement Office (FFEO),
the  EPA   Assistant   Administrator  for
Enforcement and Compliance Assurance, and
Federal Facility Coordinators from eight EPA
regions, issued the Interim EMRPolicy on May
31, 1996. Prior to issuance, the Interim Policy
was formally reviewed by staff of the Office of
Enforcement  and  Compliance  Assurance
(OECA) and the Regions.

The EMR  Pilot  Program  began shortly
thereafter to test the  policy and guidance  at
individual  federal  facilities.  Twenty-nine
EMRs  were  conducted  by seven  Regional
offices during the pilot program.  Comments on
the draft Final EMR Policy and guidance were
received from OECA and regional offices, and
revisions were  made based on the  concerns
raised. A list of the major changes made to the
Interim EMR Policy  is included below, and
those changes are further explained in Section
3.3 of this report.
         Changes Made To The
          Interim EMR Policy

     Facilities must disclose within 10
     days violations incidentally
     discovered through the EMR
     process.
     EPA will generally not conduct
     inspections at the participating
     facility for six months after the
     EMR.
     The facility must submit only one
     report to EPA.
     Only EPA 's signature is needed on
     the EMR confirmation letter.
     EPA can take various enforcement
     responses in response to discovered
     violations.
     EMR's relationship to ISO 14001
     and the Code of Environmental
     Management Principles (CEMP)
The  Final  EMR  Policy  (Appendix  B)
incorporates the lessons learned from the pilot
program reviews.
                                           11

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E,
MR Background
2.1    EMS Standards & Guidelines

As noted earlier, there are numerous standards
and guidelines used by organizations to guide
them through  the EMS development process.
The  Generic  Protocol  (Phase  3)  for
Conducting Environmental Audits at Federal
Facilities breaks a system into seven parts, or
disciplines:

1.      Organizational Structure
2.      Environmental Commitment
3.      Formality of Environmental Programs
4.      Internal and External Communications
5.      Staff  Resources,   Training,   and
       Development
6.      Program Evaluation, Reporting,  and
       Corrective Action
7.      Environmental Planning  and  Risk
       Management

The  Code  of Environmental  Management
Principles (CEMP),  developed by EPA in
response to the President's Executive Order
(EO 12856) and in conjunction with personnel
from  16  federal  departments  and agencies,
breaks environmental management into  five
primary components of an effective EMS:

1.      Management Commitment
2.      Compliance Assurance and Pollution
       Prevention
3.      Enabling Systems
4.      Performance and Accountability
5.      Measurement and Improvement

Lastly, the ISO 14001  standard views an EMS
from a different set of five areas:

1.      Environmental Policy
2.      Planning
3.      Implementation and Operation
4.      Checking and  Corrective Action
                                            5.
Management Review
                                            Even though the primary EMS  standard and
                                            guideline headings are not an exact match,
                                            there are a great number of similarities among
                                            the  standards  and  guidelines.    Table A
                                            provides information  on  the correlation
                                            between  the  EMR protocols,  ISO 14001
                                            sections, and the CEMP.
                                           12

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E,
MR Background
                                      TABLE A

   CORRELATION BETWEEN EMR DISCIPLINES, THE CEMP PRINCIPLES, AND SECTIONS OF ISO 14001
EMR DISCIPLINE
Organizational Structure
Environmental Commitment
Formality of Environmental
Programs
Internal & External
Communications
Staff Resources, Development,
and Training
Program Evaluation, Reporting, &
Corrective Action
Environmental Planning & Risk
Management
CEMP PRINCIPLE
1
1
2&3
3
3&4
3&5
2&3
ISO 14001 SECTION
3
1
1,3, & 4
3
3
4&5
2&3
2.2    Benefits of an EMR

A facility will discover that its EMS becomes
a much more  powerful management tool if
continuous  improvement is woven into the
management system's framework.  A system
should be dynamic, with procedures, policies,
job descriptions, and performance reviews all
changing as the organization evolves.  There
are numerous ways  to  update a facility's
management system; two of the more common
are: 1) an annual internal  EMS review and
revision, and 2) an annual review conducted by
an outside party. An EMR is an example of the
second method (the EMR  process steps are
located in Appendix B).

By working  collaboratively with  EPA,  a
facility can obtain many benefits from a review
of its  system.  The first benefit is that it is a
voluntary and inexpensive way  to determine
the health of a facility's EMS. A compliance
inspection is a reactive, mandatory method
used  by  EPA   to  address  a  facility's
environmental  problems.    However,
                                                      Benefits of an EMR

                                                It is a collaborative & inexpensive
                                                means to enhance a facility's EMS
                                                An outside party can discover issues
                                                overlooked by busy facility staff
                                                EPA 's wealth of regulatory and
                                                technical environmental expertise is
                                                made available to the facility
                                                The facility benefits from EPA 's
                                                ability to facilitate root cause
                                                analysis exercises
                                                It can lead to long-term
                                                environmental
                                                compliance and enhanced
                                                management accompanied by
                                                resource reduction
                                                It provides feedback on the
                                                effectiveness of a facility's system,
                                                benchmarks the facility's
                                                performance, and identifies
                                                opportunities for improvement.
                                          13

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E,
MR Background
volunteering  for a  free EMR  creates  a
partnership between the facility and EPA. In
fact, EPA officials view the reviews as a way
to work together with facility staff to enhance
the  way they have chosen to  systematically
address environmental issues. The partnership
created or improved by the EMR often helps
break  down  communications barriers  and
provides evidence that  EPA  is  no longer
simply a command-and-control organization.
EPA views federal facilities as customers and
believes that EMRs are yet another useful way
to  partner  in   the  effort  to reduce  the
government's environmental impact. EPA has
transitioned  from a   command-and-control
agency to one encouraging collaboration and
cooperation with other agencies.

Second, it is  relatively easy for a facility to
overlook an EMS's deficiencies, especially if
there are no current  noncompliance issues
attributed to them.  Many organizations  find
that a management system review conducted by
an outside party uncovers areas of the EMS
that could be improved, even after an  internal
review did not reveal such problems.

A third benefit to the facility is the opportunity
to take advantage of EPA's regulatory  and
technical  knowledge  in  a  non-threatening
environment.  Granted, the official scope of an
EMR is generally confined to the review of
management  systems  that  are designed to
address environmental matters.   However,
while  the EPA team  is on-site,  facility
personnel are encouraged to open the  lines of
communication   by  asking questions about
environmental issues, e.g., compliance issues
and  pollution  prevention opportunities, in
order to tap into the wealth of environmental
knowledge and expertise available  to the
facility. In addition, the on-site portion of the
                                             review  facilitates  discussions between the
                                             Regional Federal Facility Coordinator and the
                                             facility personnel.  These conversations often
                                             introduce facility personnel  to many  of the
                                             initiatives, conferences, and outreach activities
                                             offered by EPA of which facility staff are often
                                             unaware.
                                             Fourth, in addition to uncovering deficiencies
                                             not yet discovered, an EMR team also can help
                                             the facility work through root cause analysis,
                                             identifying underlying causal factors  which
                                             may contribute  to environmental  program
                                             deficiencies. For example, it is generally easy
                                             to find  that a staff member has not been
                                             properly trained on environmental matters.
                                             However, it takes more time and effort to
                                             determine that the root cause of the problem is
                                             a faulty training schedule database.  EPA's
                                             management   system  review  experience,
                                             combined  with  the  facility  personnel's
                                             background knowledge of the facility's EMS,
                                             produce  a strong  team that can  efficiently
                                             identify  a deficiency's  origin.    Facilities
                                             become better equipped to proactively identify
                                             and minimize  environmental impacts, in the
                                             context  of shrinking  budgetary allocations.
                                             With  a  trend  toward  downsizing  in the
                                             government, facility managers need better tools
                                             to handle complex  issues when  resources
                                             decrease. EMRs enable a facility to optimize
                                             its system, which in turn helps to ensure long-
                                             term   environmental   compliance   and
                                             improvements   in   environmental   issue
                                             resolution.

                                             Another benefit is  that EMRs often provide
                                             feedback on the effectiveness of  a facility's
                                             environmental management system. It can help
                                             a facility establish baselines so that it can
                                             benchmark its  performance,  and  identify
                                             opportunities for improvement.
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MR Background
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  jMR Pilot Program Methodology Assessment and Lessons Learned
                                      SECTIONS


                               EMR PILOT PROGRAM
              METHODOLOGY ASSESSMENT AND LESSONS LEARNED
  This section describes the goals of the EMR Pilot Program, describes the different
  approaches to conducting EMRs, explains the lessons learned, and identifies the major
  changes to the EMR Policy.
3.0    Goals of the EMR Pilot Program

EPA is always searching for better ways to
serve its customers.  After passage  of the
Pollution Prevention Act of  1990 and the
signing ofExecutive Order 12856 in 1993, the
agency focused its efforts on creating programs
to  help federal  facilities conduct PPOAs,
develop  pollution  prevention plans, train
personnel,  and  implement  projects.   In a
similar fashion, EPA developed the EMR Pilot
Program in response to the growing interest in
environmental management systems.  During
the  mid-1990s,   environmental  experts
worldwide were touting the advantages of the
facility environmental management system.  In
response to international interests, ISO 14001
was drafted and the standard became final in
September  1996.  On a parallel  path, EPA
issued the Interim Final EMR Policy and began
the EMR Pilot Program in May 1996.

EMRs were conducted at federal  facilities in
the early 1990s in EPA Regions 1, 6, and 10.
In addition, one of the recommendations in the
1994   Civilian  Federal  Agency   (CFA)
Environmental Task Force Report was that
EPA  provide  more  on-site  compliance
assistance via a comprehensive EMR program
in  all ten EPA Regions.
 One of the goals of the pilot program was to
determine how federal facilities would react to
a nationwide review program.  It was unclear
how receptive they would be and how willing
they would be to voluntarily grant EPA access.
The facilities targeted for the pilot program
were generally  smaller sites, which may not
       EMR Pilot Program Goals

     Determine types/sizes of facilities
     where EMRs are most effective
     Determine federal facility's
     reaction to/willingness to
     participate in the program
     Determine if future EMRs had to
     include the entire facility EMS
     Test different EMR methodologies
     Gain experience and incorporate
     lessons learned into the Final EMR
     Policy
have the resources to develop an EMS on their
own. Since some of the CFA sites had limited
experience interacting with EPA prior to the
EMR Pilot Program, another  goal  was to
determine how they would react  to EPA's
outreach efforts.
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  jMR Pilot Program Methodology Assessment and Lessons Learned
A third goal of the pilot program was  to
ascertain whether or not a facility's EMS could
be   reviewed  discipline-by-discipline.
Depending on the size and complexity of the
facility, a comprehensive management system
audit could take more than a week to complete
and cost more than double of what a traditional
EMR costs.  As noted earlier, the majority of
the pilot program EMRs did not review entire
systems, instead they focused only on certain
management  system—disciplines   (e.g.,
Communications, Environmental Commitment).
Closely related to the third goal was the fourth
       Questions To Be Answered
         By The Pilot Program

     What should be the process for
     conducting EMRs?
     How would the Incidental Violation
     Response Policy (IVRP) affect the
     program and its acceptance?
     Upon which standard (i.e., the
     Federal Facilities Phase 3 Protocol
    for Conducting Environmental
     Audits at Federal Facilities, the
     CEMP, or ISO 14001) should the
     EMRs be based?
     What should be the format of the
    follow-up reports?
     Who should sign the confirmation
     letter (and should there even be a
     confirmation letter)?
goal,  which  was to  test different  EMR
methodologies to determine if one methodology
was more successful than another.  Section 3.1
further explains the different approaches used
by   EPA   Regional   Federal   Facility
Coordinators.

A final  goal of the  pilot program was  to
identify areas within the interim EMR policy
that could be improved upon in order to craft a
more complete final  policy.  That goal was
achieved by identifying the  pilot program's
lessons learned and using them to develop the
final policy. The team charged with interim
policy development relied on the experience
gained from the limited number of reviews
conducted  in   the   early  1990s  and  the
experience gained from being part of the ISO
14001 development process.  However, there
were still questions  to be answered:  What
should be the process for conducting EMRs?
How would the Incidental Violation Response
Policy (IVRP) affect the program  and its
acceptance? Upon which standard should the
EMRs be based - the Federal Facilities Phase
3 Protocol for Conducting Environmental
Audits at Federal Facilities, the CEMP, or
ISO 14001? What should be the format of the
follow-up  reports?   Who should  sign  the
confirmation letter (and should there even be a
confirmation letter)?  EPA's  plan  was to
answer these and other questions by conducting
EMRs and basing its answers on facts rather
than supposition. EPA took full advantage of
the  nationwide program by allowing each
Regional  Federal  Facility  Coordinator  to
determine the ways in which EMRs would be
conducted in the region. By providing regions
with thi s flexibility, EPA could then understand
the  strengths and identify  the weaknesses of
each unique approach.

3.1    Different  Regional  Approaches to
      EMRs

Each Regional Federal Facility Coordinator
had a slightly different vision regarding how
EMRs should  be conducted.  The matrix in
Table B summarizes the methodologies used by
each  region during the pilot project.  Once
again, the  pilot  program  provided   an
opportunity   to   use   different  review
methodologies and use the  lessons learned
from the different approaches to formulate the
final EMR policy.
Some of the  facilities that  were asked to
participate   in the  pilot  program  were
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  jMR Pilot Program Methodology Assessment and Lessons Learned
concerned about the IVRP.  It should be noted
that no enforcement actions were taken and no
fines were issued under the IVRP during the
pilot  program.    However,   EMRs  were
instrumental in highlighting  ways in which
facilities could improve their processes and
potentially  reduce   their  environmental
liabilities. During the course of the interview
and document review process, EPA teams
helped   facilities   identify  potential
environmental problems. In addition, the EMR
assisted EPA personnel in focusing on which
compliance  assistance tools  and activities
would most benefit the facility in the future.
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'MR Pilot Program Methodology Assessment and Lessons Learned
                                          TABLE B
                               REGIONAL EMR METHODOLOGIES
Region
Region 1
Region 2
Region 3*
Region 4
Region 5
Region 6
Region 7*
Region 8
Region 9
Region 10*
Protocol Used
Combination of the
EPA Phase 3 audit
Protocol and the
CEMP
Developed a unique
protocol for the USPS3
based on EPA Phase 3
audit Protocol
N/A
Combination of the
EPA Phase 3 audit
Protocol and the
CEMP
EPA Phase 3 audit
Protocol
EPA Phase 3 audit
Protocol
N/A
EPA Phase 3 audit
Protocol
EPA Phase 3 audit
Protocol
N/A
Average
On-site
Time
One day
Two days
N/A
Two days
Two days
Two days
N/A
Two days
Two days
N/A
Average
Number of
Disciplines
Reviewed
All (5)
1
N/A
All (5)
2
3
N/A
3
3
N/A
Number of
Pilot EMRs
12
3
N/A
3
2
5
N/A
2
2
N/A
IVRP
Incidents
None
None
N/A
None
None
None
N/A
None
None
N/A
        * Regions 3, 7, and 10 did not conduct EMRs during the 2.5 year EMR Pilot Program.  However,
Region 10 conducted one EMR in FY 93.

        3  As requested by the customer, EPA Region 2 created a new discipline (Environmental Policy
Implementation) based on the seven existing EPA Phase 3 Audit Protocol disciplines, for the United States
Postal Service (USPS) EMRs.
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  jMR Pilot Program Methodology Assessment and Lessons Learned
3.1.a  EPA   Phase   3  Audit  Protocol
       Approach

The column labeled "Protocol Used" in Table
B  indicates the type(s) of protocol used by
each EPA region.  Of the seven EPA Regions
participating in the EMR Pilot Program, five
used the  Generic Protocol (Phase 3) for
Conducting Environmental Audits at Federal
Facilities as the basis for their review, while
the other two Regions elected to use a protocol
that was a hybrid of the Generic Protocol
(Phase  3) for Conducting Environmental
Audits at Federal Facilities and the CEMP. In
general, those Regions opting to solely use the
Generic Protocol (Phase 3) for Conducting
Environmental Audits at Federal Facilities
elected  to limit the review to two or three of
the seven disciplines. All but one of the EMRs
were conducted with the understanding that the
facility   already   had  an  environmental
management system and the EPA team was
tasked to  critique it.  However, one facility
told the  team prior to its on-site arrival that the
facility  did not have  an EMS; this facility
asked EPA to assess the facility's processes
and recommend how the facility should create
a management system.

3.1.b  EPA Phase 3 Audit Protocol/CEMP
       approach

Two regions (Regions 1 & 4) chose to create
and use a protocol that was a hybrid of the
Generic Protocol (Phase 3) for Conducting
Environmental Audits at Federal Facilities
and the CEMP; this approach split an EMS into
five disciplines. In addition, these regions also
reviewed  each facility's entire system, instead
of focusing on certain parts of the EMS. By
giving the regions  flexibility  in the EMR
methodology  they used, EPA was able to
determine the strengths and weaknesses of the
different approaches.

3.2   Lessons Learned
One of the primary goals of the  EPA pilot
program  is to determine how the program
could be optimized and where EMR team
members should look for potential pitfalls.
The 29  pilot program  reviews   not  only
identified areas for program improvement, but
also highlighted potential problem areas in the
EMR process of which team members should
be  aware.  The  following, in no particular
order, describes these areas.

3.2.a   The   IVRP  did  not   result  in
       enforcement actions or penalties at
       any facility receiving an EMR during
       the pilot program

Some facilities raised concerns about the IVRP
prior to the EMR team going onsite.  The
primary  concern was  that  by  voluntarily
allowing an EPA representative onsite, the
facility would increase  the likelihood  of
incurring a fine  or having  an  enforcement
action brought against it. However, there were
no cases where the IVRP was invoked, and no
enforcement actions, fines, or penalties were
issued  during the pilot program.  These data
underscore  the point that an EMR is not an
enforcement inspection and does not increase
a participant's environmental  liability.

3.2.b   It  is  difficult to  stay  within the
       selected EMR scope

It was difficult to stay within the confines of
the EMR scope in instances where only partial
EMS reviews were conducted.  For example,
in one review, two disciplines (Organizational
Structure and Communications) were the focus.
However, after reviewing certain documents
and interviewing a few key personnel,  it
became apparent that a lack of formality in
environmental programs was one  root cause
for the  problems in the two focus areas.  Thus,
the EMR was altered in mid-course, with a
third discipline added to the scope to help
benefit the facility as much as possible.
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  jMR Pilot Program Methodology Assessment and Lessons Learned
In addition, it takes a great amount of effort to
stick  to  the  EMR scope because there is
overlap among  the seven  disciplines.   For
example,   questions   concerning  training
(discipline number five) link with questions
pertaining  to   environmental  commitment
(discipline number two). If there is a lack of
environmental commitment, then often there are
lapses in the facility's environmental training
regimen.  In this instance, the team must decide
whether  to ask  questions pertaining  to the
facility's lack of environmental commitment
(out of the scope's boundaries), or stick to the
prescribed disciplines for  review  and risk
doing a disservice to the customer. Since the
final policy did not change on this matter in that
it still describes an EMR as a partial system
review, team members should be flexible and
willing to alter the  scope of the review if it is
agreeable to all parties involved  (i.e., the
facility and the EMR team).

3.2.c   Ample preparation time is critical

Since the EMR  is  usually something facility
personnel have to do in addition to their daily
duties, it is best to start the review process two
months prior to the on-site visit. Facilities
unfamiliar with environmental  management
reviews need extra time to understand the EPA
program's goals and  objectives, answer the
pre-site visit questionnaire (see Appendix D
for  a  sample  questionnaire developed by
Region 1), gather relevant documentation and
send it to the EMR team, assist in the creation
of  an  interview   list,  and  confirm   the
availability of the potential personnel  to be
interviewed.
It is also beneficial for everyone involved if a
list of milestones is developed  prior  to
commencement of the EMR process; this helps
reduce confusion regarding submittal dates.
             Lessons Learned

     The IVRP did not result in
     enforcement actions or penalties at
     any facility receiving an EMR
     during the pilot program
     It is difficult to stay within the EMR
     scope
     Ample preparation time is
     critical/create milestones
     Avoid surprises
     Conduct pre-site visit meetings with
     site representatives
     Post-EMR evaluations help build a
     better EMR program
     Inform personnel to be interviewed
     of the EMR process as soon as
     possible
     Neutral on-site escorts facilitate
     candid discussions
     Combine management and technical
     expertise in an EMR team for best
     results
     Produce report in a timely manner
     Note that an EMR is a snapshot in
     time
3.2.d  Avoid surprises

Trust is a key issue in EMRs.  The facility has
volunteered access to its  site.   It  is  very
important to obtain facility buy-in to the EMR,
and to ensure the facility is not  surprised by
any part of the review process. For example,
the facility should know well in advance which
federal and state EPA staff is anticipated to
participate.   In  addition, the EMR's scope
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  jMR Pilot Program Methodology Assessment and Lessons Learned
should be well established prior to the team's
arrival, and  should  be changed only after
consulting with appropriate facility personnel.
If substitutions or changes must be made close
to the on-site visit date, the facility must be
given the chance to veto the change or cancel
the review. Surprising a facility can lead to a
long-term distrust of EPA and its associated
activities, which is the exact opposite of the
EMR program's intentions.

3.2.e   Conduct pre-site visit meetings with
       site representatives

Each federal agency has its particular mission
and each facility is unique. It is important that
EMR team members  understand both the
agency's mission  and  the facility's  daily
activities (especially those activities  linked
with potential or actual environmental impacts)
prior   to arriving  for  the  on-site  visit.
Gathering and reviewing this vital information
prior to  the on-site visit allows  the team to
focus on  confirming through document review
and interviews what they know  should be
happening.  In addition, site representatives are
usually the people supplying the team with the
information; the time spent talking with team
members about  the facility  eases  facility
personnel's anxiety and gives the facility staff
a sense  of ownership of the  review EMR
process.

3.2.f   Post-EMR evaluations help build a
       better EMR program

Continuous improvement concepts should also
be  built into the  EMR  process.   After
conducting  the review, EPA Federal Facility
Coordinators should solicit facility's responses
to the management review process.   For
instance, EPA could encourage  facilities to
incorporate their thoughts on the  value of the
EMR  into  the   six-month facility  report
submitted to EPA, or the participants could fill
out  a  post-review  evaluation   form (see
Appendix D for a form used in EPA Region 8).
The ensuing comments and insights can identify
which elements of  the  EPA program  are
strongest and which could be improved.

3.2.g  Inform personnel to be interviewed
       of the  EMR process as  soon as
       possible

Since the EMR team is usually on-site for only
a day or two, time management is  a key
ingredient of a successful review. The ultimate
scenario is for the team members to interview
personnel who  1)  comprehend  the  EMR
process and understand  why  the  review is
being  conducted,  and  2) have  copies of
tangible evidence (e.g., pages from a training
database and associated procedures to keep the
database updated) of a formal EMS that they
can provide to the EPA team members.  This
scenario permits  the team members  to ask
questions instead of answer them.


3.2.h  Neutral on-site escorts can facilitate
       candid discussions

A facility usually has one or two people (e.g.,
environmental managers) who are in charge of
the  site's environmental programs.  Facility
personnel recognize this and sometimes tout the
environmental   manager's  accomplishments
during an interview if the manager is in the
same room as  the person being interviewed.
Personnel being interviewed tend to be more
candid and forthcoming with information and
anecdotes about the  environmental program
when a neutral person acts as the team's  escort.
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  jMR Pilot Program Methodology Assessment and Lessons Learned
3.2.1   Combine management and technical
       expertise in an EMR team for best
       results

Although an EMR is focused on the ways in
which a facility manages activities to achieve
and  maintain  environmental   compliance,
technical environmental questions often arise
during  the course of an EMR  site visit.  It
benefits both the team and the facility if, prior
to the on-site visit, the facility  identified its
environmental   permits/compliance
requirements.  The team leader could then
ensure  one  of the EMR team  members is
knowledgeable of the facility's processes or of
its permits/compliance requirements (or both).

3.2.J   Produce report in a timely manner
It is beneficial to complete the EMR report in
a timely manner and submit it to the facility for
their review and response. Facility personnel
often have numerous duties, so it is important
to report as quickly as possible on the strengths
of a facility's EMS as well as its areas for
improvement.  Facilities are more  apt  to
implement EPA's recommendations if the on-
site  review  experience  is still familiar  to
facility personnel.

3.2.k  Note that an EMR is a snapshot in
       time

The beginning of an EMR confirmation letter
should  stress that a review is a snapshot in
time and will discover items of concern that in
the future may not be problems at all.  A few
facilities requested that EPA delete  certain
negative  report findings because the facility
was either  "planning on working on  the
problem," or  "working  on  the  problem."
Instead of deleting these items, EPA generally
noted at  the beginning of the report that an
EMR was  an assessment of a  dynamic
organization and that EPA is reporting on the
state of the facility's EMS at a given point in
time based on interviews with select personnel
and document reviews.
3.3    Federal   Facility   Comments/
       Feedback on the Pilot Program

The  following  are  general comments from
personnel whose facilities participated in the
EMR Pilot Program:

     Federal Facility EMR Feedback
•  It gave the environmental staff a forum to
   advance EMS ideas within a structured
   framework.
•  It is easier to "sell" an EMS [to upper
   management] that is looked on favorably
   by EPA.
•  The EMR team was very well regarded
•  Communication was highly rated.
•  The EMR was helpful and better than
   expected.
•  The EMR was a great tool for federal
   facilities to  build relations  with  the
   regional EPA federal programs.
•  The EMR is also  a good program  to
   receive   a  friendly  environmental
   management audit,  which ultimately will
   help  the  facility's  environmental
   programs succeed.
   Some  of the evaluation results  were
   difficult to assess.
   The site would have benefitted from more
   information on the EMR protocol.
   Better planning and coordination would
   have  given  the  EMR team a  better
   snapshot picture of the site.
   We encourage all EMR members to sign
   the confirmation letter.
   The facility  should provide a neutral
   escort for the EMR team interviews.
   The process  needs to be explained in a
   laymen's format.  Higher managers that
   are not environmentally trained don't
   understand the concept of EMS.
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  jMR Pilot Program Methodology Assessment and Lessons Learned
•   Upper management likes to focus on the
    areas  for  improvement,  not  on  the
    strengths of the EMS.  EPA should find
    some way to highlight the positives (e.g.,
    a proclamation or certificate signed by
    the EPA Region Director).
•   Get buy-in from top management as soon
    as possible.

3.4    How Lessons Learned Resulted in
       Changes in the EMR Policy

Once the EMR pilot program was completed,
EPA Regional Federal Facility Coordinators
and other  regional  staff,  and OECA HQ
personnel   submitted comments  regarding
changes that  should  be made to the interim
EMR policy. Numerous changes were made to
the interim policy and  guidance, many of which
were editorial revisions for clarification, or
were  the  result of  merging the originally
separate EMR Policy and the EMR guidance.
However, there were  six significant revisions:

       Changing  the number of days the
       facility  has to disclose incidentally
       discovered violations

       The  interim  EMR policy required
       facilities  to   disclose  violations
       incidentally   discovered during  the
       review within 30 days.  The final EMR
       policy and  guidance  changed that
       requirement  to  10 days  to  ensure
       greater consistency with the EPA audit
       and self-disclosure  policy.

•      Adding  that   inspections  may   be
       waived for six months after an EMR

       Facilities   were   concerned   that
       voluntarily allowing EPA on-site could
       potentially  subject  the facility to a
       subsequent inspection.    To  allay
       concerns, EPA added  a provision to
       the final EMR policy which states that
       EPA  generally  will  not  conduct
inspections at the facility receiving the
review  for six months,  while  the
facility prepares its plan in response to
EPA's EMR report. The  policy also
describes  certain exceptions to  this
six-month window (e.g.,  statutory or
regulatory  mandates,   tips   or
complaints).

Changing  the  number  of  facility
reports

The interim EMR policy required the
facility to submit two reports to EPA
after the review; a recommendation
implementation plan within 60 days,
and an implementation status report six
months later.  The final EMR policy
reduced the number of reports to one.
The  facility   must   submit   an
implementation status report six months
after receiving the final management
review recommendations.

Changing  the number of required
signatures on the confirmation letter

During  the  pilot  program, EPA
required  a signature from both  the
facility and from EPA on the ground
rules letter. In the final EMR policy,
the letter is now being  referred to as
the "confirmation letter," and only one
(EPA's) signature is required, although
a facility representative  may sign it as
well.

Clarifying that EPA  has  various
enforcement options under the EMR
Program

Facilities  were  concerned  by  the
wording of the IVRP  in the interim
policy  which  implied that  formal
enforcement actions are taken for all
types of violations.  Considering  that
not all violations are the  same, EPA
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'MR Pilot Program Methodology Assessment and Lessons Learned

    clarified in the final EMR policy that
    there are various enforcement actions,
    both formal and informal, that EPA can
    take   in  response  to  violations
    discovered during a review.

    Adding the relationship between the
    EMR protocols, ISO 14001, and the
    Code of Environmental Management
    Principles (CEMP)

    During the pilot program, many facility
    personnel  asked the EPA teams how
    EMRs  related to the CEMP or ISO
    14001. The existence of different EMS
    standards  and guidelines show that
    there are  many ways to analyze  an
    EMS. The final EMR policy contains a
    discussion on the correlation between
    the EMR protocols, ISO  14001, and
    the CEMP.
                                           25

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s,
ummary Of Federal Facility Findings
                                      SECTION 4
                 SUMMARY OF FEDERAL FACILITY EMR FINDINGS
  This section summarizes the common findings of the majority of the pilot program EMRs
  in terms of the strengths and weaknesses of the facilities reviewed.
4.0    Overview   of  findings   and
       recommendations in EMR reports

The facility EMSs reviewed during the course
of the EMR pilot program differed markedly in
thoroughness, formality, and  complexity. The
systems ranged  from  a set  of disparate
environmental programs in need of a formal
program, to comprehensive, well documented,
and formal systems.  The following information
discusses   some   common  strengths   and
weaknesses encountered during the 29 pilot
program EMRs.

4.0.a   Strengths of facility EMSs

•      Personnel   acknowledge   their
       environmental responsibilities and
       are committed  to  protecting  the
       environment

Facility staff acknowledge their environmental
responsibilities and care about their site's
and/or their job's environmental impacts. If
given access  to  appropriate resources  and
training, interview results indicate that federal
facility personnel are generally committed to
protecting the environment.

•      Field staff routinely review facility
       environmental performance

Some  agencies  require  audits  or  formal
reviews of environmental performance on a
                                            three- or five-year schedule.  Interview results
                                            from some of the EMRs indicate that facility
                                            managers  and/or key staff conduct informal
                                            reviews   more   frequently.    However,
                                            implementation of recommendations from these
                                            reviews is inconsistent because of limited
                                            access to funds and technical assistance.
                                                  Strengths of Facilities' EMSs

                                                 Personnel acknowledge their
                                                 environmental responsibilities and
                                                 are committed to protecting the
                                                 environment
                                                 Field staff routinely review facility
                                                 environmental performance
                                                 Agencies participate in cooperative
                                                 environmental programs with other
                                                 organizations
                                                 Environmental considerations are
                                                 incorporated into most planning
                                                 processes
                                            •      Agencies participate in cooperative
                                                   environmental programs with other
                                                   organizations

                                            Many federal facilities support a variety  of
                                            environmental tracking and outreach efforts in
                                            cooperation with other federal organizations.
                                            For example, federal facility staff monitor air
                                          26

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s,
ummary Of Federal Facility Findings
quality,  track migratory birds,  and provide
educational programs for local schools.

•      Environmental  considerations  are
       incorporated  into  most  planning
      processes

Federal facilities often undertake new proj ects;
some  are insignificant to the  environment,
while  others  have  potentially  significant
environmental   impacts.    A mature  EMS
incorporates the environmental manager into
the project planning process. The earlier the
environmental  manager is able  to review
project  plans, the less  time is wasted  on
project revisions and stop-work issues. Many
of the facilities  participating  in  the  pilot
program EMRs incorporated environmental
considerations  into  the  project  planning
process.     However,   facilities   did  this
coordination  mainly   to   satisfy  NEPA
requirements, not because  it was  part of a
larger process of integrating environmental
considerations into everyday activities.

4.0.b   Main areas for improvement of the
       facility EMSs

•     Agencies and facilities lack adequate
       environmental staff and formal,
       annual  training  plans   and
       mechanisms  to  track  individual
       training needs and accomplishments

Environmental staffing levels at the facility,
regional, and agency level are inadequate to
ensure  compliance  with  environmental
regulations,  let alone to provide  technical
assistance   in  pollution   prevention  and
proactive  environmental   programs.     In
addition, while individual  training records
generally are maintained in personnel files,
federal facilities may enhance environmental
performance  by  reviewing  environmental
training needs and developing and monitoring
annual training plans to ensure that staff attend
environmental   training   necessary   or
                                             appropriate to their work assignments.

                                             •      Facilities lack formal environmental
                                                    management programs

                                             The majority of facility personnel described
                                             actions that they take to reduce their site's
                                             environmental   impacts.     However,   the
                                             personnel often indicated that the procedures
                                             described to the EMR team were informal, that
                                             is, not actually  written  anywhere. While this
                                             method of informal environmental management
                                             may  work  as long as the personnel  remain
                                             constant, it is vulnerable to personnel turnover.
                                             For instance, if a person were to stop working
                                             at a facility, the  experience  and  informal
                                             procedures designed to reduce the employee's
                                             environmental impact would leave  with that
                                             person.   Anyone  replacing that  employee
                                             would then have to start from the beginning and
                                             develop new procedures.  Facilities  should
                                             examine their processes and activities, identify
                                             which have the  potential to create significant
                                             environmental impacts, and develop formal,
                                             written procedures to minimize those impacts.
                                             A continuous improvement element also should
                                             be incorporated into the procedures  to ensure
                                             the facility  periodically looks for  ways to
                                             further  minimize  the  processes'  impacts.
                                             Facilities can use the Generic Protocol (Phase
                                             3) for Conducting Environmental Audits at
                                             Federal Facilities, the  CEMP, or ISO 14001
                                             to develop the procedures.
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s,
ummary Of Federal Facility Findings
•      Facilities   lack  facility-specific
       environmental   policies,  goals,
       objectives, or targets

Many agencies manage environmental issues
via a "top-down" approach.  Environmental
policies   are   often  developed   at   the
headquarters  level  and  distributed  through
organizational  channels.     However,  the
general policies  written at the headquarters
        Areas for Improvement
           for Facility EMSs

    Agencies and facilities lack adequate
    environmental staff and formal,
    annual training plans and
    mechanisms to track individual
    training needs and accomplishments
    Facilities lack formal environmental
    management programs
    Facilities lack facility-specific
    environmental policies, goals,
    objectives, or targets
    Facilities lack commitment to going
    beyond compliance; facilities seek
    only to meet compliance
    requirements
    Work being done does not match job
    descriptions and performance
    evaluations
    Lessons learned (positive and
    negative) are not shared with other
    federal facilities, let alone with
    facilities within the same agency
    Line and staff 'personnel are not
    asked for their opinion during the
    policy development process
    Tenant organizations are not held
    responsible for adhering to a site 's
    EMS
    Management is not aware of the
    work being done to minimize the
    site 's impact on the environment
                                             level lack detailed guidance on implementation
                                             procedures for field facilities as well as site-
                                             specific oversight.  Facilities should develop
                                             facility- and process-specific short- and long-
                                             term  goals,   objectives  and targets,  and
                                             implementation  plans  to   support   and
                                             complement the policies developed by agency
                                             headquarters.

                                             •      Facilities lack commitment to going
                                                   beyond compliance; facilities seek
                                                   only   to   meet   compliance
                                                   requirements

                                             Most  of a  federal facility's environmental
                                             metrics are based on the number of violations
                                             or findings of non-compliance issued to a
                                             facility in a given year. Facilities thus take a
                                             reactive, rather than a proactive, approach to
                                             environmental management.

                                             While an EMS is designed to assist a facility in
                                             achieving and maintaining  compliance,  the
                                             EMRs detected  a  lack  of measurement
                                             elements that can help the facility look beyond
                                             its environmental compliance requirements and
                                             focus on continuous improvement. By initiating
                                             reductions  in a site's environmental burdens
                                             and liabilities, an environmental manager  can
                                             demonstrate cost savings. A facility can save
                                             money by eliminating hidden costs and seeking
                                             pollution prevention solutions.  In addition,
                                             focusing only on compliance can sometimes
                                             cloud  an environmental manager's vision as to
                                             the source of a waste or emission problem. A
                                             properly designed EMS  employs root cause
                                             analysis techniques to address immediate and
                                             long-term environmental issues.

                                             •      Work being done does not match job
                                                   descriptions   and  performance
                                                   evaluations

                                             Facility personnel's environmental compliance
                                             responsibilities should be incorporated into
                                             basic job descriptions or shop responsibilities
                                             so that performance evaluations are based on
                                           28

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an accurate job description.   Many of the
facility   staff  interviewed   described
responsibilities that were not part of their
position description.  Managers  usually had
environmental responsibilities as part of their
position   descriptions,  but  environmental
responsibilities were not included in the job
descriptions of other personnel.  A complete
EMS   effectively  delegates  environmental
responsibilities  to   appropriately   trained
personnel.

Federal facilities should work with Office of
Personnel Management (OPM) (or supplement
OPM forms) by developing facility-specific
position   descriptions   and  performance
evaluation  forms to  accurately  portray the
responsibilities and expectations of facility
staff.

•      Lessons  learned   (positive  and
       negative) are  not shared with other
       federal facilities,  let  alone  with
       facilities within the same agency

Technology and information transfer was  an
afterthought to many  of the facilities visited
during the  EMR pilot program.   Numerous
facilities implemented pollution prevention
projects   that  both   reduced   the   site's
environmental  impacts  and  saved  money.
Successful processes and activities at one site
can be disseminated in the form  of case
studies, allowing staff at  similar facilities
throughout the country to learn from the lessons
learned.  Thus, it would make sense to share
the success stories  with  fellow  federal
facilities both inside  and outside individual
agencies.  In addition, line and staff were not
familiar with basic environmental information
sources  available  electronically,  such   as
Enviro$en$e  and  the  Joint Service P2
Technical Library.  The sharing of lessons

learned can be done  via electronic bulletin
boards, WWW sites, e-mail, and memoranda.
                                              •      Line and staff personnel are  not
                                                    asked for their opinion during the
                                                    policy development process

                                              Successful  environmental   management
                                              programs often have buy-in both at the top of
                                              the organization and also at the line and staff
                                              level.  Worker's attitudes about implementing
                                              a new policy change dramatically when the
                                              line and staff worker has been given  the
                                              opportunity to  help shape that policy.   In
                                              addition, line and staff personnel are often the
                                              most knowledgeable about a process and are
                                              best able to determine how a proposed policy
                                              will  affect  operations  and  environmental
                                              management issues.  Facilities should create
                                              policy development procedures that solicit
                                              employee input through the use of committees
                                              or open suggestion processes.

                                              •      Tenant organizations are  not held
                                                    responsible for adhering to a site's
                                                    EMS

                                              Federal  agencies often share building space
                                              with  other  federal agencies  or have tenant
                                              organizations located within their installation's
                                              boundaries. If the site's landlord has not fully
                                              integrated all tenants into its EMS, the landlord
                                              may not know when/if a tenant is in  danger of
                                              environmental  noncompliance.  All tenants,
                                              contractors,  and concessionaires should be
                                              active   members  of  the   installation's
                                              environmental committees and communications
                                              distribution lists to ensure tenants receive the
                                              same  environmental  information   as  other
                                              installation personnel.

                                              To facilitate oversight, tenants also should be
                                              required to comply with consistent, facility-
                                              wide reporting requirements.
                                                    Management is not aware  of the
                                                    work being done  to minimize the
                                                    site's impact on the environment
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s,
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Top management's environmental commitment
is  critical  to  a  successful  EMS.   If top
management is not familiar with the work of
the facility or regional environmental manager,
commitment and support, both in policy and
funding, may be difficult to obtain. It is crucial
for the  environmental manager to  report
regularly to the site/facility  manager.  Top
management should meet with environmental
staff  quarterly.   Environmental managers
should  submit regular reports  or provide
briefings documenting progress in compliance
and prevention, as well as current cost savings
and short and  long-term  policy and funding
needs. A representative of management should
read  and  sign these   reports to  indicate
awareness of the environmental status of each
facility.

4.1    Recommendations implemented by
       facilities

EPA Regional Federal  Facility Coordinators
are just beginning to receive feedback from
facilities that  participated in the EMR pilot
program.  It is too  early in  the  program to
measure its overall  effectiveness and/or to
determine   whether  or   not  EPA's
recommendations have been  implemented.
EPA plans to follow up with selected facilities
which had EMRs during the pilot program to
examine the impact  of  actions taken on their
environmental management systems and overall
performance.
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                                    Section 5

                                  CONCLUSION
After reviewing some  of the environmental
impacts of processes and activities at federal
facilities,   it  has  become  obvious   that
environmental regulations alone are not enough
to ensure against environmental degradation.
In addition  to  enforcing the environmental
regulations, EPA also is expanding its role as
compliance  assistance  provider  - - helping
facilities prevent pollution so that clean-up is
not required at a later  date. EMRs are one
element of that compliance assistance process.

The EMR pilot program was created to assist
federal  facilities  in  their  environmental
management activities and to implement EPA's
interim final EMR policy. Based on feedback
from the participating facilities, the  program
appears to have been a success.

Based on this success, EPA plans to conduct
more EMRs at  federal facilities, and will
continue to offer the reviews as an integral part
of  EPA's  overall  compliance  assistance
efforts. EPA's goal is to use the management
systemreviewsto further develop partnerships
with other federal  agencies, increase EPA's
accessibility to  federal facilities, and help
those facilities move beyond compliance in a
systematic manner.  As the program matures
and more EMRs are conducted, facilities can
expect a more streamlined and efficient review
process that  will  offer  recommendations
focused on the root causes  of environmental
concerns.

EPA looks  forward to the opportunity to
continue working cooperatively with federal
facilities through the use of EMRs and  other
tools to further reduce their environmental
impacts through a  proactive approach  to
environmental management.
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A
ppendices
                          Appendices
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A
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                                  APPENDIX A

                               EMR CASE STUDIES
       This Appendix contains synopses of four EMRs conducted at federal facilities during the
pilot program. The information is provided to help the reader better understand the benefits of
participating in the EMR program and the types of findings and recommendations that can be
expected from the EMR process.  Although the actual EMR reports are a matter of public record,
i.e., they can be accessed under FOIA, we chose to highlight only the EMRs findings and
recommendations in a generic manner.
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                                          Site/Facility A
A.      Facility overview
The mission of the 35,000 acre site is to conserve
and provide for the enjoyment of the scenery, the
natural  and historic  objects and the wildlife on
certain federal lands and to leave them unimpaired
for the enjoyment of future generations.

B.      EMR Logistics and Scope

During  the two-day  EMR, the  two person team
consisting of the EPA Regional Federal  Facility
Coordinator and an EPA contractor analyzed the
site's EMS in conjunction with the site's Chief of
Maintenance,   a  Maintenance   Management
Technician,  and   the   Fire   Management
Coordinator/Spill Coordinator.

The protocol used for this EMR was a combination
protocol containing  elements  of the Code of
Environmental Management Principles (CEMP)
and EPA's Generic Protocol for  Conducting
Environmental Audits at Federal Facilities, Phase
3.  All five of the protocol's disciplines were
included in this  EMR.  Those disciplines are: 1)
Management  Commitment,   2)  Compliance
Assurance and Pollution Prevention, 3) Enabling
Systems, 4) Performance and Accountability, and
5) Measurement and Improvement.

C.      EMR Findings and Recommendations

Strengths of the EMS

    If  funds  are  available in  a  department's
    operating  budget,  Maintenance  can simply
    purchase  equipment  or   initiate  new
    environmental projects.   If  funds are not
    available  in the   operations  budget,   the
    Superintendent must pursue funding through
    the  region and headquarters.

    Site staff work very closely with the public in
    a continuous effort to enhance the public's
    experience at the site. Conservation easements
    represent an ongoing local tax issue.   The
    organization  has   land use  and  zoning
    information available in GIS format. Recently,
    the  site completed  a visitor  experience and
    resource  protection   study   focusing   on
                                                     measurable  indicators  of and standards for
                                                     visitor use  that  can  be used  to develop
                                                     management strategies.  This analysis of visitor
                                                     perception of crowding on the carriage road
                                                     system utilized computer simulations to analyze
                                                     visitor perceptions of resource use.  The study
                                                     suggested that enforcement of appropriate trail
                                                     behavior and visitor education could resolve
                                                     concerns. The  site  produced a video on trail
                                                     behavior that is  available through local bicycle
                                                     shops and on local access television.
                                                     The  site   has  clearly   defined,
                                                     mechanisms to share information.
routine
                                                 •   Each employee creates an annual performance
                                                     plan and goals, against which performance is
                                                     measured.  The  system is flexible enough to
                                                     allow    a   Supervisor   to   incorporate
                                                     environmental tasks into the review criteria.
                                                     For example, the Chief of Maintenance added
                                                     responsibility for identifying less toxic product
                                                     substitutes to the performance review criteria
                                                     for the Maintenance Foreman.

                                                 Areas where the EMS needs improvement

                                                 •   The  site's HQ's  Office  of Environmental
                                                     Affairs  published  pollution prevention fact
                                                     sheets   on  a variety   of topics   including
                                                     automotive service stations. According to site
                                                     staff participating  in the EMR, they do not
                                                     utilize HQ as an  information resource and are
                                                     not familiar with the HQ's Commitment or fact
                                                     sheets.  The site does not have a Solid Waste
                                                     Management Plan.

                                                     The  site does not have a full-time staff position
                                                     responsible for coordination of environmental
                                                     compliance. The site's Administrative Officer,
                                                     whose duties include personnel, procurement
                                                     and budget, receives written policy updates and
                                                     places the information into three ring binders.
                                                     It is his  responsibility to notify Maintenance
                                                     and other Divisions of changes that may affect
                                                     their operations.  Neither the headquarters or
                                                     regional   office   appears  to   provide
                                                     implementation follow-up to ensure that site
                                                     staff has received policy and program updates
                                                     and  has  access  to the  expertise to identify
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    responsibilities and implement them.

•   The site has not implemented a facility-wide,
    formal environmental training plan.

Recommendations

1.   Hire a minimum of one FTE to manage the
    overall environmental compliance program,
     provide  on-site technical assistance and
    promote pollution prevention at the site.

2.   Establish   more  formal  procedures for
    environmental management planning and
    budget development.

3.   Establish  formal  procedures  for annual
    environmental compliance audits.

4.   Establish  a formal, annual training plan
    and track individual environmental training
    needs and accomplishments to ensure that
    all  training  requirements   for  staff
    performing  duties  with  environmental
    impacts  are  met.   Provide  additional
    funding and  opportunities for personnel
    environmental training development.
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                                          Site/Facility B
A.      Facility overview
The site provides environmental oversight to 36
facilities.   The site's primary mission  is flood
control for more than 4,600 acres.  It maintains
only about 300 total acres; the State Department of
Environmental Management (DEM), Division of
Fish and Wildlife leases 4,000 acres and OEM's
Division of Forests and Parks leases another 200
acres.  There are some privately owned properties
within the flood control area, but  there are no
habitable structures on these easement lands. DEM
is responsible for public recreation areas  and
fisheries on the  leased lands; the  site  provides
oversight but lessees are not required to comply
with the site's regulations.

B.      EMR Logistics and Scope

During the two-day EMR, the two  person team
consisting of the EPA  Regional Federal Facility
Coordinator and an EPA contractor  analyzed the
site's  EMS  in  conjunction   with the  site's
Environmental Compliance Coordinator; the River
Basin  Manager;  a  Project Manager; and a Park
Ranger.

The protocol used for this EMR was a combination
protocol containing  elements  of the  Code of
Environmental Management Principles  (CEMP)
and EPA's Generic  Protocol for  Conducting
Environmental Audits at Federal Facilities, Phase
3.  All five of the  protocol's disciplines  were
included in this EMR.  Those  disciplines are: 1)
Management  Commitment,   2)   Compliance
Assurance and Pollution Prevention, 3)  Enabling
Systems, 4) Performance and Accountability, and
5) Measurement and Improvement.

C.      EMR Findings and Recommendations

Strengths of the EMS

•   The  site's   environmental  policies   and
    procedures are codified in the Environmental
    Review  Guide  for   Operations  (ERGO).
    ERGO is a manual containing a  series of
    checklists that guide staff through the relevant
    environmental laws and regulations.  The site
    published   a  sub-manual   specific   to
                                                     environmental   issues   relevant  to  Civil
                                                     Engineering activities.

                                                 •   The site has a career training plan based on job
                                                     title requirements.

                                                     The staff has initiated a number of community
                                                     outreach efforts focusing on the environment.
                                                     For example, staff operate a booth at the local
                                                     Environmental Expo each year. Staff provide
                                                     environmental programs and facility tours for
                                                     local schools.  The Junior Project Manager
                                                     program brings students to the site for a day of
                                                     role-playing. During Earth Day, staff traveled
                                                     to  a nearby town where they  supported tree
                                                     plantings and water quality education activities.

                                                     Project  staff  conducts  an annual  internal
                                                     review and develops a Corrective Action Plan.
                                                     Project staff submits the Plan to a Manager
                                                     who reviews it and sends it on to the District
                                                     Environmental Coordinator.  Staff updates the
                                                     Corrective Action Plan every  six months, in
                                                     October and April. This requirement is spelled
                                                     out in  the site's  Facilities  Environmental
                                                     Compliance Guidance Letter, "Environmental
                                                     Compliance  Assessments."   During  audits,
                                                     performance is measured against established
                                                     Environmental-Natural  Resources   and/or
                                                     Environmental  Compliance   Performance
                                                     Measures.     ERGO  checklists  guide  the
                                                     assessment process.

                                                 Areas where the EMS needs improvement

                                                 •   Facility employees do not appear to have a
                                                     formal  method   for providing  input  to
                                                     environmental decision making.  They are not
                                                     represented on the Environmental  Steering
                                                     Committee.

                                                     While an official suggestion program allows
                                                     employees to complete a form and send it to
                                                     the District, such  suggestions may  not  be
                                                     reviewed by staff with authority to  proceed
                                                     toward implementation of suggestions.

                                                 •   The   District  Environmental  Compliance
                                                     Coordinator tries  to pass along  regulatory
                                                     information via e-mail to  the four Managers in
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his District and to the local facilities. He issues
memoranda asking whether local offices have
certain listed regulatory information.   If they
respond that they do not have the information,
he will provide it.  Given his other duties and
limited staff, however, there is not always time
for a comprehensive review of information
needs to ensure that each facility has access to
the  appropriate  federal,  state  and local
compliance  information as well as the site's
policy memos and updates.

There is no required environmental training for
field  personnel.     Staff  complete   annual
Individual   Development  Plans that may
identify  general training  interests. However,
there  is  no  specific   determination   of
environmental training needs. Park Rangers are
regarded as generalists and receive training for
broad responsibilities. The training for this title
is not focused on environmental awareness,
although the  individual  Ranger may have
responsibility for hazardous waste management
and may sign manifests.
Recommendations

1.       Develop a formal environmental policy
        and program priority statement for the
        project.

2.       Improve communications and access to
        regulatory information.

3.       Seek  additional  environmental  staff
        positions at the District and River Basin
        levels.

4.       Provide   additional   environmental
        training.

5.       Pursue   additional   funding   for
        environmental programs.
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                                          Site/Facility C
A.      Facility overview
The main laboratory complex examined during the
EMR occupies one building which houses offices
and laboratories.   The site also maintains a boat
storage  pad,  fuel storage  area, and a hazardous
waste storage area in the back parking lot.  The site
conducts   field   sampling   investigations  and
laboratory analysis.  The  planning of the field
investigations and the laboratory analyses take place
at the site. The facility is  approximately one year
old.

The site employs 138 people, about half of whom
work in one of the 60 laboratories at the facility.
The remainder of the facility is occupied by offices
for the laboratory and non-laboratory personnel.

To comply with the  Solid  Waste Disposal Act
(SWDA), non-hazardous solid wastes from all site-
occupied  facilities are collected by a contracted
disposal service and disposed of at the local landfill.

The site's main laboratory complex established a
recycling program for mixed-grade waste paper and
for beverage cans.  For the  paper, each office is
provided with a  collection bin while  centralized
collection containers are located in  Branch offices
and hallways throughout the site.  Janitorial staff
collect paper from the centralized bins for pickup
by the local recycling program.

The site has  a program  to properly  dispose  of
biomedical wastes, in  particular,  sharps  (e.g.,
needles, syringes with needles, scalpel blades).

B.      EMR Logistics and Scope

During  the two-day EMR, the two person team
consisting of the EPA Regional Federal Facility
Coordinator, an Army representative, and two EPA
contractors analyzed the site's EMS in conjunction
with  the  site's  full-time  Safety, Health,  and
Environmental Management Program (SHEMP)
Coordinator,  the  Maintenance  contractor,  and
numerous laboratory personnel.

The protocol used for this EMR was a combination
protocol containing elements  of the Code  of
Environmental Management Principles  (CEMP)
                                                 and EPA's Generic Protocol for  Conducting
                                                 Environmental Audits at Federal Facilities, Phase
                                                 3.   All  five of the protocol's disciplines were
                                                 included in this EMR.  Those disciplines are:  1)
                                                 Management  Commitment,   2)  Compliance
                                                 Assurance and Pollution  Prevention, 3)  Enabling
                                                 Systems, 4) Performance and Accountability, and
                                                 5) Measurement and Improvement.

                                                 C.      EMR Findings and Recommendations

                                                 Strengths of the EMS

                                                     The  site has  a full-time  Safety, Health, and
                                                     Environmental  Management   Program
                                                     (SHEMP) Coordinator who  works with an
                                                     Occupational Safety  and Health Committee
                                                     (OHSC)  comprised  of safety, health, and
                                                     environmental  management  representatives
                                                     from  each of the three branches and three
                                                     program offices within the Division.  These
                                                     representatives  set policy for and resolve any
                                                     management problems regarding safety, health,
                                                     and   environmental  management.     New
                                                     environmental initiatives can be implemented
                                                     by the OHSC  with  the  approval  of senior
                                                     management. In addition, there are two people
                                                     on staff who act as the Pollution Prevention
                                                     Committee.    All  of  these  representatives
                                                     conduct these duties  in addition to the duties
                                                     listed in their respective job descriptions.

                                                 •   The site implemented an excellent system used
                                                     to track hazardous components of samples to
                                                     ensure their proper  disposal.   This system
                                                     provides a foundation for the entire EMS.

                                                     Management sets the priorities to ensure that
                                                     the EMS is vital to the organization as a whole.

                                                 Areas where the EMS needs improvement

                                                     The  site has established goals and a baseline
                                                     for the pollution prevention program, but there
                                                     is some question whether other programs, such
                                                     as the solvent recycling, are being accurately
                                                     measured and benchmarked.

                                                 •   The    majority  of  the    environmental
                                                     responsibility at the site falls essentially to one
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 employee (the SHEMP Coordinator).  It may
 benefit  the  site  to  either delegate  those
 responsibilities  among  several  employees or
 document   and  formalize   all  of   the
 environmental   responsibilities  to  ensure
 continuity.

 Many procedures are established and acted on
 by verbal agreement;  sometimes  the verbal
 procedures confuse employees with minimal
 amounts of environmental compliance training.
Recommendations

1.  Formalize  the   verbal  agreements  and
    document these systems so they may  be
    reviewed and revised, as necessary.

2.  Determine whether it is feasible to create a
    formal chemical adoption plan.   Develop
    procedures for working with local labs to
    use the site's excess chemicals and materials
    if  liability  and  RCRA  issues  can  be
    overcome.

3.  Create   a   procedure  to   have   the
    Maintenance contractor coordinate with the
    SHEMP   Coordinator    on    facility
    work/routine maintenance  that  has  an
    environmental impact.
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                                           Site/Facility D
A.  Facility overview
There are over 20 different organizations using the
site's facilities.  These tenants,  referred  to as
"Resident Agencies," are taking advantage of the
many   resources  found   at   the  site.   The
Environmental  Office  is   in  charge  of  both
overseeing environmental compliance activities and
addressing environmental issues for the site.

The site is also host to a variety of temporary users,
with  short-term  agreements,   using  specified
facilities for specified periods of time. These range
from a few days to a few months. The main point
to remember is  that  the site  has a  wealth of
capabilities to be used and management is flexible
about the  terms of use.

As a shared federal facility, operation costs are
shared by the site and all Resident Agencies on a
pro-rated  reimbursable  basis.  As  the  airfield
manager,  the site is  ready, willing and  able to
provide additional services to Resident Agencies as
requested.

There are numerous operations and activities at the
site which could create environmental impacts. For
instance, the site is a fully functional federal airport
with all the necessary facilities needed for aircraft
operations.  It also  maintains  a wide  variety of
facilities available for military personnel and their
families. Of the  site's major activities, the four
which have the greatest potential environmental
impact include: 1) Facility Modifications and Site
Maintenance; 2)  Wind Tunnel Testing; 3) Life
Sciences;  and 4) Space Sciences.

On September 5, 1995, the site's HQ issued an
Agency-wide environmental policy.  In response to
that directive, the  site's Environmental  Office
worked together with other organization offices in
developing issue-specific environmental policies for
a number of areas.

B.      EMR Logistics and Scope

During the two-day EMR, the three person team
consisting of two EPA Regional Federal Facility
personnel and an EPA contractor analyzed the
site's EMS together with staff from the site's
                                                  Environmental Office.

                                                  The protocol used  for  this  EMR was  EPA's
                                                  Generic Protocol for Conducting Environmental
                                                  Audits at  Federal Facilities, Phase 3.   The
                                                  protocol   consists  of   seven  disciplines:   1)
                                                  Organizational   structure;   2)   Environmental
                                                  commitment;  3)  Formality  of  environmental
                                                  programs; 4) Internal and external communication;
                                                  5) Staff, resources, training, and development; 6)
                                                  Program  evaluation,  reporting,  and  corrective
                                                  action; and 7)  Environmental planning and risk
                                                  management.  The  goal of the  EMR  was  to
                                                  determine how well the site's EMS compared to the
                                                  following  two   disciplines:     1)  environmental
                                                  commitment, and 2) environmental planning and
                                                  risk management.

                                                  C.     EMR Findings and Recommendations

                                                  Strengths of the EMS

                                                  •   The site indicates its pursuit of environmental
                                                      excellence through the development of issue-
                                                      specific policies, through  top management
                                                      support,  and by delegating  environmental
                                                      responsibilities to the line and staff level.

                                                  •   Environmental  considerations  are generally
                                                      incorporated into the site's planning processes.
                                                      Facility projects and research and development
                                                      projects go through an Environmental Division
                                                      review prior to commencement.

                                                  Areas where the EMS needs improvement

                                                  •   Since the line and staff personnel are in charge
                                                      of addressing environmental  issues,  the site
                                                      must ensure that their EMS contains a formal
                                                      system  to  track  environmental deficiencies
                                                      through closure. Currently, the Environmental
                                                      Office is wary of environmental deficiencies,
                                                      but it does not formally track those deficiencies
                                                      nor how the deficiencies were addressed.

                                                      One   way   the  site   could   improve   its
                                                      environmental risk management program is to
                                                      conduct root cause analysis on environmental
                                                      deficiencies to help ensure similar problems do
                                                      not arise in the future.
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Recommendations

1.  Develop procedures to routinely distribute
    environmental  information  to  all   site
    personnel.

2.  Identify what regulations apply to each
    activity and ensure the courses provided to
    the staff performing task associated with
    that activity receive the  right type of
    training.

3.  Create    a    procedure   to   update
    environmental  courses  as   regulations
    change.

4.  Develop    procedures   to   ensure
    environmental issues have  been  properly
    addressed by line and staff personnel  and
    contractors once projects are complete.

5.  Modify   existing   hazardous   material
    procedures to ensure all materials are taken
    back during the appropriate time frame.
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                                           APPENDIX B


                                         Final EMR Policy

                 Environmental Management Review Policy and Guidance for Federal Facilities

        In accordance with Executive Order 12088, our national and regional federal facility program has the
responsibility to provide technical advice and assistance to federal facilities to ensure their cost effective and
timely compliance with applicable requirements. In addition, the President called on the federal government to be
the leader in achieving and maintaining a clean environment. The provision of an Environmental Management
Review (EMR) is one increasingly important means of providing this technical assistance for federal sector
leadership.

        An Interim EMR Policy was issued in May 1996, and a pilot program was undertaken to test out the
Interim Policy. Numerous EMRs were conducted as part of the pilot program, and this EMR Policy constitutes
the final policy and is based upon revisions determined to be necessary after the pilots. The EMR Policy lays out
the definition of an EMR, the operating principles under which EMRs are to be conducted by the EPA Federal
Facility Program, and the context in which EMRs will be conducted by EPA.  The EMR Guidance is a technical
accompaniment to the EMR Policy, and is intended to assist EPA personnel in conducting EMRs.

A. EMR Policy

I.  Definition and Benefits of an Environmental Management Review

        An Environmental Management Review is a review of an individual facility's program and management
systems to determine the extent to which a facility has developed and implemented specific environmental
protection programs and plans which, if properly managed, should ensure compliance and progress towards
environmental excellence. Because of the programmatic nature of an Environmental Management Review (EMR),
the focus of this review is on the  quality and/or implementation of the program, not on actual compliance
requirements. EMRs provide the federal facility information pertaining to:

o   Strengths and areas for improvement of environmental management systems and programs at federal facilities;

o   Identification of underlying causal factors which may contribute to the occurrence of compliance
    deficiencies, and development of long-term environmental compliance by helping to build an environmental
    management program foundation;

o   Review of each of the individual components of an environmental management system (such as those listed
    below); and

o   Assistance on the effectiveness of their systems, bench marking their performance, and identification of
    opportunities for improvement.

EMRs are not enforcement inspections. The EMRs are technical assistance site visits. They differ from a
compliance inspection or audit, which aim to capture a facility's compliance picture at a given point in time.
EMRs attempt to facilitate an understanding of the underlying causes of current or potential compliance problems
and to develop suggestions for actions to correct them. They attempt to facilitate an understanding of the
environmental management system (EMS) process and identify some of the more obvious weaknesses and
strengths of the facility's existing EMS. EMRs assist federal facilities in developing long-term environmental
compliance by helping to build an environmental management program foundation.  EMRs are intended to help
facility personnel understand how real environmental improvements can be achieved, by probing beyond the
immediate symptoms of non-compliance and attempting to identify and address underlying causes such as

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management system deficiencies. Further, they are not intended nor should they replace a facility's own efforts to
self-audit. Finally, an EMR is not a

Pollution Prevention Opportunity Assessment, although a review of a facility's pollution prevention program as it
relates to their environmental management system (EMS) may be conducted during an EMR.

        EPA has conducted technical assistance visits at federal facilities as part of its pollution prevention
opportunity assessments program. Now, by conducting Environmental Management Reviews, EPA hopes to
cooperatively provide facilities with advice about effective environmental management. The facility has the choice
as to whether and how to use the advice, but EPA believes that engaging in an EMR visit will foster a good working
relationship between the Agency and the federal facility, encourage a continued dialogue on environmental issues,
and help improve environmental performance.

n. Scope of an Environmental Management Review

        The scope of an EMR includes disciplines that are based on key characteristics and elements of effective
environmental management systems.  There are a number of common elements for most EMS models. For
example, the Code of Environmental Management Principles for Federal Agencies (CEMP), developed by EPA in
response to Executive Order 12856 and in conjunction with representatives from 16 federal departments and
agencies, includes management commitment, compliance assurance and pollution prevention, enabling systems,
performance and accountability, and measurement and development. The ISO 14001 EMS standard includes
environmental policy, planning, implementation and operation, checking and corrective action, and management
review. The seven EMR disciplines listed below (along with the corresponding CEMP Principles and ISO  14001
Sections) are from Phase 3 of the Generic Protocol for Conducting Environmental Audits of Federal Facilities.
They are:

o   Organizational Structure (CEMP Principle 1 and ISO 14001 Section 4.4)
o   Environmental Commitment (CEMP  Principle 1  and ISO 14001 Section 4.2)
o   Environmental Planning and Risk Management (CEMP Principles 2 & 3 and ISO 14001 Sections 4.3 & 4.4)
o   Staff Resources, Training, and Development (CEMP Principles 3 & 4 and ISO 14001 Section 4.4)
o   Formality of Environmental Programs (e.g. p2, auditing, compliance) (CEMP Principles 2 & 3 and ISO 14001
    Sections 4.2, 4.4 & 4.5)
o   Internal and External Communication (CEMP Principle 3 and ISO 14001 Section 4.4)
o   Program Evaluation, Reporting, and Corrective Action (CEMP Principles 3 & 5 and ISO 14001 Sections 4.5
    &4.6)

        While the wording of the EMR disciplines and the elements of CEMP and ISO 14001 are not identical,
the overlap, correlation and similarity are great. An EMR is a tool that can help facility personnel attain the CEMP
and move toward conformance with ISO 14001. This  is because an EMR will provide a review of the individual
components of the facility's EMS, as well as provide the facility with information regarding areas for improvement
of the EMS, feedback on the effectiveness of their systems, and bench marking their performance.

        An EMR is not a full-fledged Environmental  Management Systems Audit. A management systems audit
would provide a thorough, systematic evaluation of all elements of a facility's implementation of an environmental
management system.  EPA currently does not have the resources to conduct an in-depth environmental
management systems audit, which most often requires a week or several weeks stay at a given facility, and
significant resources depending on the size and type of facility. EPA envisions that an EMR may cover anywhere
from one to seven areas depending on EPA and the needs of the facility.  The determination of this need can be
accomplished through consultations between  EPA and the federal facility.
        This document (EPA Document No. 300-B-96-012 A&B) can be obtained by contacting U.S. EPA
Federal Facilities Enforcement Office at 202-564-2461.
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        An EMR is based on a combination of staff interviews, pre-site visit document reviews and a site visit at
the facility.  Interviews are especially important in conducting an environmental management review. They provide
the primary means of understanding the organizational relationships, roles and responsibilities, policies, and
systems that form the framework for the management of environmental matters. More importantly, they often
reveal differences in the actual versus the documented practices.  Document review is important to verify the
formality of the system and confirm interview information. A site visit is necessary to verify an EMS'
implementation and effectiveness.

        Depending on the characteristics of the federal facility such as the degree of sophistication of the
environmental management program, the EMR could take place over the course of a day's visit or up to a week.
Those participating may include representatives from the EPA Regional Federal Facility program,  Headquarters
and Regional technical assistance offices, other federal Agencies, contractors, and/or State Environmental
Agencies. As appropriate, EPA regional offices can conduct joint EMRs with their states, and should contact the
appropriate state technical assistance program as part of the development process for an EMR.

Where EMRs Are Likely to Be Conducted

        Federal facility participation in an EMR under all circumstances is voluntary. In general, EPA would
prefer to conduct EMRs at facilities where there is a potential for environmental impact (e.g., facility is a permit
holder or notifier under one or more environmental statutes), and/or at facilities that have limited resources for
hiring a private consultant or where their Agency does not already have an internal environmental management
system audit program.  This is more likely to be  the case at smaller agencies such as civilian federal agencies
(CFAs). This is consistent with the nature of the overall findings  of the Strategy for Improving Environmental
Management Programs at CFAs, which recommended training,  technical support, and compliance assistance for
CFAs. However, EPA may conduct an EMR at larger facilities if invited by the facility or where an EMR will be
useful to follow-up on an enforcement action to identify root causes.

        There may be some factors that could prohibit EPA from conducting an EMR at a facility. If a facility is
subject to an open criminal investigation, it should not be selected for an EMR. However, if a facility  is a recent
recipient of an enforcement action, this would not prohibit EPA from conducting an EMR at that facility.  In fact,
an EMR may be helpful in determining the root cause(s) of the violation(s).  In cases of a state enforcement
action, EPA should contact the state as part of the development process for the EMR.

m. Operating Principles

        The following are intended to provide EPA staff with general guidelines or operating principles for
conducting EMRs at federal facilities:

a.      An EMR visit is not an inspection.

b.      Participation in an EMR by a federal facility is voluntary, and facilities are invited to request an EMR. A
        federal facility may also be contacted at least one to two months in advance of a visit to solicit interest,
        and to ask for appropriate written documentation of their environmental management system.

c.      While the primary focus and intent of the EMR program is at the facility level, EMRs may also
        be appropriate at the regional and/or agency headquarters level. Agency headquarters are
        encouraged to contact EPA about having an EMR conducted at the headquarters and/or regional
        level. It  would be helpful if agency headquarters would encourage individual facilities to
        participate in an EMR.

d.      The date for the EMR is mutually arranged between the federal facility and EPA. Information regarding
        the topics that will be covered in the review will be discussed prior  to the visit.

e.      The facility will receive a confirmation letter prior to the EMR visit which will generally lay  out the

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        ground rules for the EMR. The confirmation letter will be signed by the appropriate EPA Regional
        manager, and may be co-signed by the facility manager as well (See Attachment One for examples of
        suggested components of a confirmation letter.) The confirmation letter will also ensure that EMR staff
        have access to the appropriate personnel and documents at the facility, as well as summarize the
        conditions of the Incidental Violations Response Policy (See Section IV).

f.       Each EMR visit will include an in-briefing and an exit-briefing or close-out session in which preliminary
        EMR results are shared with the host facility.  Provisions for additional technical assistance such as a
        future pollution prevention assessment can be discussed at this time.

g.       Within 60 days after the visit, the EPA regional office will provide the facility with a written report
        regarding the facility's environmental management system and provides recommendations for further
        activities. EPA and the facility can make arrangements for the sharing of draft findings prior to issuance
        of the final report. This EMR report will not contain information on incidental violations. All
        communication with the federal facility with respect to incidental violations will be conducted separate
        from the EMR report.

h.       To better inform the federal facility's headquarters office about the potential resource needs that may
        result from the EMR report, EPA may share a copy of the final report with headquarters,  unless the
        federal facility requests EPA to do otherwise.

i.       The facility will, no later than six months after receipt of the EPA EMR report, produce a response plan
        that lays out how they plan to address the EMR findings and reports on progress made to that point.
        During this  six-month period, EPA generally will not conduct inspections at the facility receiving the
        EMR unless such inspection is required by statute, regulation, or EPA policy involving compliance with
        environmental statutes, or unless good cause exists including belief of misrepresentation or falsification
        of any report required by law, to determine whether the facility may present an imminent  and substantial
        danger to public health or the environment, or to investigate a tip, complaint or other information
        concerning potential civil or criminal violations at the facility.

j.       Within approximately twelve months of the EPA EMR report,  the EPA regional office will
        informally contact the facility to get an update on, for example, the areas of change that resulted
        from the EMR, any staffing or resources changes, and any other appropriate information
        regarding the facility's response to the recommendations made in the EPA EMR report.

IV. Incidental Violations Response Policy (IVRP)

        The purpose of an EMR is not to assess the compliance status of a federal facility. There may, however,
be circumstances when an EMR incidentally uncovers violations either through document review  or while on site.
EPA's Office of Enforcement and Compliance Assurance (OECA) has developed enforcement response policies
for several programs with industry such as the Environmental Leadership Program, the Common Sense Initiative,
and Project XL that detail how violations will be treated if they are discovered as part of these programs. The
Incidental Violations Response  Policy (IVRP) described below details how violations will be treated that are
incidentally uncovered at a federal facility that is participating in the EMR program. As previously stated, EMRs
are not enforcement inspections. In fact, situations presenting enforcement issues have occurred  very infrequently
in the EMRs conducted at federal facilities to date.

Imminent and Substantial Endangernient

        In cases where the EMR team finds situations that may cause an imminent and substantial endangerment to
public health or the environment or serious actual harm, EPA expects the  facility to address the situation
immediately and retains the right to respond as necessary.

Other Violations

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        OECA's Federal Facilities Enforcement Office (FFEO) is responsible for ensuring that federal facilities
take all necessary actions to prevent, control and abate environmental pollution. FFEO uses a comprehensive
approach encompassing compliance assistance, compliance oversight and enforcement, and systematic reviews of
federal agency environmental plans and programs to ensure that federal agencies are in compliance and taking
steps toward pollution prevention. Generally, EPA bases its initial response to a violation on the type of violation
and the potential risk posed by the violation. Although the pertinent statute/regulation and media-specific or
program-specific guidance governs the type of initial EPA response, they can vary from a Notice of Violation
(NOV)/Notice of Noncompliance (NON), to an Order or Compliance  Agreement without penalties, to a Complaint
or Order assessing penalties.

        Consistent with EPA's Audit Policy (Incentives for Self-Policing, 60 FR 66706, December 22, 1995),
and in the context of the EMR program and the IVRP, following the identification of a violation(s) as a result of an
EMR, the federal facility will be required to disclose the violation(s) in writing to EPA within 10 days of its
identification. In addition, the federal facility must correct the violation(s) within 60 days of its disclosure to
EPA, certifying in writing that the violation(s) has been corrected, and take appropriate measures as determined by
EPA to remedy any environmental or human harm due to the violation(s).

        If more than 60 days will be needed to correct the violation(s), the federal facility must notify EPA in
writing before the 60-day period has passed. The facility must then enter into a written compliance agreement
that:

 o  establishes a specified period for correcting all outstanding violations; and

o   incorporates interim milestones that demonstrate reasonable progress toward compliance and sets forth the
    additional correction period and any additional steps to be undertaken by  the facility to achieve compliance.

        The total period of time for correction is not to exceed one-year, except in cases where pollution
prevention is used as the means of correction, in which case the facility could have a total of 18 months for
correction. The correction period may be limited based on statutory/regulatory requirements, as well as media-
specific policy and guidance regarding significant non-compliers.

        Consistent with EPA's Audit Policy, this IVRP does not apply to criminal violations, repeat violations,
        Identification of a potential violation can either occur during the EMR visit or after the EPA staff on
the EMR team consults with other appropriate regional staff. EPA will generally take no longer than 10 days
after the EMR visit to contact the federal facility with information about any additional violations that result
from this consultation.

        In special cases an EPA region may grant a facility more than a year to correct violations due to the
particular budget constraints at the facility.  A region must first make the Federal Facilities Enforcement
Office aware of the situation prior to granting additional time to the facility.  A region should also make a
facility aware that such facility may be inspected to verify that the facility has corrected violations pursuant
to this IVRP.

        See also the Audit Policy Interpretive Guidance for additional definitions and information
concerning the EPA Audit Policy.

        The specific violation (or closely related violation) can not have occurred previously within the past
three years, or is not part of a pattern of federal, state or local violations by the facility's parent Agency,
which have occurred within the past five years.  A violation is: (a) any violation of federal, state or local
environmental law identified in a judicial or administrative order, consent  agreement or order, complaint, or
notice of violation, conviction or plea agreement; (b) any act or omission for which the regulated entity has
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violations that resulted in serious actual harm (or may have presented an imminent and substantial endangerment
to) human health or the environment, violations of the specific terms of any judicial or administrative order or
consent agreement, or actions to address recurrences of violations.

        In those instances where the media-specific or program-specific guidance calls for the assessment of a
penalty, EPA will completely waive the gravity-portion of such penalty for federal facilities that disclose and
correct violations detected during the EMR as described above. EPA reserves the right to collect any economic
benefit that may have been realized as a result of noncompliance. Economic benefit may be waived, however,
where EPA determines that it is insignificant.

        Where EPA and or the state is concerned about appropriate response from the facility, EPA reserves its
rights to respond as it deems appropriate to instances of non-compliance. Except where explicitly noted, nothing
in this policy should be construed to limit any legal authority EPA may have.
previously received penalty mitigation from EPA or a state or local agency.
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B. EMR Guidance

I.      Purpose:

        This guidance is intended as a technical accompaniment to the EPA Environmental Management Review
Policy for Federal Facilities. Its purpose is to assist EPA Headquarters and EPA Regional personnel in conducting
Environmental Management Reviews (EMRs).  This document will outline key areas of performance that should be
considered when EPA staff and contractors are conducting EMRs. The guidance refers the users of this guidance
to the Generic Protocol for  Conducting Environmental Audits of Federal Facilities (EPA Document No. 300-B-
96-012 A&B) for reference to expected performance criteria during the conduct of an EMR (performance
objectives, key evaluative concerns, and criteria) and are therefore not restated within this guidance.  The
definition of an EMR as well as the scope of these reviews are discussed in Section II of the EMR Policy. This
technical guidance will not define a specific technical approach to be followed in all circumstances. Instead, the
guidance emphasizes the planning (Section II) and communications (Section III) aspects of the EMR process, and
also provides discussion on the use of protocols and checklists during the  EMR process (Section IV).  These
sections were developed to help ensure consistency in the quality of the work to be performed, and to ensure that
the expectations between the EPA regions and the participating federal facilities on the outcome of the EMR
process are one and the same.

        To a great extent, the success of the EMR program will depend on the quality of the products and service
provided to federal facility participants. For this reason, FFEO strongly recommends that EPA staff and EPA
contractors participating in the EMRs are trained in environmental audit procedures, and especially in the
techniques of auditing environmental management systems.  To help ensure an appropriate degree of expertise,
Section VI of this guidance outlines training considerations (e.g., skills) needed by  EPA staff and contractors.

n.     Planning:

        EPA regional staff responsible for organizing and conducting the  EMR should spend a  significant amount
of time planning for the site visit.  Careful planning is crucial to ensuring that the limited time typically available
for the site visit is used most effectively. Careful planning also minimizes the time necessary for follow-up
activities after the site visit, and reduces the burden on facility management by efficiently utilizing the time and
talents of their staff during the EMR process. The factors to consider in planning an EMR: (1) the goals and scope
of the EMR;  (2) the size and complexity of the facility operations; (3) the regional staffs familiarity with the site;
(4) resources available for conducting the EMR; and (5) the desired form  and content of the final EMR report.

        If a contractor will be accompanying the EPA regional staff while conducting the EMR, regional staff
should develop a scope of work that clearly establishes roles and protocols for each phase of the EMR (i.e., pre-
visit, on-site, post-visit).  If in-house regional staff are conducting the EMRs, the Federal Facility Coordinator or
other regional member in charge of the EMR should select team members and assign roles and responsibilities.
Regardless of who performs  the EMRs, as part of the planning phase, EPA regional staff should ensure that the
members of the EMR team:

1.      clearly understand the goals and scope of the EMR;

2.      upon reviewing preliminary information, are familiar with the facility's operations, environmental
        management policies, compliance history, waste streams and other environmental releases;

3.      have the correct checklists and protocols and understands how to use them;

4.      agree to follow the detailed EMR agenda formulated specifically for that facility;

5.      are aware of potential health and safety issues and are prepared to handle them on-site; and

6.      understand how information collected on-site will be presented in the EMR final report.

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m.     Communications With Facility Management:

        Once contact is initiated by either EPA, the facility management, or federal agency headquarters staff
who have expressed an interest in having an EMR conducted at a particular site, EPA staff and federal facility
management should discuss, in detail, the purpose and scope of the EMR, especially the ground rules for engaging
in the process. Additionally, facility management should be briefed on the Operating Principles contained in
Section III of the EMR Policy, including the outcome of the process (i.e., development of a written report) and the
time frame under which that occurs. Following these discussions, a confirmation letter/ground rules letter will be
sent to the facility prior to conducting the EMR planning process and site visit (see Section III (e) and Attachment
One of the EMR Policy) to ensure that all parties understand the conditions under which the EMR will be
conducted. This letter will also ensure that EMR staff have access to the appropriate personnel and documents at
the facility, and also document that all participants are aware of terms and conditions of the Incidental Violations
Response Policy (IVRP) discussed in Section IV of the EMR Policy.   Examples of suggested components of a
sample confirmation letter are included as Attachment One of the EMR Policy document.

        EPA regional environmental staff should also use the confirmation letter to confirm the scope and dates
of the EMR site visit, and to establish points of technical contact (POC) for both parties.  In addition, EPA staff
involved in the EMR will have an opportunity to propose an agenda for the site visit, and to  send a pre-site visit
questionnaire which will be helpful in determining the specific focus of the EMR. All EPA regional staff
members involved in the EMR should be mindful of the fact that the facility to be visited is volunteering for this
effort and, therefore,  developing and maintaining a positive relationship with the facility POC is  vital to the
success of the EMR.  Taking care to set the right tone when contacting facility personnel is critical. Important
points to communicate to facility management include:

1.  The purpose of the EMR Both facility management and EPA regional staff assigned to conduct the EMR
    should be fully aware of the EMR's goals and scope, and the EPA  EMR Policy document. In addition, facility
    management and staff should understand how the EMR results will be used both by their agency headquarters
    personnel (if appropriate) and by EPA.  Facility understanding of how the EMR results will  be used and how it
    may impact facility operations and relationship with EPA is particularly important.

2.  Information needs and critical persons needed for interview: EPA regional staff conducting the EMR should
    work with facility management to develop a list of information needs and persons to be  interviewed as part of
    a site visit, including management and line and staff personnel at all levels at the facility. To accomplish this
    task, a pre-site visit questionnaire should be  forwarded to facility management in advance of the site visit to
    alert facility management of the documents that should be available for review  (e.g.,  organizational charts,
    job-descriptions and environmental planning documents), and the facility staff that the EMR team will want to
    interview during the site visit. A timely and well crafted pre-site visit questionnaire will save EPA regional
    staff considerable time by answering fundamental questions about the facility practices  and  policies, and
    allowing the regional staff to focus the site visit on the critical issues and matters requiring  a more in-depth
    review. FFEO has provided an appendix to the EPA Phase III protocol, Selecting Documents to Review and
    Individuals to Interview for Environmental Management Assessments, to assist personnel in this phase of
    the EMR process.  EPA Region 1 has also developed a pre-site visit questionnaire that may prove useful for
    other Regions (See Attachment Two).

3.  Time schedules: Regional environmental staff should work with the facility to develop an appropriate agenda
    and schedule for the EMR. The time schedule will depend on the size and complexity of the facility and the
    number of individuals that need to be interviewed.

IV.     Protocols/Checklists:

        Because the scope of the EMR site visit will likely involve a review and assessment of more than one of
the environmental organizational disciplines outlined in Section II of this technical guidance and Section II of the

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ppendix B - Final EMR Policy
EMR Policy, FFEO recommends that Phase III of the EPA Generic Protocol For Conducting Environmental
Audits of Federal Facilities be consulted by EPA regional staff when developing the actual working documents
and specific tools for a given site. The Phase III Protocol will provide specific guidance to EMR team members in
evaluating the facility activities, and in documenting the procedural elements that are to be reviewed during the
EMR. The Protocol also identifies performance objectives, and key evaluative concerns and criteria related to
each of the organizational disciplines to be evaluated.  Once the scope of the EMR is agreed upon by EPA regional
staff and facility management, the EMR team conducting the review should select the appropriate performance
objectives and criteria needed from the Phase III Protocol, and develop the appropriate protocols and checklists
for that site. EPA Region 1 has also developed an EMR protocol which incorporates many items from the Phase
III Protocol, and is organized around the Code of Environmental Management Principles for Federal Agencies
(CEMP) (See Attachment Three). Both of these documents may be helpful to EMR team members in other
Regions developing protocols and checklists for a specific site.

         A checklist is an actual on-site tool developed specifically for the facility that is being reviewed. A
checklist is dynamic, and should reflect only the areas to be evaluated for a particular facility based upon
information gathered from the pre-site visit questionnaire, and pre-site visit communications with facility
management.  FFEO recommends that EPA staff conducting EMRs either develop a unique checklist for each
facility undergoing a review, or annotate and modify existing checklists to reflect the specific scope agreed upon
for a particular facility visit. Points to consider in developing or using a checklist include:

o   Is the checklist applicable to the type of facility being evaluated?

o   Is it pertinent to the organizational disciplines being reviewed?

o   Is it consistent with the goals and scope of the EMR for that particular facility ?

         Protocols and checklists are  essential tools for assuring that an EMR has adequately addressed all issues
that need to be examined during an EMR. However, they are not static (i.e., one  size fits all), and should reflect the
unique considerations and differences attributable for each federal facility program and management system being
reviewed. Protocols and checklists also are not a substitute for critical and independent judgement or decision
making,  and should only be used as a reference point to affirm that key criteria and evaluative areas have been
examined.

V.      Training and Development of Expertise:

         The success of the EMR program depends on the quality of the service being provided to facility
management.  Since federal agencies  and their facilities will be looking to EPA for guidance in improving their
overall environmental management systems, EPA staff and contractors conducting EMRs should be able to
demonstrate having both appropriate knowledge of the issues included in the scope of the EMR, and sufficient
training and proficiency prior to participating in EMRs.

         The qualifications of the staff assigned to conduct EMRs should be commensurate with the objectives,
scope and complexities of that particular EMR assignment.  Although EMRs will vary in scope, they all require
some degree of professional assessment of apparent problems as well as  some verification and documentation of
the facility's systems for the full range of potential hazards - not just those related to compliance requirements.
While the balance between assessment and verification will vary, in general the EPA staff member's  background
should include at a minimum:

o        technical training and experience appropriate to the work called for by the particular EMR;

o        an understanding of basic auditing theory and procedures, and the experience needed to apply it in
         particular situations;

o        a working knowledge of environmental regulations, evaluation criteria in the Phase 3 Protocol, and

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   ppendix B - Final EMR Policy


        general EMS standards appropriate to the scope of the EMR; and

o       general familiarity with the type of operations to be reviewed, and the issues likely to be encountered
        within the scope of the EMR.

While the precise mix of experience and knowledge that is desirable can vary, the EMR team as a whole should
represent sufficient depth in these four areas of experience.
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ppendix B - Final EMR Policy
                                             Attachment One
                      Examples of Suggested Components of a Sample Confirmation Letter

The confirmation letter for an EMR could include the following elements:

a.      specific objectives of the EMR~a brief discussion of which components of an environmental
        management system the review will focus on;

b.      a statement that an EMR is not an inspection.

c.      brief discussion of EPA's  expectations of the federal facility with respect to requests for access to
        specific staff,  parts of the  facility, access to info, etc.

d.      a brief explanation of the Incidental Violations Response Policy (IVRP) and any necessary definitions.
        Emphasize that instances involving the IVRP are very infrequent.

e.      a brief explanation of how the site visit will be conducted, what documents will be requested in advance,
        what federal facility personnel will be interviewed, etc.

f      a disclaimer that the facility is responsible for compliance with all applicable regulations regardless of
        whether or not they have an EMR.

g.      a statement that the facility will, no later than six months after receipt of the EPA EMR report, produce a
        response plan  that lays out how they plan to address the EMR findings and reports on progress made to
        that point.

h.      a statement that the EMR is available through FOIA.
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ppendix C-Process Steps For A Sample EMR
                                    APPENDIX C
                            Process steps for a sample EMR
TASK#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TASK
U.S. EPA provides federal facility with a draft
Confirmation Letter for comment and a pre-site visit
questionnaire for completion
Federal facility provides U.S. EPA with Confirmation
Letter comments
Federal facility submits to U.S. EPA completed EMR
pre-site visit questionnaire
Federal facility submits to U.S. EPA samples and
copies of documents requested in the Confirmation
Letter
Confirmation Letter is signed by both U.S. EPA and
federal facility
Federal facility submits to U.S. EPA a list of
personnel available for on-site interviews
U.S. EPA submits EMR protocol to federal facility
for distribution to personnel who will be interviewed
U.S. EPA submits to federal facility EMR logistical
plan
U.S. EPA develops draft interview schedule and
submits to federal facility for comment
Federal facility submits to U.S. EPA interview
schedule comments
U.S. EPA submits to federal facility final interview
schedule
On-site portion of the EMR - document review and
interviews
U.S. EPA submits to federal facility EMR findings
and recommendations
Federal facility submits to U.S. EPA a plan to
implement certain EMR recommendations
Federal facility submits to U. S. EPA an implementation
progress report
DATE OF COMPLETION
May 18, 1998
June 1, 1998
June 1, 1998
June 8, 1998
June 15, 1998
July 10, 1998
July 13, 1998
July 20, 1998
July 27, 1998
July 30, 1998
August 7, 1998
Two days during the week of
August 17, 1998
60 days after on-site portion
of the EMR
60 days after receipt of the
U.S. EPA report
Six months after submitting
initial report
                                         58

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ppendix D-EMR Tools And Related Compliance Assistance Resources
                                        APPENDIX D
               EMR TOOLS AND RELATED COMPLIANCE ASSISTANCE RESOURCES
               Regional Federal Facility Coordinator Contact Information
  Anne H. Fenn
  US EPA Region I (CT, MA, ME, NH, RI, VT)
  One Congress St.-Suite 1100
  Mail: SPP
  Boston, MA 02114-2023
  Tel: 617-981-1805
  Fax:617-918-1810
  fenn.anne@epa. gov

  Bill Arguto
  US EPA Region III (DE, DC, MD, PA, VA, WV)
  841 Chestnut St.
  Philadelphia, PA  19107
  Tel: 215-814-3367
  Fax:215-566-2783
  arguto.wilriam@epa. gov
  Lee Regner
  US EPA Region V (IL, IN, MI, MN, OH, WI)
  77 West Jackson Blvd.
  Chicago, IL 60604
  Tel: 312-353-6478
  Fax:312-353-5374
  regner.lee@epa. gov
  Diana Jackson
  US EPA Region VII (IA, KS, MO, NE)
  901 N. 5th St.
  Mail: RA/ECO
  Kansas City, KS 66101
  Tel: 913-551-7744
  Fax:913-551-7941
  iackson.diana@epa.gov

  Sara Segal
  US EPA Region DC (AZ, CA, HI, NV, AS, GU,
  TTP)
  75 Hawthorne St., CMD-2
  San Francisco, CA 94105
  Tel: 415-744-1569
  Fax:  415-744-1598
  se gal. sara@epa. gov
                                             Jeanette Dadusc
                                             US EPA Region II (NJ, NY, PR, VI)
                                             290 Broadway-21th Fl.
                                             New York, NY 10007
                                             Tel: 212-637-3492
                                             Fax: 212-637-4086
                                             dadusc.ieanette@epa.gov
                                             Stacy Howard
                                             US EPA Region IV (AL, FL, GA, KY, MS, NC, SC,
                                             TN)
                                             61 Forsyth St., SW
                                             Atlanta, GA 30303
                                             Tel: 404-562-9633
                                             Fax: 404-562-9598
                                             howard.stacy@epa.gov

                                             Joyce Stubblefield
                                             US EPA Region VI (AR, LA, NM, OK, TX)
                                             Mail: 6EN-XP
                                             1445 Ross Ave.
                                             Dallas, TX 75202
                                             Tel: 214-665-6430
                                             Fax: 214-665-7446
                                             stubblefield.ioyce@epa. gov

                                             Dianne Thiel
                                             US EPA Region VIII (CO, MT, ND, SD, UT, WY)
                                             999 18th St. -Ste. 500
                                             Mail: 8P-P3T
                                             Denver, CO 80202-2466
                                             Tel: 303-312-6389
                                             Fax: 303-312-6044
                                             thiel.dianne@epa. gov

                                             Michele Wright
                                             US EPA Region X (ID, OR, WA, AK)
                                             1200 6th Ave., OEC-157
                                             Seattle, WA 98101
                                             Tel: 206-553-1747
                                             Fax: 206-553-7176
                                             wright.michele@epa. gov
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                    ENVIRONMENTAL MANAGEMENT REVIEW (EMR)
                                  Process Evaluation — Team
  Thank you for participating in this management system review.  In an effort to continuously improve
  our process, we are asking for your evaluation and suggestions.  Your candid insights will be
  extremely helpful to us.
How well prepared did you feel you were for the EMR?
    Knowledge of objectives and process
    Understanding of organization to be reviewed
    Understanding of EMR criteria

How efficient was the process?
    Preparation
    On-site
    Synthesis of data

How effective were communications?
    Within the team
    With organization being reviewed

Were your views and ideas heard and accommodated?
How useful were the tools we used?
How thorough was  the process?
How useful was the outcome to the organization reviewed?
How challenging was the process?
How close was the actual experience to your expectations?
How useful to you was the process as a learning experience?
How could the process be improved?  (Please be specific. Continue  on reverse if necessary)
very
very
very
very
very
very
very
very
very
very
very
very
very
better
very
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
close
somewhat
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
worse
not at all
                                              61

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ppendix D-EMR Tools And Related Compliance Assistance Resources
                    ENVIRONMENTAL MANAGEMENT REVIEW (EMR)
                                   Process Evaluation — Site
  Thank you for participating in this management system review. In an effort to continuously improve
  our process, we are asking for your evaluation and suggestions.  Your candid insights will be
  extremely helpful to us.   (Feel free to skip questions that do not apply.)
How well prepared did you feel you were for the EMR?
    Knowledge of objectives and process
    Understanding of EMR criteria
                                                                        somewhat     not at all
                                                                        somewhat     not at all
How efficient was the process?
    Preparation
    On-site
How disruptive to the organization was the activity?
How effective were communications from the team?
Were your views and ideas heard and accommodated?
How useful were the tools we used?
How thorough was the process?
How accurate were the observations?
How useful were the recommendations?
How timely was the report?
How helpful was the overall experience?
How close was the actual experience to your expectations?
How professional  were the team members?
How knowledgeable were the team members?
How objective were the team members?
How flexible were the team members?
How responsive were the team members?
How could the process be improved?  (Please be specific.  Continue on reverse if necessary)
                                                                        somewhat     not at all
very
very
very
very
very
very
very
very
very
very
better
very
very
very
very
very
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
somewhat
close
somewhat
somewhat
somewhat
somewhat
somewhat
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
not at all
worse
not at all
not at all
not at all
not at all
not at all
                                              62

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              EPA ENVIRONMENTAL MANAGEMENT REVIEWS
                     FOR FEDERAL FACILITIES
                 FACILITYPRE-SITE QUESTIONNAIRE


    FACILITY CONTACT INFORMATION
 NAME OF FACILITY:
 FACILITY
 DIRECTOR/COMMANDER:

 ADDRESS:
 TELEPHONE:
                         FAX:
 FACILITY ENVIRONMENTAL COORDINATOR:
 ADDRESS:
 TELEPHONE:
                         FAX:
 PARENT ORGANIZATION:
 PARENT ORGANIZATION
 ENVIRONMENTAL MANAGER:
 ADDRESS:
E-MAIL:
E-MAIL:
 TELEPHONE:
                         FAX:
 H.    FACILITY ORGANIZATIONAL STRUCTURE
                                  64
E-MAIL:

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   ppendix D-EMR Tools And Related Compliance Assistance Resources
1.      Please describe your facility's mission/major activities:
2.     How does your facility fit into the organizational structure of your parent agency?
3.     Has your parent agency issued a formal, organization-wide environmental policy and
       standards?  When?
4.     Does your parent agency provide environmental assistance and/or oversight? How does
       your parent agency collect reporting data from and/or provide environmental information to
       your facility? Who is your facility's point of contact with your parent agency?
5.     How does your Environmental Program fit into your facility's organizational structure?
       What is the facility's annual budget? What is the level of funding for the Environmental
       Program?
6.     Do any other facility staff or programs have environmental management responsibilities?
       If yes, please explain.
7.     How is your facility Environmental Management Program organized? How many staff at
       your facility have full-time or part-time environmental responsibilities? Briefly describe
       the general responsibilities of your Environmental Program.
8.     What is the internal process for implementing new environmental initiatives? What is the
       approval process and how are funds allocated for new environmental initiatives?
9.     What methods are used to track and measure facility environmental performance? How
       frequently is such measurement performed?
PLEASE PROVIDE COPIES OF THE FOLLOWING:

	               Parent agency organization chart

                                            65

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	              Parent agency environmental policy and standards


	              Staffing and organization chart for your facility
	               Samples of supporting documentation for reporting and communication
                     networks such as meeting notices, meeting minutes, memoranda, etc.

	               Samples of written Environmental Program performance and status reports

	               Samples of facility-specific environmental policies and procedures

Please complete the following chart.  The information will help the EMR team determine what
environmental issues should be planned for and taken into account by your facility. When
completing the chart, please indicate the policies, procedures, and personnel that are pertinent to
the various aspects of the media/program.
                                            66

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ppendix D-EMR Tools And Related Compliance Assistance Resources
m.
   FACILITY BACKGROUND INFORMATION
MEDIA PROGRAM REVIEW
MEDIA/
PROGRAM
CAA
SDWA
UIC
FIFRA
PLANS/
PERMITS




SOURCES/
DISCHARGES




UNDERSTAND
REGS?




MGMT.
PROCEDURES




PERSONNEL
TRAINING




RECORDKEEPING/
REPORTING




OVERSIGHT/
EVALUATION




                                                       67

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MEDIA PROGRAM REVIEW
MEDIA/
PROGRAM
NPDES
WETLANDS
RCRA
Generator
Status:
PLANS/
PERMITS




SOURCES/
DISCHARGES




UNDERSTAND
REGS?




MGMT.
PROCEDURES




PERSONNEL
TRAINING




RECORDKEEPING/
REPORTING




OVERSIGHT/
EVALUATION




                                                                68

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ppendix D-EMR Tools And Related Compliance Assistance Resources
MEDIA PROGRAM REVIEW
MEDIA/
PROGRAM

TSCA/PCBS
UST
PLANS/
PERMITS



SOURCES/
DISCHARGES



UNDERSTAND
REGS?



MGMT.
PROCEDURES



PERSONNEL
TRAINING



RECORDKEEPING/
REPORTING



OVERSIGHT/
EVALUATION



                                                                69

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vvEPA
United States
Environmental Protection Agency
(2261A)
Washington, DC 20460

Official Business
Penalty for Private Use
$300
      Printed on recycled paper

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