U.S. Environmental
Protection Agency
Safety, Health and
Environmental Audit Protoco
March
1994
Safety, Health and Environmental
Management Division
401 M Street, SW
Washington, DC 20460
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SwZ $
U.S. Environmental
Protection Agency
Safety, Health and
Environmental Audit Protocol
March 1994
Safety, Health and Environmental
Management Division
401 M Street, SW
Washington, DC 20460
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SAFETY, HEALTH AND ENVIRONMENTAL AUDIT PROTOCOL
Introduction
Management Systems Protocol
Environmental Management Protocol
I. Air Pollution Control
II. Drinking Water Management
III. Water Pollution Control
IV. Medical Waste Management
V. Solid and Hazardous Waste Management
VI. Underground Storage Tank Management
VII. Past Disposal Practices
VIII. Toxic Substances Management
IX. Emergency Planning and Community Right-to-Know
X. Pesticide Management
XI. Radioactive Materials Management
Safety and Health Protocol
XII. Safety
XIII. Occupational Health
XIV. Fire and Life Safety
XV. Diving and Small Boat Safety
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U.S. ENVIRONMENTAL PROTECTION AGENCY
SAFETY, HEALTH AND ENVIRONMENTAL AUDIT PROTOCOL
INTRODUCTION
The U.S. Environmental Protection Agency (EPA) Safety, Health and Environmental Audit Protocol is intended to serve as a
guide for planning and conducting audits at EPA facilities and operations. This protocol facilitates the collection of
management systems and compliance information pertinent to and necessary for accomplishing the objectives of EPA's
internal Safety, Health and Environmental Audit Program. While it provides the foundation for internal Agency auditing
efforts, this protocol may require additions or modifications to meet the needs of facility-specific audit objectives or to
accommodate specialized review initiatives.
The EPA Safety, Health and Environmental Audit Protocol comprises three chapters:
• Management Systems Protocol
• Environmental Management Protocol
Safety and Health Protocol
Within each chapter, individual sections address the range of safety, health and environmental management systems and
compliance program areas applicable to EPA facilities. These topics covered in each chapter are listed in Exhibit 1.
INTRODUCTION
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Exhibit 1
Safety, Health and Environmental Topics for EPA Audits
Management System
Review Protocol
Environmental Management
Review Protocol
Safety and Health
Review Protocol
Top Management Commitment and
Support
Safety, Health and Environmental
Organization
Policies and Procedures
Training and Awareness Programs
Information Management Systems
Internal Verification and Inspection
Programs
Regulatory and Trends Tracking
Planning and Decision Making
Processes
Air Pollution Control
Drinking Water Management
Water Pollution Control
Medical Waste Management
Solid and Hazardous Waste
Management
Underground Storage Tank
Management
Past Disposal Practices
Toxic Substances Management
Emergency Planning and
Community Right-to-Know
Pesticide Management
Radioactive Materials Management
Safety
Occupational Health
Fire and Life Safety
Diving and Small Boat Safety
ii
INTRODUCTION
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To assure efficient and cost-effective review of EPA facilities and operations, the EPA Safety, Health and
Environmental Audit Protocol provides auditors a systematic process for planning, conducting, and reporting
Agency auditing activities. To this end, individual sections of the protocol (e.g., Occupational Health) are
organized as follows:
• Background Information — Describes the types of information to be used in identifying relevant
program activities and operations
• Opening Meeting — Discusses the procedures for conducting audit in-briefings to describe the audit
objectives, scope and approach
• Audit Planning — Discusses developing and/or revising audit team plans based on preliminary
understanding of facility operations
• Information Gathering and Finding Development — Contains the majority of the procedural steps
(observations, interviews, testing) necessary to understand management systems and verify compliance
with applicable Federal, state, and local regulations as well as EPA Headquarters and facility policies
• Evaluation of Findings — Describes the steps involved in verifying the accuracy of preliminary audit
findings and observations.
The process to be used for conducting EPA audits is summarized in Exhibit 2.
in
INTRODUCTION
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Pre-Audit
Activities
Exhibit 2
EPA Audit Process
On-Site Activities
Evaluating and
Reporting
Background
Information Review
- Federal, state and
local regulations
- Facility profile
information
- Previous audit reports
- Completed pre-audit
questionnaire
Protocol modification
for state and local
requirements
Preliminary Activities
Opening Meeting
Audit Planning
Information Gathering/
Finding Development
Activities
Understand
Management Systems
Interviews
Internal Controls
A
Assessment
• Detailed Review of
Facility Practices
Tours
Interviews
Testing
Examination of
Records
Evaluating and Reporting
Verify Accuracy of
Preliminary Findings
through Follow-up
Evaluation
Conduct Exit Briefing
Develop Audit
Reports
IV
INTRODUCTION
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MANAGEMENT SYSTEMS PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA safety, health, and environmental management review
program. It is intended to serve as a guide for planning and conducting an evaluation of
operating unit-level management systems and internal controls. The protocol may require
additions or other modifications to meet the needs of specific operating unit assessments.
The purpose of assessing management systems and internal controls is to confirm that
appropriate systems are in place and functioning effectively to achieve and sustain
compliance with safety, health, and environmental regulations and to minimize EPA's risks.
MANAGEMENT SYSTEMS PROTOCOL
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MANAGEMENT SYSTEMS PROTOCOL
Table of Contents
Section Page Number
A. Introduction 1
B. Top Management Commitment and Support 2
C. Safety, Health and Environmental Organization 3
D. Policies and Procedures 6
E. Training and Awareness Programs 8
F. Information Management Systems 11
G. Internal Verification and Inspection Programs 15
H. Regulatory and Trends Tracking 20
I. Planning and Decision Making Processes 22
J. Evaluation of Findings 23
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I. MANAGEMENT SYSTEMS PROTOCOL
A. Introduction
Background Information
1)
2)
Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a)
Map or plot plan
b) Descriptions of operating unit
activities
c) Previous safety, health and
environmental audit reports.
Review the following background
information related to management
systems before arriving at the
operating unit (If it is not
available prior to conducting the
field work, review the information
as early in the field visit as
possible):
a) EPA and operating unit safety,
health and environmental
directives and orders
b) EPA and operating unit safety,
health and environmental
program manuals and procedures
c) Organizational charts and
staffing tables
d) Training and awareness program
documents
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e) Emergency response program and
plans.
Opening Meeting
3) The EPA Team Leader will provide the
operating unit management with an
overview of the objectives/ scope
and methodology for the review. The
audit team should be prepared to
provide an overview of the
management systems review scope and
approach in response to specific
questions posed by the management
staff.
4) Attend the presentation given by the
operating unit to expand knowledge
of general operations. Pay
particular attention to management
systems.
B. Top Management Commitment and Support
Visible Top Management Involvement in
Safety, Health and Environmental Matters
5) Determine:
a) Last year's safety, health and
environmental goals and the
level of accomplishment
b) This year's goals and
objectives
c) The method (e.g., written
memoranda, staff meetings) and
frequency used by top
management to communicate
goals, objectives and
performance requirements to
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instill an effective safety,
health and environmental ethic
in the workforce.
6) Evaluate the methods that top
management uses to keep abreast of
the operating unit's safety, health
and environmental performance by
performing the following steps:
a) Determine whether safety,
health and environmental
reporting to top management is
a routine activity. Verify the
reporting system frequency and
content.
b) Review the reporting procedure
to determine whether top
management is provided with
adequate information to judge
the effectiveness of safety,
health and environmental
programs.
c) Assess top management's
involvement in corrective
action planning to address
identified safety, health and
environmental problems.
C. Safety, Health and Environmental
Organization
Structural Integrity
7) Evaluate the methods used to define
safety, health and environmental
responsibilities. Verify that they
are effectively communicated.
Review the formal statement of
organizational roles and
responsibilities that addresses
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safety, health and environmental
functions. Note whether the
statement has been disseminated to
the staff.
8) Selectively interview safety, health
and environmental staff, as well as
managers and operating personnel, to
identify if individuals understand
their responsibilities for safety,
health and environmental matters.
On the basis of these interviews,
determine whether personnel have a
consistent understanding of the
safety, health and environmental
organization.
Formal Organizational Systems
9) Verify that the job descriptions of
key safety, health and environmental
personnel clearly delineate their
responsibilities. Determine whether
their job descriptions are current
and reflective of existing duties.
10) Determine whether safety, health and
environmental performance measures
have been identified for specific
jobs. Verify that safety, health
and environmental performance is
evaluated in staff performance
reviews.
11) Determine if a safety and health
committee has been established.
Determine if the members represent a
cross section of site staff and
safety and health professionals.
Review minutes of the meeting to
determine if they are effective.
Meetings should be held no less than
quarterly.
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Informal Organizational Interactions
12) Determine whether the facility
safety, health and environmental
managers have established close
working relationships with other key
functional personnel within EPA
(e.g., FMSD, Legal, Personnel).
Authorities and Authorizations
13) Review and evaluate how
authorizations to deviate from
internal procedures are made and
recorded.
Staffing
14) Identify the full-time and
collateral safety, health and
environmental personnel within the
organization. Evaluate the adequacy
of the time allocated for
performance of their duties related
to safety, health and environmental
management.
15) Considering the operating unit's
total safety, health and
environmental mission, goals and
objectives, review staffing levels
to determine if the number of
personnel who have been assigned to
execute the safety, health and
environmental programs is
sufficient.
Personnel Qualifications
16) Evaluate the educational backgrounds
of key personnel responsible for
safety, health and environmental
matters. (Educational backgrounds
should be related to science or
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D.
engineering.)
17) Evaluate the work experience of key
safety, health and environmental
staff. Determine if their expertise
is commensurate with their job
requirements.
18) Review and evaluate the adequacy of
the certifications and special
training of key safety, health and
environmental staff.
Policies and Procedures
Availability and Understanding of EPA
Directives
19) Determine the availability of
relevant EPA directives and orders
at the operating unit. Evaluate
whether the appropriate personnel
have access to these documents,
including:
(a) EPA Occupational Health and
Safety Manual, 1440, and EPA
Orders 1440.2 through 1440.7
(b) Facilities Safety Manual, 4870
(c) EPA 1480.1, EPA Facility
Compliance with SARA Title III
Facility Policies and Procedures
20) Determine whether the operating unit
has written procedures addressing
the following program areas:
a) Emergency Action Plan
b) Chemical Hygiene Plan
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21)
22)
23)
c) Respiratory Protection
d) Hearing Conservation
e) Hazard Communication
f) Emergency Response
g) Confined Space Entry
h) Lockout/Tagout
i) Pollution Control
j) Waste Management
k) Asbestos O&M Program
(Refer to the appropriate technical
protocol areas for content of each
program)
Based on interviews with selected
management and operating staff,
determine if there is a consistent
understanding of the operating
unit's safety, health and
environmental policies. Verify that
safety, health and environmental
procedures are understood by the
individuals who are responsible for
accomplishing them.
Tour the facility to determine
whether copies of safety, health and
environmental standard operating
procedures (SOPs) are available at
the locations where they are to be
implemented, or, at a minimum,
whether a reference exists for a
central location for the procedures.
Determine whether the facility
conducts routine procedural reviews
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to identify needed changes to
internal procedures as a result of
changes in safety, health and
environmental regulations and EPA
directives. Evaluate the frequency
of the review cycle in terms of its
ability to identify outdated
requirements.
24) Determine if informal walk-through
inspections are performed by
facility safety and health
personnel. Review the inspection
frequency and documentation
(including form 1440-2 "Health and
Safety Inspection Checklist").
Determine if the reports are
properly distributed and if
corrective actions are implemented
and documented.
25) Review all reports of Unhealthful or
Unsafe Working Conditions (Form
1440-6). Determine if the
facility's safety and health
personnel respond appropriately (24
hours for an imminent danger
situation, 3 working days for a
serious condition and 20 working
days for other conditions).
Determine if corrective actions were
appropriate and effective.
E. Training and Awareness Programs
Awareness Programs
26) Review the new employee orientation
program. Examine elements that are
intended to increase employee
awareness of good safety, health and
environmental practices. Evaluate
the effectiveness of the orientation
materials for instilling a sound
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safety/ health and environmental
ethic in a new workforce.
27) Determine whether middle and senior
managers have received adequate
awareness training on their
potential civil and criminal safety,
health and environmental
liabilities.
Generai Environmental Training
28) Review the training plan to
determine environmental training
requirements for all personnel whose
actions can impact the operating
unit's environmental performance.
29) Determine if the environmental
training content and frequency meets
regulatory requirements, as noted
below:
a) Hazardous Waste Management
Facilities 40 CFR (264/5.16)
b) Hazardous Waste Generators [40
CFR 262.34 (with cross-
reference to 265.16)]
c) Nuclear Regulatory Commission
(NRC) (10 CFR 19.12 for
workers in or frequenting
"restricted" area)
30) Review the environmental training
materials. Determine whether the
materials are appropriate for their
intended purposes. Compare the
qualifications of the environmental
trainers to the specific types of
training delivered.
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Issue - Specific Environmental Training
31) Review and evaluate the formal
training programs for pollution
prevention, waste management and
materials recovery.
32) Verify that the environmental
training programs ensure employee
knowledge in developing required
environmental reports and hazardous
substance release notifications
(i.e. CERCLA, SARA Title III).
General Safety and Health Training
33) Determine whether the safety and
health training content meets
regulatory requirements and good
operating practices noted below.
Review training records to verify
and document that all necessary
personnel receive initial training
and all relevant follow up training.
a) Occupational health and
environmental control
• Occupational noise
exposure
• Ionizing radiation
b) Field activities
• 24-hour safety and
health training, plus 8
hours of annual
refresher training for
employees engaged in
field activities
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c)
d)
e)
f)
g)
h)
i)
j)
k)
1)
m)
Respiratory protection
• 6-hour respiratory
protection training,
plus 2-hour annual
refresher training
Lockout/Tagout (control of
hazardous energy)
Emergency evacuations
Portable fire extinguishers
Powered industrial trucks
Welding, cutting and brazing
Diving proficiency
Toxic and hazardous substances
Hazard communication
Laboratory safety
• 24-hour laboratory
safety training, plus 4
hours of annual
refresher training
Confined space entry
F. Information Management Systems
Recordkeeping
34) Review the safety, health and
environmental records management
procedures. Evaluate the procedures
in terms of completeness and
clarity. Determine if the
procedures will ensure formal,
systematic recordkeeping practices.
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35) Review the accident and illness
reports and OSHA log. EPA form 1440-
9 "Supervisors Report of Accident
and Illness" should be used to
report accidents, signed by the
supervisor and forwarded to the
facility safety and health
supervisor (complete this step
jointly with the applicable portion
of the occupational health
protocol) .
a) Determine the frequency rate
b) Determine the severity rate
c) Analyze the loss data and try
to identify any trends.
Determine if the accidents are
investigated, and if
corrective actions seem
appropriate and effective.
36) Review OSHA form 100-F "Annual
Summary of Federal Occupational
Injuries and Illness." Verify that
all injuries and illnesses are
logged onto the form, that the form
is accurate and complete (complete
this step jointly with the
applicable portion of the
occupational health protocol).
Reporting
37) Evaluate the adequacy of
environmental reports that should be
submitted to regulatory agencies.
For example:
a) SARA Title III MSDS and
inventory reports
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b) PCB inventory and disposal
reports
c) Water discharge monitoring and
POTW notification reports
d) Hazardous waste generator/TSD
reports
e) Underground storage tank
notifications, release and
removal/closure reports
38) Veriify that a completed copy of the
Log of Federal Occupational Injuries
and Illnesses is posted during
November.
39) Evaluate the adequacy of safety and
health reports that should be kept
at the operating unit or submitted
to regulatory agencies. For example:
a) Log of occupational injuries
and illnesses
b) EPA Reporting Unit annual
occupational safety and health
narrative
c) Supplementary log of
occupational injuries and
illnesses
40) Determine if safety, health and
environmental reports are routinely
prepared for internal management
purposes. Evaluate the content,
frequency, distribution and use of
these reports. Assess whether
routine or exception reports are
used. Determine whether these
reports are adequate tools to aid
management in assessing safety,
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health and environmental
performance.
Management Information Systems
41) Review and evaluate the systems used
by the facility to manage
information storage, retrieval and
use.
42) Determine accessibility of safety,
health and environmental records at
the facility. Evaluate the extent of
automation used to streamline
records management.
43) Determine whether safety, health and
environmental records are adequately
covered in the facility's formal
records retention policy or
guidelines.
44) Determine whether the facility has
instituted a "tickler" schedule for
safety, health and environmental
training, maintenance, permit
renewals and reporting.
45) Review abatement records to verify
that corrective actions have been
completed and documented. Abatement
records include:
a) EPA Form 1440-6 Unhealthful
and Unsafe Working Conditions
b) Asbestos/lead abatement
activities
c) Other previously identified
corrective actions.
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G. Internal Verification and Inspection
Programs
Worker Hazard Exposure Verification
46) Determine how the facility assesses
and documents chemical, biological
and hazardous exposures in the
workplace. Evaluate the
effectiveness of the facility's
chemical exposure assessment program
in terms of identification of
applicable hazards, exposure limits,
written monitoring plan, scope and
frequency of monitoring,
recordkeeping and reporting. Verify
that exposure information is passed
on to the medical monitoring program
for incorporation into medical
records. Verify that copies of
monitoring results are provided to
employees.
Medical Monitoring
47) Review and evaluate the facility's
occupational medical monitoring
program to determine whether it
addresses the following critical
issues:
a) Routine physical examination
or medical monitoring
b) Evaluation and biological
monitoring of worker response
to hazards
c) Health promotion and
exposure/prevention oriented
activities
d) Rehabilitative or follow-up
medical surveillance.
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Pollutant Discharge Verification
48) Determine the adequacy of the
facility's program to identify air
and water pollutant discharges by
performing the following steps:
a) Review and evaluate the
facility's program or
procedures to identify all
point sources of air and water
pollution emissions (e.g.,
facility tours, operations
reviews).
b) Review and evaluate the
facility's program or
procedures to identify all
non-point sources of air and
water pollution emissions
(e.g., facility tours,
operations reviews).
c) Review and evaluate the
process used by the facility
to characterize the nature and
volume of air and water
pollutants emitted from each
source (e.g., monitoring,
material balance calculations,
extrapolations from operations
at other facilities).
49) Determine the adequacy of the
facility's program to identify
hazardous wastes by performing the
following steps:
a) Review and evaluate the
programs used at the facility
to identify all potential
points of waste generation.
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b) Review and evaluate the
facility's procedures for
classifying its wastes in
accordance with regulatory
requirements. Confirm that
sound engineering, sampling,
analysis and quality assurance
procedures are in place to
assure characterization
results are reliable.
c) Review and evaluate the
facility's procedures for
identifying and classifying
new waste streams.
50) Review and evaluate the procedures
for handling and reporting
identified exceedances of permit
limitations or regulatory standards.
51) Review and evaluate the procedures
for identifying problems and
initiating corrective actions.
Equipment And System Inspections
52) Verify conformance with good
management practices for the
inspection and safe operation of
equipment. Written procedures and
preventive maintenance schedule
should be established for each
system. Verify adherence to the
schedule by reviewing schedule logs
or documents.
a) Verify that HVAC systems are
maintained according to
schedule.
RESPONSE
COMMENTS
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b) Verify by a review of records
that boilers have been
inspected by accepted
procedures.
c) Review test procedures for
equipment alarms to assess
their adequacy. Verify that
alarms are tested regularly.
d) Review and evaluate procedures
for testing and maintaining
safety interlocks. Obtain
records and verify that safety
interlocks are tested and
maintained.
e) Review and evaluate the
facility's procedures for
testing electrical grounding.
Verify that the procedures are
implemented by reviewing
documentation of inspections
and by examining a sample of
equipment.
f) Select a sample of equipment
placed into service or
modified during the review
period. Review startup/shut
down records to confirm the
implementation of the above
programs.
g) Verify that the facility
regularly inspects forklift
trucks, hoisting equipment and
lifting equipment.
h) Verify that elevators are
maintained and inspected
according to the prescribed
schedule.
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i) Verify that laboratory fume
hoods are certified annually.
53) Evaluate the facility's program for
testing, inspecting and maintaining
fire protection equipment used
onsite by touring the facility,
reviewing records, and completing
the following steps:
a) Verify that a comprehensive
inspection and testing program
is being implemented by
checking a representative
sample of records for the
following types of equipment:
fixed extinguishing system
(inspect); sprinkler system
main drain flow (test); fire
pumps or jockey pumps (test);
portable fire extinguisher
(inspect and test);
unsupervised and supervised
alarms (test); smoke or fire
detectors (test); emergency
lighting and power and fire
hoses (inspect).
Incident Investigation
54) Verify that the facility has a
formal procedure for investigating
accidents, incidents and illnesses.
Review investigation procedures to
determine whether the investigation
examines the causes of the incident,
corrective actions and preventive
measures.
Regulatory Compliance Verification
55) Review and evaluate the process used
by facility personnel to assess
compliance with applicable safety,
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H.
health and environmental laws and
regulations. Verify that an
information reference library exists
within the facility.
56) Verify that there is a process to
identify, document, and implement
corrective actions for all
deficiencies identified in the
inspections.
57) Determine whether top management
requests and receives feedback on
the inspection results and
corrective action schedules.
58) Verify that the staff responsible
for inspections is sufficiently
independent to avoid conflicts of
interests.
Regulatory and Trends Tracking
Environmental Surveillance
59) Review and evaluate the resources
for environmental regulatory
tracking. Determine whether the
operating unit has access to
adequate resources such as:
a) Federal Register and State
register notices
b) Environmental Reporter or
similar commercial summaries
of new/proposed regulations
c) Professional society journals
or bulletins highlighting new
legislative/regulatory
developments
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d) Commercial environmental
computerized regulatory
tracking databases.
60) Verify whether the facility has
identified and understands
environmental requirements under
state and local regulations in
addition to Federal standards.
61) Review the procedures for
transmitting information on new
environmental legislation or
regulations to the appropriate
staff. Determine whether staff with
environmental responsibilities are
informed of regulatory changes.
62) Review the internal documentation
used to disseminate environmental
regulatory and legislative changes.
Evaluate the effectiveness of this
documentation in terms of its
completeness, accuracy, and ability
to be easily understood.
63) Determine the extent to which the
facility works with state and local
environmental officials to identify
new regulatory initiatives or issues
under consideration for regulation.
Safety And Health Surveillance
64) Review and evaluate the facility's
resources for safety and health
regulatory tracking. Determine
whether the facility has access to
adequate resources such as:
a) Federal Register
b) Commercial summaries of
new/proposed regulations
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c) Professional society journals
or bulletins highlighting new
legislative/regulatory
developments
d) Commercial safety and health
computerized regulatory
tracking databases
65) Review the facility's procedures for
transmitting information on new
safety and health legislation or
regulations to the appropriate
staff. Determine whether staff with
safety and health responsibilities
are informed of regulatory changes.
66) Review the internal documentation
used to disseminate safety and
health regulatory and legislative
changes. Evaluate the effectiveness
of this documentation in terms of
its completeness, accuracy and ease
of understanding.
I. Planning and Decision Making Processes
Budgetary Planning
67) Review the process by which safety,
health and environmental staffing
and budgetary requirements are
determined. Determine whether the
process is integrated with a formal
safety, health and environmental
planning process.
68) Determine whether safety, health and
environmental concerns are taken
into account in budget decisions.
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Project Reviews
69) Determine whether safety, health and
environmental reviews are conducted
for the following:
a) Capital projects
b) Research and development
projects
c) Major maintenance
modifications
70) Determine whether the reviews are
conducted routinely. If not,
evaluate the circumstances under
which reviews must be completed.
71) Assess the objectives and content of
the reviews to define compliance
requirements or identify risks.
72) Determine whether the number of
reviews is appropriate to the nature
of the project. (For example, at
what design stages are reviews
completed and are they appropriate?)
J. Evaluation of Findings
73) Review actions taken to complete
each step of the management systems
protocol and summarize your
conclusions as to the facility's
status.
74) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in your
working papers.
23
MANAGEMENT SYSTEMS PROTOCOL
-------
PROTOCOL
RESPONSE
COMMENTS
75) Develop a written list of management
systems findings. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
76) Review all findings with the
facility safety, health and
environmental contact.
24
-------
AIR POLLUTION CONTROL REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility air pollution control programs is to confirm that appropriate
systems are in place and functioning effectively to achieve and sustain compliance with
applicable air pollution control regulations and to minimize EPA's risks.
Applicable Laws and Regulations
The Federal regulations governing emissions of pollutants to the air were promulgated
pursuant to the Clean Air Act, as amended. The Clean Air Act regulations are codified in 40
CFR Parts 50-87 and any applicable state regulations.
SECTION I - AIR POLLUTION CONTROL
-------
AIR POLLUTION CONTROL REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction 1-1
B. Air Pollution Control 1-2
C. Source Characteristics Determination 1-3
D. Applicability of Air Pollution Control Regulations 1-4
E. Registrations, Permits, and Variances 1-5
F. Compliance with Air Emission Standards 1-6
G. New Source Performance Standards 1-8
H. National Emissions Standards for Hazardous Air Pollutants 1-10
I. Recordkeeping and Reporting Requirements 1-11
J. Evaluation of Findings 1-12
ons^mTS-M T — X TO BnT T r?»l»TV"IKT
-------
PROTOCOL
I. AIR POLLUTION CONTROL
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to air pollution
control management programs and
activities prior to the on-site
visit (If it is not available prior
to conducting the field work, review
the information as early in the
field visit as possible):
a) Facility-specific air
pollution control policies and
guidance
b) Organizational charts and
staffing tables
C) Training and employee
orientation documents
d) Applicable Federal, State and
local regulations.
RESPONSE
COMMENTS
1-1
AIR POLLUTION CONTROL
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PROTOCOL
RESPONSE
COMMENTS
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the air pollution control
audit protocol, perform the review
of the facility for compliance with
applicable policies, regulations and
recommended professional practices.
B. Air Pollution Control
Emission Source Identification
Using information gained from the facility
and the facility tour, verify the
facility's programs for identifying its
emission sources by conducting the
following investigation.
6) Identify and note on a facility map
all (or a representative sample, if
appropriate) points of continuous or
periodic emissions, including
stacks, vents, ports, and
underground and above ground storage
tanks containing volatile organic
chemicals (VOCs) .
1-2
r>r>nrpi>r>T.
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PROTOCOL
7) Locate all emission control and
monitoring facilities/equipment and
cross-reference to the emission
source map.
8) Identify any new or changed air
emission sources through a review of
appropriate facility construction,
planning and budget (capital
expense) documents.
9) Compare the emission sources
identified in audit steps 6 through
8 with the most recent emission
inventory conducted by the facility
(if available). Note any
discrepancies.
10) Identify any changes in facility
operations or equipment that have
increased or reduced air emissions.
C. Source Characteristics Determination
For each of the emission sources
identified, determine the following:
11) Verify the year in which the source
(or pollution control device) was
registered, permitted, constructed
or modified.
12) Identify the nature of pollutants
emitted from each source including,
but not limited to, particulate
matter, sulfur oxides, nitrogen
oxides, toxics, VOCs, etc.
13) Determine whether the facility emits
any chemicals or compounds (i.e.,
asbestos, beryllium, mercury, vinyl
chloride, lead, hydrogen sulfide,
and benzene) regulated under the
National Emissions Standards for
RESPONSE
COMMENTS
1-3
AIR POLUmOM rONTPOL
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PROTOCOL
Hazardous Air Pollutants (NESHAPs)
regulations [40 CFR Part 61 and
applicable State regulations].
14) Using facility records and
interviews with key personnel,
identify the number, if any, of
major sources associated with the
facility. A major source is defined
as a stationary air pollutant source
emitting greater than 100 tons per
year of the following chemicals and
compounds: carbon monoxide,
nitrogen oxides, sulfur oxides,
particulate matter, ozone and lead.
15) Tour the facility to identify the
presence, if any, of visible air
emissions. Obtain opacity
monitoring data if available.
16) Determine the emission rate (Ib/hr)
of particulate matter for fossil
fuel burning sources. Also note the
total heat input value (BTU/hr) as
certified for the equipment, if
applicable.
D. Applicability of Air Pollution Control
Regulat ions
17) Using the information collected in
the above steps, determine if the
facility exceeds any of the
following permitting thresholds:
a) The facility emits more than
100 tons of carbon monoxide,
nitrogen oxides, sulfur
oxides, particulate matter,
lead or ozone [40 CFR
52.21(b)(1)(i)(a)]
RESPONSE
COMMENTS
1-4
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PROTOCOL
b) The facility emits NESHAPs
chemicals or compounds [40 CFR
Part 61]
c) The facility has fossil fuel-
fired steam generators with a
total heat input value of more
than 250 million BTU/hr [40
CFR 60.40(a)]
d) The facility uses fossil fuel-
fired equipment with emissions
exceeding threshold levels of
1.2 pound sulfur dioxide per
million BTU (solid fossil
fuel,or solid fossil fuel and
wood residue) or 0.10 pound
particulate matter per million
BTU (If different fossil fuels
are burned simultaneously,
refer to 40 CFR 60.4(b)) [40
CFR 60.42 and.43]
e) The facility emits pollutants
into the atmosphere in excess
of 20 percent opacity as
measured by EPA Method 9 [40
CFR 60.42 (a) (2)] .
If any of the responses to "a" through "e"
are yes, complete steps 18 through 45 of
the audit protocol. Determine if any
sources may be excluded by consulting with
exemption sections of applicable air
pollution control regulations.
E. Registrations, Permits, and Variances
18) Examine the air emissions source
permit applications for completeness
of data, accuracy, and compliance
with required filing dates, as
specified in 40 CFR Part 60 and
applicable State regulations.
RESPONSE
COMMENTS
1-5
AIR POLLUTION CONTROL
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PROTOCOL
19) Confirm that the applications were
signed by the person specified in
applicable regulations or that
person's duly authorized
representative.
20) Confirm that all emission sources
and equipment identified in audit
steps 13 and 14 are permitted.
21) Determine through a review of
facility construction or
modification documents, whether any
process changes have occurred that
are not reflected in the permit
application data or permit updates.
22) For new or recently installed
equipment, check compliance with
applicable Prevention of Significant
Deterioration (PSD) regulations by
identifying applicable requirements
set forth in 40 CFR 52.21.
23) Conclude as to the overall
effectiveness of the facility's
systems for ensuring that all permit
applications are properly completed,
submitted in a timely fashion, and
revised or amended to reflect
modifications or process changes.
F. Compliance with Air Emission Standards
Verify facility conformance with permit
conditions, if applicable, by performing
the following:
24) Develop a schedule of all permit
requirements and compliance order
schedules currently in effect
(including emission limitations,
equipment maintenance and inspection
frequency provisions, etc.).
RESPONSE
COMMENTS
1-6
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PROTOCOL
25) Verify that operating procedures and
installed systems (e.g., monitoring
devices) are capable of providing
information substantiating
compliance with these requirements.
26) Review operational data and, if
available, monitoring records to
determine whether all applicable
permit standards have been met or if
any operational malfunctions have
occurred.
27) For any permit or regulatory
deviations, equipment malfunctions,
or emission complaints noted, review
internal records for proposed and
corrective actions.
28) Conclude as to the overall adequacy
of the facility's systems for
maintaining compliance with permit
conditions.
29) Verify that continuous sulfur
dioxide emission and opacity
monitoring is in place for
facilities with fossil fuel-fired
steam generators that exceed the 250
million BTU per hour heat input
threshold (except those where only
gaseous fuel or other exempted fuel
mixtures are burned) [40 CFR 60.42c
and 60.47c]
30) If sulfur dioxide monitoring is not
being conducted, determine whether a
state approved sampling plan has
been issued to determine the amount
of sulfur in the fuel [40 CFR
60.46c(d)].
RESPONSE
COMMENTS
1-7
AIR POLLUTION CONTROL
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PROTOCOL
31) For facilities subject to sulfur
dioxide monitoring, determine
whether a continuous monitoring
program is also in place for either
oxygen or carbon dioxide [40 CFR
60.46C] .
32) Determine if the facility is subject
to state air pollution control
requirements for the storage of
volatile organic compounds in above
ground storage tanks.
G. New Source Performance Standards
33) Determine if the facility is subject
to any Federal or State New Source
Performance Standards (NSPS).
Facilities are subject to NSPS if
they are specifically identified in
the industrial categories set forth
in 40 CFR Part 60 and applicable
state regulations. If the facility
is subject to NSPS, complete audit
steps 34 through 39 [40 CFR Part
60] .
34) Review relevant documentation and
interview facility personnel to
confirm that the appropriate
notifications regarding new source
performance have been made (i.e.,
construction date, performance
testing) [40 CFR 60.7(a)] .
(NOTE: Complete this step in
conjunction with appropriate
sections under Recordkeeping and
Reporting, which describes
notification requirements for NSPS).
35) Verify conformance with monitoring
and performance testing requirements
including the following:
RESPONSE
COMMENTS
1-8
-------
PROTOCOL
a) Verify that monitoring systems
and devices were installed and
operational prior to
conducting performance tests
b) Confirm that performance
specifications noted in
Appendix B of 40 CFR Part 60
for continuous monitoring of
sulfur dioxide and nitrogen
oxides are met
c) Determine that the
manufacturer's written
requirements or
recommendations for checking
the operation or calibration
were carried out
d) Document the adequacy of any
alternative monitoring
requirements used in the
absence of a continuous
monitoring system.
[40 CFR 60.7 and .8]
36) Review monitoring data to determine
whether all applicable standards and
limitations are being met for
regulated emissions from all sources
[40 CFR Part 60].
37) Interview facility personnel and
review facility records to verify
that performance tests were
conducted within the 180 days after
the startup of the facility [40 CFR
60.8(a)] .
38) Confirm that the facility conducted
performance tests according to
approved methods and conditions by
interviewing facility personnel and
RESPONSE
COMMENTS
1-9
AIR POLLUTION CONTROL
-------
PROTOCOL
reviewing facility records [40 CFR
60.8 (b) and (c)] .
39) Review facility records to confirm
thaj, the administrator (or
representative) is notified at least
30 days prior to performance testing
[40 CFR 60.8 (d)].
H. National Emissions Standards for Hazardous
Air Pollutants
40) Determine whether permit or emission
limitations under NESHAPs [40 CFR
Part 61] are being met where such
emissions of hazardous air
pollutants are associated with the
facility's operation. Establish
that approved testing and reporting
procedures for emissions of
hazardous air pollutants are being
complied with, especially for:
a)
Asbestos
M]
[40 CFR 61, Subpart
(Note: 40 CFR 61, Subpart M,
contains detailed regulations for
the abatement and disposal of
asbestos-containing materials.
Facilities conducting asbestos
abatement and management activities
should also verify compliance with
applicable Federal, State and local
occupational safety and health
regulations and standards.)
b)
Beryllium
C]
[40 CFR 61, Subpart
c) Mercury [40 CFR 61, Subpart E]
d) Vinyl chloride [40 CFR 61,
Subpart F]
RESPONSE
COMMENTS
1-10
ATI* POI.IJTT10N mNTROI.
-------
e)
PROTOCOL
Benzene [40 CFR 61, Subpart
J] .
I. Recordkeeping and Reporting Requirements
Verify the implementation of regulatory
and permit driven recordkeeping and
reporting procedures by carrying out the
following steps.
41) Develop a list of recordkeeping
requirements outlined in air permits
or state requirements.
42) Interview facility personnel and
review facility records to confirm
that the facility submitted the
required written notifications
(under NSPS and NESHAPs) to EPA (or
State as appropriate). In
particular, look for the following:
a) Notifications of dates of
construction and startup [40
CFR 60.7 (a) and 40 CFR
61.09(a)]
b) Notifications of physical or
operations changes to an
existing facility, which may
increase the emission rate of
any pollutant regulated under
the New Source Performance
Standards [40 CFR 60.1 (a) (4)]
c) Notifications of the date when
demonstration of the
performance of the continuous
monitoring system commences,
postmarked at least 30 days
prior to such date [40 CFR
60.7(a) (5)]
RESPONSE
COMMENTS
1-11
AIR POLLUTION CONTROL
-------
PROTOCOL
d) Notifications associated with
conducting performance testing
related to opacity
observations and monitoring
[40 CFR 60.7(a)(5) and (7)].
43) Review facility files to verify that
required records are maintained
regarding the occurrence and
duration of any facility startup and
shutdown, air pollution control
equipment malfunctions, or periods
during which continuous monitoring
systems are inoperative [40 CFR
60.7(b)].
44) Determine whether the facility has
maintained a file of all
measurements, evaluations,
calibrations checks, and maintenance
of continuous monitoring systems or
devices for at least 2 years
following the dates of such
measurements, maintenance, reports
and records [40 CFR 60.7(e)] .
45) Confirm that the facility has
submitted quarterly reports to the
State regulatory agency regarding
continuous emissions monitoring [40
CFR 60.7 (c)] .
J. Evaluation of Findings
46) Review actions taken to complete
each step of the protocol and
summarize conclusions as to the
facility's status.
47) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
RESPONSE
COMMENTS
1-12
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PROTOCOL
48) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
RESPONSE
COMMENTS
1-13
AIR POLLUTION CONTROL
-------
-------
DRINKING WATER MANAGEMENT REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility drinking water management programs is to confirm that appropriate
systems are in place and functioning effectively to achieve and sustain compliance with
applicable drinking water management regulations and to minimize EPA's risks.
Applicable Laws and Regulations
Drinking water quality is addressed by the Safe Drinking Water Act (SDWA). The SDWA
implementing regulations at the Federal level are codified in 40 CFR Parts 141 through 143.
State and local health agencies may have established additional drinking water criteria.
SECTION II — DRINKING WATER MANAGEMENT REVIEW PROTOCOL
-------
DRINKING WATER MANAGEMENT REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction II-l
B. Applicability II-2
C. Community Versus Non-Transient Non-Community Water Systems II-3
D. Monitoring and Analytical Practices II-4
E. Conformance with Drinking Water Standards and
Public Notifications II-6
F. Drinking Water Reporting and Recordkeeping II-7
G. Recommended Professional Practices II-7
H. Evaluation of Findings II-8
-------
PROTOCOL
II. DRINKING WATER MANAGEMENT
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to drinking
water management programs and
activities prior to the on-site
visit (If it is not available prior
to conducting the field work, review
the information as early in the
field visit as possible):
a) Facility drinking water
policies
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
d) Applicable Federal, State and
local regulations
RESPONSE
COMMENTS
II-l
DRINKING WATER MANAGEMENT
-------
PROTOCOL
e) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the drinking water management
audit protocol provided, perform the
review of the facility for
compliance with applicable policies,
regulations and recommended
professional practices.
B. Applicability
6) Determine whether any of the
following conditions are applicable
to the facility's drinking water
system:
a) Any portion of the facility's
drinking water supply comes
from on-site wells or surface
water sources
RESPONSE
COMMENTS
II-2
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PROTOCOL
b) The facility treats water
received from a water utility
using a point-of-entry
treatment device
c) The facility's drinking water
system regularly serves at
least 25 of the same persons
over 6 months per year (i.e.,
non-transient, non-community
water system).
[40 CFR Part 141]
7) If the responses to questions "a"
and/or "b" are yes, and the facility
regularly serves 25 of the same
persons over 6 months per year,
complete audit steps 8 through 18 of
the Drinking Water Management
Protocol. All facilities, however,
should be reviewed against the
recommended professional practices
in step 19.
C. Community Versus Non-Transient Non-
Community Hater Systems
8) Through a review of facility records
and interviews with facility
personnel, determine whether the
facility's drinking water system is
a community or a non-transient, non-
community system [40 CFR 141.3]. If
applicable, confirm that the
facility has permission to operate a
drinking water supply system and
verify that the facility has
received any required permits and
licenses. If a waiver or variance
from permitting requirements has
been obtained, determine if the
procedures described in 40 CFR 141.4
have been followed.
RESPONSE
COMMENTS
II-3
DRINKING WATER MANAGEMENT
-------
PROTOCOL
9) Confirm that employees managing the
drinking water program are trained
or certified.
D. Monitoring and Analytical Practices
10) Obtain and review the facility's
written drinking water monitoring
program and/or procedures. Assess
the adequacy of the facility's
monitoring and analytical procedures
by performing the following:
a) Verify that the location of
sampling points results in
representative samples and the
sampling frequency is
consistent with regulatory
provisions or good management
practices [40 CFR Part 141,
Subpart C]
b) If monitoring and analysis are
performed more frequently than
specified in the regulations,
determine whether all results
and instances of noncompliance
are submitted to the
appropriate state agency [40
CFR 141.31]
c) If samples are analyzed by an
outside laboratory, confirm
that the laboratory is
certified by the state to
perform drinking water
analyses [40 CFR 141.28 (a)]
RESPONSE
COMMENTS
II-4
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PROTOCOL
d) If samples are evaluated on-
site, verify that the
appropriate and up-to-date
certification has been
obtained and that approved
test procedures are utilized
[40 CFR 141.28 (a)] .
11) Verify that systems are in place for
monitoring the following parameters
for non-transient, non-community
drinking water supply:
a) Microbiological contaminants
(coliform bacteria) [40 CFR
141.21]
b) Turbidity [40 CFR 141.22]
c) Inorganic chemicals - nitrate
[40 CFR 141.23]
d) Organic chemicals - volatile
synthetic organic chemicals
(VSOCs), unregulated organic
chemicals [40 CFR 141.24].
12) Confirm, by reviewing maintenance
logs, that monitoring equipment is
routinely maintained and calibrated.
13) Verify that the facility has
conducted periodic monitoring for
contaminants typically arising from
building water distribution systems.
Determine if monitoring has been
conducted for:
a) Lead in drinking water to
verify that levels are below
the action level of 0.015 mg/L
[40 CFR 141.80 (c)]
RESPONSE
COMMENTS
II-5
DRINKING WATER MANA^KMFNT
-------
PROTOCOL
b) Copper in drinking water to
verify that levels are below
the action level of 1.3 mg/L
[40 CFR 141.80(c)].
E. Confonnance with Drinking Water Standards
and Public Notifications
For each maximum contaminant level (MCL) or
other applicable drinking water standard, verify
conformance with these standards by performing
the following:
14) Review treatment log sheets,
analytical data, and records
relating to compliance monitoring.
Using this information, prepare a
schedule describing any incidents
where drinking water quality did not
meet established standards.
15) For each event of noncompliance:
a) Review internal records for
proposed corrective actions
b) Determine that corrective
actions were effected promptly
for noncompliance situations
(i.e., revisions of operating
procedures, repair of
equipment).
16) Verify that for every time an MCL or
other applicable drinking water
standard is exceeded, the affected
population and/or regulatory agency
is notified. Note whether the
State regulatory agency was notified
within 48 hours of the event of
noncompliance [40 CFR 141.32(b)].
RESPONSE
COMMENTS
II-6
r>D T ww T wr: LJiTC-D
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PROTOCOL
RESPONSE
COMMENTS
F. Drinking Water Reporting and Recordkeeping
Confirm the implementation of recordkeeping and
reporting procedures by carrying out the
following.
17)
Verify, by reviewing correspondence
files, that analytical results were
reported to the State (in cases
where a state laboratory does not
perform the analysis) within the
required time frame (i.e., within
the first 10 days following the
month in which the results are
received or the first 10 days
following the required monitoring
period determined by the State,
whichever is shortest) [40 CFR
G.
18) Review facility files to verify
retention of records for
bacteriological analyses and
variances (5 years) , chemical
analyses and sanitary sewer surveys
(10 years) , corrective actions (3
years) [40 CFR 141. 33 (a) and (b) ] .
Recommended Professional Practices
19) Verify that any bottled water used
by the facility has been
characterized by either of the two
following methods:
a) Obtain manufacturer's analyses
of the bottled water's
chemical and biological
quality.
II-7
DRINKING WATER MANAGEMENT
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PROTOCOL
b) Use an independent laboratory
certified by the State
regulatory agency to confirm
the safety of bottled water
for routine consumption.
H. Evaluation of Findings
20) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
21) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
22) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
RESPONSE
COMMENTS
II-8
TM>T*nrT»in
-------
WATER POLLUTION CONTROL REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility water pollution control programs is to confirm that appropriate
systems are in place and functioning effectively to achieve and sustain compliance with
applicable water pollution control regulations and to minimize EPA's risks.
Applicable Laws and Regulations
Accidental discharges of oil and hazardous substances into navigable waters of the United
States are regulated by the Federal Spill, Prevention, Control and Countermeasures (SPCC)
Program codified in 40 CFR Part 112. The program establishes procedural and technical
controls to minimize hazards associated with the release of oil and hazardous substances.
Point source discharges of wastewater from industrial activity are regulated under the
National Pollutant Discharge Elimination System (NPDES) provisions in 40 CFR Part 122.
Individual states can gain authorization to implement the Federal NPDES program and establish
a permit program.
General pretreatment regulations for discharges to publicly owned treatment works are found
in 40 CFR Part 403. State and local authorities may also establish more specific
restrictions on these discharges.
SECTION III - WATER POLLUTION CONTROL
-------
WATER POLLUTION CONTROL REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction • III-l
B. Spill Prevention and Control III-2
C. Discharge Identification III-4
D. Point Source Discharge Permit Applications III-5
E. Conformance with NPDES or POTW Standards III-6
F. Recordkeeping and Reporting Systems III-9
G. Evaluation of Findings 111-12
TTT — UBTRB DOT.T.TTTTnM PflNTROT.
-------
PROTOCOL
RESPONSE
COMMENTS
III. WATER POLLUTION CONTROL
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to water
pollution control programs and
activities prior to the on-site
visit (If it is not available prior
to conducting the field work, review
the information as early in the
field visit as possible):
a) Facility-specific water
pollution control procedures
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
d) Applicable Federal, State and
local regulations
III-l
WATER POLLUTION CONTROL
-------
PROTOCOL
e) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the water pollution control
audit protocol provided, perform the
review of the facility for
compliance with applicable policies,
regulations and recommended
professional practices.
B. Spill Prevention and Control
6) Determine that the facility has
prepared a Spill Prevention Control
and Countermeasures (SPCC) plan if
oil is stored in excess of the
following quantities:
a)
42,000 gallons underground
b) 1,320 gallons above ground
total
RESPONSE
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c) 660 gallons in any single
container above ground.
[40 CFR 112.l(b) and (d)(2) and
112.3]
If no SPCC plan is required, proceed to
step 8 of this protocol.
1) Evaluate the adequacy of the
facility's oil and hazardous
substances spill prevention and
control program. Confirm that the
SPCC plan is complete by:
a) Determining whether the plan
has been amended if the
facility discharged more than
1000 gallons of oil onto or
into the U.S. or adjoining
shorelines in a single spill
event, two or more spills have
occurred in the past 2 months,
or there has been a change in
facility design which affects
possible oil discharge. The
amendment should also address
the corrective actions taken
and planned for minimizing the
likelihood of future spills
[40 CFR 112.4]
b) Identifying if the plan
provides direction, rate of
flow, and total quantity of
oil that could be discharged
from a major failure of
equipment at the facility [40
CFR 112.7(b)]
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c) Confirming that a description
of containment measures used
to prevent discharge of oil to
navigable water is provided
[40 CFR 112.7]
d) Verifying that the plan is
certified by a Registered
Professional Engineer [40 CFR
112.3(d)].
C. Discharge Identification
8) Confirm that the facility has
identified all wastewater discharge
points (i.e., locations where
wastewater leaves the site) and
sources (i.e., where the wastewater
comes from) by performing the
following:
a) Prepare a list of discharge
points and sources by:
• Reviewing sewer maps and
plumbing system diagrams
• Touring the facility and
noting all places where
normal or unusual
discharges of wastewater
or contaminated surface
water leave or may leave
the facility boundary
b) Compare your list with
facility records and note any
points and sources
contributing to the wastewater
discharge(s) that have not
been identified and accurately
described.
RESPONSE
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9) Using information gathered during
the above review, determine if the
facility discharges pollutants
through point sources to surface
waters or groundwater. If no point
sources are verified, proceed to
step 12 of this protocol.
D. Point Source Discharge Permit Applications
10) Verify that the facility has
submitted permit applications and
received approved permits for: (1)
discharges of waste which could
affect the quality of waters of the
State, including both groundwater
and surface water; or (2) wastewater
or pollutant discharges into
navigable waters of the State [40
CFR 122.21 and applicable state
regulations].
11) Verify that these permit
applications are accurate and
complete by performing the
following:
a) Examine the applications for
completeness of data,
compliance with required
filing dates, and accuracy
(i.e., whether listed effluent
constituents reflect current
operations) [40 CFR 122.21,
122.41, and 122.42]
b) Confirm that the applications
were signed by the person
specified in applicable
requirements or that person's
fully authorized
representative [40 CFR 122.22]
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c) Confirm that expansion or
modification of facilities or
processes are properly
reflected in permit
applications [40 CFR 124.5]
d) Confirm that all point sources
noted above are permitted.
List any discharges which are
not permitted and note if a
variance or exception has been
obtained
e) For any new or altered
discharge of water, verify
that notification has been
provided to, and that a
revised permit application has
been submitted to the
authorized State or EPA
Region, if necessary [40 CFR
122.21, 122.41, and 122.42].
E. Conformance with NPDES or POTW Standards
12) Develop a schedule of all point
source permit conditions, sewer use
ordinance provisions, Publicly Owned
Treatment Works (POTW) regulations
and/or pretreatment standards
currently in effect for the
facility.
13) Confirm that operating procedures or
installed systems are capable of
providing information substantiating
compliance with these requirements
by performing the following:
a) Review calibration and
maintenance records for water
pollution control equipment to
verify conformance with permit
requirements [40 CFR 122.48]
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b) Document and assess the
calibration and maintenance
programs for the following:
Composite sampling
• Effluent flow measuring
• In-place monitoring and
recording devices
• Control equipment
c) Confirm that the location of
sampling points results in
representative samples, and
that sampling frequency agrees
with permit guidelines [40 CFR
122.48]
d) Verify that all analyses are
performed using approved test
procedures set forth in 40 CFR
Part 136 or special methods
set forth in the permit [40
CFR 122.41(1) (4)]. Determine
whether sample containers,
preservation techniques,
holding times, and quality
control procedures are used.
(Note any significant
discrepancies between
procedures used and those
approved).
14) Review a representative sample of
monitoring records (e.g., recorder
charts and laboratory results) and
note the frequency with which
effluent guidelines are exceeded.
Confirm that all exceptions were
properly reported in accordance with
40 CFR 122.41(1) .
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15) Review internal records for proposed
corrective actions for equipment
malfunctions, breakdowns, or
noncompliance with effluent
standards. Determine whether
corrective action was promptly
performed (i.e., revision of
operating procedures, repair of
equipment, installation of new
equipment) [40 CFR 122.41(1)].
Pretreatment Standards
16) If the facility discharges to a
POTW, confirm that the discharge
does not contain any of the
following:
(Note: The national pretreatment
standards were significantly revised
on July 24, 1990, (55 FR 30082) to
include more stringent pretreatment
standards and program components.
These standards apply to all
facilities regardless of whether the
new requirements have been
incorporated into State and local
pretreatment programs.)
a) Flammable or explosive
pollutants including, but not
limited to, waste streams with
a closed cup flashpoint of
less than 140 degrees
Fahrenheit
b) Pollutants with a pH less than
6 or greater than 9
c) Solid or viscous pollutants
which cause flow obstructions
in the POTW
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d) Pollutants capable of
releasing toxic fumes or
vapors in sufficient
quantities to detrimentally
affect the safety and health
of treatment works personnel
e) Petroleum oil,
nonbiodegradable cutting oil,
or products of mineral origin
f) Wastewater with sufficient
heat to inhibit biological
activity in the POTW,
resulting in interference
[40 CFR 403.5(b)]
17) Determine whether facility
discharges to a POTW are subject to
any categorical pretreatment
requirements. Review discharges
against the standards in 40 CFR Part
403, Appendix C, to make this
determination.
18) Compare your list of pretreatment
requirements with monitoring data to
determine if pretreatment limits for
the applicable industrial
category(ies) have been met.
F. Recordkeeping and Reporting Systems
Complete steps 19 through 22 if the
facility is subject to point source
discharge NPDES permitting requirements.
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Point Source Discharge Requirements
19) Confirm the implementation of water
pollution control recordkeeping and
reporting procedures in accordance
with point source discharge permit
conditions by carrying out the
following steps:
a) Determine date, type, exact
place, and time of sampling
b) Determine the individual
performing the sampling or
measurements
c) Determine date analyses were
performed
d) Verify the analytical methods
used and results of such
analyses.
20) Review facility files to verify that
accurate records on sampling and
analysis, equipment maintenance, and
any required reports (e.g.,
unanticipated batch discharges,
emergencies) are maintained for
three years [40 CFR 122.41 (j) (2)] .
21) Confirm that discharge monitoring
reports have been submitted to the
appropriate regulatory agencies in
accordance with the required
frequency and contain the required
information [40 CFR 122.42(1)].
22) Confirm that discharges that
exceeded specified limits were
reported to regulatory agencies [40
CFR 122.41 (1)] .
RESPONSE
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(Note: Under Federal and State
regulations, discharges that exceed
NPDES limits should be reported
within 24 hours and followed with a
written notification letter 5 days
later unless a waiver is granted.
[40 CFR 122.41 (1) (6)].)
POTW Discharges
If the facility discharges to a POTW,
complete steps 23 and 24 of this protocol.
23) Requirements for facilities subject
to categorical pretreatment
standards: Confirm that the
following reports are complete,
accurate, reflect current
operations, and are submitted as
required:
a) Monitoring reports for
discharges to the POTW subject
to categorical pretreatment
standards (submitted at least
90 days prior to discharge)
[40 CFR 403.12 (b)]
b) Reports on compliance with the
categorical pretreatment
standards for new discharges
(submitted within 90 days
following the date for final
compliance with applicable
standards) [40 CFR 403.12(d)]
c) Periodic reports on continued
compliance for industrial
users subject to categorical
pretreatment standards [40 CFR
403.12(e)] .
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24) Requirements applicable to all
facilities discharging to POTWs:
Confirm that the following reports
are complete, accurate, reflect
current operations and are submitted
as required:
a) Notification of any batch
discharge [40 CFR 403.12(f)]
b) Notice of changed or modified
discharge [40 CFR 403.12(j)]
c) Notification of hazardous
waste releases to POTWs [40
CFR 403.12(p)]
d) Local reporting requirements
required by the local control
authority.
Evaluation of Findings
25) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
26) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
27) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
RESPONSE
COMMENTS
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MEDICAL WASTE MANAGEMENT REVIEW PROTOCOL
OPERATING UNIT: ; DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility medical waste programs is to confirm that appropriate systems are
in place and functioning effectively to achieve and sustain compliance with applicable
medical waste regulations and to minimize EPA's risks.
Applicable Laws, Regulations and Recommended Practices
Federal standards for tracking and managing medical waste expired in 1991. There are
currently no Federal regulations regarding the management of medical waste. The EPA document
Guide for Infectious Waste Management can be used as guidance in developing facility-specific
procedures for medical waste handling. Individual state regulations vary widely and should
be consulted for specific management requirements.
SECTION IV - MEDICAL WASTE MANAGEMENT
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MEDICAL WASTE MANAGEMENT REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction IV-1
B. Medical Waste Management Recommended Practices IV-2
C. State and Local Requirements IV-3
D. Evaluation of Findings IV-4
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PROTOCOL
RESPONSE
COMMENTS
IV. MEDICAL WASTE MANAGEMENT
A. Int roduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting field
work, review the .information as
early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to medical waste
management programs and activities
prior to the on-site visit (If it is
not available prior to conducting
the field work, review the
information as early in the field
visit as possible):
a) Facility-specific medical
waste management procedures
b) EPA document Guide for
Infectious Waste Management
c) Organizational charts and
staffing tables
d) Training and employee
orientation documents
IV-1
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e) Applicable State and local
regulations
g) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the medical waste management
audit protocol provided, perform the
review of the facility for
compliance with applicable policies,
regulations and recommended
professional practices.
B. Medical Haste Management Recommended
Practices
6) Determine through observation,
review of documentation and
interviews with selected personnel
whether the facility generates
medical or infectious waste. If so,
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evaluate the effectiveness of the
facility's medical waste management
program by completing the following
procedures.
The following recommended medical waste
management practices reference the EPA Guide for
Infectious Wastes Management.
1) Verify that infectious waste stored
on-site is marked with the universal
biohazard symbol or is stored in red
colored bags/containers.
8) Determine that contaminated sharps
are stored in un-penetrable
containers and are managed
separately from infectious fluids.
9) Determine whether the facility has a
program to periodically inspect its
infectious waste management
containers and associated storage
areas for visible leaks or spills,
appropriate labelling, etc.
10) Confirm that the transportation,
treatment and ultimate disposal of
the facility's infectious wastes is
documented through shipping papers,
manifests and certificates of
destruction.
C. State and Local Requirements
11) Review State and local requirements
for medical waste management and
perform steps to verify the
facility's compliance with those
requirements.
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D. Evaluation of Findings
12) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
13) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
14) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
IV-4
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SOLID AND HAZARDOUS WASTE MANAGEMENT REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility solid and hazardous waste programs is to confirm that appropriate
systems are in place and functioning effectively to achieve and sustain compliance with
applicable solid and hazardous waste regulations and to minimize EPA's risks.
Applicable Laws and Regulations
The Resource Conservation and Recovery Act (RCRA) governs the management of solid and
hazardous waste. Federal regulations in 40 CFR Parts 260 through 270 detail standards for
the identification and management of waste as well as applicable inspection, maintenance, and
recordkeeping requirements. Individual states may gain authorization to implement the RCRA
program in lieu of Federal authorities. These state programs may be more stringent and
broader in scope than the Federal RCRA regulations.
SECTION V - SOLID AND HAZARDOUS WASTE MANAGEMENT
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SOLID AND HAZARDOUS WASTE MANAGEMENT REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction V-l
B. Waste Determination V-2
C. Hazardous Waste Generator Activities V-4
D. Land Disposal Restrictions V-22
E. Recordkeeping and Reporting V-23
F. Evaluation of Findings V-24
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PROTOCOL
RESPONSE
COMMENTS
V. SOLID AND HAZARDOUS WASTE MANAGEMENT
A. Int roduct ion
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports and reports on
inspections of the facility.
2) Review the following background
information related to solid and
hazardous waste management programs
and activities prior to the on-site
visit (If it is not available prior
to conducting field work, review the
information as early in the visit as
possible):
a) Facility-specific solid and
hazardous waste management
procedures, plan or guidance
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
d) Applicable Federal, State, and
local regulations
V-l
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e) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the solid and hazardous waste
management review protocol provided,
perform the review of the facility
for compliance with applicable
policies, regulations, and
recommended professional practices.
B. Waste Determination
6) Using facility records, tours and
interviews with facility personnel,
verify that all potential points of
waste generation have been
identified. Determine that the
facility is performing the required
waste determinations for these
wastes by performing the following
steps.
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7) Verify that wastes are classified as
hazardous or non-hazardous based
upon the determination hierarchy set
forth in 40 CFR 262.11. Confirm
that the facility either uses
knowledge of the waste or process
generating the waste to make this
determination or uses EPA-approved
testing methods. [40 CFR 262.11]
8) Verify that the facility is
accurately identifying its waste as
either non-acute hazardous waste
(characteristic and non-P-listed) or
acutely hazardous waste (P-listed
and F020-23, F026, F027) [40 CFR
261.20-.33] .
9) Review the facility's classification
of its waste streams. Note any
waste stream that may not be
classified appropriately, especially
for wastes subject to recent
hazardous waste listings or
identification (e.g., new toxicity
characteristic constituents).
10) Confirm that wastes not classified
as hazardous meet the applicable
criteria for exemptions or
exclusions. Note any discrepancies
and discuss with facility personnel
[40 CFR 261.2-.6].
11) Determine if wastes that are
exempted when recycled are managed
(and classified) as hazardous waste
up to the point of recycling, or are
managed in accordance with the
appropriate sections of 40 CFR Part
266 [40 CFR 261.6 and 40 CFR 266.20-
.112] .
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C.
Hazardous Waste Generator Activities
12) Based upon the information gathered
to this point, estimate the quantity
of hazardous wastes generated by the
facility on a monthly basis (e.g.,
review quantities in satellite
accumulation or a representative
sample of manifests). Complete the
applicable portion of the protocol
based upon the facility's generator
status, as defined below:
a) Conditionally Exempt
Generators (generators of
less than 1 kg/month or less
of acute hazardous waste or
100 kg/month or less of other
hazardous waste) - Complete
steps 13 through 15 and
proceed to step 66 [40 CFR
261.5]
b) Small Quantity Generators
(generators of greater than
100 but less than 1,000
kg/month of other hazardous
waste) - Complete steps 16
through 35 and proceed to step
58 [40 CFR 262.34(d)]
c) Full Quantity Generators
(generators of greater than 1
kg/month of acute hazardous
waste or greater than or equal
to 1,000 kg/month of other
hazardous waste) - proceed to
step 36.
Conditionally Exempt Generators
13) Verify that each waste stream is
correctly identified according to 40
CFR 262.11.
V-4
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14) Determine if wastes generated are
sent to either an on-site or off-
site facility that is a state
licensed municipal facility,
state/federal permitted hazardous
waste management facility, or a
recycling facility [40 CFR
261.5(f) (3) and (g) (3)] .
15) Through records review and personnel
interviews, confirm that no more
than 1,000 kg of non-acute hazardous
waste or 1 kg of acute hazardous
waste is accumulated on-site at any
one time [40 CFR 261.5(f)(2) and
(g) (2)] . If these thresholds were
exceeded, verify that the
appropriate small quantity or full
quantity generator requirements were
met.
Small Quantity (100-1,000 kg per month)
Generator Requirements
16) Review the facility's hazardous
waste generator notification and
corresponding documents. Verify the
following:
a) An identification number for
hazardous waste activity has
been obtained using EPA Form
8700-12 [40 CFR 262.12(a)]
b) The information on the Notice
of Regulated Waste Activity
form 8700-12 is correct [40
CFR 262.12(b)].
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17) Obtain copies of facility manifests
for the review period. From
observations of waste generation
activities and discussions with
facility personnel, confirm that
manifests were completed for all
hazardous waste shipments
transported off-site
[40 CFR 262.20] .
18) Review the manifests to ensure that
the following information is
provided:
a) Name, address, and EPA
identification number of the
designated treatment, storage
and disposal facility
b) Name, address, and EPA
identification number of the
designated alternative
treatment, storage or disposal
facility (if any)
c) Name, address, and EPA
identification number of the
transporter(s)
d) Generator's name, address,
identification number, and
telephone number
e) Manifest document number
(numbered sequentially)
f) U.S. Department of
Transportation (DOT)
description
g) Type of container and total
quantity of wastes (wt./vol.)
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PROTOCOL
RESPONSE
COMMENTS
h) Generator certifications (DOT
shipping descriptions/waste
minimization)
i) Generator and transporter
signatures.
[40 CFR Part 262, Appendix]
19) Determine if wastes designated for
transportation are packaged, marked,
and labeled in accordance with
applicable DOT requirements. These
requirements are specified in the
DOT Hazardous Materials Table in 49
CFR 172.101 [40 CFR 262.30-.32].
20) Determine how the generator assures
that the transporter has proper
placarding prior to shipping waste
off-site per 49 CFR Part 172,
Subpart F [40 CFR 262.33].
21) If the generator accumulated
hazardous waste at or near the point
of generation in a satellite
accumulation area, confirm that the
wastes are managed as follows:
a) The waste is accumulated in
containers that are in good
condition and compatible with
the waste being stored [40 CFR
262.34 (c) (1) (i), 265.171, and
265.172]
b) Containers are closed during
storage, except when adding or
removing waste [40 CFR
262.34(c)(1)(i) and
265.173(a)]
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c) Containers are marked with the
words "Hazardous Waste" or
with other words that identify
the waste contents [40 CFR
262.34(c) (1) (Li)]
d) If either 55 gallons of non-
acute waste, or 1 quart of
acute hazardous waste is
accumulated, verify that the
container is marked with the
date that the excess occurred
and that the excess waste is .
removed within 3 days [40 CFR
262.34(c) (2)] .
22) Tour the facility and note all areas
used for storage of hazardous wastes
(other than satellite accumulation
areas). By reviewing accumulation
logs and operating records, verify
that the wastes are not held in
central storage longer than 180 days
for small quantity generators (100-
1,000 kg per month). Small quantity
generators that must transport waste
off-site in excess of 200 miles,
however, may accumulate waste on-
site for up to 270 days [40 CFR
262.34(d) and (e)].
23) Verify compliance with the standards
of [40 CFR 262.34(d)] outlining
requirements for hazardous waste
containers in on-site accumulation
area:
a) Wastes are marked with the
date of accumulation [40 CFR
262.34U)(2) and (d)(4)]
V-8
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PROTOCOL
RESPONSE
COMMENTS
b) Containers are labeled with
the words "Hazardous Waste"
[40 CFR 262.34(a)(3) and
(d)(4)]
c) The waste is accumulated in
containers that are in good
condition and compatible with
the waste being stored [40 CFR
262.34(d)(2), 265.171 and
265.172]
d) Containers are closed except
when adding or removing wastes
[40 CFR 262.34(d)(2) and
265.173]
e) Containers in storage are
inspected weekly for leaks and
container deterioration [40
CFR 262.34(d)(2) and 265.174]
f) Incompatible wastes are not
stored in the same container.
Storage containers holding a
hazardous waste that is
incompatible with any waste or
other materials stored nearby
or other materials stored
nearby in other containers,
piles, open tanks or surface
impoundments are separated
from the other materials or
protected by means of a dike,
berm, wall, or other device
[40 CFR 262.34 (d) (2) and
265.177] .
24) Verify that no more than 6,000 kg of
non-acute hazardous waste are
accumulated on-site at any one time
if the facility is a small quantity
generator [40 CFR 262.34(d)(1)].
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SOLID AND HAZARDOUS WASTE MANAGEMENT
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RESPONSE
COMMENTS
25) For small quantity generators
accumulating hazardous waste in
tanks, verify that the facility is
meeting the special requirements for
tank storage [40 CFR 262.34(d)(3)
and 265.201].
26) Verify that the facility ensures
that no incompatible wastes are
commingled in tank storage [40 CFR
262.34(d)(3) and 265.20l(f)(1) ].
27) Confirm that uncovered tanks are
operated to ensure a minimum of 60
centimeters of freeboard unless
equipped with a containment
structure [40 CFR 262.34(d)(3) and
265.201] .
28) Verify that inspections are
conducted daily for leaks, spills,
operation of monitoring equipment
and tank levels [40 CFR 262.34
(d)(3) and 265.201(c)(l)-(3)].
29) Verify that inspections are
conducted weekly to detect corrosion
of tanks and to identify any erosion
or leakage of construction materials
associated with the tank [40 CFR
262.34(d)(3) and 265.201 (c) (5)] .
30) Confirm that the facility conducts
treatment or renders the waste
inactive for the characteristics of
ignitability and reactivity prior to
placement in tanks [40 CFR
262.34(d)(3) and 265.201 (e) (1)] .
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PROTOCOL
RESPONSE
COMMENTS
31) Verify that the facility maintains
the required buffer zone for tanks
contained in NFPA "Flammable and
Combustible Liquids Code," for any
tanks used to treat ignitable or
reactive wastes [40 CFR 262.34
(d) (3) and 265.201(e) (1)] .
32) Document that the facility and its
respective hazardous waste storage
areas (non-satellite accumulation)
adhere to the applicable
preparedness and prevention
requirements per 40 CFR Part 265,
Subpart C by confirming the
following:
a) Aisle space is sufficient for
unobstructed movement of
personnel or emergency
equipment [40 CFR 262.34(d)(4)
and 265.35]
b) Fire extinguishers and other
fire control equipment, and
two way communications are
present and in proximity to
the storage area [40 CFR
262.34(d)(4) and 265.32].
c) Water is available at adequate
volume and pressure to supply
water hose streams, foam-
producing equipment, automatic
sprinklers, or water spray
systems [40 CFR 262.34(d)(4)
and 265.32]
d) All facility communications or
alarm systems and spill
control equipment are
inspected to assure proper
operation in time of emergency
[40 CFR 262.34(d)(4) and 265.33]
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SOLID AND HAZARDOUS WASTE MANAGEMENT
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RESPONSE
COMMENTS
e) All appropriate arrangements
with local authorities are
made based upon the hazards
associated with the wastes in
accumulation [40 CFR
262.34(d)(4) and 265.37].
33) Verify that the facility is meeting
the reduced contingency plan
requirements of 40 CFR 262 .34(d) (5) .
These include the following:
a) Designating an emergency
coordinator who is either on
the premises or on call [40
CFR 262.34(d)(5)(i)]
b) The generator has posted the
following information:
• Name and telephone
number of the emergency
coordinator
Location of fire
extinguishers and spill
control equipment, and
if present, fire alarm
Telephone number of the
fire department, unless
the facility has a
direct alarm.
[40 CFR 262.34(d) (5) (ii) ]
34) Verify that the emergency
coordinator has systems or standard
operating procedures in place to
respond to emergencies that may
arise in accordance with 40 CFR
262.34(d)(5)(iv)(A)-(C).
V-12
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WASTR MANARRMRNT
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PROTOCOL
35) Verify that the generator has taken
measures to ensure that all
employees are familiar with proper
waste handling and emergency
procedures, relevant to their
responsibilities during normal
facility operations and emergencies
[40 CFR 262.34(d) (5) (iii)] .
Full Quantity (greater than or equal to
1, 000 kg per month) Generator Requirements
36) Review the facility's hazardous
waste generator notification and
corresponding documents. Verify the
following:
a) An identification number for
hazardous waste activity has
been obtained using EPA Form
8700-12 [40 CFR 262.12 (a)]
b) The information on the
Notification of Regulated
Waste Activity Form 8700-12 is
correct [40 CFR Part
262.12(b)].
37) Obtain copies of facility manifests
for the review period. From
observations of waste generation
activities and discussions with
facility personnel, confirm that
manifests were completed for all
hazardous waste shipments
transported off-site [40 CFR
262.20] .
38) Review the manifests to ensure that
the following information is
provided:
RESPONSE
COMMENTS
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RESPONSE
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39)
a) Name, address, and EPA
identification number of the
designated treatment, storage
and disposal facility
b) Name, address, and EPA
identification number of the
designated alternative
treatment, storage or disposal
facility (if any)
c) Name, address, and EPA
identification number of the
transporter (s)
d) Generator's name, address,
identification number, and
telephone number
e) Manifest document number
(numbered sequentially)
f) U.S. Department of
Transportation (DOT)
description
g) Type of container and total
quantity of wastes (wt./vol.)
h) Generator certifications (DOT
shipping descriptions/waste
minimization)
i) Generator and transporter
signatures .
[40 CFR Part 262, Appendix]
Determine if wastes designated for
transportation are packaged, marked
and labeled in accordance with
applicable DOT requirements in 49
CFR 172.101 [40 CFR Part 262.30-
.32] .
V-14
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PROTOCOL
40) Determine how the generator assures
that the transporter has proper
placarding prior to shipping waste
off-site per 49 CFR Part 172,
Subpart F [40 CFR 262.33].
41) If the generator accumulated
hazardous waste at or near the point
of generation or satellite
accumulation area, confirm that the
wastes are managed as follows:
a) The waste is accumulated in
containers that are in good
condition and compatible with
the waste being stored [40 CFR
262.34(c)(1)(i), 265.171 and
265.172]
b) The containers are closed
during storage except when
adding or removing waste [40
CFR 262.34(c)(1)(i) and
265.173(a)]
c) Containers are marked with the
words "Hazardous Waste" or
with other words that identify
the waste contents [40 CFR
262.34 (c) (1) (ii)]
d) If either 55 gallons of non-
acute waste or 1 quart of
acute hazardous waste is
accumulated, verify that the
container is marked with the
date that the excess occurred
and that the excess waste is
removed within 3 days [40 CFR
262.34(c) (2)] .
42) Tour the facility and note all areas
used for storage of hazardous wastes
(other than satellite accumulation
RESPONSE
COMMENTS
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SOLID AND HAZARDOUS HASTE MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
areas) . By reviewing accumulation
logs and operating records, verify
that the wastes are not held in
central storage greater than 90 days
[40 CFR 262.34(a)] .
43) Verify compliance with the following
generator requirements for hazardous
waste containers in on-site storage,
short—term accumulation:
a) Wastes are marked with the
date of accumulation [40 CFR
262.34(a) (2)]
b) Containers are labeled with
the words "Hazardous Waste"
[40 CFR 262.34(a) (3)]
c) Waste is accumulated in
containers that are in good
condition and compatible with
the waste being stored [40 CFR
262.34(a)(1)(i), 265.171 and
265.172]
d) Containers are closed except
when adding or removing wastes
[40 CFR 262.34(a)(1)(i) and
265.173].
e) Containers in storage are
inspected weekly for leaks and
container deterioration [40
CFR 262.34(a)(1)(i) and
265.174]
f) Incompatible wastes are not
stored in the same container.
Storage containers holding a
hazardous waste that is
incompatible with any waste or
other materials stored nearby
in other containers, piles,
V-16
<*nr i-n nun
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PROTOCOL
RESPONSE
COMMENTS
open tanks or surface
impoundments are separated
from the other materials or
protected by means of a dike/
berm, wall, or other device
[40 CFR 262.34(a) (1) (i) and
265.177].
44) Verify that ignitable, reactive or
incompatible wastes accumulated in
containers are stored at least 50
feet from the facility's property
line [40 CFR 262.34 (a) (1) (i) and
265.176] .
45) Determine if the facility uses tanks
for the accumulation of hazardous
wastes. If so, verify that an
assessment of each existing tank
system was performed by a registered
engineer by January 12, 1988, or
within one year of a tank system
becoming a hazardous waste tank
system subsequent to July 14, 1986
[40 CFR 262.34(a)(1)(ii) and
265.194].
46) Determine if annual assessments of
tank integrity have been performed
for each tank that does not have
secondary containment. Review the
assessment for conformance with the
requirements in 40 CFR 265.191 [40
CFR 262.34(a) (1) (ii) and 265.191].
47) Review assessment reports to
determine whether tank systems that
were found to be leaking or unfit
for use have been taken out of
service [40 CFR 262.34 (a) (1) (ii)
and 265.191].
V-17
SOLID AND HAZARDOUS WASTE MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
48) Determine if new tank systems or
components installed after July 14,
1986, meet design and installation
standards [40 CFR 262 . 34 (a) (1) (ii)
and 265.192].
49) Review tank system designs and
systems to ensure that secondary
containment and release detection
are provided [40 CFR
262.34(a) (1) (ii) and 265.193].
50) Determine that daily tank system
inspections are conducted [40 CFR
262.34(a)(1)(ii) and 265.195].
51) Review the facility's procedures for
responding to a leak or spill from
the hazardous waste tanks to ensure
that they are consistent with the
requirements of 40 CFR 265.196 [40
CFR 262.34(a)(1)(ii) and 265.196].
52) Document that the facility and its
respective hazardous waste storage
areas (non-satellite accumulation)
adhere to the applicable
preparedness and prevention
requirements [40 CFR Part 265,
Subpart C] by confirming the
following:
a) Aisle space is sufficient for
unobstructed movement of
personnel or emergency
equipment [40 CFR 262.34(a)(4)
and 265.35]
b) Fire extinguishers, other fire
control equipment, and two way
communications are present and
in close proximity to the
storage area [40 CFR 262.34
(a) (4) and 265.32 (a)-(c)]
V-18
/-.T -rr» »wr» IIH-7 Hun/in C
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PROTOCOL
RESPONSE
COMMENTS
c) Water is available at adequate
volume and pressure to supply
water hose streams, foam
producing equipment, automatic
sprinklers, or water spray
systems [40 CFR 262.34(a)(4)
and 265.32(d)]
d) Facility communications or
alarm systems, fire protection
equipment, and spill control
equipment are tested and
maintained to assure their
proper operation in time of
emergency [40 CFR 265.33]
e) Appropriate arrangements with
local authorities are made,
based upon the hazards
associated with the wastes in
accumulation [40 CFR 265.37].
53) Verify that the facility has a
hazardous waste contingency plan.
(This plan may be part of the
facility's emergency response or
spill control plan.) Review the
plan to ensure that it includes:
a) Location of each satellite
accumulation and generator
storage area at which waste is
accumulated [40 CFR 262.34]
b) A description of the actions
facility personnel must take
to respond to fires,
explosions, or any unplanned
sudden or non-sudden release
of hazardous waste or
hazardous waste constituents
[40 CFR 262.34(a)(4) and
265.52]
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SOLID AND HAZARDOUS WASTE MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
c) List of emergency coordinators
and telephone numbers [40 CFR
262.34(a)(4) and 265.52(d)]
d) List of emergency equipment
[40 CFR 262.34(a)(4) and
265.32(e)]
e) Arrangements with local
authorities (or list of local
authorities and range of
assistance provided). These
arrangements should include:
• Documentation of
training sessions
conducted to familiarize
the local authorities
with the facility layout
and waste management
practices
• Information pertaining
to the designation of a
primary emergency
response authority, if
there is more than one
police or fire
department which may
respond to an emergency
• Copies of agreements
made with local and
state emergency response
authorities, including
emergency response
contractors
Emergency response
telephone numbers which
are posted in key
locations and are
available to all
emergency coordinators
V-20
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PROTOCOL
RESPONSE
COMMENTS
Documentation that the
facility has informed
local hospitals and
emergency teams of the
types of wastes handled
and the potential
injuries which could
result from operations
Documentation of any
emergency response team
or local authority which
has refused to enter
into an agreement with
the facility.
[40 CFR 262.34(a)(4), 265.37
and 265.52(c)]
54) Verify that the facility has an
evacuation plan that will be used in
the event of an emergency. Verify
that the evacuation plan reflects
existing facility conditions and
site characteristics [40 CFR
262.34(a)(4) and 265.52(f)].
55) Review and determine the adequacy of
emergency response procedures [40
CFR 262.34(a)(4), 265.52(a) and
265.56].
56) Document whether the contingency
plan has been submitted to local and
state emergency response teams [40
CFR 262.34(a)(4) and 265.53(b)].
57) Verify that employees associated
with waste management are trained in
the handling of hazardous wastes,
including relevant course material
on emergency procedures, equipment
and systems. Additionally,
V-21
SOLID AND HAZARDOUS WASTE MANAGEMENT
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D.
PROTOCOL
determine that training is provided
within the first 6 months of
employment for new personnel and
annually for existing personnel.
Determine if records are maintained
as documentation [40 CFR
262.34(a) (4) and 265.16] .
Land Disposal Restrictions
58) Verify that the facility, unless
subject to the conditionally exempt
small quantity generator
requirements in 40 CFR 261.5,
prepares Land Disposal Restrictions
Notifications for all prohibited
hazardous wastes (as identified in
40 CFR 268.35) that are transported
off-site for treatment, storage or
disposal. Document that the
notifications contain the following
information:
a) EPA waste code number for each
hazardous waste
b) Corresponding treatment
standards for each hazardous
waste
c) Accompanying manifest number
d) Waste analysis data, if
applicable.
[40 CFR 268.7]
(Note: If the facility is managing wastes
that are characteristic for ignitability
(D001) or corrosivity (D002), ensure that
the facility is complying with new
treatment standards under 40 CFR 268.42
(58 FR 29886; May 24, 1993). Pursuant to
these rules, the facility must, in some
RESPONSE
COMMENTS
V-22
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PROTOCOL
RESPONSE
COMMENTS
cases, identify and treat for underlying
hazardous constituents in addition to
deactivating the characteristic (e.g.,
neutralizing corrosive waste).
E. Recordkeeping and Reporting
59) If the facility treats hazardous
waste during accumulation to meet
Land Disposal Restrictions treatment
standards, verify that the facility
maintains and follows a waste
analysis plan that meets the
following requirements:
a) Contains a detailed chemical
and physical analysis of a
representative sample of the
waste
b) Filed with the Regional
Administrator or the
authorized state agency.
[40 CFR 268.1(a) (4)]
60) Verify that the facility maintains
copies of all manifests for 3 years
from the date that the waste was
accepted by the initial transporter
[40 CFR 262.40(a)] .
61) For full quantity generators, verify
that the facility has submitted an
exception report to the appropriate
state agency for any manifest that -
has not been signed and returned
within 45 days of the date the waste
was accepted by the initial
transporter [40 CFR 262. 42 (a)].
62) For small quantity generators,
verify that the facility has
V-23
SOLID AND HAZARDOUS WASTE MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
submitted an exception report to the
appropriate state agency for any
manifest that has not been signed
and returned within 60 days of the
date the waste was accepted by the
initial transporter [40 CFR
262.42(b)].
63) Verify that the facility maintains
copies of each biennial report (full
quantity generators only) and
exception report for a period of at
least 3 years from the due date of
the report (March 1 for biennial
reports) [40 CFR 262.40(b)].
64) Verify that the facility retains
records of test results, waste
analyses, or other determinations
made in accordance with 40 CFR
262.11 for at least 3 years from the
date that the waste was last sent to
on-site or off-site treatment,
storage or disposal [40 CFR
262.40(c)].
65) Verify that the facility maintains
copies of all Land Disposal
Restrictions Notifications for
prohibited hazardous wastes sent
off-site for treatment, storage or
disposal. These records are
required to be maintained for a
period of 5 years from the date that
the waste was transported off-site
[40 CFR 268.7] .
F. Evaluation of Findings
66) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
V-24
o/vr TII »*m ua^.itJTVWTC WftSTR MANATCKMRNT
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PROTOCOL
67) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in your
working papers.
68) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
RESPONSE
COMMENTS
V-25
SOLID AND HAZARDOUS WASTE MANAGEMENT
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UNDERGROUND STORAGE TANK MANAGEMENT REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility underground storage tank management programs is to confirm that
appropriate systems are in place and functioning effectively to achieve and sustain
compliance with applicable underground storage tank management regulations and to minimize
EPA's risks.
Applicable Laws and Regulations
Subtitle I of the Resource Conservation and Recovery Act (RCRA) provides the authority for
the Federal underground storage tank (UST) regulations of 40 CFR Part 280. The Federal
standards include detailed requirements for UST design, construction, and installation;
operation and maintenance; release detection, reporting, and response; closure; and financial
responsibility. Individual states may gain authorization to implement UST regulations in
lieu of Federal authorities. These state programs may be more stringent and broader in scope
than the Federal regulations.
SECTION VI - UNDERGROUND STORAGE TANK MANAGEMENT
-------
UNDERGROUND STORAGE TANK MANAGEMENT REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction VI-1
B. Applicability VI-2
C. Registration and Application Requirements VT-3
D. Performance Standards for New and Existing USTs VI-4
E. General Operating Requirements VI-5
F. Release Reporting, Investigations, and Response VI-6
G. Recordkeeping VI-8
H. Evaluation of Findings VI-8
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PROTOCOL
RESPONSE
COMMENTS
VI. UNDERGROUND STORAGE TANK (UST) MANAGEMENT
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/
operations
c) Previous environmental reports
or reports on inspections of
the facility.
2) Review the following background
information related to environmental
management programs and activities
prior to the on-site visit (If it is
not available prior to conducting
the field work, review the
information as early in the field
visit as possible):
a) Facility-specific UST
management policies or
guidance
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
VI-1
UNDERGROUND STORAGE TANK MANAGEMENT
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PROTOCOL
d) Applicable Federal, State and
local regulations
e) Completed facility safety/
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the underground storage tank
management review audit protocol,
perform the review of the facility
for compliance with applicable
policies, regulations and
recommended professional practices.
B. Applicability
6) Determine whether the facility uses
underground tanks for the storage of
petroleum liquids or hazardous
substances including the 44 new
hazardous substances added by the
CAA of 1990 which have not been
RESPONSE
COMMENTS
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UNDERGROUND STORAGE TANK MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
incorporated into the CFR. If so,
verify whether the following
exemption criteria are applicable:
a) The capacity of each tank is
less than 110 gallons [40 CFR
280.10(b)(4)]
b) The tank is used to store
hazardous wastes subject to
the provisions of 40 CFR Parts
261-270 [40 CFR 280.10(b)(1)]
c) The tank is used solely to
store substances for use by
emergency generators [40 CFR
280.10(d)]
d) If the facility stores
substances in USTs not meeting
the exemptions or deferrals in
"a" through "c", complete
steps 7 through 25. If only
"Ic" is applicable, complete
steps 7 through 25 with the
exceptions of steps 14 and
23a.
C. Registration and Application Requirements
7) Determine if the facility has
provided a notification for each
regulated UST with the appropriate
state agency [40 CFR 280.22].
vi-3
UNDERGROUND STORAGE TANK MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
D. Performance Standards for New and Existing
USTs
8) For new tank systems (installed
after December 22, 1988), verify
that the tank and associated piping
are:
a) Constructed of fiberglass-
reinforced plastic; or
b) Constructed of steel and are
corrosion protected; or
c) Constructed of steel-
fiberglass-reinforced plastic
composite; or
d) Constructed of metal without
corrosion protection, provided
that a corrosion expert has
determined that site
conditions could not cause
sufficient UST corrosion to
cause a release during the
operating life of the tank.
[40 CFR 280.20]
9) Confirm that new tank systems
(installed after December 22, 1988)
are equipped with spill and overfill
prevention equipment [40 CFR
280.20(c)].
10) Verify that a new tank system or
upgraded tank system has received a
certification of installation for
both the tank and its associated
piping [40 CFR 280.20 (e)] .
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UNDERGROUND STORAGE TANK MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
11) Confirm that all existing UST
systems (installed prior to December
22, 1988) complied with either of
the following not later than
December 22, 1998:
a) New tank performance standards
listed in protocol items 8, 9,
and 10 above
b) Tank upgrading requirements
including corrosion
protection, piping upgrades,
and spill/overfill prevention
equipment standards
[40 CFR 280.21] .
E. General Operating Requirements
12) By reviewing standard operating
procedures and interviewing facility
personnel, document that the
facility has established procedures
to ensure that releases due to
spilling or overfilling of USTs do
not occur [40 CFR 280.30 (a)].
13) Verify that the facility is meeting
the following requirements for steel
tanks that are currently equipped
with corrosion protection:
a) Corrosion protection systems
are operated and maintained to
continuously provide corrosion
protection to the metal
components of the tank system
[40 CFR 280.31(a)]
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UNDERGROUND STORAGE TANK MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
b) UST systems with cathodic
corrosion protection are
inspected within 6 months of
installation and at least
every 3 years thereafter to
determine the adequacy of
corrosion protection [40 CFR
280.31(b) (1)]
c) UST systems with impressed
current cathodic protection
systems are also inspected
every 60 days to ensure the
equipment is running properly
[40 CFR 280.31(c)]
d) For UST systems using cathodic
corrosion protection, verify
that records of inspections
are maintained on-site [40 CFR
280.31(d)]
14) Verify that the facility is meeting
applicable leak detection
requirements for all tank systems
[40 CFR 280.40-.45] .
F.
Release Reporting,
Response
Investigations and
15) Verify that the facility has
provided a suspected release report
to the regulatory agency within 24
hours of the following conditions:
a) Discovery of contamination at
the UST
b) Unusual operating conditions
observed by facility personnel
(e.g., loss of product from
the system)
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PROTOCOL
RESPONSE
COMMENTS
16)
17)
18)
19)
20)
c) Monitoring results from
release detection indicating
that a release may have
occurred (unless the results
are questionable and a
second month's calculation
indicates no release
occurred).
[40 CFR 280.50]
Verify that the facility
investigated and confirmed all
suspected releases within 7 days [40
CFR 280.52].
Verify that the facility immediately
cleaned up any spill or overfill,
took action to prevent further
release, identified/mitigated
hazards, and reported the incident
to the regulatory agency within 24
hours of the incident [40 CFR 280.53
and 40 CFR 280.61] .
Confirm that the facility has
submitted a report to the regulatory
agency regarding clean-up activities
performed by the facility in
response to spill or overfill [40
CFR 280.62 (6) (b)] .
Confirm that the facility has taken
all required measures requested by
the regulatory agency after review
of the clean-up report [40 CFR
280.62] .
Verify that the facility has
complied with the closure
requirements, including pre-closure
notification, for any UST that is
being removed from service. Confirm
VI-7
UNDERGROUND STORAGE TANK MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
21)
that the tank has been emptied of
all free product and liquids and
either removed from the ground or
filled with an inert solid material
(e.g., sand, clay) [40 CFR 280.70-
.71] .
Verify that permanent closure of UST
is accompanied by a site assessment
to confirm the absence of
contamination [40 CFR 280.72].
Recordkeeping
22) Verify that the following records
are maintained by the facility:
a) Results of all UST testing,
monitoring, inspections,
maintenance and repair work
for the past year
b) Results of site assessments
conducted during permanent
closure for at least 3 years
after completion
c) Registration records for all
in-service and closed tank
systems.
[40 CFR 280.34]
H. Evaluation of Findings
23) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
VI-8
UNDERGROUND STORAGE TANK MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
24) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
25) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
and trends.
VI-9
UNDERGROUND STORAGE TANK MANAGEMENT
-------
-------
PAST WASTE DISPOSAL PRACTICES REVIEW PROTOCOL
OPERATING UNIT: ; DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility past waste disposal programs is to confirm that appropriate systems
are in place and functioning effectively to achieve and sustain compliance with applicable
past waste disposal regulations and to minimize EPA's risks.
Applicable Laws
The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA)
establishes a system for the clean up of abandoned hazardous waste sites. CERCLA requires
owners and operators of facilities to notify EPA of any past waste management activities and,
if necessary, requires investigation and clean up of releases of hazardous substances. The
Resource Conservation and Recovery Act (RCRA) also requires Federal agencies to notify EPA
of past waste management and disposal activities. Individual states may have their own laws,
regulations, or policies regarding past waste disposal.
SECTION VII — PAST WASTE DISPOSAL PRACTICES
-------
PAST WASTE DISPOSAL PRACTICES REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction VII-1
B. General Information VTI-2
C. Past Disposal Practices Evaluation VII-3
D. Evaluation of Findings VII-3
-------
PROTOCOL
VII. PAST WASTE DISPOSAL PRACTICES
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/
operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to past waste
disposal practices prior to the on-
site visit (If it is not available
prior to conducting the field work,
review the information as early in
the field visit as possible):
a) Facility-specific guidance or
policies on past waste
disposal practices
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
d) Applicable Federal, State and
local regulations
RESPONSE
COMMENTS
VII-1
PAST WASTE DISPOSAL PRACTICES
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PROTOCOL
RESPONSE
COMMENTS
e) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the past waste disposal
practices audit protocol, perform
the review of the facility for
compliance with applicable policies,
regulations and recommended
professional practices.
B. General Information
6) Verify that the facility considers
the release potential for hazardous
wastes/substances managed on-site.
7) Confirm that the facility keeps and
updates reporting and recordkeeping
systems to document contamination or
known potential environmental
impacts associated with past
disposal.
VI1-2
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PROTOCOL
RESPONSE
COMMENTS
8) Document the history of past
disposal practices at the facility.
Past Disposal Practices Evaluation
9) Determine through interviews with
selected personnel and review of
aerial photographs or other
documents, how and where wastes have
been disposed of since the facility
started operations.
10) Confirm that the facility has filed
notification of past on-site
treatment, storage or disposal
activities required under CERCLA
103(c) and RCRA 3016.
11) Review the facility's evaluation of
the need for, and extent of,
conducting groundwater assessments.
Assess the adequacy of the
evaluation.
12) Confirm that the groundwater
monitoring system meets established
criteria or good management
practices.
13) Evaluate monitoring results with
regard to the adequacy of methods
used and reliability of data, and
assure that the facility has
conducted additional activities as
appropriate (e.g., preliminary
assessment/site investigation).
Evaluation of Findings
14) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
VI1-3
PAST HASTE DISPOSAL PRACTICES
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PROTOCOL
RESPONSE
COMMENTS
15) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
16) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
VII-4
-------
TOXIC SUBSTANCES AUDIT PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility toxic substances management programs is to confirm that appropriate
systems are in place and functioning effectively to achieve and sustain compliance with
applicable toxic substances regulations and to minimize EPA's risks.
Applicable Laws and Regulations
The regulations governing the use, management, and disposal of PCBs are codified in 40 CFR
Part 761 pursuant to the authority established under section 6(e)(i) of the Toxic Substances
Control Act. In contrast to the majority of environmental programs, the PCB management
program is implemented solely through Federal authority (i.e., no state authorization).
However, some states may have independent PCB management regulations.
SECTION VIII - TOXIC SUBSTANCES AUDIT PROTOCOL
-------
TOXIC SUBSTANCES AUDIT PROTOCOL
Table of Contents
Section Page Number
A. Introduction • VIII-1
B. Identification and Management of PCB Equipment VIII-2
C. Storage Practices VIII-5
D. Fire Risk Reduction Activities VIII-9
E. PCB Waste Disposal Records and Report Manifesting VIII-9
F. Records Retention and Reporting Programs VIII-13
G. Evaluation of Findings VIII-18
SECTION VIII - TOXIC SUBSTANCES AUDIT PROTOCOL
-------
PROTOCOL
RESPONSE
COMMENTS
VIII. TOXIC SUBSTANCES MANAGEMENT
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to PCS
management programs and activities
prior to the on-site visit (If it is
not available prior to conducting
the field work, review the
information as early in the field
visit as possible):
a) Facility-specific PCB
management policies and
guidance
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
VIII-1
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
d) Applicable Federal, State and
local regulations
e) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the toxic substances
management protocol provided,
perform the review of the facility
for compliance with applicable
policies, regulations and
recommended professional practices.
B. Identification and Management of PCB
Equipment
6) Through a review of electrical
records and tours of the facility,
identify PCB items in storage and in
use (i.e., transformers and their
enclosures, capacitors, contaminated
equipment, voltage regulators).
f»«/-»v T/-»
VIII-2
T m wr1 v c
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PROTOCOL
RESPONSE
COMMENTS
7) Note all pieces of equipment that
have been reclassified as PCS
contaminated or non-PCBs.
8) Verify that each PCB transformer
identified in step 6 is accurately
labeled, and all PCB items are
completely documented in facility
information. Note any equipment
that is not labeled or identified in
facility records. In addition,
examine vault doors or other means
of access to a PCB transformer to
confirm that they are marked and
that the markings can easily be read
by fire fighters responding to a
fire involving the PCB transformer
[40 CFR 761.40] .
9) Confirm that combustible materials
are not stored within 5 meters of
PCB items and that each PCB item and
storage area is appropriately
labeled [40 CFR 761.30 (a) (1) (viii)].
10) Confirm that PCB transformers are
not stored in close proximity to (or
where they may pose an exposure risk
to) food or feed. Ensure that areas
where PCB transformers are stored
are diked, enclosed, and inspected
weekly [40 CFR 761.30 (a) (1) (i),
(xiv)].
11) Note and evaluate secondary
containment practices around PCB
transformers and other equipment
containing PCBs to ensure that spill
protection is provided (i.e.,
potential discharges to the sewer or
surface water is minimized) [40 CFR
761.65(b)] .
VIII-3
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
12) Identify and note any evidence of
spills around items containing PCBs.
13) Verify by reviewing inspection
records and interviewing key
personnel whether PCB items are
regularly inspected (e.g.,
transformers in use or stored for
reuse should be inspected at least
once every three months. Confirm
that these inspections are
documented. In addition, verify
that any required repairs or
maintenance of PCB items are made
and documented in an appropriate and
timely manner [40 CFR
761.30(a)(1)(ix)].
14) Confirm that the facility did not
have network PCB transformers with
higher secondary voltages in use in
or near commercial buildings after
October 1, 1990 [40 CFR
761.30U) (1) (ii)]
15) Verify that the facility did not
have network PCB transformers with
lower secondary voltages in use in
or near commercial building after
October 1, 1993 [40 CFR 761.30 (a)
(1) (iv) (B)] .
16) Confirm compliance with the PCB
capacitor use restrictions effective
October 1, 1988, by inspecting all
capacitors (or a representative
sample) and interviewing facility
maintenance and compliance personnel
[40 CFR 761.30(1)] .
17) Confirm that employees responsible
for inspecting and maintaining PCB
items are familiar with facility
procedures relating to their
VIII-4
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
C.
responsibilities, notification
requirements/ approved methods for
handling spills, and the safety and
health precautions to be taken when
cleaning up spills.
Storage Practices
18) Interview facility personnel to
determine how the PCB storage area
is managed. Confirm by observation
that all articles and containers are
dated when they are placed into
storage and that PCBs are stored
according to the date that they
enter storage [40 CFR 761.65(0(8)].
19) Inspect PCB equipment and PCB items
in storage and review storage and
disposal records to confirm that PCB
equipment and PCB items are disposed
of within one year from the date
when they were first placed into
storage [40 CFR 761.65(a)].
20) Inspect the storage area to confirm
that one year storage facilities
meet federal requirements,
including:
a) Roof and walls which prevent
rainwater from reaching PCB
equipment and PCB items [40
CFR 761.65(b)(1)(i)].
b) Adequate floor and continuous
curbing (minimum 6 inches) to
meet containment requirements.
[40 CFR 761.65(b) (1) (ii)] .
(Note: Containment volume should
equal or exceed the volume equal to
twice the internal volume of the
largest PCB container or 25 percent
VIII-5
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
of the total internal volume of all
PCB articles or containers,
whichever is greater) [40 CFR
761.65(b)(1)(ii)J.
c) No openings which would permit
liquids to flow from the
curbed area [40 CFR
76l.65(b) (1) (iii)] .
d) Floors and curbing, which are
continuously smooth and
impervious [40 CFR
761.65(b)(1)(iv)].
e) Storage area located above the
100-year flood plain [40 CFR
761.65(b)(1)(v)].
21) If PCB items are stored in areas not
meeting the requirements referenced
above, inspect those areas to
confirm that:
a) PCB items and containers have
a notation which indicates the
date they were taken out of
service [40 CFR 761. 65(c) (1)] .
b) PCB items and containers have
not been in storage greater
than 30 days [40 CFR
761.65(c) (1)] .
c) The types of PCB items that
may be stored are limited to
the following:
Non-leaking PCB articles
and PCB equipment [40
CFR 761.65(c)(1)(i)]
VIII-6
m^\vTr« OTTO eni axil"1!?c
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PROTOCOL
RESPONSE
COMMENTS
22)
• Leaking PCB articles and
PCB equipment, only if
they are placed in a
non-leaking PCB
container that contains
sufficient absorbent
materials to absorb any
liquid PCBs remaining in
the PCB items [40 CFR
761.65(c) (I) (ii)]
• PCB containers
containing non-liquid
PCBs such as
contaminated soil/ rags,
and debris [40 CFR
761.65(c)(1) (ill)]
• PCB containers
containing 50 to 500 ppm
concentrations of liquid
PCBs, only if the
containers are marked
with a notation
indicating the PCB
concentrations, and an
SPCC plan has been
prepared for the
temporary storage area
(see 40 CFR Part 112)
[40 CFR 761.65(C)(1)
(iv)] .
If large PCB high voltage capacitors
and/or PCB-contaminated equipment
are stored immediately outside an
approved storage facility, confirm
that there is available storage
capacity equal to 10 percent of the
total volume of the capacitors and
equipment stored outside the
facility. Additionally, confirm
that these PCBs are stored on
VII1-7
TOXIC SUBSTANCES MANAGEMENT
-------
PROTOCOL
pallets and inspected weekly for
leaks [40 CFR 761.65(c)(2)].
23) Inspect temporary and long-term PCB
storage areas to confirm that these
areas are properly marked [40 CFR
761.65(c) (3)] .
24) Review relevant documents to confirm
that PCB articles and containers in
temporary and long-term PCB storage
are inspected every 30 days for
leaks [40 CFR 761.65 (c)(5)].
25) Review Federal requirements and
confirm by observation that liquid
PCBs are stored in U.S. DOT-approved
containers [40 CFR 761.65 (c) (6)] .
26) If liquid PCBs are stored in
containers larger than 110 gallons,
confirm the following:
a) The facility complies with
OSHA standards for flammable
and combustible liquids [40
CFR 761.65(c) (7)
-------
PROTOCOL
RESPONSE
COMMENTS
disposition of PCB removed
from a container [40 CFR
761.65(c) (8)] .
Fire Risk Reduction Activities
27) Evaluate the facility's PCB fire
risk reduction activities by
reviewing facility records to
confirm that:
a) All PCB transformers
(including those in storage
for reuse) were registered
with the fire response
personnel that have primary
jurisdiction by December 1,
1985. Note any which have not
been registered [40 CFR
761.30(a)(1)(vi)]
b) PCB transformers involved in a
fire related incident have
been reported to the National
Response Center (NRC). Note
any which have not been
reported [40 CFR 761.30(a)(l)
(xi)].
c) Plans have been developed to
remove PCB equipment off-site
or out of service.
PCB Waste Disposal Records and Report
Manifesting
28) If the facility disposes PCB wastes,
confirm that the following
requirements are met:
a) The facility has obtained an
EPA identification number [40
CFR 761.202]
VIII-9
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
b) Facilities commencing PCB
waste handling activities
after February 7, 1990,
notified EPA and received an
EPA identification number
prior to engaging in PCB waste
handling activities [40 CFR
761.202(d)]
c) The facility prepared a
manifest for all PCB wastes
shipped off-site [40 CFR
761.207(a)].
29) Review state PCB disposal and
manifesting requirements (if
applicable), and determine if either
the State in which the generator is
located, or the State to which a
shipment of PCB waste is manifested,
supplies a manifest and requires its
use. Ensure that all additional
state-required information appears
on each manifest and that the
facility uses the correct manifest
form [40 CFR 761.207(c)-(f)] .
30) Review a sample of manifests to
ensure that the following
information appears:
a) For each bulk load of PCBs,
the identity of the PCB waste,
the earliest date of removal
from service for disposal, and
the weight (in kg) of the PCB
waste
b) For each PCB article container
or PCB container, the unique
identifying number, type of
PCB waste (i.e., soil, debris,
small capacitors), earliest
date of removal from service
vni-io
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
for disposal, and weight (in
kg) of PCBs
c) For each PCB article not in a
PCS container or PCB article
container, the serial number
(if available), date of
removal from service for
disposal, and weight (in kg)
of the PCB waste in each PCB
article.
[40 CFR 761.207(a)]
31) Review manifests for the additional
required information:
a) Manifest document number
(sequentially number)
b) Generator's name, address,
telephone number, and EPA I.D.
number
c) Name, address, and EPA I.D.
number of the transporter(s)
d) Name, address, and EPA I.D.
number of the designated
facility
e) 'U.S. DOT description
(including proper shipping
name, hazard classification,
and I.D. number)
f) Generator certification
g) Generator, transporter, and
designated facility signatures
indicating acknowledgement of
acceptance of the PCB waste.
[40 CFR 761.207(a)]
VIII-11
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
32) If there were any incidences where
the facility did not receive a
signed copy of the manifest from the
designated facility within 35 days,
confirm that the facility initiated
efforts to locate the wastes.
(Review files for documentation of
telephone calls, other contact,
etc.) [40 CFR 761.215(a)].
33) Where the manifest was not returned
within 45 days, confirm that the
generator filed an exception report
with the EPA. If exception reports
are on file, review to verify that
they include the following:
a) Legible copy of the manifest
for which the generator does
not have confirmation of
delivery
b) Cover letter signed by the
generator or his authorized
representative explaining the
efforts taken to locate the
hazardous waste and the
results of those efforts.
[40 CFR 761.215(b)]
34) Confirm, by documentation review,
that the facility received a
Certificate of Disposal from the
designated facility within 30 days
of completion of disposal of each
shipment of PCB waste [40 CFR
761.218]
35) Review files and interview personnel
to determine if:
a) PCBs or PCB items were
transferred to a disposer more
VIII-12
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PROTOCOL
RESPONSE
COMMENTS
than 9 months after the date
of removal from service
b) The facility did not receive a
Certificate of Disposal within
13 months from the date of
removal from service
c) The facility received a
Certificate of Disposal
confirming the disposal of the
affected PCBs or PCB items on
a date more than 1 year after
the date of removal from
service.
If so, confirm that the
facility submitted a complete
and accurate 1-year Exception
Report to the EPA Regional
Administrator [40 CFR
761.215(c)].
F. Records Retention and Reporting Programs
(Note: Beginning February 5, 1990,
facilities storing, at any one time,
the following quantities of PCBs
were required to maintain annual
records and a written annual
document log):
At least 45 kilograms
(99.4 pounds) of PCBs in
PCB container (s)
One or more PCB
transformers
50 or more PCB large
high or low voltage
capacitors.
[40 CFR 761.180(g)]
vni-13
TOXIC S
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PROTOCOL
RESPONSE
COMMENTS
36) Interview facility personnel to
determine if annual PCB records and
a written annual document log are
prepared and maintained. If so,
review the method that the facility
used to assimilate the data used to
compile the records. If there is
any question regarding the
completeness or accuracy of the
records, select daily inventory
records and manifests to confirm
that they are representative of PCB
activities during that year.
37) Review facility records to confirm
that the annual records include the
following:
a) All signed manifests generated
by the facility during the
calendar year
b) All Certificates of Disposal
that have been received by the
facility during the calendar
year.
[40 CFR 761.180(a) (1)]
38) Review the PCB annual document log
to confirm that it contains the
following elements:
a) Name, address, and EPA
identification number of the
facility [40 CFR 761.180 (a) (2)
(i)]
b) The following information from
each manifest and for
unmanifested waste generated
at the facility during the
calendar year:
VIII-14
TOVTP
MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
Unique identification
numbers for each item
(i.e., serial number)
The dates when PCBs and
PCS items (i.e., bulk
PCB waste, PCB
containers, PCB
articles, PCB article
containers) were removed
from service, were
placed into storage for
disposal, and were
placed into transport
for disposal
Quantities of PCBs and
PCB items using the
following breakdown:
- Weight in
kilograms of bulk
PCB waste (e.g.,
in tanker or
truck);
- Total weight of
material in
kilograms of PCB
in each
transformer or
capacitor;
- Total weight in
kilograms of the
material in each
PCB container
(with a
description of
container
contents, such as
liquid, soil,
clean-up debris,
etc.)
VIII-15
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
- Total weight in
kilograms of the
contents of each
PCB article
container (with a
description of the
container
contents, such as
pipes, capacitors,
electric motors,
pumps, etc.).
[40 CFR 761.180(a)(2)(ii)]
39) Verify that the'total number of PCB
articles (by specific type) and
article containers, total weight in
kilograms of the contents of
articles and article containers, and
the total weight of bulk PCB waste
that was placed in storage for
disposal or disposed of during the
calendar year is provided in the
annual log [40 CFR 761.180(a)(2)
(iii] •
40) Confirm that the log includes the
total number of PCB transformers and
total weight in kilograms of PCBs
contained in the transformers
remaining in service at the end of
the calendar year [40 CFR 761.180
(a) (2) (iv) ] .
41) Determine if the log includes the
total number of large high or low
voltage PCB capacitors remaining in
service at the end of the calendar
year [40 CFR 761.180 (a) (2) (v)].
42) Verify that the log contains the
total weight in kilograms of any
PCBs and PCB items in PCB containers
(including identification of
VIII-16
OTTtJCT»M/-
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PROTOCOL
RESPONSE
COMMENTS
container contents) remaining in
service at the end of the calendar
year [40 CFR 761.180(a)(2)(vi)].
43) Confirm that the facility maintains
a record of each telephone call, or
other means of verification agreed
upon by both parties, made to each
designated commercial storer or
disposer to confirm receipt of PCS
waste transported by an independent
transporter [40 CFR 761.180(a) (2)
(viii)].
44) Verify that annual document logs and
annual records are maintained for at
least 3 years after the facility
ceases using or storing the
specified quantities of PCBs and PCB
items [40 CFR 761.180 (a)].
45) Review PCB transformer inspection
and maintenance records to confirm
that they contain the following
information:
a) Location
b) Date of each inspection
c) Date that each leak was
discovered and location of
leak
d) Person performing the
inspection
e) Estimate of the amount of
dielectric fluid released from
any leak
f) Date and description of any
cleanup, containment, repair,
or replacement activities
VIII-17
TOXIC SUBSTANCES MANAGEMENT
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PROTOCOL
g) Results of any containment and
daily inspection required for
uncorrected active leaks
h) Records of quarterly and/or
annual PCB transformer
inspections.
[40 CFR 761.30(a)(1)(xii)]
G. Evaluation of Findings
46) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
47) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
48) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
RESPONSE
COMMENTS
VIII-18
TOXTP. RTTRSTANPKS MANAGEMENT
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EMERGENCY PLANNING AND COMMUNITY RIGHT-TO-KNOW
REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility emergency planning and community right-to-know programs is to
confirm that appropriate systems are in place and functioning effectively to achieve and
sustain compliance with applicable emergency planning and community right-to-know regulations
and to minimize EPA's risks.
Applicable Laws and Regulations
Title III of the Superfund Amendments and Reauthorization Act (SARA) of 1986 establishes
comprehensive requirements for emergency planning, emergency release notification, community
right-to-know, and toxics release inventory reporting. The implementing regulations at the
Federal level for SARA Title III are codified at 40 CFR Parts 355 through 372. On August 3,
1993, President Clinton signed Executive Order 12856, which subjects Federal facilities to
EPCRA regulations. In addition, individual states may establish reporting requirements or
lower thresholds for reporting.
SECTION IX - EMERGENCY PLANNING AND COMMUNITY RIGHT-TO-KNOW
-------
EMERGENCY PLANNING AND COMMUNITY RIGHT-TO-KNOW
REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction IX-1
B. Emergency Planning IX-2
C. Emergency Release Notification IX-3
D. MSDS and Inventory Reporting IX-5
E. Toxic Chemical Release Reporting IX-7
F. Evaluation of Findings IX-8
IT KMUTMI? »mr> rviMMTTMTTV t --um_ipr>—vwniii
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PROTOCOLS
IX. EMERGENCY PLANNING AND COMMUNITY RIGHT-TO-KNOW
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to emergency
planning and community right-to-know
programs and activities prior to the
on-site visit (If it is not
available prior to conducting the
field work, review the information
as early in the field visit as
possible):
a) Facility-specific emergency
planning and release response
manuals and procedures
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
RESPONSE
COMMENTS
IX-1
EMERGENCY PLANNING AND COMMUNITY RIGHT-TO-KNOW
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PROTOCOLS
d) Applicable Federal, State and
local regulations
e) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3)
The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the emergency planning and
community right-to-know audit
protocol, perform the review of the
facility for compliance with
applicable policies, regulations and
recommended professional practices.
B. Emergency Planning
6) Verify through facility tours and a
review of operating and purchasing
records whether the facility
maintains extremely hazardous
substances as identified in 40 CFR
Part 355, Appendix A. Based upon
RESPONSE
COMMENTS
IX-2
(-OMMTTNTTY RTRHT-TO-KNOW
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PROTOCOLS
RESPONSE
COMMENTS
amounts present on-site (e.g., in
storage, in process) and a review of
historical purchasing records,
determine if any extremely hazardous
substances maintained at the
facility are in quantities equal to
or exceeding the corresponding
threshold planning quantity (TPQ).
Confirm that facilities meeting
these criteria have taken the
following steps in accordance with
40 CFR Part 355.30:
a) Notified the State Emergency
Response Commission (SERC) [40
CFR 355.30(b)]
b) Designated an emergency
coordinator to participate in
the local emergency planning
process [40 CFR 355.30(c)]
c) Informed the Local Emergency
Planning Committee (LEPC) of
any changes that may affect
emergency planning [40 CFR
355.30(d)(1)]
d) Provided information when
requested by the LEPC to
support the development or
implementation of the local
emergency plan [40 CFR
355.30(d)(2)].
C. Emergency Release Notification
7) Document that the facility has
provided the required emergency
release notifications for releases
of extremely hazardous substances or
CERCLA hazardous substances (listed
in 40 CFR 302.4) above the TPQ or
IX-3
EMERGENCY PLANNING AND COMMTTNITY PIGHT-TO-KNOW
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PROTOCOLS
reportable quantities. Verify that
the facility has met the following
requirements for reporting releases:
a) Notification of the release
has been provided to the
community emergency
coordinator for the LEPC and
SERC [40 CFR 355.40 (b)(l)]
b) The notice included the
following information:
• Chemical name or
identity of the
substance involved in
the release
• Indication of whether
the substance was an
extremely hazardous
substance
• Estimate of the quantity
of such substance that
was released into the
environment
• Time and duration of the
release
Media or medium into
which the release
occurred
• Known or anticipated
acute or chronic health
risks associated with
the emergency release
and/ where appropriate,
advice regarding medical
attention necessary for
exposed individuals
RESPONSE
COMMENTS
IX-4
RMRBRRMfV PT.ANNTNr: AND fOMMIINTTY RICHT-TO-KNOW
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PROTOCOLS
RESPONSE
COMMENTS
Proper precautions to
take as a result of the
release, including
evacuation (unless such
information is readily
available to the LEPC)
• The names and telephone
numbers of the person or
persons to be contacted
for further information.
[40 CFR 355.40(b)(2)(i) - (viii)]
8) Confirm that the facility provided a
written follow-up notice setting
forth and updating the information
required above and including
additional information:
a) Actions taken to respond to
and contain the release
b) Known or anticipated acute or
chronic health risks
associated with the release
c) Advice regarding medical
attention for exposed
individuals.
[40 CFR 355.40(b)(3)]
D. MSDS and Inventory Reporting
9) Determine if the facility maintains
any OSHA hazardous chemicals in
excess of 10,000 pounds or extremely
hazardous substances in quantities
equal to or exceeding 500 pounds, 55
gallons, or the TPQ, whichever is
less [40 CFR 370.20]. Confirm that
IX-5
EMERGENCY PLANNING AND COMMUNITY RIGHT-TO-KNOW
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PROTOCOLS
facilities meeting these criteria
have performed the following:
a) The facility has submitted an
MSDS for each hazardous
chemical present at the
facility in regulated
quantities to the LEPC, SERC
and local fire department [40
CFR 370.21(a)]
b) In lieu of submitting a MSDS
for each hazardous chemical,
the owner or operator may
submit:
• A list of the hazardous
chemicals for which an
MSDS is required,
grouped by hazard
category as defined in
40 CFR 370.2
• The chemical or common
name of each hazardous
chemical provided on the
MSDS
• The hazardous component
of each hazardous
chemical provided on the
MSDS, except for
mixtures.
[40 CFR 370.21(b)]
c) The facility has submitted a
Tier I and, if specifically
requested, a Tier II inventory
to the LEPC, SERC and local
fire department for hazardous
chemicals exceeding the
reporting thresholds [i.e.,
RESPONSE
COMMENTS
IX-6
DT.AMMTMR AMTI POMMTINTTY RTGHT-TO-KNOW
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PROTOCOLS
RESPONSE
COMMENTS
E.
10,000 pounds for hazardous
chemicals, 500 pounds, 55
gallons, or TPQ for extremely
hazardous substances]. Verify
that the submittal of these
inventories has been
accomplished by reviewing
facility operating records [40
CFR 370.25].
Toxic Chemical Release Reporting
10) Determine if the facility meets the
following requirements that invoke
Toxic Chemical Release Reporting:
a) Facility has 10 or more full-
time employees
b) The facility manufactures,
processes, or uses a toxic
chemical or chemical category
in excess of reporting
thresholds:
manufacturing - 25,000
pounds
processing - 25,000
pounds
otherwise using 10,000
pounds
[40 CFR 372.22]
11) Verify that the facility has
submitted a Form R if the above
conditions and thresholds are met.
All records associated with this
reporting should be maintained on-
site for 3 years after date of
IX-7
EMERGENCY PLANNING AND COMMUNITY RIGHT-TO-KNOW
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PROTOCOLS
RESPONSE
COMMENTS
submission [40 CFR 372.10 and
372.30].
(Note: This requirement began for
Federal facilities in the 1994
reporting year (January to December
1994), with reports due on July 1,
1995.)
F. Evaluation of Findings
12) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
13) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
14) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
IX-8
ANT> COMMUNITY RIGHT-TO-KNOW
-------
PESTICIDE MANAGEMENT REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW: ,
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility pesticide management programs is to confirm that appropriate
systems are in place and functioning effectively to achieve and sustain compliance with
applicable pesticide management regulations and to minimize EPA's risks.
Applicable Laws and Regulations
The Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) governs the storage,
handling, and disposal of pesticides. Implementing regulations are codified in 40 CFR Parts
152-186.
SECTION X - PESTICIDE MANAGEMENT
-------
PESTICIDE MANAGEMENT REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction X-l
B. General Information X-2
C. Worker Protection X-4
D. Pesticide Storage X-6
E. Pesticide Disposal X-7
F. Exemption from FIFRA Regulations X-8
G. Evaluation of Findings X-8
v _ p»QTTrTnr
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PROTOCOLS
RESPONSE
COMMENTS
X. PESTICIDE MANAGEMENT
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous environmental audit
reports or reports on
inspections of the facility.
2) Review the following background
information related to pesticide
management programs and activities
prior to the on-site visit (If it is
not available prior to conducting
the field work, review the
information as early in the field
visit as possible):
a) Suspended/ Cancelled, and
Restricted Pesticides, EPA
Office of Pesticides and Toxic
Substances, January 1985, 3rd
Revision
b) Organizational charts and
staffing tables
c) Training and employee
orientation documents
X-l
PESTICIDE MANAGEMENT
-------
PROTOCOLS
RESPONSE
COMMENTS
d) Applicable Federal, State and
local regulations
e) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations, as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the pesticide management audit
protocol provided, perform the
review of the facility for
compliance with applicable policies,
regulations and recommended
professional practices.
B. General Information
Obtain an understanding of the pesticide
management systems at the facility by performing
the following steps:
6) Determine if pesticides are applied,
used or stored at the facility. If
X-2
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PROTOCOLS
RESPONSE
COMMENTS
so, determine whether the facility
or a contractor applies pesticides
on facility grounds or structures.
7) Identify all areas of the facility
where pesticide formulations,
residues or empty containers are
stored. Note the location of the
areas on a facility map.
8) Evaluate the facility's pesticide
disposal practices by reviewing
standard operating procedures and
interviewing appropriate personnel.
Note whether pesticides are disposed
on-site in a manner other than the
manufacturer's instructions.
Using the information gathered from protocol
steps 6 through 8, evaluate the facility's
pesticide management practices by conducting the
following review.
9) Confirm that all pesticides
purchased are registered by the
manufacturer by inspecting container
labels and manufacturing
registrations [40 CFR 156.10].
10) Through a review of standard
operating procedures and observation
of pesticide handling practices,
verify that pesticides are used in
accordance with label directions
[40 CFR 152.175 and 156.10].
11) Confirm that a restricted-use
pesticide is applied only by an
applicator currently certified to
apply the pesticide by a Federal or
approved State or government agency
certification program, or by a
noncertified applicator under the
direct supervision of a certified
X-3
PESTICIDE MANAGEMENT
-------
PROTOCOLS
applicator
.175] .
[40 CFR 152.171, and
C.
12) Document that applicators of
restricted use pesticides are
certified in the appropriate
category or categories of materials
to be handled by reviewing
applicator licenses and
certifications [40 CFR 171.3].
13) Review facility pesticide management
practices to confirm that no
pesticide that has been suspended,
or restricted (not to be confused
with restricted-use pesticide) under
40 CFR 164, is applied in accordance
with the "Action" section for the
particular pesticide listed in
Suspended, Cancelled, and Restricted
Pesticides, EPA, Office of
Pesticides and Toxic Substances,
Jan. 1985, 3rd Revision [40 CFR
164] .
Worker Protection
14) Perform a review of standard
operating procedures to confirm that
the worker protection standards of
Part 170 are met by the agricultural
handler or employee. These
standards apply to workers and
pesticide handlers at agricultural
establishments, including workers
performing hard labor operations in
fields treated with pesticides,
employees in forests, nurseries, and
greenhouses, and employees who
handle pesticides for use in these
locations, except as otherwise noted
in 40 CFR 170.102, and .202.
Confirm that the procedures
RESPONSE
COMMENTS
X-4
-------
PROTOCOLS
incorporate the following
requirements:
a) Workers' access to treated
areas is limited to no-contact
and short-term activities
during the restricted-entry
interval [40 CFR 170.112].
b) All workers and handlers are
notified orally and via posted
statements of pesticide
applications. Appropriate
pesticide-specific information
is displayed [40 CFR 170.120,
.121, and .122] .
c) Pesticides are applied so as
not to contact any non-
handlers. Handlers and
handler employers follow
visual and voice communication
requirements during
application [40 CFR 170.210].
d) Workers and pesticide handlers
should have received pesticide
safety training that enables
them to fully understand all
information related to safe
handling of pesticides as well
as be able to safely operate
all equipment related to
pesticide handling [40 CFR
170.130, .230, .232, and
.234] .
e) Pesticide handlers wear
clothing and personal
protective equipment specified
on the pesticide label [40
CFR 170.240].
RESPONSE
COMMENTS
X-5
PESTICIDE MANAGEMENT
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PROTOCOLS
f) Appropriate decontamination
facilities are provided, as
well as emergency assistance,
when necessary [40 CFR
170.150, .160, .250, and
.260].
D. Pesticide Storage
15) Inspect pesticide containers to
ensure that labels meet
manufacturing labeling requirements.
Verify that labels contain the
worker protection statements,
restricted-entry statements,
notification to worker statements,
and personal protective equipment
statements [40 CFR 156.10, .206,
.208, .210, and .212]
16) Through an evaluation of pesticide
storage procedures and facilities,
confirm that pesticides classified
as highly or moderately toxic, as
well as empty containers of such
pesticides, are stored in accordance
with the following requirements:
a) Storage facilities are well
ventilated and equipped with
fire protection
b) Storage areas have adequate
security through locks and
fences
c) Provisions for personnel and
equipment decontamination are
in place
d) Wastewater from
decontamination procedures is
collected and managed as a
pesticide waste
RESPONSE
COMMENTS
X-6
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PROTOCOLS
RESPONSE
COMMENTS
E.
e) Containers are stored with
labels plainly visible
f) Pesticide containers are
inspected regularly for
corrosion and leaks, and
absorbent spill materials are
available
g) Pesticide storage areas are
free of food, beverage and
tobacco products
h) Persons handling pesticides
use appropriate protective
clothing including, but not
limited to: gloves, aprons,
face splash shields, and
respirators (if handling
organophosphates or N-alkyl
carbamates).
[40 CFR 165.10]
Pesticide Disposal
17) Review pesticide disposal practices
and records to confirm that no
pesticide is disposed of by open
dumping, open burning, or in a
manner that is inconsistent with its
labeling [40 CFR 165.7].
18) Review pesticide disposal records to
confirm that organic or non-organic
pesticides are disposed of according
to the recommended procedures for
each type of pesticide [40 CFR
165.8] .
19) Tour facility storage areas and
interview personnel responsible for
pesticide management to confirm that
pesticide containers and pesticide-
X-7
PESTICIDE MANAGEMENT
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PROTOCOLS
related waste (residues) are
disposed of according to recommended
procedures [40 CFR 165.9].
Exemption From FIFRA Regulations
20) Through documentation review and
interviews with facility personnel,
determine that if the facility is
not operating in compliance with
FIFRA regulations that it has been
granted an emergency exemption by
EPA [40 CFR 166].
Evaluation of Findings
21) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
22) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
23) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
results or identify overall patterns
or trends.
RESPONSE
COMMENTS
X-8
PESTICIDE MANAGEMENT
-------
RADIOACTIVE MATERIALS MANAGEMENT REVIEW PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility radioactive materials management programs is to confirm that
appropriate systems are in place and functioning effectively to achieve and sustain
compliance with applicable radioactive materials management regulations and to minimize EPA' s
risks.
Applicable Laws and Regulations
Radioactive materials management is regulated by the Nuclear Regulatory Commission under the
authority of the Atomic Energy Act. The applicable implementing regulations are codified in
10 CFR Parts 1 through 71.
SECTION XI - RADIOACTIVE MATERIALS MANAGEMENT
-------
RADIOACTIVE MATERIALS MANAGEMENT REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction XI-1
B. Notices to Workers XI-2
C. Instructions to Workers XI-3
D. Reports to Workers XI-4
E. Inspections XI-4
F. Precautionary Procedures XI-5
G. Waste Disposal XI-9
H. Records, Reports and Notification XI-12
I. Licensing of Byproduct Material XI-14
J. Licenses XI-14
K. Records, Inspections, Tests and Reports XI-15
L. Licenses for Byproduct Material XI-16
M. Packaging and Transportation of Radioactive Material XI-17
N. Evaluation of Findings XI-19
CFf-TTOM YT - RADTOAPTIVF MATFPIM.S MANAGEMEKT
-------
PROTOCOL
RESPONSE
COMMENTS
XI. RADIOACTIVE MATERIALS MANAGEMENT
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not available
before conducting the field work, review
the information as early in the visit as
possible):
a) Facility diagrams and floorplans
b) Descriptions of primary facility
activities/operations
c) Previous environmental audit reports
or reports on inspections of the
facility.
2) Review the following background
information related to radioactive waste
management programs and activities prior
to the on-site visit (If it is not
available prior to conducting the field
work, review the information as early in
the field visit as possible):
a) EPA and facility-specific
radioactive management policies or
guidance
b) Organizational charts and staffing
tables
c) Training and employee orientation
documents
d) Applicable Federal, state and local
regulations
xi-l
RADIOACTIVE KATFPIAT.S MANAHF.MENT
-------
PROTOCOL
RESPONSE
COMMENTS
e) Completed facility safety, health
and environmental pre-audit
questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with the
facility management and staff to provide
an overview of the objectives, scope,
methodology, approach and reporting for
the review.
4) Based on your initial understanding of the
facility and operations as well as a
review of the completed pre-audit
questionnaire, develop a plan for
conducting the audit.
Information Gathering and Finding Development
5) Using the Radioactive Materials Management
Protocol, perform the review of the
facility for compliance with applicable
policies, regulations and recommended
professional practices.
B. Notices to Workers
6) Confirm that current copies of the
following documents are posted for the
information of workers:
a) Form NRC-3, "Notice to Employees"
b) Title 10 CFR Parts 19 and 20*
c) License, license conditions, or
documents incorporated into a
license by reference, and amendments
thereto*
d) Operating procedures applicable to
the licensed activities*
XI-2
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PROTOCOL
RESPONSE
COMMENTS
e) Notice of violation involving
radiological working conditions and
any response from the licensee or, a
notice posted which describes these
documents and states where they may
be examined.*
*Note: Form NRC-3, "Notice to Employees"
may be amended to include a reference to
an alternative location where the above
documents are available. This enables
employees to review applicable licenses
and regulations.
[10 CFR 19.11]
7) Confirm that the postings appear in a
sufficient number of places to enable
workers to observe them on the way to or
from licensed activities [10 CFR 19.11].
8) Determine if standard practice calls for
documents pertaining to violations of the
license to be posted within two days of
availability and remain posted for five
days or until the violation has been
corrected, whichever is later [10 CFR
19.11] .
C. Instructions To Workers
9) Confirm that workers in or frequenting a
restricted area are:
a) Informed of storage, transfer and
use of radioactive materials and
radiation in the area [10 CFR
19.12].
b) Instructed in health protection;
precautions or procedures to
minimize exposure; purposes and
function of protective devices;
XI-3
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
their responsibility to report
license violations; the appropriate
response to warnings of unusual
conditions; and radiation exposure
reports that they may request [10
CFR 19.12] .
D. Reports to Workers
10) Confirm that exposure data for an
individual, including any measurements,
analyses and calculations of radioactive
material deposited in the body, are
reported to the individual in writing [10
CFR 19.13] .
11) Check the report to confirm that it
includes a statement that the report is
furnished under the provisions of 10 CFR
19 and that the report should be preserved
for future reference [10 CFR 19.13].
12) Confirm that the licensee, upon request,
advises each worker annually of exposure
to radioactive materials or radiation as
shown in the license records [10 CFR
19.13].
E. Inspections
13) Determine if workers are aware that they
may write to the NRC for an inspection
when they believe that a violation of the
Atomic Energy Act, 10 CFR 19, or license
provisions has occurred [10 CFR 19.16].
14) Determine whether workers also are aware
that, upon their request, their name will
not be furnished to their employer except
for good cause shown [10 CFR 19.16].
XI-4
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PROTOCOL
RESPONSE
COMMENTS
F. Precautionary Procedures
15) Determine if surveys are conducted to
evaluate radiation hazards associated with
the production, use, release, disposal, or
presence of radioactive materials [10 CFR
20.201] .
16) Confirm that appropriate personnel
monitoring equipment is provided and used
by:
a) Individuals entering a restricted
area who are likely to receive a
dose in excess of 25 percent of the
applicable limit
b) Individuals under 18 years of age
entering a restricted area who are
likely to receive a dose in excess
of 5 percent of the applicable limit
c) Each individual who enters a high
radiation area.
[10 CFR 20.202]
17) Determine whether personnel dosimeters
that require processing to determine the
radiation dose are processed and evaluated
by a laboratory that is:
a) Currently accredited by the National
Voluntary Laboratory Accreditation
Program (NVLAP) of the National
Institute of Standards and
Technology
b) Approved by the NVLAP for the type
of radiation being monitored.
[10 CFR 20.202]
XI-5
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
18) Confirm that each radiation area is posted
conspicuously with a sign bearing the
radiation caution symbol and the words:
Caution
Radiation Area
[10 CFR 20.203]
19) Verify that areas containing airborne
radioactivity are posted with a sign
bearing the radiation caution symbol and
the words:
Caution
Airborne Radioactivity Area
[10 CFR 20.203]
20) Determine whether areas in which licensed
material is used or stored and which
contains any radioactive material in an
amount exceeding 10 times the amount
specified in Appendix C, 10 CFR 20, are
posted with a sign bearing the radiation
caution symbol and the words:
Caution
Radioactive Material(s)
[10 CFR 20.203]
a) Confirm that containers of licensed
material bear a durable, clearly
visible label identifying the
radioactive contents [10 CFR
20.203]
RESPONSE
COMMENTS
XI-6
BanrnarTTVE MATERIALS MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
b) Verify that the label bears the
radiation caution symbol and the
words:
Caution
Radioactive Material
or
Danger
Radioactive Material
[10 CFR 20.203]
c) Confirm that information is provided
to allow individuals to take
precautions to avoid or minimize
exposures [10 CFR 20.203].
21) Check that the labels of empty
uncontaminated containers are removed or
defaced prior to the container being moved
to unrestricted areas [10 CFR 20.203].
22) Confirm that exceptions to the posting of
signs are in accordance with the
provisions of 10 CFR 20.204 or the
applicable byproduct material license [10
CFR 20.204].
23) Check that procedures have been
established and implemented to:
a) Receive shipments of radioactive
material at the facility when
offered for delivery by the carrier
b) Receive notification from the
carrier of shipment arrival and to
make arrangements to pick-up
shipments expeditiously at the
carrier's terminal
XI-7
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
c) Monitor the external surfaces of the
package for radioactive
contamination caused by leakage of
the radioactive contents, when
appropriate, within 3 hours of
receipt during normal working hours
or 18 hours of receipt if received
after normal working hours
d) Monitor the radiation levels
external to the package when the
shipment contains radioactive
material in quantities in excess of
the Type A quantities specified in
10 CFR 20.205, within 3 hours of
receipt during normal working hours,
or within 18 hours of receipt if
received after normal working hours
e) Immediately notify the carrier and
the NRC Regional Office when:
removable radioactive contamination
in excess of 0.01 microcuries per
100 square centimeters of package
surface is found on the external
surfaces of the package; or
radiation levels on the package
external surface exceed 200 millirem
per hour; or exceed 10 millirem per
hour at 3 feet from the external
surface of the package
f) Safely open packages in which
licensed material is received.
[10 CFR 20.205]
24) Confirm that licensed materials stored in
an unrestricted area are secured to
prevent unauthorized removal [10 CFR
20.207] .
RESPONSE
COMMENTS
XI-8
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PROTOCOL
RESPONSE
COMMENTS
25) Determine if licensed materials in an
unrestricted area, but not in storage, are
under constant surveillance and immediate
control of the licensee [10 CFR 20.207].
G. Waste Disposal
26) Confirm that licensed material is disposed
of only:
a) By transfer to an authorized
recipient
b) As authorized in the radioactive
material license
c) By authorized release into the
sanitary sewerage system
d) As authorized by 10 CFR 20.106, or
10 CFR 20.306.
[10 CFR 20.301]
27) Confirm that licensed material discharged
to the sanitary sewerage system is readily
soluble/dispersible in water, and does not
exceed:
a) The quantity in any one day which,
if diluted by the average daily
quantity of sewage released into the
sewer by the licensee, will result
in an average concentration equal to
the limits specified in Appendix B,
10 CFR 20, or 10 times the quantity
of such material specified in
Appendix C, 10 CFR 20.
b) The quantity in any one month which,
if diluted by the average monthly
quantity of water released by the
licensee, will not result in an
average concentration exceeding the
XI-9
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
limits specified in Appendix B, 10
CFR 20.
c) One curie per year [excluding
hydrogen-3 and carbon-14].
d) Five curies per year for hydrogen-3
and one curie per year for carbon-
14.
[10 CFR 20.303] .
28) Determine if treatment or disposal of
licensed material by incineration is
limited to materials:
a) Listed under 10 CFR 20.306
b) Specifically approved by the NRC as
listed in the activity's radioactive
material license.
[10 CFR 20.305]
29) Confirm that when disposing of 0.05
microcuries or less of hydrogen-3 or
carbon-14, per gram of medium, used for
scintillation counting and per gram of
animal tissue averaged over the disposed
weight of the animal, records are
maintained showing the receipt, transfer
and disposal of such by-product material
[10 CFR 20.306].
30) Verify that each shipment of radioactive
waste to a licensed land disposal facility
is accompanied by a manifest that contains
the following:
a) Name, address and telephone number
of the person generating the waste
XI-10
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
31)
b) Name, address and telephone number
or the name and EPA hazardous waste
identification number of the person
transporting the waste to the land
disposal facility
c) Physical description of the waste,
the volume, radionuclide identity
and quantity, the total
radioactivity, the principal
chemical form, and the
solidification agent
d) Certification by the generator that
the materials are properly
classified, described, packaged,
marked and labeled and in proper
condition for transportation
e) Date and signature of an authorized
representative of the generator.
[10 CFR 20.311]
Verify that waste is transferred to a land
disposal facility or a licensed waste
collector only after:
a) Classified according to 10 CFR 61.55
criteria and meeting the waste
characteristics requirements in 10
CFR 61.56
b) Labeled to identify whether it is
Class A, B or C waste
c) Manifested according to requirements
of 10 CFR 20.311.
[10 CFR 20.311]
XI-11
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
32) For wastes transferred to a land disposal
facility, a licensed waste collector or to
a licensed waste processor that treats or
repackages waste, verify that a copy of
the manifest is:
a) Forwarded to the intended recipient
at the time of shipment
b) Provided to the collector at time of
collection, obtaining
acknowledgement of receipt from the
collector
c) Included with the shipment
d) Retained as the record of transfer
of licensed material (along with
documentation of receipt).
[10 CFR 20.311]
H. Records, Reports And Notification
33) Confirm that the results of personnel
monitoring for radiation exposure are
maintained on Form NRC-5, or equivalent
other form, with doses entered for period
of time not exceeding one calendar quarter
[10 CFR 20.401] .
34) Confirm that the records of individual
exposures are preserved until the NRC
authorizes disposition [10 CFR 20.401].
35) Verify that records of the results of
surveys and monitoring are preserved for
two years after completion of the survey
[10 CFR 20.401] .
XI-12
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PROTOCOL
RESPONSE
COMMENTS
36) Confirm that records of the results of
surveys to determine compliance with 10
CFR 20.103, to determine external
radiation dose in the absence of personnel
monitoring data, and to evaluate the
release of radioactive effluents to the
environment are maintained until the NRC
authorizes disposition [10 CFR 20.401].
37) Verify that records of disposal of
licensed materials are maintained until
the NRC authorizes disposition [10 CFR
20.401] .
38) Confirm that the NRC Regional Office is
phoned immediately when theft or loss of
licensed material occurs in such
quantities and if substantial hazard may
result to persons in unrestricted areas
[10 CFR 20.402] .
39) Determine that the procedure requires that
the telephone call is followed within 30
days with a written report containing the
required information [10 CFR 20.402].
40) Confirm that the report format shows the
names of individuals who may have received
exposure to radiation and are stated in a
separate part of the report [10 CFR
20.402] .
41) Confirm that the facility has established
procedures for reporting incidents to the
NRC [10 CFR 20.402] .
42) Ascertain that the facility has
established procedures for reporting
overexposures, excessive levels of
radiation and excessive concentrations of
radioactive materials to the NRC [10 CFR
20.402] .
XI-13
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
I. Licensing of Byproduct Material
43) Confirm that byproduct material in the
facility is authorized by either a general
or specific license issued pursuant to the
regulations in 10 CFR 30 through 36 and 39
[10 CFR 30.3] .
44) Confirm that for facilities having
specific licenses, Form NRC-3, "Notice to
Employees," is posted on the premises in
sufficient locations to permit protected
employees to observe a copy on their way
to or from their place of work [10 CFR
30.7(e)] .
J. Licenses
45) Confirm that possession and use of
licensed byproduct material is confined to
the location and purposes authorized in
the license [10 CFR 30.34].
46) Confirm that an application for license
renewal or a notification of intent not to
renew a license was submitted no less than
30 days before the expiration date
specified in the specific license [10 CFR
30.37] .
47) Confirm that if the license is expired,
the following actions were taken on or
before the expiration date:
a) Use of byproduct material was
terminated
b) Radioactive contamination was
removed to the extent practicable
c) Byproduct material was disposed of
properly
XI-14
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PROTOCOL
RESPONSE
COMMENTS
d) Form NRC-314 was submitted to the
NRC Regional Office
e) A radiation survey report was
submitted to the NRC to confirm the
absence of radioactive materials or
to establish the levels of residual
radioactive contamination
f) A plan for decontamination, if
required, was submitted to the NRC.
[10 CFR 30.36]
48) Confirm that access to restricted areas
remained controlled until the NRC notified
the facility that the license was
terminated and that the areas were
suitable for release for unrestricted use
[10 CFR 30.36] .
49) Confirm that before transferring byproduct
material to a specific licensee, the
facility verified that the transferee's
license authorized the receipt of the
type, form and quantity of byproduct
material [10 CFR 30.41].
K. Records, Inspections, Tests and Reports
50) Check that records showing the receipt,
transfer and disposal of licensed
byproduct material are maintained as
follows:
a) Receipts are maintained during
possession and for 3 years following
transfer or disposal.
b) Transfer records are maintained for
3 years after the transfer, unless a
longer period is specified by other
regulations.
XI-15
RADIOACTIVF MATFPTAI.«?
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c)
PROTOCOL
Disposal records are maintained as
prescribed in 10 CFR 20. 401(c).
[10 CFR 30.51]
L. Licenses for Byproduct Material
51) Confirm that measuring, gauging and
controlling devices are operated under the
following conditions:
a) Labels, that bear the statement that
removal is prohibited, are not
removed
b) Instructions and precautions
provided on the labels are
implemented
c) The device is tested for leakage and
proper operation of the on-off
mechanism and indicator, if any, at
no longer than 6-month intervals or
as indicated on the label
d) Testing, installation, servicing,
and removal from installation
involving the radioactive material,
its shielding or containment are
performed either in accordance with
label instructions or by a person
holding a specific license to
perform such activities
e) Records are maintained
f) Upon failure of or damage to the
shielding or on-off mechanism or
upon detection of 0.005 microcurie
or more of removable radioactive
material, the device is removed from
service until: repaired by the
manufacturer or person holding a
RESPONSE
COMMENTS
XI-16
MATF.RTAT.S MANARRMENT
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PROTOCOL
RESPONSE
COMMENTS
M.
52)
53)
specific license for repairs or
disposed of by transfer to a person
holding a specific license^ to
receive the material contained in
the device
g) Such failure, damage or leakage is
reported to the NRC Regional Office
within 30 days
h) The device is not abandoned
i) Transfer or disposal of the device
is only by transfer to a person
having specific license to receive
the device
j) Such transfer, unless to receive a
replacement device, is reported to
the NRC Regional Office within 30
days.
[10 CFR 31.5]
Packaging and Transportation of
Radioactive Material
Check that the facility staff complies
with the requirements of 10 CFR Parts 20,
21, 30, 39, 40, 70, 71, and 73, as
appropriate, during packaging and
transport of licensed material [10 CFR
71.0] .
Confirm that shipments of licensed
material conform to Department of
Transportation (DOT) regulations in 49 CFR
Parts 170 through 189, regarding the
regulations for the following areas and
modes of transportation:
XI-17
RADIOACTIVE MATERIALS MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
54)
55)
a) Packaging - 49 CFR Part 173,
Subparts A and B and Parts 173.401
through 173.478
b) Marking and Labeling - 49 CFR Part
172, Subpart D; Parts 172.400
through 172.407; and 172.436 through
172.440
c) Placarding - 49 CFR Parts 172.500
through 172.519, 172.556 and
Appendices B and C
d) Monitoring - 49 CFR Part 172,
Subpart C
e) Accident Reporting - 49 CFR Part
171.15 and 171.16
f) Shipping Papers - 49 CFR Part 172,
Subpart C
g) Rail - 49 CFR Part 174, Subparts A-D
and K
h) Air - 49 CFR Part 175, Subparts A-D
and M
i) Vessel - 49 CFR Part 175, Subparts
A-D and M
j) Public Highway - 49 CFR Part 177.
[10 CFR 71.5]
Confirm that packages meet the standards
contained in 10 CFR 71.43.
Confirm that external radiation levels for
packages meet the standards prescribed in
10 CFR 71.47.
XI-18
T. MATRRTAI.S MANAGEMENT
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PROTOCOL
RESPONSE
COMMENTS
N. Evaluation of Findings
56) Review actions taken to complete each step
of the audit protocol and summarize
conclusions as to the facility's status.
57) Review and discuss any unresolved issues
with appropriate facility personnel. Note
explanations and the disposition of issues
in working papers.
58) Develop a written list of exceptions and
observations. Discuss this list at a team
meeting prior to the exit conference to
substantiate the results or identify
overall patterns or trends.
XI-19
RADIOACTIVE MATERIALS MANAGEMENT
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-------
SAFETY PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA safety audit program. It is intended to serve as a
guide for planning and conducting an evaluation of operating unit-level safety management
systems and internal controls. The protocol may require additions or revisions to meet the
needs of specific operating unit assessments. The purpose of assessing EPA facility safety
management programs is to confirm that appropriate systems are in place and functioning
effectively to achieve and sustain compliance with applicable safety regulations and to
minimize EPA's risks.
Applicable Laws, Regulations, Policies, and Recommended Practices
The Williams-Steiger Occupational Safety and Health Act of 1970 was enacted to ensure that
employees are provided with a place of employment that is free from recognized hazards that
are likely to cause physical harm. Pursuant to the Act, the Occupational Safety and Health
Administration codified safety regulations within 29 CFR 1910 - Occupational Safety and
Health Standards. Title 29 CFR 1910 establishes safety standards for general industry —
specifically, in the areas of walking and working surfaces, hazardous materials, process
safety, environmental controls, machine guarding, and electrical safety.
The EPA Facilities Safety Manual (FSM), 4870 (Draft, September 30, 1991), establishes the
Agency's safety requirements in the areas of ventilation, mechanical systems, electrical
systems, and building construction and arrangement.
Applicable safety aspects of the EPA Region 4 Child Care Center Health Policy and the State
of Rhode Island Day Care Center and Day Nurseries Standard for Licensure were referenced as
recommended practices for child care center programs.
SECTION XII - SAFETY
-------
SAFETY PROTOCOL
Table of Contents
Section
A. Introduction
B. Walking-Working Surfaces
C. Laboratory Fume Hoods and Local Exhaust Systems
D. Hazardous Materials
E. General Environmental Controls
F. Material Handling and Storage
G. Machinery and Machine Guarding
H. Welding, Cutting and Brazing
I. Electrical
J. Indoor Air Quality
K. Child Care Centers
L. Evaluation of Findings
Page Number
XII-1
XII-2
XII-4
XII-6
XII-28
XII-50
XII-52
XII-55
XII-56
XII-62
XII-66
XII-71
Attachment A - Appendix A to 29 CFR 1910.119 — List of Highly Hazardous
Chemicals, Toxics and Reactives A-2
Attachment B - Electrical Equipment Working Clearance
B-l
SPPTTON XTT — SAFETY
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PROTOCOL
RESPONSE
COMMENTS
XII. SAFETY MANAGEMENT
A. Int roduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/
operations
c) Previous safety audit reports
or reports on inspections of
the facility
2) Review the following background
information related to safety
management programs and activities
prior to the on-site visit (If it is
not available prior to conducting
the field work, review the
information as early in the field
visit as possible):
a) EPA and facility-specific
safety directives and orders
b) EPA and facility-specific
safety operating manuals and
procedures
c) Organizational charts and
staffing tables
XII-1
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
d) Training and employee
orientation documents
e) Applicable regulatory
requirements
f) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
In .formation Gathering and Finding
Development
5) Using the safety management audit
protocol, perform the review of the
facility for compliance with
applicable policies, regulations and
recommended professional practices.
B. Walking-Working Surfaces
Using information gained from the facility and
the facility tour, verify that walking-working
surfaces in the facility meet applicable safety
standards by completing the following
investigations.
XI1-2
SAFF.TY
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PROTOCOL
RESPONSE
COMMENTS
General Requirements
6) Verify that all places of
employment, such as passageways,
storerooms, and service rooms, are
clean and maintained in a sanitary
condition [29 CFR 1910.22 (a) (1)].
7) Verify that aisles and passageways
are kept clear and in good repair,
with no obstruction across or in
aisles that could create a hazard
[29 CFR 1910.22(b)(1)].
8) Verify that permanent aisles and
passageways are appropriately marked
[29 CFR 1910.22(b)(2)].
9) Verify that ladders are maintained
in a reliable condition [29 CFR
1910.25(b)(1) and .26(c)(2)(iv)].
10) Verify that floor load capacities
are approved by the building
official. Note whether the building
owner has marked load capacities on
plates of approved design and
securely affixed them in a
conspicuous location in each space
to which they relate. Typically,
this relates to spaces used for
mercantile, storage or industrial
purposes, such as print shops,
computer rooms, etc. [29 CFR
1910.22(d)(1)].
Guarding Floor and Wall Openings and Holes
11) Verify that stairway floor openings
are guarded by standard railings on
all exposed sides (top and
intermediate rails; railing height
of 42 inches is standard)
[29 CFR 1910.23(a)(1)].
XII-3
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
12) Determine whether all floor openings
into which persons may accidentally
walk are guarded by either standard
railings with toeboards or floor
hole covers of appropriate strength
and construction [29 CFR 1910.23(a)
(8) (i) and (ii) ] .
13) Determine whether floor holes into
which persons can not accidentally
walk are protected by a cover that
has openings not more than one inch
in width [29 CFR 1910 .23 (a) (9)].
14) Verify that flights of stairs with
four or more risers are equipped
with standard stair railings or
handrails [29 CFR 1910.23(d)(1)].
15) Verify that a standard toe rail is
installed for railings provided for
an open-sided floor or a platform
four feet or more above the adjacent
floor, if the open side is above an
area where:
a) A person can pass
b) There is moving machinery
c) Falling materials could create
a hazard
[29 CFR 1910.23 (c)(l) and (e)(3)].
C. Laboratory Fume Hoods and Local Exhaust
Systems
Determine whether the facility uses fume hoods
or local exhaust systems to control occupational
exposure to toxic substances. If so, verify the
effectiveness facility's engineering controls
management program by conducting the following
procedures .
XH-4
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PROTOCOL
RESPONSE
COMMENTS
16) Verify that laboratories are
provided with one-pass air and
maintained at negative pressure
relative to surrounding areas [EPA
FSM, 4870 FS 1-07 (10)] .
17) Verify through a documentation
review that fume hoods are certified
annually. Certification requires an
average face velocity of 100 to 120
feet per minute (FPM) [EPA FSM, 4870
FS 1-05(13)] .
18) Confirm through a documentation
review that new hoods or hoods that
have undergone significant
maintenance are performance tested
prior to use [EPA FSM, 4870 FS 1-
05(13)]
19) Confirm that air movement (from
make-up systems) at the face of the
hood does not exceed 25 FPM. (Note:
Measurements should be performed
with the hood exhaust in the off
position) [EPA FSM, 4870 FS 1-05
(13)] .
20) Determine that individual exhaust
systems are provided for each fume
hood. (Note: Combining exhaust
systems for fume hoods in the same
laboratory room may be considered if
operators are aware of other fume
hood operations) [EPA FSM, 4870 FS
1-05(13)] .
21) Determine that an audible and visual
alarm system is provided to verify
the operation of hood exhaust fans
[EPA FSM, 4870 FS 1-05(13)].
XI1-5
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
22) Verify that perchloric acid hood
systems (hoods, ducts and fans) are
posted with a service risk,
constructed with non-reactive, acid
resistant materials, and provided
with a wash down system. (Note:
Perchloric acid should only be used
in perchloric acid hoods.) [EPA
FSM, 4870 FS 1-05(13)].
23) Verify that hood exhaust stacks
extend no less than seven feet above
the roof [EPA FSM, 4870 FS 1-05
(13) ] .
24) Verify that noise exposure at the
working position of the hood does
not exceed 70 dba [EPA FSM, 4870 FS
1-05(13)].
25) Verify that analytical instruments
that produce toxic vapors or
aerosols are provided with local
exhaust or placed within a hood [EPA
Occupational Health and Safety
Manual, 1440, Chapter 8(3)(b)(4)].
D. Hazardous Materials
Evaluate the facility's program for managing
hazardous materials by completing the following
procedures. (Note: Additional requirements for
managing hazardous materials are outlined in the
Fire and Life Safety Protocol.)
Compressed Gas Cylinders
26) By reviewing facility records and
interviewing facility personnel,
determine whether visual safety
inspections of gas cylinders are
conducted [29 CFR 1910 .101(a)] .
xn-6
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PROTOCOL
RESPONSE
COMMENTS
27) Verify that high pressure cylinder
supply lines are securely anchored
every five feet [EPA FSM, 4870-1 FS
1-07(6)].
28) Verify that flasks of cryogenic
materials (- 100°F) are not stored
in places of routine access by non-
involved personnel (e.g. corridor)
[EPA FSM, 4870-1 FS 1-07(6)].
29) Verify that the number of flammable
gas and oxygen cylinders does not
exceed six in a sprinklered
laboratory and three in a non-
sprinklered laboratory [EPA FSM,
4870 FS 1-07(6)].
30) Verify that gas cylinders are
legibly marked identifying the gas
content [29 CFR 1910 .101 (a)].
31) Confirm that cylinders are securely
supported in an upright position via
a chain, nylon strap or metal
channel. (Note: Gang chaining is
prohibited in laboratory areas)
[EPA FSM, 4870 FS1-07(6)].
32) Verify that cylinders are not used
as rollers, supports, or for any
purpose other than to contain
content [29 CFR 1910.10Kb)].
33) Confirm that cylinder valves are
closed except when the cylinder is
in use [29 CFR 1910.101(b)].
34) Inspect areas where gases of
different types are stored, to
verify that cylinders are grouped by
type of gas. (Note: Full and empty
cylinders should be stored
separately) [29 CFR 1910 .101(b)] .
XII-7
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
35) Verify that cylinders stored inside
a building are not located near
exits, stairways, or in areas
intended for the safe exit of
personnel [29 CFR 1910.101(b)].
36) Confirm that removable caps are
maintained in place until the
cylinder valve is connected to
equipment [29 CFR 1910.101(b)].
37) Verify that a pressure regulator and
pressure relief device are used
where gas is admitted to a system of
lower pressure rating than the
supply pressure. [29 CFR 1910.101
(b)] .
38) Confirm that gas cylinders are not
located where they may become part
of an electric circuit [29 CFR
1910.10Kb) ] .
Process Safety Management of Highly
Hazardous Chemicals
39) Determine through facility tours and
a review of operating records
whether the facility conducts
processes which involve a chemical
equal to or exceeding the OSHA
threshold quantity or a process that
involves a flammable liquid or gas
in one location in a quantity of
10,000 pounds or more. The OSHA
list of toxic and highly hazardous
chemicals is provided in Attachment
A. (Note: The following are
exceptions to this requirement:
a) Normally unoccupied remote
facilities
XII-8
CAB-P.TV
-------
PROTOCOL
RESPONSE
COMMENTS
b) Hydrocarbon fuels used solely
for workplace consumption as a
fuel, if these fuels are not
part of a process containing
another highly hazardous
chemical covered by the
Process Safety Management of
Highly Hazardous Chemicals
Standard
c) Flammable liquids stored in
atmospheric tanks or
transferred which are
maintained below the normal
boiling point without benefit
of chilling or refrigerating
and are not connected to a
process)
[29 CFR 1910.119(a)].
If the facility conducts a process that is
subject to the Process Safety Management
of Highly Hazardous Chemicals Standard,
complete the applicable portions of the
protocol, steps 40 through 94. If not,
proceed to step number 95 of this
protocol.
40) Verify that the facility has
established a written program
regarding employee participation in
process safety management. The
program should include:
a) Consultation with employees on
the conduct and development of
process hazard analyses and on
the development of additional
elements of process safety
management
XII-9
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
b) Employee access to process
hazard analyses and all
additional relevant
information
[29 CFR 1910.119(c)].
41) Confirm that written process safety
information has been compiled before
conducting a process hazard
analysis. The process safety
information should include:
a) Hazards of the highly
hazardous chemicals employed
in the process:
Toxicity information
Permissible exposure
limit
Physical, reactivity and
corrosivity data
Thermal and chemical
stability data
Hazardous effects of the
inadvertent mixing of
material that could
foreseeably occur.
(Note: Material Safety Data Sheets
(MSDSs) may be used to the extent
they contain the required
information.)
b) Technology of the process:
Block flow diagram or
simplified process flow
diagram
XII-10
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PROTOCOL
RESPONSE
COMMENTS
Process chemistry
Maximum intended
inventory
Safe maximum and minimum
limits (e.g.,
temperatures, pressures,
flows or compositions)
Evaluation of the
consequences of
deviation.
(Note: Where the original technical
information no longer exists, the
information may be developed in
conjunction with the process hazard
analysis.)
c) Equipment in the process:
Materials of
construction
Piping and
instrumentation diagrams
(P&IDs)
Electrical
classification
Relief system design and
design basis
Ventilation system
design
Design codes and
standards employed
XII-11
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
Material and energy
balances for processes
constructed after
May 26, 1992
Safety systems (e.g.,
interlocks, detection or
suppression systems)
[29 CFR 1910.1l9(d)(1), (2), and
(3)] .
42) Determine whether the facility
documents that the process equipment
complies with recognized and
generally accepted good engineering
practices [29 CFR 1910.119
(d) (3) (ii)] .
43) Verify that the facility documents
that existing equipment designed and
constructed in accordance with
codes, standards or practices that
are no longer in general use, is
designed, maintained, inspected,
tested and operated in a safe manner
[29 CFR 1910.119(d) (3) (iii)] .
44) Confirm that the facility has
documented the priority for
performing initial process hazard
analysis based on a rationale that
includes:
a) Extent of process hazards
b) Number of potentially affected
employees
c) Age of process
d) Operating history of process
[29 CFR 1910.119(e)(1)].
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45)
46)
47)
Evaluate through a review of
facility operating records whether
the initial process hazard analysis
is conducted as soon as possible [29
CFR 1910.119(6) (1)] .
Review the priority schedule for the
process hazard analysis to verify
that the initial hazard analysis
will be completed by May 26, 1997,
and that:
a)
b)
c)
No less that 25 percent of the
initial process hazard
analyses are completed by
May 26, 1994
No less than 50 percent of the
initial process hazard
analyses are completed by
May 26, 1995
No less than 75 percent of the
initial process hazard
analyses are completed by
May 26, 1996.
(Note: Process hazard analyses
completed after May 26, 1987, are
acceptable as initial process hazard
analysis, however, they should be
updated and revalidated no less than
every five years by a team with
expertise in engineering and process
operations.)
[29 CFR 1910.119(6) (1)]
Confirm that the hazard evaluation
employs no less than one of the
following process hazard
methodologies:
a)
What-if
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b) Checklist
c) What-if/checklist
d) Hazard and operability study
e) Failure mode and effects
analysis
f) Fault tree analyses
g) Other appropriate methodology
[29 CFR 1910.119(e) (2)] .
48) Determine whether the process hazard
analysis addresses:
a) Process hazards
b) Previous incidents with likely
potential for catastrophic
consequences
c) Engineering and administrative
controls applicable to the
hazards and their
interrelationships (e.g.,
detection methodologies,
inventory reduction,
substitution of less hazardous
substances)
d) Consequences of failure of
engineering and administrative
controls
e) Facility siting
f) Human factors
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g) Qualitative evaluation of the
possible safety and health
effects on employees from
failure of controls
[29 CFR 1910.119(e) (3)] .
49) Verify that the process hazard
analyses are performed by teams with
expertise in engineering and process
operations, including no less than
one employee with experience and
knowledge specific to the process
being evaluated and one member
knowledgeable in the specific
process hazard analyses methodology
employed [29 CFR 1910.119 (e) (4)] .
50) Review a representative sample of
process safety documentation to
verify that the facility has
established a system to promptly
address the team's findings and
recommendations. The system should:
a) Resolve and document
recommendations in a timely
manner
b) Document actions to be taken
c) Complete actions as soon as
possible
d) Develop a written schedule of
when actions are to be
completed
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e) Communicate the actions to
employees whose work
assignments are in the process
and may be affected by the
recommendations or actions
[29 CFR 1910.119(e)(5)].
51) Verify that the process hazard
analyses are updated and revalidated
no less than every five years by a
qualified team (expertise in
engineering, process operations, and
process hazard analysis methodology)
[29 CFR 1910.119(e)(6)].
52) Determine whether initial process
hazard analyses, updates or
revalidations, and documented
resolutions of recommendations are
maintained for the life of the
process [29 CFR 1910.119(e)(7)].
53) By observing a representative
number of processes, verify that
written standard operating
procedures are established with the
following operating phase elements:
a) Initial startup
b) Normal operations
c) Temporary operations
d) Emergency shutdown including
conditions requiring shutdown
and assignment of shutdown
responsibility to qualified
operators
e) Emergency operations
f) Normal shutdown
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g) Startup following a turnaround
or emergency shutdown
[29 CFR 1910.119(f)(1)(i)].
54) Confirm that operating procedures
include operating limits that
outline consequences of process
deviation and steps required to
correct or avoid deviations [29 CFR
1910.119(f) (1) (ii)] .
55) Determine whether the following
safety and health considerations are
included in the operating
procedures:
a) Chemical properties and
hazards
b) Precautions to prevent
exposure
c) Control measures if physical
contact or airborne exposure
occurs
d) Quality control for raw
material and control of
hazardous chemical inventory
levels
e) Special or unique hazards
[29 CFR 1910.119(f) (1) (iii)] .
56) Confirm whether safety systems and
their functions are included in the
operating procedures [29 CFR
1910.119(f) (D (iv)] .
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57) Verify that operating procedures are
readily accessible to employees who
work in or maintain a process [29
CFR 1910.119 (f) (2)] .
58) Determine whether operating
procedures are reviewed and
certified annually to ensure they
reflect current operating practice
[29 CFR 1910.119(f)(3)].
59) Verify that safe work practices have
been established for employees and
contractors to control hazards
during the following operations:
a) Lockout/tagout
b) Confined space entry
c) Opening process equipment or
piping
d) Control over entrance into a
facility by maintenance,
contractor, laboratory or
support personnel
[29 CFR 1910.119(f)(4)].
60) Confirm that employees presently
involved in operating a process and
each employee before being involved
in a newly assigned process receive
training that includes review of the
process and the operating procedures
including:
a) Safety and health
considerations
b) Steps for each operating phase
c) Operating limits
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d) Safety systems and their
functions.
(Note: In lieu of initial training
for employees involved in operating
a process on May 26, 1992, the
facility may certify that the
employee has the required knowledge,
skills and abilities to safely
perform the duties and
responsibilities specified in the
operating procedures.) [29 CFR
1910.119(g) (1)] .
61) Determine through a review of
facility records whether the
facility has consulted with
employees involved in operating the
process to determine the appropriate
frequency of refresher training.
(Note: .Refresher training should be
provided no less than every three
years.) [29 CFR 1910.119 (g) (2)] .
62) Verify that the facility maintains
training documentation that contains
the identity of the employee, date
of training, and the means used to
verify that the employee understood
the training [29 CFR 1910.119(g)
(3)] .
63) Confirm that the safety process
management program includes
contractors performing maintenance
or repair, major renovation or
specialty work on or adjacent to
covered processes [29 CFR
1910.119(h) (1)] .
64) Verify that the facility evaluates
information regarding each potential
contract employer's safety
performance and programs prior to
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selecting a contractor [29 CFR
1910.119(h)(2)].
65) Determine whether the facility
informs contractor employees of the
known potential fire, explosion or
toxic release hazards related to the
contractor's work and the process.
Verify that contractor employees are
informed of the applicable portions
of the emergency action plan [29 CFR
1910.119(h) (2) (ii) and (iii)] .
66) Confirm that safe work practices
have been established to control the
entrance, presence and exit of
contractor employees in covered
process areas [29 CFR 1910.119(h)(2)
(iv)] .
67) Verify that the facility
periodically evaluates the
performance of contract employers in
fulfilling their obligations to:
a) Train contractor employees in
safe work practices required
to perform the assignment
b) Instruct contractor employees
in the known potential fire,
explosion, or toxic release
hazards related to the
assignment and the applicable
provisions of the emergency
action plan
c) Document the required training
and the means to verify their
employees have understood the
training
d) Follow the facility safety
rules and work practices
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e) Advise the facility of unique
hazards presented by the
contractor's work
[29 CFR 1910.119(h)(2)(v)].
68) Determine whether the facility
maintains a contractor employee
injury and illness log related to
the contractor's work in process
areas [29 CFR 1910.119(h)(2)(vi)].
69) Confirm whether a pre-startup safety
review is performed for all new
facilities (buildings, containers or
equipment which contain a process)
and for modified facilities when the
modification is sufficient to
require a change in process safety
information [29 CFR 1910 .119 (i) (1)].
70) Verify that pre-startup reviews
confirm that prior to the
introduction of highly hazardous
chemicals to a process:
a) Construction and equipment are
in accordance with design
specifications
b) Safety, operating, maintenance
and emergency procedures are
in place and adequate
c) For new facilities, a process
hazard analysis has been
performed and recommendations
resolved or implemented before
startup
d) For modified facilities,
verify that steps 84 through
86 of the protocol are
implemented
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SAFFTY
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71)
72)
e) Training of employees involved
in operating the process has
been completed
[29 CFR 1910.119 (i) (2)] .
(Note; Protocol steps 71 through 76
apply to the following process
equipment:
a) Pressure vessels and storage
tanks
b) Piping systems (including
piping components such as
valves)
c) Relief and vent systems and
devices
d) Controls (including monitoring
devices and sensors, alarms
and interlock devices)
e) Pumps
[29 CFR 1910.119(j) (1) ] .
Determine whether the facility
establishes and implements written
procedures to maintain the integrity
of process equipment [29 CFR
1910.119( j) (2)] .
Confirm that training is provided to
each employee involved in
maintaining the integrity of process
equipment. The training should
include:
a)
Overview of the process
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RESPONSE
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b) Procedures applicable to
safely performing job task
[29 CFR 1910.119(j) (3)] .
73) Verify that inspections and tests
that follow good engineering
practices are performed on process
equipment [29 CFR 1910.119(j)(4)(i)
and (ii) ] .
74) Confirm that inspection and test
frequency is consistent with
manufacturer recommendation and good
engineering practice [29 CFR
1910.119(j) (4) (iii)] .
75) Verify that the facility documents
inspections and tests.
Documentation should include:
a) Inspection or test date
b) Name of person who performed
the inspection or test
c) Serial number or other
identifier of the equipment
inspected or tested
d) Description of inspection or
test performed
e) Results
[29 CFR 1910.119(j)(4)(iv)].
76) Determine in the construction of new
plants and equipment whether:
a) Equipment as it is fabricated
is suitable for the
anticipated process
application
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SAFETY
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RESPONSE
COMMENTS
b) Appropriate checks and
inspections are performed to
ensure that the equipment is
installed properly and
consistent with design
specifications and
manufacturer instructions
c) Maintenance materials are
appropriate for the process
application
[29 CFR 1910.119(j)(6)].
77) Verify that hot work permits are
issued for hot work operations
conducted on or near a covered
process. The hot work permit should
be filed until hot work operations
are complete and include:
a) Authorized date(s)
b) Identity of the object on
which hot work is performed
[29 CFR 1910.119(k) (1)] .
78) Confirm that the hot work permit
identifies openings, cracks and
holes where sparks may drop to
combustible material [29 CFR
1910.252(a) (2) (i)]
79) Determine whether the hot work
permit identifies fire extinguishers
and assigns fire watchers where
welding is performed in locations
where other then a minor fire may
develop [29 CFR 1910 .252 (a) (2) (ii)
and (iii)] .
XII-24
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PROTOCOL
RESPONSE
COMMENTS
80) Verify that the hot work permit is
authorized by the person responsible
for welding and cutting operations
after conducting a site inspection
and designating appropriate
precautions [29 CFR 1910.252(a)(iv)
and (xiii)].
81) Confirm that the hot work permit
describes precautions associated
with combustible materials on
floors, walls, partitions, ceilings
or roofs of combustible construction
[29 CFR 1910.252(a) (v) and (ix)] .
82) Determine whether the facility has
designated the person responsible
for authorizing cutting and welding
operations and established areas and
procedures for safe welding and
cutting [29 CFR 1910.252 (a) (xiii) (A)
and (B)].
83) Verify that the facility ensures
that welders, cutters and
supervisors are trained in the safe
operation of their equipment [29 CFR
1910.252(a) (xiii) (C)] .
84) Confirm that the facility
establishes and implements written
procedures for managing changes
(except for replacements in kind) to
process chemicals, technology,
equipment, and containers and
buildings that affect a covered
process. The procedures should
address:
a) Technical basis for the
proposed change
b) Impact on safety and health
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COMMENTS
c) Modifications to operating
procedures
d) Time period for the change
e) Authorization requirements for
the proposed change
[29 CFR 1910.119(1)(2)].
85) Verify that employees and contractor
employees are trained in the change
prior to startup of process
[29 CFR 1910.119(1) (3)] .
86) Confirm that process safety
information and operating procedures
or practices are revised if modified
[29 CFR 1910.119(1) (4) and (5)].
87) Verify that incidents which resulted
in or could have reasonably resulted
in a catastrophic release of highly
hazardous chemicals are investigated
no less than 48 hours after the
incident [29 CFR 1910.119(m)(1) and
(2)] .
88) Determine whether an incident
investigation team consisting of no
less than one person knowledgeable
in the process involved and other
members with appropriate knowledge
and experience to thoroughly
investigate the incident is
established [29 CFR 1910.119(m)(3)].
89) Confirm that incident investigation
reports containing the following
information are prepared at the
conclusion of the investigation:
a)
Incident date
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PROTOCOL
RESPONSE
COMMENTS
b) Commencement date of
investigation
c) Contributing factors
d) Recommendations
(Note: Incident investigation
reports should be retained for no
less than five years.) [29 CFR
1910.119(m)(4) and (7)]
90) Verify that a system has been
established to promptly address and
resolve the incident investigation
report findings and recommendations.
(Note: Resolution and corrective
actions should be documented.) [29
CFR 1910.119(m)(5)]
91) Confirm that the incident
investigation report is reviewed
with all personnel whose job tasks
are relevant to the incident
findings [29 CFR 1910.119(m)(6)].
92) Verify that the facility has
established and implemented an
emergency action plan. (Note: The
emergency action plan should include
procedures for handling small
releases.) [29 CFR 1910.119(n)]
93) Confirm that the facility certifies
that there has been a process safety
management compliance audit no less
than every three years. (Note: The
two most recent compliance audits
should be retained.) [29 CFR
1910.119(0)(1) and (5)].
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COMMENTS
94) Verify that the compliance audit is
conducted by a person knowledgeable
in the process; findings report is
developed; and documentation of
corrective actions is maintained [29
CFR 1910.119(0)(2),(3) and (4)].
E. General Environmental Controls
Using information gained from the facility and
the facility tour, evaluate the effectiveness of
the facility's environmental controls by
completing the following procedures.
Sanitation
95) Verify that all areas of the
facility are kept clean [29 CFR
1910.141 (a) (3)] .
96) Confirm that receptacles used for
solid or liquid waste are
constructed to ensure the receptacle
does not leak and may be thoroughly
cleaned and maintained in a sanitary
condition [29 CFR 1910 .141(a) (4) ].
97) Verify that an enclosed workplace is
constructed, equipped, and
maintained to prevent the entrance
or harborage of rodents, insects and
other vermin [29 CFR 1910.141
(a) (5) ] .
98) Confirm that potable water is
provided in places of employment [29
CFR 1910.141(b) (1)] .
99) Verify that toilet facilities are
provided in places of employment [29
CFR 1910.141(c) (1)] .
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RESPONSE
COMMENTS
100) Verify that washing facilities are
maintained in a sanitary condition
[29 CFR 1910.141(d)(1)].
101) Verify that there is no consumption
of food or beverages, smoking,
chewing gum or tobacco, application
of cosmetics or storage of utensils,
food or food containers in any
laboratory area [EPA Occupational
Health and Safety Manual, 1440,
Chapter 8] .
Permit-Required Confined Spaces
102) Determine whether the facility has
been evaluated for permit-required
confined spaces. A permit-required
confined space has one or more of
the following characteristics:
a) Contains or has the potential
to contain a hazardous
atmosphere.
b) Contains material that is
capable of engulfment.
c) Has an internal configuration
such that an entrant could be
trapped or asphyxiated by
inwardly converging walls or
by a floor which slopes
downward and tapers to a
smaller cross-section.
d) Contains other serious safety
or health hazards.
[29 CFR 1910.146 (c)(1)]
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SAFETY
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RESPONSE
COMMENTS
If the facility contains a permit-
required confined space, complete
applicable portions of the protocol,
steps 103 through 123. If not,
proceed to step number 124 of this
protocol.
103) Verify that facilities containing
permit-required confined space
inform exposed employees of the
existence, location, and danger
posed by the permit-required
confined spaces by posting danger
signs or other equally effective
means. [29 CFR 1910.146 (c) (2) ] .
104) Determine whether the facility has
decided that its employees will not
enter permit-required confined
spaces; if so, verify that effective
measures have been taken to prevent
employees from entering these
spaces. (Note: For facilities that
do not permit employees to enter
permit-required confined spaces,
complete applicable portions of the
protocol, steps 107 and 109. If
employees are permitted to enter
permit spaces, proceed to step
number 105 of this protocol.) [29
CFR 1910.146 (c)(3)].
105) Determine that facilities permitting
employees to enter permit-required
confined spaces have established a
written permit space entry program.
[29 CFR 1910.146 (c)(4)].
106) Through a review of operating
procedures, evaluate whether the
facility satisfies the following
conditions before entering a
permitted confined space:
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PROTOCOL
RESPONSE
COMMENTS
a) The entrance cover is safely
removed
b) The opening (entrance) is
promptly guarded by a railing,
temporary cover, or other
temporary barrier that will
prevent personnel and foreign
objects from accidentally
falling through the opening
c) The initial atmosphere is
tested before entry with a
calibrated direct-reading
instrument for the following
conditions in the order
provided:
Oxygen content
Flammable gases and
vapors
Potential toxic air
contaminant s
d) A hazardous atmosphere does
not exist within the space
when employees are inside
e) Continuous forced air
ventilation may be used as
follows:
Personnel may not enter
the space until forced
air ventilation has
eliminated the hazardous
atmosphere.
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SAFETY
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COMMENTS
Forced air ventilation
is directed to ventilate
the employees' immediate
areas and continues
until all employees have
vacated the space.
Air supply for the
forced air ventilation
is from a clean source.
f) The permitted confined space's
atmosphere is periodically
tested to ensure that the
forced air ventilation
prevents a hazardous
atmosphere.
g) If a hazardous atmosphere is
detected during entry:
Personnel immediately
vacate the space.
The space is evaluated
to determine how the
hazards developed.
Measures are implemented
before a subsequent
entry to protect
employees from the
hazardous atmosphere.
h) A written certification is
developed before entry, that
contains preventive measures
undertaken, date, location,
and signature of the person
certifying that the space is
safe.
[29 CFR 1910.146 (c)(5)(ii)].
XII-32
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COMMENTS
(Note: Facilities that can
demonstrate through monitoring and
inspection data that the only hazard
posed by the permit-required
confined space is an actual or
potential hazardous atmosphere (that
is controlled) do not have to comply
with the requirements of: permit-
required confined space program;
permit system; entry permit; duties
of authorized entrants, attendants
and entry supervisors; and rescue
and emergency services. If the
facility contains a permit-required
confined space with hazards other
than a hazardous atmosphere, proceed
to step number 107 of the protocol.
If not, proceed to step number 122
of the protocol.) [29 CFR 1910.146
(c) (5) (i)] .
107) Determine that changes in the use or
configuration of a non-permit
confined space that may increase
hazards initiates a reevaluation
and, if necessary, reclassification
of the space to a permit-required
confined space. [29 CFR 1910.146
(0 (6)] .
108) Confirm that permit-required
confined spaces are reclassified as
non-permit confined spaces through
the following procedures:
a) Determination that the permit-
required confined space poses
no actual or potential
atmosphere hazards, and all
hazards within the space are
eliminated without entering
the space.
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b) Testing and inspection during
entry to demonstrate that the
hazards within the permit
space have been eliminated.
(Note: The control of atmospheric
hazards through forced air
ventilation does not constitute
elimination of hazards.)
c) Certification that includes
the date, location of the
space, and signature of the
individual determining that
all hazards in the permit
space have been eliminated.
d) If hazards arise within a
permit space that has been
declassified to a non-permit
space, the space is
reevaluated to determine
whether it must be
reclassified as a permit
space. [29 CFR 1910.146
(0 (7)] .
109) Confirm that when contractor
personnel perform work that involves
permit-required confined space entry
the facility:
a) Notifies the contractor of
permit-required confined
spaces and permit programs
b) Apprises the contractor of
permit-required confined space
hazards
c) Apprises the contractor of
precautions or procedures that
the facility has implemented
for the protection of
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PROTOCOL
RESPONSE
COMMENTS
employees in or near permit
spaces
d) Coordinates entry operations
with the contractor, when both
facility and contractor
personnel will be working in
or near permit spaces
e) Debriefs the contractor at the
conclusion of the operations
regarding hazards confronted
or created in the permit-
required confined space during
entry operations. [29 CFR
1910.146(c)(8)]
110) Verify that under the auspices of
the permit-required confined space
program the facility:
a) Implements measures to prevent
unauthorized entry
b) Identifies and evaluates the
hazards of permit-required
confined spaces before
employees enter
c) Establishes the procedures for
safe permit entry operations,
including:
Specifying acceptable
entry conditions
Isolating the permit
space
Purging, inerting,
flushing, or eliminating
the space to eliminate
or control atmospheric
hazards
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SAFETY
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RESPONSE
COMMENTS
Providing barriers (as
necessary) to protect
entrants from external
hazards
Providing acceptable
conditions for entry
throughout the duration
of authorized entry
d) Provides, maintains, and
ensures that employees
properly use:
Testing and monitoring
equipment
Ventilating equipment
Communication equipment
Personal protective
equipment (if
engineering and work
practice controls do not
adequately protect
personnel)
Lighting equipment
Barriers and shields
Equipment (e.g.,
ladders) for safe
ingress and egress by
authorized entrants
Rescue and emergency
equipment (if the
equipment is not
provided by rescue
services)
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RESPONSE
COMMENTS
e) Evaluates permit conditions:
Tests conditions in the
permit-required confined
space before entry to
determine if acceptable
entry conditions exist
Monitors areas where
authorized entrants are
working
f) Provides no less than one
attendant outside the permit-
required confined space for
the duration of entry
operations.
g) Includes in the permit
program, if multiple spaces
are to be monitored by a
single attendant, the
procedures to enable the
attendant to respond to an
emergency affecting one or
more of the permit-required
confined spaces being
monitored without distraction
from the attendant's
responsibilities.
h) Designates the individuals who
have active roles in entry
operations, identifies their
respective duties, and
provides employees with
appropriate training.
i) Establishes procedures for
summoning rescue and emergency
services
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RESPONSE
COMMENTS
j) Establishes a system for the
preparation, issuance, use,
and cancellation of entry
permits.
k) Establishes procedures to
coordinate entry operations
when employees from more than
one employer are
simultaneously working as
authorized entrants in a
permit-required confined
space.
1) Establishes procedures for
concluding the entry.
m) Reviews entry operations and
corrects deficiencies when
measures established under the
program do not protect
employees.
n) Reviews annually the permit-
required confined space
program (using canceled
permits) to ensure that
employees participating in the
program are properly
protected.
[29 CFR 1910.146(d)].
Ill) Verify that an entry permit is
prepared, signed by the entry
supervisor and posted before entry
begins [29 CFR 1910.146 (e)(l)].
112) Confirm that the facility retains
entry permits for no less than one
year to facilitate the review of the
permit-required space program.
(Note: Problems encountered during
an entry operation should be noted
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PROTOCOL
RESPONSE
COMMENTS
on the permit to ensure that
appropriate revisions to the permit-
required confined space program can
be made.) [29 CFR 1910.146 (e) (6) ] .
113) Verify that the entry permit
identifies:
a) Permit space to be entered
b) Purpose of entry
c) Date and authorized duration
of the entry permit
d) Authorized entrants,
attendants, and entry
supervisor's name
e) Hazards of the space and
acceptable entry conditions
f) Measures used to isolate the
space and to eliminate or
control hazards before entry
g) Results of initial and
periodic tests performed to
determine acceptable entry
conditions accompanied by
names or initials of the
tester and an indication of
when the tests were performed.
h) Rescue and emergency services
that can be summoned and the
means for summoning those
services
i) Communications procedures used
by authorized entrants and
attendants.
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j) Equipment (e.g., PPE, testing
equipment, communications
equipment, alarm systems)
k) Additional permits, such as
hot work, that have been
issued to authorize work in
the permit-required confined
space
[29 CFR 1910.146(f)].
114) Through observation and a review of
procedures, determine whether
authorized entrants:
a) Know the hazards that may be
faced during entry, including
the mode, signs or symptoms,
and consequences of exposure
b) Properly use equipment
c) Communicate with the attendant
to monitor entrant status and
to alert entrants of the need
to evacuate the space
d) Communicate with the attendant
of warning signs or symptoms
of exposure to a dangerous
situation or a prohibited
condition
e) Exit whenever: a prohibited
condition is detected; an
evacuation alarm is activated;
a warning sign or symptom of
dangerous exposure is
determined; or the entry
supervisor or attendant orders
an evacuation.
[29 CFR 1910.146(h)].
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115) Through observations and a review of
procedures, determine whether
attendants of permit-required
confined spaces:
a) Know the hazards that may be
faced during entry, including
the mode, signs or symptoms,
and consequences of exposure
b) Are aware of possible
behavioral effects of hazard
exposure
c) Maintain an accurate count and
the identity of authorized
entrants in the permit space
d) Remain outside the permit-
required confined space during
entry operations or until
relieved by another attendant
(Note: When the permit entry
program permits attendant
rescue, attendants may enter
the space, if trained and
equipped for rescue
operations, and if they are
relieved by another attendant)
e) Communicate with authorized
entrants to monitor entrant
status and to alert entrants
of the need to evacuate the
space
f) Monitor activities inside and
outside the space to determine
if it is safe for entrants to
remain in the space
g) Order authorized entrants to
evacuate the space whenever:
a prohibited condition is
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detected; behavior effects of
hazard exposure are detected
in authorized entrants; a
dangerous situation exists
outside the space; or the
assigned duties of the
attendant can not be safely
performed
h) Summon rescue and emergency
services when entrants may
need assistance to escape from
permit space hazards
i) Prohibit unauthorized
personnel from entering the
space
j) Perform non-entry procedures
that are specified in
facility's rescue plan
k) Perform no duties that may
interfere with their primary
duty to monitor and protect
authorized entrants
[29 CFR 1910.146(1)].
116) Through observations and a review of
procedures, determine whether the
entry supervisor:
a) Knows the hazards that may be
faced during entry, including
the mode, signs or symptoms,
and consequences of exposure
b) Verifies that all tests
specified by the permit have
been conducted and that all
procedures and equipment
specified by the permit are in
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place before endorsing the
permit
c) Terminates the entry and
cancels the permit when entry
operations are complete or a
condition not permitted under
the permit occurs in or near
the permit-required confined
space
d) Verifies that rescue services
are available and the means
for summoning them are
operable
e) Removes unauthorized
individuals who enter or
attempt to enter the permit-
required confined space during
entry operations
f) Determines that entry
operations remain consistent
with the terms of the entry
permit and that acceptable
entry conditions are
maintained.
[29 CFR 1910.146(j)]
117) Confirm that facilities who have
employees perform rescue services:
a) Train each member of the
rescue service to properly use
personal protection and rescue
equipment
b) Train each member of the
rescue service to perform
assigned rescue duties.
(Note: Each member of the
rescue service also should be
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trained as authorized
entrants.)
c) Practice with representative
permit-required confined
spaces no less than annually
d) Train each member of the
rescue service in first aid
and in cardiopulmonary
resuscitation
[29 CFR 1910.146(k)(1)].
118) Confirm that facilities who arrange
to have non-facility personnel
perform permit-required confined
space rescue:
a) Notify the rescue service of
the potential permit-required
confined space hazards
b) Provide the rescue service
with access to all permit-
required confined spaces to
develop rescue plans and
practice rescue procedures
[29 CFR 1910.146(k)(2)].
119) Evaluate whether retrieval systems
are used to facilitate non-entry
rescue. (Note: Retrieval equipment
should not be used if it increases
the overall risk of entry or does
not contribute to the rescue of the
entrant.) [29 CFR 1910.146 (k) (3)] .
120) Verify that retrieval systems
furnish each authorized entrant with
a chest or full body harness that
has the retrieval line attached at
the center of the entrant's back
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near shoulder level or above the
entrant's head. (Note: Wristlets
may be employed in lieu of the chest
or full body harness if the facility
can demonstrate that the use of a
chest or full body harness is not
feasible or creates a greater
hazard.) [29 CFR 1910 .146(k) (3)
(i)] •
121) Confirm that the other end of the
retrieval line is attached to a •
mechanical device or fixed point
outside the permit-required confined
space. (Note: Mechanical devices
should be available for vertical
permit-required confined spaces
greater than five feet deep.) [29
CFR 1910.146(k)(3)(ii)].
122) Verify that the facility provides
employees working with permit-
required confined spaces the
understanding, knowledge, and skills
for safe performance of assigned
duties, and that training is
provided:
a) Before the employee's first
assigned duties or if there is
a change in assigned duties or
hazards
b) Whenever there are deviations
from the permit-required
confined space entry
procedures or the employee is
lacking knowledge of the
procedures
[29 CFR 1910.146(g) (1) and (2)].
123) Verify that the facility certifies
the training received by employees.
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(Note: The certification should
include the employee's name,
signature, or initials of trainers,
and the date of training.) [29 CFR
1910.146(g) (4)] .
Accidental Prevention Signs and Tags
124) Confirm that caution signs are used
to warn against potential hazards or
to caution against unsafe practices
[29 CFR 1910.145(c) (2)]
125) Verify that safety instruction signs
are used where there is a need for
general instructions and suggestions
relative to safety measures [29 CFR
1910.145(c) (3)] .
126) Confirm that danger tags are used in
hazard situations where the
immediate hazard presents a threat
of death or serious injury to
personnel [29 CFR 1910 .145 (f) (5)].
127) Verify that caution tags are used in
minor hazard situations where non-
immediate, potential hazard or
unsafe practice presents a lesser
threat of personnel injury. (Note:
Warning tags may be used to
represent a hazard between caution
and danger.) [29 CFR 1910.145(f)
(6) ] .
128) Confirm that biological hazard tags
are used to identify actual or
potential biological hazards [29 CFR
1910.145 (f) (8)] .
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Control of Hazardous Energy
129) Verify that the facility has a
program for managing employee
maintenance of equipment that is
capable of unexpected energization.
Program elements should include
energy control procedures, employee
training, and inspections. [29 CFR
1910.147 (c) (1)] .
130) Confirm that procedures have been
developed, documented and used for
the control of hazardous energy [29
CFR 1910 .147 (c) (4) (i)] .
Exception: Where all of the
following elements exist for a
machine or equipment item the
facility need not document the
energy control procedure:
a) Equipment has no potential for
stored, residual or
reaccumulation of stored
energy after shutdown which
could endanger personnel
b) Equipment has a single energy
source which can be readily
identified and isolated
c) Isolation and locking out of
the energy source will
completely deenergize and
deactivate the equipment
d) Equipment is isolated from the
energy source and locked-out
during maintenance
e) Locked-out condition will be
achieved with a single lock-
out device
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f) Lock-out device is under the
control of the authorized
employee performing
maintenance
g) Maintenance does not create a
hazard for other personnel
h) No accidents involving the
unexpected activation or
energization of the equipment
have occurred
[29 CFR 1910.147(c) (4) (i) ]
131) Verify that energy control
procedures outline the scope,
purpose, authorization, rules and
techniques to be used for the
control of hazardous energy, and the
means to enforce compliance [29 CFR
1910.147(c) (4) (ii)] .
132) Confirm that lock-out and tag-out
devices are singularly identified
and not used for purposes other than
controlling energy [29 CFR 1910.147
(c) (5) (ii) ] .
133) Verify that lock-out and tag-out
devices are capable of withstanding
the environment to which they are
exposed for the maximum period of
time that exposure is expected [29
CFR 1910.147 (c) (5) (ii) (A) ] .
134) Verify through facility records and
interviews with facility personnel
that annual inspections of the
energy control procedure are
conducted [29 CFR 1910 .147 (c) (6)
(i)] .
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135) Confirm certification and employee
training. Training should address
the noted elements for each type of
employee:
a) Authorized Personnel
(personnel who lock out or tag
out equipment) - Hazardous
energy sources available at
the facility and the methods
for energy isolation and
control
b) Affected Personnel (personnel
who operate equipment on which
maintenance is performed) -
Purpose and use of the energy
control procedure
c) Other Employees Who Work in
the Area Where Energy Control
Procedures May be Used -
Prohibition procedures
relating to reenergize locked-
out or tagged-out equipment
[29 CFR 1910.147 (c) (7) (iv)] .
136) Verify that retraining is provided
for authorized or affected personnel
whenever there is a change in
assignment, equipment, processes
present a new hazard, or the energy
control procedures change [29 CFR
1910.147 (c) (7) (iii) (A) ] .
137) Confirm that lock-out or tag-out
procedures are only performed by
authorized personnel who are
performing the maintenance [29 CFR
1910.147 (c) (8)] .
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F. Material Handling and Storage
Using information gained from the facility and
the facility tour, evaluate the effectiveness of
the facility's material handling and storage
program by completing the following
investigation.
138) Verify that material storage does
create a hazard (e.g. limited in
height and stable) [29 CFR
1910.176(b)].
139) Verify that storage areas are free
from tripping, fire, explosion or
pest hazards [29 CFR 1910 .176 (c)].
140) Confirm that clearance limit signs
are provided [29 CFR 1910.176(e)].
Powered Industrial Trucks
141) Verify that facilities for battery
charging include spill control, fire
protection, ventilation and
protection from physical damage [29
CFR 1910.178(g) (2)] .
142) Confirm that a conveyor, overhead
hoist or equivalent material
handling equipment is provided for
handling batteries [29 CFR
1910.178(g)(4)].
143) Confirm through selected employee
interviews and facility records that
only trained authorized operators
are permitted to operate powered
industrial trucks [29 CFR 1910.178
(1)] -
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144) Verify that concentration levels of
carbon monoxide do not exceed the
permissible exposure limit (50 parts
per million) [29 CFR 1910.178(i)
(1)].
145) Verify that only approved powered
industrial trucks are designated to
enter hazardous atmosphere locations
[29 CFR 1910.178(c)(2)].
146) Confirm that power-operated
industrial trucks not in safe
operating condition are removed from
service [29 CFR 1910 .178(q)].
Cranes and Derricks
147) Verify, depending on the frequency
of use, that either frequent (daily
to monthly) or periodic (1 to 12
month intervals) crane/derrick
inspections are conducted [29 CFR
1910.179(j) (1) (ii) and .181(d)(l)
(ii)] -
148) Confirm that a crane/derrick
preventive maintenance program has
been established [29 CFR 1910.179
(1) (1) and .181(f) (1)] .
149) Verify monthly certification of
crane/derrick running ropes [29 CFR
1910.179(m)(1) and .181(g)(l)].
150) Verify that the rated load capacity
of the crane/derrick is clearly
designated [29 CFR 1910 .179(b) (5)
and .181(c) (1)] .
151) Verify that only designated
personnel are permitted to operate a
crane or derrick [29 CFR
1910.179 (b) (8) and .16Kb) (3)].
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G. Machinery and Machine Guarding
Evaluate the effectiveness of the facility's
machine guarding program by examining the
following procedures.
152) Evaluate the methods of machine
guarding and determine whether one
or more methods are provided to
protect the operator and other
employees in the vicinity of the
machine (s) from hazards such as
those created by point of operation,
ongoing nip points, or rotating
parts [29 CFR 1910.212(a)(1)].
153) Verify that guards are affixed
directly to machines, where
feasible, and secured elsewhere if
for any reason attachment to the
machines is not possible [29 CFR
1910.212(a) (2)] .
154) Determine whether the point of
operation of machines whose
operation exposes the operator to
injury are properly guarded to
prevent injury [29 CFR 1910.212(a)
(3)] .
155) Evaluate whether all machines
designed for a fixed location are
securely anchored to prevent walking
or movement [29 CFR 1910.212(b)].
Woodworking
156)
Determine if there is a means to
prevent woodworking machinery from
automatically restarting after
restoration of power from a power
failure or shutdown [29 CFR
1910.213(b) (3)] .
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157) Verify that the cutting head on a
radial arm saw will gently return to
the starting position when released
[29 CFR 1910.213(h) (4)] .
158) Verify that radial saws used for
ripping are equipped with anti-
kickback devices [29 CFR 1910.213(h)
(2)] .
159) Confirm that an adjustable stop is
provided on radial saws to prevent
the forward travel of the blade
beyond the position necessary to
complete the cut in repetitive
operations [29 CFR 1910 .213 (h) (3)].
160) Verify that there is a power shut-
off switch within reach of the
woodworking operator position [29
CFR 1910.213(b)(1)].
161) Confirm that band saw blades are
enclosed or guarded, except for the
working portion of the blade between
the bottom of the guide rolls and
the table [29 CFR 1910.213 (i) (1)].
162) Verify that a hand-fed planer or
jointer with a horizontal head is
equipped with a cylindrical cutting
head. The knife projection should
not exceed one-eighth inch beyond
the cylindrical body of the head [29
CFR 1910.213(j)(i)]
163) Verify that noncurrent-carrying
metal parts of portable electric
woodworking machines operated at
more than 90 volts are grounded [29
CFR 1910.213(a) (11)] .
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164) Confirm that profile and swing-head
lathes have cutting heads covered by
a metal guard, and wood-turning
lathes have cutting heads covered as
completely as possible by hoods or
shields [29 CFR 1910.213 (o) (1) and
(2)] .
165) Confirm that self-feeding sanding
machine feed rolls are protected
with a semicylindrical guard to
protect the operator's hands from
contacting the in-running rolls [29
CFR.1910.213(p)(1)].
166) Verify that dull, badly set,
improperly filed or improperly
tensioned saws are removed from
service [29 CFR 1910 .213 (s) (1)].
167) Verify that knives and cutting heads
are sharp, adjusted and secured [29
CFR 1910.213(3)(2)].
168) Confirm that woodworking machines
are maintained in a sanitary manner
[29 CFR 1910.213(3)(6)].
169) Confirm that cracked saws are
removed from service [29 CFR
1910.213(3)(7)].
Abrasive Wheel Machinery
170) Verify that the work rest on
abrasive wheel machinery is within
one-eighth inch of the wheel [29 CFR
1910.215(a) (4)] .
171) Confirm that the adjustable tongue
on the top side of the grinder is
within one-fourth inch of the wheel
[29 CFR 1910.215(b)(9)].
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H.
172) Verify that guards cover the
spindle, nut and flange of abrasive
wheel machinery [29 CFR 1910.215 (a)
(2)] .
Portable Power Tools
173) Verify that compressed air used for
cleaning machinery is controlled
(less than 30 p.s.i., chip guarding
and personal protective equipment)
[29 CFR 1910.242(b)].
174) Verify that portable power tools are
safely used and maintained [29 CFR
1910.242 (a)] .
Welding, Cutting and Brazing
Evaluate the effectiveness of the facility's
welding, cutting and brazing program by
examining the following procedures.
175) Verify that before welding or
cutting is permitted, the area is
inspected by the individual
responsible for authorization and
precautions are designated [29 CFR
1910.252{a) (2) (iv)] .
176) Confirm that management designates
an individual responsible for
authorizing welding and cutting in
areas not designed for such
processes [29 CFR 1910.252 (a)(2)
(xiii) (B)] .
177) Verify that management advises
contractors about hazardous
conditions [29 CFR 1910.252
(a)(2)(xiii)(D)].
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I.
178) Confirm that supervisors are
responsible for the safe handling of
cutting or welding equipment and the
safe use of cutting and welding
process [29 CFR 1910.252(a)(2)
(xiv)] .
179) Verify through employee interviews
and a review of facility records
that authorized personnel and their
supervisors are trained in the safe
operation of welding and cutting
equipment [29 CFR 1910 . 252 (a) (2)
(xiii) ] .
180) Confirm that welding and cutting
personnel are protected from hazards
(non-ionizing radiation, heat,
noise, fumes and gases) by
appropriate personal protective
equipment and clothing (e.g.,
helmets, hand shields, face shields,
aprons) [29 CFR 1910.252(b)(2) and
(3)] .
181) Verify through the facility tour and
facility records that ventilation is
provided to maintain concentration
levels of toxic fumes, gases or dust
below their respective PEL (e.g.,
cadmium, fluorine compounds, zinc,
mercury, ozone, beryllium, copper,
nickel, phosgene and magnesium) [29
CFR 1910.252 (c) (i) (C) (iii)].
Electrical
Evaluate the condition of the facility's
electrical systems by completing the following
procedures.
182) Review electrical equipment to
verify that it is free from
recognized hazards (e.g., equipment
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is U.L. listed, insulation rating is
appropriate, proper grounding and
polarity, no frayed cords) that are
likely to cause death or serious
injury to employees [29 CFR
1910.303(b)(1)].
183) Verify that no electrical equipment
is used unless the manufacturer's
name, trademark, or other
descriptive marking identifying the
organization responsible for the
product is provided [29 CFR
1910.303(e)].
184) Verify that all disconnect means and
circuits are legibly marked to
designate its purpose [29 CFR
1910.303(f)] .
185) Verify that all electrical
installations operating at 50 volts
or more are constructed to guard all
live parts from unqualified
personnel. If live parts are
accessible, verify that the
installation is accessible to
qualified personnel only [29 CFR
1910.303(g) (2)] .
186) Confirm that the working clearance
distance to live parts operating at
600 volts or less and likely to
require examination or maintenance
while alive are not less than
required. (See Attachment B for
minimum distance requirements)
[29 CFR 1910.303 (g)(l)(i)].
187) Verify that a conductor used as a
ground conductor is identifiable and
distinguishable from other
conductors [29 CFR 1910 . 304 (a) (1)] .
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188) Confirm that a grounding device on a
receptacle, cord connector, or
attachment plug is not used for
purposes other than grounding [29
CFR 1910.304(a) (3)] .
189) Verify that outlet devices have an
ampere rating no less than the load
to be served [29 CFR 1910.304(b)
(2)] .
190) Verify that a means is provided to
disconnect conductors in a building
from the service-entrance
conductors. (Note: The
disconnecting means should indicate
the open or closed position and be
installed at a readily accessible
location nearest the entrance of the
service-entrance conductors)
[29 CFR 1910.304(d)(1)].
191) Verify that fuses and circuit
breakers are located or shielded to
ensure personnel will not be injured
by their operation [29 CFR
1910.304(e)(1)(v)].
192) Confirm that circuit breakers
clearly indicate whether they are in
the off or on position. (Note:
Circuit breaker handles should be
operated vertically or rotationally.
The up position of the handle should
be the on position) [29 CFR
1910.304 (e) (1) (vi)] .
193) Verify that wiring systems are not
installed in ducts used to transport
dust, loose stock, or flammable
vapors [29 CFR 1910.305 (a) (1) (ii)] .
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194) Confirm that flexible cords and
cables are protected from accidental
damage [29 CFR 1910.305 (a)(2)(iii)
(G)] .
195) Verify that cabinets, cutout boxes,
fittings, boxes and panelboard
enclosures in damp or wet locations
are installed to prevent moisture or
water from entering the enclosure
[29 CFR 1910.305(e)(1)].
196) Confirm that switches, circuit
breakers and switchboards installed
in wet locations are enclosed in
weatherproof enclosures [29 CFR
1910.305(e) (2)] .
197) Verify that flexible cords and
cables are approved and suitable for
conditions of use and location.
(Note: Flexible cords and cables
should only be used for:
a) Pendants
b) Miring of fixtures
c) Connection of portable lamps
or appliances
d) Elevator cables
e) Connection of stationary
equipment to facilitate the
frequent interchange
f) Prevention of the transmission
of noise or vibration
g) Appliances where the fastening
means and mechanical
connections are designed to
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permit removal for maintenance
and repair
h) Data processing cables)
[29 CFR 1910.305(g)(1)].
198) Confirm that flexible cords and
cables are not:
a) A substitute for fixed wiring
a structure
b) Run through holes in walls,
ceilings, or floors
c) Run through doorways or
windows
d) Attached to building surfaces
e) Concealed behind walls,
ceilings, or floors
[29 CFR 1910.305(g) (1) (iii)] .
199) Verify that color coded ground fault
circuit interrupters (GFCIs) are
used for all receptacles in:
a) Aquatic laboratories
b) Outside receptacles
c) Equipment requiring GFCI by
the manufacturer
d) Contact with wet surfaces
[EPA FSM, 4870, FS1-06 (19)].
200) Evaluate temporary electrical power
and lighting to determine whether it
meets minimum permanent installation
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requirements as to grade and class.
Temporary electrical wiring is
permitted during remodeling,
maintenance or repair operation;
experimental or developmental work;
or not to exceed 90 days for
decorative lighting (e.g., Christmas
lights) [29 CFR 1910.305 (a) (2)].
201) Verify that all temporary wiring has
grounding type receptacles [29 CFR
1910.305(a) (2) (iii) (C)] .
202) For data processing systems, verify
that a means is provided to
disconnect all power to all
electronic equipment and room air
conditioning systems. The
disconnect should be readily
accessible at the exit door [29 CFR
1910.306(e)].
203) Verify that equipment, wiring and
installation in hazardous locations
is intrinsically safe for the
hazardous location [29 CFR
1910.307(b)].
204) Verify that space heaters are not
used in laboratories, hazardous
material storage areas, or
administrative spaces [EPA FSM,
4870, FS 1-05(11)] .
205) Confirm that employees who face a
risk of electrical shock that is not
reduced to a safe level by the
electrical installation requirements
are trained in and familiar with
safety-related work practices [29
CFR 1910.332(a)]
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206) Verify that safety-related work
practices are used to prevent injury
resulting from either direct or
indirect electrical contacts, when
work is performed near or on
equipment or circuits which are or
may be engaged. [29 CFR 1910.333
(a) ]
207) Determine whether employees working
in areas where there are potential
electrical hazards are provided with
and use appropriate electrical
protective equipment [29 CFR
1910.335(a)]
208) Confirm that safety signs, safety
symbols, or accident prevention tags
are used to warn employees of
electrical hazards [29 CFR
1910.335(b)(1)]
J. Indoor Air Quality
Ventilation is one of the most critical factors
affecting indoor air quality. Other factors are
physical (e.g., dusts), chemical (e.g.,
cleaners) and biological (e.g., fungus/molds)
materials present in the facility. The following
ASHRAE guidelines and EPA policy requirements
are provided to help the auditor observe obvious
indoor air quality problems.
209) Verify that the ventilation
distribution system (both return and
supply) is visible in each room and
free from obstructions/blockage
[ASHRAE 62-1989] .
210) Verify that the ventilation system
is designed to prevent the entrance
of contaminants (e.g., air intakes
should not be located near cooling
towers, vehicle exhaust or
XII-62
-------
PROTOCOL
RESPONSE
COMMENTS
laboratory exhaust systems) [EPA
FSM, 4870, FS 1-05 (12)] .
211) If soil contains high concentrations
of radon, determine whether
ventilation practices or building
design features exist to remove
radon gases from under the
foundation and basement areas.
These areas should not be designed
to be at less than atmospheric
pressure [ASHRAE 62-1989] .
212) Review records to determine if the
following parameters have been
tested and compared to the noted
requirements:
a) Temperature and humidity:
1. Summer: Maximum 78
degrees Fahrenheit (F)
and 60 percent Relative
Humidity (RH)
2. Winter: Minimum 68
degrees F and 30 percent
RH [ASHRAE 62-1989]
b) Carbon dioxide should not
exceed 1000 parts per million
(ppm)
[EPA FSM, 4870, FS1-05(12)].
c) Carbon Monoxide:
1.
2.
Shops and industrial
areas - 18 ppm
Offices and laboratories
- 9 ppm
[EPA FSM 4870, FS1-05U2)].
XII-63
SAFFTY
-------
PROTOCOL
RESPONSE
COMMENTS
d) Formaldehyde:
1. Shops and industrial
areas - 0.5 ppm
2. Offices and laboratories
- 0.1 ppm
[EPA FSM, 4870, FS 1-05(12)].
e) Fresh Air Supply: 15 cubic
feet per minute (CFM) of
outdoor air per person in a
non-smoking office
environment, 20 CFM of outdoor
air per person in laboratories
and 60 CFM of outdoor air per
person in smoking lounges [EPA
FSM, 4870, FS1-05U2) ] .
If the above test results reveal
measurements that are outside
guidelines, verify that appropriate
corrective actions were implemented
by the building engineer under the
direction of a qualified indoor air
quality professional [ASHRAE 62-
1989] .
213) Review the ventilation design to
ensure that specialty areas, such as
rest rooms, locker rooms, smoking
lounges, are exhausted directly to
the outside with no recirculation
[ASHRAE 62-1989, Table 2].
214) Verify that the facility institutes
and documents a HVAC maintenance
program [EPA FSM, 4870, FS 1-05(12].
215) Review HVAC maintenance program
documentation to verify:
XII-64
-------
PROTOCOL
RESPONSE
COMMENTS
a) Air filters are changed and
replaced [EPA FSM, 4870, FS1-
05(12)]
b) HVAC duct and air handler room
cleaning [EPA FSM, 4870, FS1-
05(12)]
c) Biological testing of water in
cooling towers and
condensation drip pans [EPA
FSM, 4870, FS1-05U2)]
d) If steam is used as a source
of humidification, steam
supply additives should not be
used [ASHRAE 62-1989]
e) If cold water humidifiers are
used, the water supply should
originate from a potable
source [ASHRAE 62-1989]
f) If cold potable water is
recirculated, maintenance and
blow-down specifications
should be followed [ASHRAE 62-
1989]
g) Standing water used in
conjunction with water sprays
in a HVAC distribution system
should be treated with
microbial inhibitors. [ASHRAE
62-1989]
216) Review records to verify that indoor
air quality complaints, symptoms and
corrective actions are documented.
Documentation should include:
a)
List of symptoms
XII-65
SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
K.
b) Dates, times and durations of
symptoms
c) Specific building areas of
complaint
d) Investigation results (e.g.,
source of potential pollutant,
HVAC measurements)
e) Corrective actions.
[EPA Building Air Quality: A Guide
for Building Owners and Facility
Managers]
Child Care Centers
If the facility contains a child care program,
complete the applicable portions of the
protocol, steps 217 through 250. If not,
proceed to step number 251 of the protocol.
217) Determine whether the child care
center is located on the level of
exit discharge which is at grade
level and along an outside wall with
operable windows. [EPA FSM, 4870,
FS1-04 (8)] .
218) Verify that paint and similar
surface coating materials are
prohibited from containing lead or
lead compounds [EPA FSM, 4870, FS1-
04(8)] .
219) Confirm that the potable water
distribution system is tested to
ensure that excessive levels of lead
are not present [EPA FSM, 4870,
FS1-04(8)]
XII-66
-------
PROTOCOL
RESPONSE
COMMENTS
220) Verify that the child care center is
not located in an area containing
friable asbestos or PCBs. [EPA FSM,
4870, FS1-04(8)] .
221) Determine whether the child care
center is separated from the
remainder of the building by one
hour fire resistant construction
with 20 minute fire doors. [EPA
FSM, 4870, FS1-04(8)].
222) Confirm that smoke detectors are
provided throughout the child care
center. [EPA FSM, 4870, FS1-04(8)].
223) Verify that Group II occupancies are
separated from the child care center
by one hour fire resistive
construction with 45 minute fire
doors. (Note: If complete
sprinkler protection is provided,
separation from Group II hazards is
not required) [EPA FSM, 4870, FS1-
04(8)] .
224) Confirm that higher hazard areas
(such as laboratories) are not
located in the same fire area as the
child care center and are separated
by no less than two hour
construction (regardless of
sprinkler protection). [EPA FSM,
4870, FS1-04(8)].
225) Determine whether the child care
center is provided with sufficient
physical security to prevent entry
by unauthorized personnel. [EPA
FSM, 4870, FS1-04(8)] .
226) Evaluate whether unused electrical
receptacles within the reach of pre-
school children are equipped with
XII-67
SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
227)
228)
229)
230)
231)
232)
233)
socket guards
04(8)].
[EPA FSM, 4870, FS1-
Verify that the child care center is
provided with lockable storage
spaces containing shelving that is
out of reach of pre-school children
for storing toxics (e.g., cleaning
materials) [EPA FSM, 4870, FS1-
04(8)].
Determine whether furniture and
equipment are constructed and
finished to minimize pinch points
and splinters [EPA FSM, 4870, FS1-
04(8)].
Evaluate whether hot water available
to children is limited to 120
degrees Fahrenheit [EPA FSM, 4870,
FS1-04(8)].
Confirm that the child care center
precludes children's access to
kitchen areas [EPA FSM, 4870, FS1-
04(8)].
Verify that fans are located no less
than five feet above floor level and
that fan blades are guarded [EPA
FSM, 4870, FS1-04(8)] .
Confirm that electric or fueled
space heaters are not employed [EPA
FSM, 4870, FS1-04(8)] .
Determine whether outside play areas
are located and secured to minimize
the exposure of children to
unauthorized personnel, vehicular
traffic, animals, overhead
electrical power lines, or to
overspray from a HVAC cooling tower
[EPA FSM, 4870, FS1-04(8)].
XII-6B
-------
PROTOCOL
RESPONSE
COMMENTS
234) Verify that the facility's occupant
emergency action plan addresses the
child care center and that child
care center employees are trained in
executing the plan [EPA FSM, 4870,
FS1-04 (8)].
235) Confirm that the child care center
is in compliance with applicable
state and local requirements.
Recommended Practices
The recommended practices for child care
centers were developed from the following
reference documents:
a) EPA Region 4 Regional Child
Care Center Health Policy
b) State of Rhode Island Day Care
Centers and Day Nurseries
Standard for Licensure.
236) Confirm that the child care center
is licensed in accordance with state
and local requirements.
237) Verify that the child care center
maintains a written policy for
actions to be taken in the event of
an injury or acute illness.
238) Determine whether the child care
center maintains a properly secured
first aid kit.
239) Verify that child care center staff
are trained in CPR and emergency
first aid precautions.
XII-69
SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
240)
241)
242)
243)
244)
245)
246)
247)
Confirm that emergency telephone
numbers are displayed near all
telephones.
Verify that guidelines for
administering medication have been
established.
Determine whether the child care
center maintains a written record of
medication administered. Records
should include:
a)
Child's name
b) Name and dosage of medication
administered
c) Date and time medication was
administered
d) Name and signature of person
administering medication.
Evaluate whether medication is
maintained under lock in a clearly
labeled container.
Confirm that smoking is not
permitted.
Verify that the child care center is
adequately lighted and ventilated.
Determine whether child care centers
operating infant/toddler programs
protect stairwells by secured gates
and/or doors.
Confirm that a disinfectant solution
is provided for cleaning diaper
changing surfaces.
XII-70
-------
PROTOCOL
RESPONSE
COMMENTS
248) Verify that child care center
maintenance activities are not
performed when children are present.
249) Determine whether outdoor play areas
are fenced, reasonably level, well
drained, free from obstructions and
maintained in good condition.
250) Confirm that the child care center
has established policies for the
control of communicable diseases and
that staff are trained in
precautions to reduce the spread of
communicable diseases.
L. Evaluation of Findings
251) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
252) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
253) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
trends or identify overall patterns
or trends.
XII-71
SAFETY
-------
-------
ATTACHMENT A
APPENDIX A TO 29 CFR 1910.119 — LIST OF HIGHLY
HAZARDOUS CHEMICALS, TOXICS AND REACTIVES
-------
-------
Appendix A to § 1910.119—List of Highly Hazardous
Chemicals, Toxics and Reactives (Mandatory)
This Appendix contains a listing of toxic and reactive highly hazard-
ous chemicals which present a potential for a catastrophic event at
or above the threshold quantity.
CHEMICAL name
CAS*
CHEMICAL name
Acetaldehyde
Acrolein (2-Propenal)
Acrytyl Chloride
Allyl Chloride
Allylamine
Alkylaluminums
Ammonia Anhydrous
Ammonia solutions
(>44% ammonia by weight)
Ammonium Perchlorate
Ammonium Pflrmannanats ....
Arsine (also called Arsenic
Hydride)
Bis(Chloromethyl) Ether
Boron Trichloride
Boron Trifluoride
Bromine
Bromine Chloride
Bromine Pentafluoride
Bromine Trifluoride
3-Bromopropyne (also called
Propargyl Bromide)
Butyl Hydroperoxide (Tertiary)
Butyl Perbenzoate (Tertiary)
Carbonyl Chloride
(see Phosgene)
Carbonyl Fluoride
Cellulose Nitrate (concentration
>12 6% nitrogen
Chlorine •
Chlorine Dioxide
Chlorine Pentrafluoride
Chlorine Trifluoride
Chlorodiethylaluminum (also called
Diethylaluminum Chloride)
1-Chloro-2 4-Dinitrobenzene ....
Chloromethyl Methyl Ether
Chlorooicrin
CAS*
75-07-0
107-02-8
814-68-6
107-05-1
107-11-9
Varies
7664-41-7
7664-41-7
7790-98-9
7787-36-2
7784-42-1
542-88-1
10294-34-5
7637-07-2
7726-95-6
13863-41-7
7789-30-2
7787-71-5
106-96-7
75-91-2
614-45-9
75-44-5
353-50-4
9004-70-0
7782-50-5
10049-04-4
13637-63-3
7790-91-2
96-10-6
97-00-7
107-30-2
76-06-2
TO"
2500
150
250
1000
1000
5000
10000
15000
7500
7500
100
100
2500
250
1500
1500
2500
15000
100
5000
7500
100
2500
2500
1500
1000
1000
1000
5000
5000
500
500
Chloropicrin and Methyl
Bromide mixture
Chloropicrin and Methyl
Chloride mixture
Cumene Hydroperoxide
Cyanogen
Cyanogen Chloride
Cyanuric Fluoride
Diacetyl Peroxide
(concentraton >70%)
Diazomethane
Dibenzoyl Peroxide
Diborane
Dibutyl Peroxide (Tertiary)
Dichloro Acetylene
Dichlorosilane
Diethylzinc
Diisopropyl Peroxydicarbonate
Dilaluroyl Peroxide
Dimethyldichlorpsilane
Dimethylhydrazine, 1,1-
Dimethylamine, Anhydrous
2,4-Dinitroanitine
Ethyl Methyl Ketone Peroxide
(also Methyl Ethyl Ketone
Peroxide; concentration >60%)
Ethyl Nitrite
Ethylamine
Ethylene Fluorohydrin
Ethylene Oxide
Ethyleneimine ,
Fluorine ,
Formaldehyde (Formalin)
Furan
Hexafluoroacetone
Hydrochloric Acid, Anhydrous
Hydrofluoric Acid, Anhydrous
Hydrogen Bromide ..„
Hydrogen Chloride
Hodrogen Cyanide, Anhydrous .'
Hydrogen Fluoride
Hydrogen Peroxide (52% by
weight or greater
Hydrogen Selenide
Hydrogen Sulfide
None
None
80-15-9
460-19-5
506-77-4
675-14-9
110-22-5
334-88-3
94-36-0
19287-45-7
110-05-4
7572-29-4
4109-96-0
557-20-0
105-64-6
105-74-8
75-78-5
57-14-7
124-40-3
97-02-9
1338-23-4
109-95-5
• 75-04-7
371-62-0
75-21-8
151-56-4
7782-41-4
50-00-0
110-00-9
684-16-2
7647-01-0
7664-39-3
10035-10-6
7647-01-0
74-90-8
7664-39-3
7722-84-1
7783-07-5
7783=06-4
TO"
1500
1500
5000
2500
500
100
5000
500
7500
100
5000
250
2500
10000
7500
7500
1000
1000
2500
5000
5000
5000
7500
100
5000
1000
100
1000
500
5000
5000
1000
5000
5000
1000
1000
7500
150
1500
ATTACHMENT A
-------
CHEMICAL name
Hydroxlamine
Iron Pentacarbonyl ....
Ketene
Mothaprwlnul OhlnriHp
Methacryloyloxyethyl
Isocyanate
Methyl Acrylonitrile
Meinyiamine, Mnnyurous
Methyl Bromide
Molhul ChlnriHo
Methyl Chloroformate
Methyl Ethyl Ketone Peroxide
fr*nnf*antratinn "»fiO°/*\
Meinyi riuoruautJiaitz
Methyl Fluorosulfate
MotHi/l WuHraTinp
MAttiul InHirlo
ivieinyi isocyaiidie
Meinyi Mercapian
Meinyi vinyi i\eione
Nickel CaFbonly (Nickel
1 eiracarDonyi/
Nitric Acid (94.5% by
weight or greater)
iNiinc vjxiuo
Nitroaniline (para Nitroaniline)
iNiiromeinane
nitrogen uioxiue
Nitrogen Oxides (NO; NO2;
MorM- KIODI\
NtU**, INtUo;
Nitrogen Tetroxide (also called
Nitrogen Peroxide)
Nitrogen Trifluoride
Nitrnnpn Trioxide
Oleum (65% to 80% by weight;
also called Fuming Sulfuric Acid
Osmium Tetroxide
Oxygen Difluoride (Fluorine
Monoxide)
Ozone
Pentaborane
CAS*
7803-49-8
13463-40-6
75-31-0
463-51-4
78-85-3
920-46-7
30674-80-7
126-98-7
74-89-5
74-83-9
74-87-3
79-22-1
1338-23-4
453-18-9
421-20-5
60-34-4
74-88-4
624-83-9
74-93-1
79-84-4
75-79-6
13463-39-3
7697-37-2
10102-43-9
100-01-6
75-52-5
10102-44-0
10102-44-0
10544-72-6
7783-54-2
10544-73-7
8014-94-7
20816-12-0
7783-41-7
10028-15-6
19624-22-7
TQ"
2500
250
5000
100
1000
150
100
250
1000
2500
15000
500
5000
100
100
100
7500
250
5000
100
500
150
500
250
5000
2500
250
250
250
5000
250
1000
100
100
100
100
CHEMICAL name \ CAS
j
Peracetic Acid (concentration ;
>60% Acetic Acid; also called ,
Peroxyacetic Acid) -I
Perchloric Acid (concentration
>60% by weight) j
Perchloromethyl Mercaptan J
Darohlnrvl Flllfiririfi Ji
Peroxyacetic Acid (concentration
>60% by Acetic Acid; also called
Paracetic Acid)
Phosgene (also called
Carbonyl Chloride)
Phosphine (Hydrogen Phosphide)
Phosphorus Oxychloride (also
called Phosphoryl Chloride)
Phosphorus Trichloride
Phosphoryl Chloride (also called
Phosphorus Oxychloride
Propargyl Bromide
Propyl Nitrate
Sarin
Selenium Hexafluoride
Stibine (Antimony Hydride)
Qnlfiir Dioxide Hklllid)
Sulfur Pentafluoride
Ciillur Totraf li inrids
Sulfur Trioxide (also called
Sulfuric Anhydride)
Sulfuric Anhydride (also called
Sulfur Trioxide)
Tellurium Hexafluoride
Totrofli inrnothvtene
Tetrafluorohydrazine
Thionyl Chloride
Trichloro (chloromethyl) Silane ....
Trichtoro (dtohlorophenyl) Silane .
Trilli i rnrhlnrnpthvlftns
Trimethyoxysilane
79-21-0
7601-90-3
594-42-3
7616-94-6
79-21-0
75-44-5
7803-51-2
10025-87-3
7719-12-2
10025-87-3
106-96-7
627-3-4
107-44-8
7783-79-1
7803-52-3
7446-09-5
5714-22-7
7783-60-0
7446-11-9
7446-11-9
7783-80-4
116-14-3
10036-47-2
75-74-1
7719-09-7
1558-25-4
27137-85-5
. 10025-78-2
j 79-38-9
.. 2487-90-3
TQ"
1000
5000
150
5000
1000
100
100
1000
1000
1000
100
100
100
1000
500
1000
250
250
1000
1000
250
5000
5000
1000
250
100
2500
5000
10000
1500
•Chemical Abstract Service Number.
"Threshold Quantity in Pounds (Amount necessary to be
covered by this standard).
ATTACHMENT A
-------
ATTACHMENT B
ELECTRICAL EQUIPMENT WORKING CLEARANCES
-------
-------
WORKING CLEARANCES
Nominal voltage to ground
0-150
151-600
Minimum clear distance for
condition2 (ft)
(a)
J3
n
(b)
»3
3 1/2
(c)
3
4
1 Minimum clear distances may be 2 feet 6 inches for Installations built prior to April 16, 1981.
2 Conditions (a), (b), and (c) are as follows: (a) Exposed live parts on one side and no live or grounded parts on the other side
of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating material.
Insulated wire or Insulated busbars operating at not over 300 volts are not considered live parts, (b) Exposed live parts on one
side and grounded parts on the other side, (c) Exposed live parts on both sides of the workspace (not guarded as provided in
Condition (a)] with the operator between.
ATTACHMENT B
-------
-------
OCCUPATIONAL HEALTH AUDIT PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA environmental management review program. It is
intended to serve as a guide for planning and conducting an evaluation of operating unit-
level environmental management systems and internal controls. The protocol may require
additions or revisions to meet the needs of specific operating unit assessments. The purpose
of assessing EPA facility occupational health management programs is to confirm that
appropriate systems are in place and functioning effectively to achieve and sustain
compliance with applicable occupational health regulations and to minimize EPA's risks.
Applicable Laws, Regulations, Policies and Recommended Practices
The Williams-Steiger Occupational Safety and Health Act of 1970 was enacted to ensure that
employees are provided with a place of employment that is free from recognized hazards that
are likely to cause physical harm. Pursuant to the Act, the Occupational Safety and Health
Administration codifies occupational health regulations within 29 CFR 1910 - Occupational
Safety and Health Standards. 29 CFR 1910 establishes occupational health standards for
general industry — specifically, in the areas of occupational health and environmental
controls, hazardous materials, personal protective equipment, toxic and hazardous substances,
medical surveillance, and hazardous chemicals in laboratories.
Title 29 CFR 1960 - Basic Program Elements for Federal Employee Occupational Safety and
Health Programs and Related Matters, establishes requirements for Federal agency safety and
health programs. The EPA Occupational Health and Safety Manual, 1440 (March 18, 1986),
establishes the Agency's occupational safety and health program.
The American National Standards Institute (ANSI) establishes recommended practices for the
safe use of lasers (ANSI Z136.1-1986), and the design, installation, and maintenance of
emergency eyewashes and showers (ANSI Z358.1-1990).
SECTION XIII - OCCUPATIONAL HEALTH
-------
5 U.S. Code delineates requirements for establishing a Federal Health Service Program. The
Department of Health and Human Services (DHHS), Public Health Service (PHS), Availability of
Occupational Health Services for Federal Employees document establishes recommended health
services program practices for Federal agencies.
-------
OCCUPATIONAL HEALTH MANAGEMENT REVIEW PROTOCOL
Table of Contents
Section Page Number
A. Introduction XIII-1
B. Occupational Health and Environmental Controls XIII-2
C. Hazardous Materials XIII-15
D. Personal Protective/Emergency Response Equipment XIII-26
E. Safety and Health Programs for Federal Agencies XIII-30
F. Toxic and Hazardous Substances XIII-38
G. Hazardous Chemicals in Laboratories XIII-56
H. Medical Surveillance XIII-60
I. Health Service Program XIII-61
J. Evaluation of Findings XIII-63
SECTION XIII - OCCUPATIONAL HEALTH
-------
-------
PROTOCOL
XIII. OCCUPATIONAL HEALTH MANAGEMENT
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous occupational health
audit reports or reports on
inspections of the facility.
2) Review the following background
information related to occupational
health management programs and
activities prior to the on-site
visit (If it is not available prior
to conducting the field work, review
the information as early in the
field visit as possible):
a) EPA and facility-specific
occupational health directives
and orders
b) EPA and facility-specific
occupational health operating
manuals and procedures
c) Organizational charts and
staffing tables
d) Training and employee
orientation documents
RESPONSE
COMMENTS
XIII-1
OCCUPATIONAL HEALTH
-------
PROTOCOL
RESPONSE
COMMENTS
e) Emergency response
programs/plans
f) Applicable Federal regulations
g) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the occupational health audit
management protocol, perform the
review of the facility's compliance
with applicable policies,
regulations and recommended
professional practices.
B. Occupational Health and Environmental
Controls
Ionizing Radiation
Ionizing radiation includes alpha rays,
beta rays, gamma rays, X-rays, neutrons,
high-speed electrons, high-speed protons
and other atomic particles. Evaluate the
XIII-2
LUP&T.TU
-------
PROTOCOL
effectiveness of the facility's
radioactive materials management program
by completing the following protocol
steps.
6) Verify through a documentation
review and interviews with employees
that employee exposure to ionizing
radiation does not exceed:
a) Whole Body: 1-1/4 Rems per
calendar quarter
b) Hands/forearms and
feet/ankles: 18-3/4 Rems per
calendar quarter
c) Skin of whole body: 7-1/2 Rems
per calendar quarter
Note the following exceptions:
a) The whole body dose does not
exceed 3 Rems in a calendar
quarter
b) The dose to the whole body
when added to the whole body
occupational dose does not
exceed 5 (N-18) Rems, where
"N" is the individual's age
c) Exposure records demonstrate
that an additional dose will
not exceed the applicable
limit
[29 CFR 1910.96(b)(1) and (2)].
7) Verify that employee exposure (40
hours in any work week of seven
consecutive days) to airborne
radioactive material does not exceed
the average concentrations specified
in Table 1 of Appendix B, 10 CFR 20.
RESPONSE
COMMENTS
XIII-3
OCCUPATIONAL HEALTH
-------
PROTOCOL
RESPONSE
COMMENTS
If the number of hours of exposure
exceeds 40, then the limits
specified in the table should be
decreased proportionately [29 CFR
1910.96(c) (1)].
8) Verify that employees who are likely
to receive a dose within a calendar
quarter in excess of 25 percent of
the applicable dose or who enter a
high radiation area are
appropriately monitored (film
badges/pocket dosimeters) [29 CFR
1910.96(d)].
9) Confirm that each radiation area is
conspicuously posted with a sign
bearing the radiation caution symbol
and the words:
Caution
Radiation Area
[29 CFR 1910.96(6)(2)].
10) Confirm that each high radiation
area is conspicuously posted with a
sign bearing the radiation caution
symbol and the words:
Caution
High Radiation Area
Verify the use of a control device
that will either reduce radiation
below a dose of 100 millirems in one
hour upon entry into the area or a
visible or audible alarm that
notifies the employee and the
employer of entry into the area
(Note: Control devices are not
required for high radiation areas
established for 30 days or less.)
[29 CFR 1910.96(e)(3)].
XIII-4
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11) Confirm that areas containing
airborne radioactivity are
conspicuously posted with a sign
bearing the radiation caution symbol
and the words:
Caution
Airborne Radioactivity Area
[29 CFR 1910.96(e)(4)(ii)].
12) Confirm that areas in which
radioactive material is used or
stored and which contains any
radioactive material (other than
natural uranium or thorium) in an
amount exceeding 10 times the amount
specified in Appendix C, 10 CFR 20,
are posted with a sign bearing the
radiation symbol and the words:
Caution
Radioactive Materials
[29 CFR 1910.96(6)(5)(i)].
13) Confirm that areas in which natural
uranium or thorium is used or stored
in an amount exceeding 100 times the
amount specified in 10 CFR 20, are
posted with a sign bearing the
radiation symbol and the words:
Caution
Radioactive Materials
[29 CFR 1910.96(e) (5) (ii)] .
14) Verify that containers of
radioactive materials (other than
natural uranium or thorium) in
amounts greater that the quantity
specified in Appendix C, 10 CFR 20
and containers of natural uranium or
thorium in amounts greater than 10
RESPONSE
COMMENTS
XIII-5
OCCUPATIONAL HEALTH
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15)
16)
PROTOCOL
times specified in Appendix C, 10
CFR 20 have a durable, clearly
visible label bearing the
radioactive symbol and the words:
Caution
Radioactive Materials
The label should also identify the
type and quantity of radioactive
material [29 CFR 1910.96(e)(6)(i)].
(Note: Containers of radioactive
material that do not exceed the
amount specified in Table 1,
Appendix B, 10 CFR 20 and laboratory
containers used transiently for
laboratory procedures in which the
user is present are exempt from this
requirement) [29 CFR 1910.96(e)
(6) ] .
Verify that radioactive storage
containers state the quantity and
type of radioactive material and the
date of measurement of quantity [29
CFR 1910.96(6)(6)(iv)].
Confirm that exceptions to posting
signs are in accordance with the
following provisions:
a) A room or area is not required
to be posted if the radiation
source is sealed and the
radiation level 12 inches from
the surface of the source
container does not exceed 5
millirem per hour.
b) Medical facilities are not
required to be posted if
personnel in attendance take
precautions to prevent
RESPONSE
COMMENTS
XIII-6
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PROTOCOL
radiation exposure in excess
of established limits.
c) Areas or rooms are not
required to be posted if the
room contains radioactive
material for less than eight
hours and the materials are
constantly attended by
individuals who take
precautions to prevent
radiation exposure in excess
of established limits
[29 CFR 1910.96(g)].
17) Determine if the facility is
governed by the Nuclear Regulatory
Commission (NRC), or a State
Program.
For facilities governed by the NRC:
18) Verify that workers in or
frequenting a restricted area are:
a) Informed of storage, transfer
and use of radioactive
materials and radiation in the
area [10 CFR 19.12] .
b) Instructed in health
protection; precautions or
procedures to minimize
exposure; purposes and
function of protective
devices; their responsibility
to report license violations;
the appropriate response to
warning of unusual conditions;
and radiation exposure reports
that they may request [10 CFR
19.12] .
RESPONSE
COMMENTS
XIII-7
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RESPONSE
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19) Confirm that current copies of the
following documents are posted for
the information of the worker:
a) Title 10 CFR Parts 19 and 20
b) Form NRC-3, "Notice to
Employees"
c) License, license conditions or
documents incorporated into a
license by reference and
amendments thereto
d) Operating procedures
applicable to the licensed
activities.
e) Notice of violation involving
radiological working
conditions and any response
from the license or a notice
which describes these
documents and states where
they may be examined
[10 CFR 19.11] .
For facilities not governed by the NRC:
20) Verify that the workers in or
frequenting a radiation area are:
a) Informed of the occurrence of
radioactive materials or of
radiation in the area
b) Instructed in the safety
problems and precautions
associated with exposure to
radioactive materials
c) Instructed in applicable
sections of 29 CFR 1910.96
regulating worker exposure and
XIII-8
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RESPONSE
COMMENTS
21)
22)
23)
24)
d)
protection from radioactive
materials
Advised of radiation exposure
reports that they may request
[29 CFR 1910.96(1)(2)].
Confirm that current copies of
operating procedures applicable to
radiological activities are posted
conspicuously or are available for
examination by the worker [29 CFR •
1910.96(1) (3)] .
Verify that radioactive materials
stored in a non-radioactive area are
secured against unauthorized removal
[29 CFR 1910.96(j)].
Verify that the disposal of
radioactive material is managed by
an authorized recipient or in a
manner approved by the NRC or by or
an approved State program [29 CFR
1910.96(k)].
Verify that the facility has
established procedures for reporting
incidents to the appropriate
governing authority [29 CFR
1910.96(1)] .
Nonionizing Radiation
Nonionizing radiation (radio frequency
region of the spectrum) includes radiation
originating from radio stations, radar
equipment and other possible sources of
electromagnetic radiation.
25) Confirm that employee exposure to
electromagnetic energy of
frequencies from 10 MHz to 100 GHz
does not exceed the recommended
XIII-9
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PROTOCOL
RESPONSE
COMMENTS
guide of 10 mW/cm2 averaged over a
0.1 hour period [29 CFR 1910.97(a)
(2) ] .
Laser Safety (Recommended Practices)
The following recommended laser safety
practices reference the American National
Standards Institute, Safe Use of Lasers,
Z136.1-1986 Standard.
26) Confirm that a Laser Safety Officer
(LSO) is designated for the
operation, maintenance, and service
of a Class 3a, Class 3b or Class 4
laser or laser system [ANSI Z136.1-
1986 (1.3.1)] .
27) Determine whether the LSO:
a) Verifies laser classification
b) Prescribes and audits the
functionability of control
measures
c) Approves standard operating
procedures
d) Recommends and audits the use
of protective equipment
e) Approves laser installation
and equipment prior to use
f) Verifies the adequacy of
training provided to laser
area personnel
[ANSI Z136.1-1986 (1.3.2)].
28) Verify that the beam height of the
laser is maintained at a level other
than the normal position of the eye
XIII-10
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PROTOCOL
RESPONSE
COMMENTS
of a person in the standing or
seated position [ANSI Z136-1-
1986(4.1)] .
29) Confirm that a protective housing is
provided for all classes of lasers
or laser systems (Note: During
research and manufacturing
activities the LSO may permit the
removal of the protective housing)
[ANSI Z136.1-1986 (4.3.1)].
30) Determine whether protective
housings which enclose embedded
Class 3a, Class 3b or Class 4 lasers
are provided with an interlock
system that activates when the
protective housing is opened during
operation and maintenance [ANSI
Z136.1-1986 (4.3.2)].
31) Verify that lasers (except Class 1)
have warning labels and a cautionary
statement on the laser housing or
control panel [ANSI Z136.1-1986
(4.3.14)] .
32) Confirm that standard operating
procedures are established for Class
4 lasers [ANSI Z136.1-1986 (4 . 4 .1)] .
33) Determine whether training is
provided for operators, maintenance
or service personnel for Class 3a,
Class 3b or Class 4 lasers [ANSI
Z136.1-1986(4.4.3)] .
34) Verify that protective eyewear is
donned whenever operational
conditions for the Class 3b or Class
4 laser may result in an eye hazard
[ANSI Z136.1-1986(4.6.2)] .
35) Confirm that lasers are permanently
designated with their primary
XIII-11
OCCUPATIONAL HEALTH
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PROTOCOL
electrical ratings in volts,
frequency, and watts or amperes
[ANSI Z136.1-1986 (7.4.6] .
36) Verify that a laser safety program
has been established by the
facility. Program elements should
include:
a) Delegation of authority and
responsibility to the LSO for
laser safety
b) Training
c) Protective measures
d) Incident investigation
e) Medical surveillance
[ANSI Z136.1-1986 (5.1)].
Occupational Noise Exposure
Evaluate the effectiveness of the
facility's hearing conservation program by
performing the following procedure.
37) Determine whether the facility has a
program covering all work areas
where employee noise exposures equal
or exceed an 8-hour time-weighted
average sound level of 85 decibels
measured on the A scale. (If
exposures equal or exceed an 8-hour
TWA of 85 decibels, complete the
applicable portions of the protocol,
steps 38 through 53. If not,
proceed to step number 54 of the
protocol) [29 CFR 1910 . 95 (c) (1) ] .
38) Verify that sound level monitoring
programs are developed whenever
information indicates that an
RESPONSE
COMMENTS
XIII-12
TH
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RESPONSE
COMMENTS
employee's exposure may equal or
exceed an 8-hour time-weighted
average of 85 decibels [29 CFR
1910.95(d)(1)].
39) Verify that sound level monitoring
is repeated whenever a change in
equipment or controls increases
noise exposures [29 CFR 1910.95(d)
(3)].
40) Determine whether employees exposed
at or above an 8-hour time-weighted
average of 85 decibels are notified
of the results of monitoring [29 CFR
1910.95(e)].
41) Determine whether affected employees
or their representatives are
provided with the opportunity to
observe noise measurements [29 CFR
1910.95(f)] .
42) Evaluate the facility's audiometric
testing program and determine
whether it is provided for all
employees whose exposures equal or
exceed an 8-hour time-weighted
average of 85 decibels [29 CFR
1910.95(g) (1)] .
43) Verify that audiometric tests are
performed by a licensed or certified
audiologist, otolaryngologist, or
other physician, or by a technician
certified by the Council of
Accreditation in Occupational
Hearing Conservation [29 CFR
1910.95(g) (3)] .
44) Verify that baseline audiograms are
established for employees within six
months of their first exposure at or
above the action level to compare
XIII-13
OCCUPATIONAL HEALTH
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PROTOCOL
with subsequent audiograms [29 CFR
1910.95(g)(5)].
45) Determine whether new audiograms are
obtained from employees no less than
annually after obtaining the
baseline audiogram [29 CFR
1910.95(g) (6)].
46) Verify that employee annual
audiograms are compared against
baseline audiograms to determine
whether the audiogram is valid and ,
if a standard threshold shift has
occurred [29 CFR 1910.95 (g) (7)]
47) Verify that employees are informed
in writing within 21 days of any
determination indicating the
occurrence of a standard threshold
shift from their audiograms
(baseline and annual) [29 CFR
1910.95(g)(8)].
48) Determine whether hearing protection
is provided and used by employees
exposed to an 8-hour time-weighted
average of 85 decibels or greater
[29 CFR 1910.95(i) (1) and (2)].
49) Verify that all employees exposed to
noise at or above an 8-hour time-
weighted average of 85 decibels
participate in a training program
[29 CFR 1910. 95 (k) (1)] .
50) Verify that training is repeated
annually for employees included in
the hearing conservation program [29
CFR 1910.95(k)(2)].
51) Determine whether copies of the
Occupational Noise Exposure Standard
are provided to affected employees
RESPONSE
COMMENTS
XIII-14
rVTTTPATIONAI. HEALTH
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PROTOCOL
RESPONSE
COMMENTS
and posted in a conspicuous location
in the workplace [29 CFR 1910.95(1)
(1)] .
52) Evaluate the accuracy of employee
exposure measurement records and
verify that they are maintained for
no less than 2 years [29 CFR
1910.95(m)(1) and (3)(i)].
53) Verify that employee audiogram test
records are retained for the
duration of the affected employee's
employment [29 CFR 1910.95(m)(2) and
(m)(3)(ii)].
C. Hazardous Materials
Evaluate the facility's program for managing
hazardous materials by completing the following
procedures.
Hazardous Waste Operations
If employees participate in hazardous
waste and/or emergency response activities
complete the applicable portions of the
protocol, steps 54 through 79. If not/
proceed to step number 80 of this
protocol.
54) Verify that personnel working at a
hazardous waste site and exposed to
safety and health hazards receive
the following training:
a) Names of personnel responsible
for site safety and health
b) Safety and health hazards
present on the site
c) Use of personal protective
equipment
XIII-15
OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
d) Safe work practices
e) Safe use of engineering
controls and equipment
f) Medical surveillance
requirements, including
symptoms that may indicate
overexposure to hazards
g) Decontamination procedures
h) Emergency response plan
i) Confined space entry
procedures.
[29 CFR 1910.120(e)]
55) Confirm that general site workers at
a hazardous waste site potentially
exposed to hazardous substances and
health hazards receive no less than
40 hours of instruction off site and
three days of field experience under
the supervision of a trained,
experienced supervisor [29 CFR
1910.120(e)(3)(i)].
56) Verify that workers on site only
occasionally for a specific limited
task and who are unlikely to be
exposed over permissible exposure
limits (PEL) receive a minimum of 24
hours of instruction off site and
one day of field experience under
the direct supervision of a trained,
experienced supervisor [29 CFR
1910.120(e) (3) (ii)] .
57) Confirm that workers regularly on
site who work in areas that have
been monitored and fully
characterized indicating exposure
under the PEL, where respirators are
XIII-16
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PROTOCOL
RESPONSE
COMMENTS
not necessary and the
characterization indicates there are
no health hazards or the possibility
of an emergency, receive 24 hours of
instruction off site and one day of
field experience under the direct
supervision of a trained,
experienced supervisor [29 CFR
1910.120(e) (3) (iii)] .
58) Verify that on-site managers and
supervisors directly responsible for
or who supervise employees engaged
in hazardous waste site operations
receive 40 hours of training and
three days of supervised field
experience. (Training may be
reduced to 24 hours and one day if
the only area of their
responsibility is employees covered
by procedures 56 and 57 of this
protocol) [29 CFR 1910 .120 (e) (4)] .
59) Confirm that personnel trained in
hazardous waste site operations
receive a certificate of training
[29 CFR 1910.120(6) (6)] .
60) Verify that personnel engaged in
emergency response at hazardous
waste sites are trained [29 CFR
1910.120(6) (7)] .
61) Confirm that personnel engaged in
hazardous waste activities receive
eight hours of annual refresher
training [29 CFR 1910.120 (e) (8)].
(Note: With documentation that
employee work experience or training
has resulted in equivalent training,
the employer need not provide
initial training requirements except
for site-specific training) [29 CFR
1910.120(e) (9)] .
XIII-17
OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
62) Verify through training records that
the following personnel have
completed the appropriate level of
training:
a) Field employees should have
completed a 24-hour Basic
Course
b) Field employees involved in
uncontrolled hazardous waste
sites and hazardous spill
investigations should have
completed an 8-hour
Intermediate Course and 24-
hour Basic Course
c) Field employees involved in
managing basic activities at
field sites should have
completed an 8-hour Advanced
Course, a 24-hour Basic Course
and an 8-hour Intermediate
Course.
[EPA Order 1440.2].
63) Confirm that a written safety and
health program is developed for
employees involved in hazardous
waste site operations. The program
should include the following
elements:
a) Organizational structure
b) Comprehensive workplan
c) Site-specific safety and
health plan
d) Safety and health training
program
e) Medical surveillance program
XIII-18
UFBTTU
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PROTOCOL
RESPONSE
COMMENTS
f) Safety and health standard
operating procedures
g) Interface between general
program and site-specific
activities.
[29 CFR 1910.120(b)(1)]
64) Confirm that a medical surveillance
program is implemented for employees
that:
a) Are exposed to hazardous
substances at or above the PEL
b) Wear a respirator 30 days or
more a year
c) Are injured, ill or develop
symptoms due to possible
overexposure to a hazardous
substance
d) Are members of a HAZMAT team.
[29 CFR 1910.120(f)(2)]
65) Confirm that medical examinations
are provided:
a) Prior to assignment
b) Every 12 months unless the
examining physician believes a
longer interval is appropriate
c) At termination or reassignment
to an area where the employee
is not covered if the employee
had an examination within the
previous six months
XIII-19
OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
d) Upon notification of symptoms
of possible overexposure to
health hazards
e) If the examining physician
determines that an increased
examination frequency is
medically necessary
[29 CFR 1910.120(f)(3)(i)]
66) Verify that medical surveillance
records are maintained for the
duration of employment plus 30 years
[29 CFR 1910.120(f) (8)] .
67) Confirm that engineering controls,
work practices and personal
protective equipment are implemented
to protect personnel from
overexposure to hazardous substances
and safety hazards [29 CFR 1910.120
(g)] -
68) Confirm that air monitoring is used
to identify and quantify airborne
levels of hazardous substances and
safety hazards to determine the
appropriate level of protection on
site [29 CFR 1910.120 (h) (ii)].
69) Verify that an emergency response
plan is developed for hazardous
waste operations [29 CFR
1910.120 (1)].
TSD Operations and Emergency Response
70) Confirm that a written safety and
health program is developed for
employees involved in hazardous
waste operations. The program
should address as appropriate:
a)
Site analysis
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PROTOCOL
RESPONSE
COMMENTS
b) Engineering controls
c) Maximum exposure limits
d) Hazardous waste handling
procedures
e) New technologies
[29 CFR 1910.120(p)(1)].
71) Verify that a medical surveillance
program is implemented in accordance
with procedures 64 through 66 of
this protocol [29 CFR 1910.120(p)
(3)] .
72) Verify that employees exposed to
health hazards receive 24 hours of
initial training and eight hours of
refresher training annually [29 CFR
1910.120(p)(7)].
(Note: With documentation that
employee work experience or training
is equivalent to initial training,
the employer need not provide
initial training) [29 CFR 1910.120
(p) (7) ] .
73) Confirm that an emergency response
plan is developed for TSD
operations. (Note: Employers who
evacuate employees during an
emergency and do not permit
employees to assist in handling the
emergency are exempt from this
requirement if an emergency action
plan has been established) [29 CFR
1910.120(p)(8)].
74) Verify that members of TSD facility
emergency response organizations are
trained to a level of competence in
the recognition of safety and health
XIII-21
OCCTTTATI'-'NA!. MFAI.TH
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PROTOCOL
RESPONSE
COMMENTS
hazards [29 CFR 1910.120(p)(8)
(iii)l-
Emergency Response to Hazardous Substance
Release
75) Confirm that an emergency response
plan is developed to handle
anticipated emergencies (Note:
Employers who evacuate employees
during an emergency and do not
permit employees to assist in
handling the emergency are exempt
from this requirement if an
emergency action plan has been
established.) [29 CFR 1910.120(q)
(1)] .
76) Verify that the emergency response
plan contains the following
elements:
a) Pre-emergency planning and
coordination with outside
parties
b) Personnel roles/ lines of
authority, training and
communication
c) Emergency recognition and
prevention
d) Safe distances and places of
refuge
e) Site security and control
f) Evacuation routes and
procedures
g) Decontamination
h) Emergency medical treatment
and first aid
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PROTOCOL
RESPONSE
COMMENTS
i) Emergency alerting and
response procedures
j) Critique of response
k) Personal protective equipment
and emergency equipment.
[29 CFR 1910.120(q)(2)].
77) Verify that employees who are
expected to participate in emergency
response are provided with the
following training:
a) First Response Awareness
Level - Demonstrate competency
in: understanding the risks
associated with an incident;
ability to recognize the
presence of hazardous
substances; ability to
identify hazardous substances;
understanding the role of the
first responder awareness
individual; and the ability to
realize the need for
additional resources and to
notify the communication
center
b) First Responder Operations
Level - Receive eight hours of
training or sufficient
experience to demonstrate
competency in the following
elements in addition to the
elements of the awareness
level: knowledge of basic
hazard and risk assessment
techniques; selection and use
of personal protective
equipment provided to the
first response level;
performing basic containment
XHI-23
OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
operations; understanding
basic hazardous material
terms; implementing basic
decontamination procedures;
and standard operating and
termination procedures
c) Hazardous Material
Technician - Receive no less
than 24 hours of training
equal to the first responder
operations level and have
competency in the following
areas: implementing emergency
response plan; classifying,
identifying and verifying
known and unknown materials
using field equipment;
functioning within an assigned
role in the incident control
system; selecting and using
personal protective equipment;
hazard and risk assessment
techniques; advance control
and containment operation;
decontamination procedures;
termination procedures; and
basic chemical toxicological
terminology and behavior
d) Hazardous Material
Specialist - Receive no less
than 24 hours of training
equal to the technician level
and, in addition, have
competency in the following
areas: implementing emergency
response plan; classifying,
identifying and verifying
known and unknown material by
using advanced field
equipment; knowledge of state
emergency response plan;
selection and use of personal
protective equipment; in depth
XIII-24
HEALTH
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PROTOCOL
RESPONSE
COMMENTS
knowledge of hazard and risk
techniques; specialized
control and containment
operations; determination and
implementation decontamination
procedures; ability to develop
a site safety and control
plan; and knowledge of
chemical, radiological and
toxicological terminology and
behavior.
e) On-Scene Incident Commander -
Receive no less than 24 hours
of training equal to the first
responder operations level; in
addition, have competency in
the following areas:
implementing incident command
center; implementing emergency
response plan; understanding
the hazards and risks
associated with personnel
working in chemical protective
clothing; implementing state
emergency response plan and
the Federal Regional Response
Team; and decontamination
procedures.
[29 CFR 1910.120(q)(6)]
78) Confirm that emergency responders
receive annual refresher training or
demonstrate competency annually [29
CFR 1910.120(q)(8)].
79) Verify that members of a HAZMAT team
and hazardous material specialists
receive baseline physical
examinations in accordance with
procedures 64 through 66 of this
protocol [29 CFR 1910.120(q)(9)].
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OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
D. Personal Protective/Emergency Response
Equipment
Determine whether the facility's personal
protective equipment program is designed
and implemented to ensure the safety of
personnel by completing the following
protocol steps.
80) Determine whether appropriate
personal protective equipment is
provided, used and maintained in a
sanitary and reliable condition [29
CFR 1910.132U) ] .
81) Verify that employees who perform
animal experimentation with toxic
substances are provided with and use
head cover, foot cover, gloves, jump
suit or complete clothing change
and, if appropriate, respiratory
protection [EPA Occupational Health
and Safety Manual 1440, Chapter 8].
82) Determine whether suitable eye
protection is provided to employees
working with machines or operations
that present a hazard from flying
objects, glare, liquids, injurious
radiation, or any combination of
these hazards [29 CFR 1910.133(a)
(1)] -
83) Evaluate the overhead and foot
exposures to determine if hazards
exist. If hazards exist, then
verify that the appropriate head and
foot protection is used [29 CFR
1910.135 and .136]
84) Verify that employees have access to
first aid supplies [29 CFR 1910.151
(b) ] .
XIII-26
orr~lTP»T TOMAt HFAt.TH
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RESPONSE
COMMENTS
85) Verify that suitable emergency eye
wash stations and showers are
provided within the immediate work
area of any operations where the
eyes or body may be exposed to
injurious corrosive materials [29
CFR 1910.151(c)] .
86) Verify that the emergency showers
and eyewash stations are plumbed and
capable of providing 15 minutes of
water, by single action activation.
(Note: Eyewashes should be capable
of washing both eyes
simultaneously.) [EPA Facilities
Safety Manual, 4870-1, FS 1-07(12)].
Emergency Eyewash and Shower (Recommended
Practices)
The following recommended emergency
eyewash and shower practices reference the
American National Standard Institute,
Emergency Eyewash and Shower Equipment,
Z358-1990 Standard.
87) Confirm that emergency showerheads
are designed and located to provide
a water column no less than 82
inches or more than 96 inches in
height [ANSI Z358.1-1990 (4.1)].
88) Verify that the emergency shower is
capable of delivering a minimum of
30 gallons per minute of water at a
velocity low enough not to be
injurious to the user [ANSI Z358.1-
1990(4.1)].
89) Confirm that the emergency shower is
designed to remain activated until
intentionally shut off [ANSI Z358.1-
1990 (4.2)].
XIII-27
OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
90) Determine whether emergency shower
and eyewash locations are identified
with a highly visible sign and the
area around the units are well-
lighted [ANSI Z358.1-1990 (4.6.2 and
5.4.5)] .
91) Verify that emergency showers and
eyewashes are activated weekly to
flush the line and to verify proper
operation [ANSI Z358.1-1990 (4.7.1
and 5.5.1)].
92) Confirm that employees are
instructed in the proper use of
emergency showers and eyewashes
[ANSI Z358.1-1990 (4.7.2 and
5.5.2)] .
93) Determine whether emergency eyewash
nozzles are protected from airborne
contaminants [ANSI Z358.1-1990
(5.1.3)] .
94) Verify that emergency shower manual
activators are located no more than
69 inches above the floor [ANSI
Z358.1-1990 (E 4.3)].
Respiratory Protection
95) Determine whether engineering
controls are feasible to prevent
occupational disease caused by
breathing atmospheric contamination
during operation of equipment or
procedures. If not, verify through
interviewing employees and reviewing
facility records that employees are
provided respiratory protection as
part of a respiratory protection
program. The respiratory protection
program should address:
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a) Written standard operating
procedures
b) Selection of respiratory
protection equipment
c) Inspection, cleaning,
maintenance and storage of
respiratory protection
equipment
d) Medical examinations
e) Work area surveillance
f) Approved respirators
g) Program evaluation
h) Training.
(Note: EPA Order 1440.3 requires
six hours of initial training and
two hours of annual refresher
training) (29 CFR 1910 . 134 (b) ].
96) Verify that respirators are not worn
when conditions prevent a good face
seal (e.g., beard growth, sideburns,
dentures) [29 CFR 1910 . 134 (e) (5)
97) Confirm that employees do not wear
contact lenses in contaminated
atmospheres with a respirator [29
CFR 1910.134(e) (5) (ii) ] .
98) Determine whether self-contained
breathing apparatuses are inspected
monthly [29 CFR 1910 . 134 (f ) (2) (ii) ] .
99) Verify that emergency use
respirators are inspected after each
use and no less than monthly. In
addition, confirm that records of
RESPONSE
COMMENTS
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emergency use respirator inspection
dates and analysis are maintained
[29 CFR 1910.134(f)(2)(i) and (iv)].
100) Determine whether respirators are
stored to protect against dust,
sunlight, heat, extreme cold,
excessive moisture, and damaging
chemicals [29 CFR 1910.134(f)(5)
(i)] .
E. Safety and Health Programs for Federal
Agencies
Using information gained from the facility
and interviews of selected employees,
evaluate the effectiveness of the
facility's Safety and Health Programs by
completing the following procedures.
Reporting and Recordkeeping Occupational
Injury and Illness
Evaluate the effectiveness of the
facility's reporting and recordkeeping
program through examination of the
following procedures.
101) Confirm that the Agency's
Occupational Safety and Health
Program poster is displayed [29 CFR
1960.12(c)] .
102) Verify through Office of Workers'
Compensation Program (OWCP)
documents that all accidents and
illnesses are promptly investigated
[29 CFR 1960.29].
103) Confirm that the facility maintains
a log and supplementary log of
occupational injuries and illnesses.
(Note: If logs are not maintained
at the facility for reasons of
RESPONSE
COMMENTS
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efficient administration, a copy of
the logs updated within 6 months of
an injury or illness occurrence
should be available at the facility)
[29 CFR 1960.67, .68 and .71].
104) Confirm that yearly totals of
injuries and illnesses are posted in
each facility by November 14. The
summary report should remain posted
for 30 consecutive days [29 CFR
1960.69 and .71(d)].
105) Verify that the occupational injury
and illness logs are maintained for
five years [29 CFR 1960.73].
106) Confirm that the facility submits an
annual narrative report describing
its occupational safety and health
program to the EPA Safety, Health,
and Environmental Management
Division [EPA Occupational Health
and Safety Manual, 1440, Chapter 3].
Inspections
107) Verify that formal (annual in-depth
evaluations), informal (unscheduled
and frequent) and walk-through
(formal documentation not required)
inspections are conducted [EPA
Occupational Health and Safety
Manual, 1440, Chapter 4].
108) Determine whether employee
representatives are afforded the
opportunity to accompany safety and
health staff during inspections of
the facility [29 CFR 1960.27 (a)].
109) Verify that the facility has
identified high risk areas and that
the areas are inspected more
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RESPONSE
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frequently than annually [29 CFR
1960.25(c)] .
110) Confirm that safety and health
inspectors issue Notices of Unsafe
and Unhealthful Working Conditions
when warranted. (Notices should
include an abatement schedule and be
posted until the hazard is abated or
for three working days, whichever is
later) [29 CFR 1960.26(c)].
Ill) Verify that the facility promptly
abates unsafe and unhealthful
working conditions in response to a
Notice of an Unsafe or Unhealthful
Working Condition. A plan should be
established for abatement of unsafe
conditions that can not be corrected
within 30 days. [29 CFR 1960.30(a)
and (c)].
112) Confirm that upon an official agency
request, reports of unsafe or
unhealthful conditions are
investigated. Investigations should
be completed with 24 hours for
imminent danger, within three
working days for potentially serious
conditions and within 20 working
days for other safety and health
risk conditions [29 CFR 1960.34(a)
(5)] .
113) Confirm that the facility conducts a
follow-up investigation to verify
that unsafe and unhealthful working
conditions are corrected [29 CFR
1960.30(b)].
114) If the facility is leased through
the General Services Administration
(GSA), determine whether the
facility coordinates with GSA to
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RESPONSE
COMMENTS
ensure that safety and health
problems are responded to prior to
renegotiation of the lease [29 CFR
1960.34(a) (8)] .
115) Verify that reports of an existing
or potential unsafe or unhealthful
working condition are recorded on a
log maintained at the facility
(Note: If the log is not maintained
at the facility, a copy of the log
updated within six months of a
report should be made available at
the facility) [29 CFR 1960. 28 (d) and
Safety and Health Committee
116) Confirm that the facility has an
active safety and health committee
that effectively represents all
employees [EPA Occupational Health
and Safety Manual, 1440, Chapter 5] .
117) Verify that the committee meets at
least quarterly, develops meeting
agendas, and records minutes [EPA
Occupational Health and Safety
Manual, 1440, Chapter 5] .
118) Evaluate the committee's policy and
procedure document to determine
whether it addresses:
a) Scope and authority
b) Frequency and location of
meetings
c) Recordkeeping
d) Attendance
[EPA Occupational Health and Safety
Manual, 1440, Chapter 5] .
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COMMENTS
Safety and Health Program Personnel
Training
119) Determine whether top managers
receive training on the requirements
of EPA's safety and health program,
Occupational Safety and Health Act,
Executive Order 12196, and 29 CFR
1960 [29 CFR 1960.54] .
120) Confirm that employees are
authorized official time to
participate in the safety and health
program [29 CFR 1960. 10 (d) ] .
121) Evaluate the facility's training
program to determine whether
supervisors (managers) receive
training in:
a) Providing and maintaining
healthful working conditions
b) EPA's safety and health
program
c) Requirements of the
Occupational Safety and Health
Act, Executive Order 12196 and
29 CFR 1960
d) Applicable safety and health
standards
e) Procedures for reporting and
investigating accidents and
illnesses
f) EPA's procedures for abatement
of hazards
[29 CF"R 1960.55] .
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COMMENTS
122) Evaluate the facility's training
program to determine whether safety
and health specialists receive
training in:
a) Developing a safety and health
program
b) Recognizing, evaluating and
controlling hazards
c) Understanding EPA's safety and
health program
d) Reviewing equipment and
facilities designs for safety
e) Analysis of accident and
illness data
[29 CFR 1960.56] .
123) Evaluate the facility's training
program to determine whether
collateral duty safety and health
personnel receive training in:
a) Understanding the Agency's
safety and health program and
requirements of the
Occupational Safety and Health
Act, Executive Order 12196, 29
CFR 1960 and safety and health
standards
b) Reporting, evaluating and
abating hazards
c) Recognizing hazards
[29 CFR 1960.58] .
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RESPONSE
COMMENTS
124) Evaluate the facility's training
program to determine whether safety
and health committee members receive
training in:
a) Understanding the Agency's
safety and health program and
requirements of the
Occupational Safety and Health
Act, Executive Order 12196 and
29 CFR 1960
b) Reporting and investigating
employee allegations/reprisals
c) Duties of committee members
d) Identifying and using safety
and health standards
[EPA Occupational Health and Safety
Manual, 1440, Chapter 7].
125) Evaluate the facility's training
program to determine whether
employees receive training that is
appropriate to the operations they
perform and their rights and
responsibilities [29 CFR 1960.59].
126) Verify that copies of the Act,
Executive Order 12196, 29 CFR 1960,
applicable safety and health
standards and details of EPA's
safety and health program are
available for employee review [29
CFR 1960.12(a)].
127) Confirm that managers and
supervisors are evaluated on their
performance in meeting the
requirements of EPA's safety and
health program [29 CFR 1960.11].
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128) Determine whether the facility has
sufficient personnel to implement
and administer the safety and health
program (Reference applicable
sections of the Management Systems
Review Protocol) [29 CFR 1960.7(c)].
Access to Employee Exposure and Medical
Records
129) Confirm that employee access to
records is provided in a reasonable
time, place, and manner. (Note: J,f
the employer can not provide access
within 15 working days, the employer
should apprise the employee or
designated representative requesting
the record within 15 working days of
the reason for delay and the
earliest date when the record can be
available.) [29 CFR 1910.20 (e)]
(Note: The employer may withhold
the specific chemical identity from
disclosable record, provided:
a) Information withheld is a
trade secret
b) All other available
information on the properties
and effects of the toxic
substance is disclosed
[29 CFR 1910. 20 (f) (2) ]
130) Verify upon initial employment and
no less than annually, that the
employer informs employees of:
a) Existence, location, and
availability of applicable
records
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RESPONSE
COMMENTS
b) Person responsible for
maintaining and providing
access to records
c) Employee's rights of access to
the records
[29 CFR 1910.20(g)(1)]
131) Verify that the employer makes the
Access To Employee Exposure and
Medical Records Standard readily
available to employees. [29 CFR
1910.20(g)(2)].
Mine Safety Training
132) Confirm that employees who enter
underground and surface mines
receive eight hours of initial and
four hours of annual refresher mine
safety training [EPA Order, 1440.4,
Mine Safety].
F. Toxic and Hazardous Substances
Evaluate the effectiveness of the
facility's management of toxic and
hazardous substances by conducting the
following investigation.
Air Contaminants (Non-Laboratory Areas)
133) Through a review of monitoring data,
determine whether employees are
exposed to substances in
concentrations in excess of their
designated exposure limit value [29
CFR 1910.1000] .
Asbestos
134) Review the facility's 1985/1986
asbestos survey and other subsequent
surveys to assess the presence of
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RESPONSE
COMMENTS
asbestos-containing material (ACM)
in the facility.
135) If ACM was identified in the survey
report (s) (and is still present in
the facility), obtain and document
your understanding of the asbestos
management program established by
the facility to prevent employee
exposure to asbestos. The
Operations and Management (O&M)
Program should include:
a) Location and description of
ACM
b) Surveillance of ACM areas
c) Procedures to control
potential fiber release
episodes, either planned or
unplanned
d) Work practices/worker
protection
e) Notification to all building
occupants, listing ACM
locations in their areas, and
how and why to avoid
disturbing the ACM
f) Recordkeeping of activities
g) Designation of an Asbestos
Program Manager
h) Training.
[EPA 20T-2003, July 1990]
136) If an occupational exposure to the
asbestos action level is expected,
verify that employee exposure has
been monitored by breathing zone air
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RESPONSE
COMMENTS
samples representative of the 8-hour
time-weighted average (TWA) of each
employee [29 CFR 1910 . 1001 (d) (1)
137) When occupational exposure to the
asbestos action level is expected,
determine whether airborne fiber
concentration monitoring is
conducted at least semi-annually to
represent with reasonable accuracy
the levels of exposure [29 CFR
1910.1001(d) (3) ] .
Formaldehyde
(Non-laboratory areas with the exception
of anatomy, histology, and pathology
laboratories)
138) Confirm that employees are neither
exposed to an airborne concentration
of formaldehyde (CAS No. 50-00-0)
that exceeds 0.75 ppm as an 8-hour
TWA nor 2 ppm as a Short Term
Exposure Limit (STEL) [29 CFR
1910.1048(c) ] .
139) Verify that employees are monitored
to determine formaldehyde exposure,
considering the following:
a) Employee exposure need not be
monitored if the employer
documents (using objective
data) that the presence of
formaldehyde or formaldehyde
releasing products can not
result in employee airborne
exposure to formaldehyde at or
above the action level (0.5
ppm as an 8-hour TWA) or the
STEL under foreseeable
conditions of use.
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RESPONSE
COMMENTS
b) When an employee's exposure is
determined from representative
sampling, the measurements
used should be representative
(as appropriate) of the
employee's full shift or short
term exposure to formaldehyde.
c) Representative samples for
each job classification in
each work area should be
collected for each shift
unless the employer can
document (with objective data)
that exposure levels for a
given job classification are
equivalent for different work
shifts.
[29 CFR 1910.1048(d)(1)]
140) Verify that all employees who may be
exposed at or above the action level
or the STEL are identified and that
their formaldehyde exposure is
accurately determined [29 CFR
1910.1048(d)(2)].
141) Confirm that the initial monitoring
process is repeated each time there
is a change in production,
equipment, process, personnel or
control measures that may result in
new or additional exposure to
formaldehyde [29 CFR 1910.1048(d)(2)
(ii)]-
142) Confirm that the employer
periodically measures and accurately
determines exposure to formaldehyde
for employees demonstrated to be
exposed at or above the action level
or STEL by initial monitoring [29
CFR 1910.1048(d) (3) (i)] .
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RESPONSE
COMMENTS
143) Determine that when employee
formaldehyde exposure exceeds the
PELs, a written plan is implemented
to reduce exposure to or below both
PELs and a written notice is
provided to employees containing a
description of corrective actions
[29 CFR 1910.1048(d)(6)].
144) Confirm that regulated areas are
established when the concentration
of airborne formaldehyde exceeds
either the TWA or the STEL and that
all entrances and access ways are
posted with signs bearing:
DANGER FORMALDEHYDE
IRRITANT AND POTENTIAL
CANCER HAZARD
AUTHORIZED PERSONNEL ONLY
[29 CFR 1910.1048(e) (1)] .
145) Determine whether regulated area
access is limited to authorized
personnel who have been trained to
recognize formaldehyde hazards [29
CFR 1910.1048(6) (2)] .
146) Verify that respirators used to
protect against formaldehyde
exposure are used only in the
following circumstances:
a) During the time needed to
install and implement feasible
engineering and work practice
controls.
b) During activities (e.g.,
maintenance, repair, and
vessel cleaning) that
engineering and work practice
controls are not feasible.
XIII-42
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RESPONSE
COMMENTS
c) In situations where feasible
engineering and work practice
controls are not yet
sufficient to reduce exposure
to or below the PELs
d) In emergencies
[29 CFR 1910.1048(g)] .
147) Confirm that contact with the eyes
and skin from liquids containing no
less than one percent formaldehyde
is prevented by the use of chemical
protective clothing made of material
impervious to formaldehyde and the
use of personal protective equipment
[29 CFR 1910.1048 (h) (1) (i)].
148) Confirm that only personnel trained
to recognize the hazards of
formaldehyde remove contaminated
material from the storage area for
cleaning, laundering, or disposal
[29 CFR 1910.1048(h)(2)(iii)].
149) Verify that change rooms (equipped
with storage facilities for street
clothes and protective clothing) are
provided for employees who are
required to change into protective
clothing [29 CFR 1910.1048 (i) (1)].
150) Verify that quick drench showers are
provided for personnel that may be
splashed with solutions containing
no less than one percent
formaldehyde [29 CFR 1910.1048(1)
(2)] .
151) Determine that acceptable eyewash
facilities are provided where there
is a possibility of an employee's
eyes being splashed with solutions
containing no less than one percent
XIII-43
OCCUPATIONAL HEALTH
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formaldehyde [29 CFR 1910.1048(1)
(3)] .
152) Confirm that a program to detect
leaks and spills, including regular
visual inspections, is developed for
operations involving formaldehyde
liquid or gas [29 CFR 1910 .1048 ( j)].
153) Verify that an equipment preventive
maintenance program is performed
regularly [29 CFR 1910 .1048 ( j) (1)].
154) Determine that a medical
surveillance program is instituted
for employees: exposed to
formaldehyde at concentrations at or
exceeding the action level or STEL;
developing symptoms or signs of
formaldehyde overexposure; or
exposed in emergencies [29 CFR
1910.1048(1) (1)] .
155) Confirm that medical examinations
are provided to employees who the
physician believes may be at
increased risk from exposure to
formaldehyde, at the time of initial
assignment and no less than annually
for employees required to wear a
respirator [29 CFR 1910.1048
(1) (4)] .
(NOTE: Formaldehyde gas, all
mixtures or solutions composed of
more than 0.1 percent formaldehyde
and materials capable of releasing
formaldehyde into the air under
reasonably foreseeable conditions of
use at concentrations no less than
0.1 ppm are subject to the following
hazard communication requirements)
[29 CFR 1910.1048(m)(1)(i)].
RESPONSE
COMMENTS
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RESPONSE
COMMENTS
156) Verify that hazard warning labels
are applied to all applicable
formaldehyde containers with the
following exceptions:
a) Signs, placards, process
sheets, batch tickets, or
operating procedures may be
used in lieu of affixing
labels to individual
stationary process containers
as long as the formaldehyde
and its hazard warning are
noted and readily accessible
to employees.
b) Portable containers into which
hazardous chemicals are
transferred from labeled
containers and which are
intended for immediate use of
the employee who performs the
transfer.
[29 CFR 1910.1048(m)(3)].
157) Determine that for materials capable
of releasing formaldehyde at levels
exceeding 0.5 ppm, labels contain
the words "Potential Cancer Hazard."
[29 CFR 1910.1048(m)(3)(iii)].
158) Confirm that MSDSs are maintained
for each formaldehyde containing
material [29 CFR 1910.1048(m)(4)].
159) Verify that a written hazard
communication program that contains
procedures for labeling MSDSs, and
employee information and training is
implemented [29 CFR 1910.1048(m)
(5)] .
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RESPONSE
COMMENTS
160) Review records to determine whether
they document that employees exposed
to formaldehyde concentrations at or
exceeding 0.1 ppm have received
information and training on the
hazards of formaldehyde at the time
of initial assignment, when a new
exposure to formaldehyde is
introduced and no less than annually
[29 CFR 1910.1048(n) (1) and (2)].
161) Evaluate the formaldehyde training
program to determine whether it
addresses :
a) 29 CFR 1910.1048 and the
contents of the MSDS
b) Medical surveillance program,
including hazards, signs and
symptoms of exposure to
formaldehyde, and adverse
reaction notification
procedures
c) Operations involving
formaldehyde and safe work
practices
d) Personal protective equipment
and clothing
e) Spills, emergencies, and
clean-up procedures
f) Engineering and work practice
controls
g) Emergency procedures
[29 CFR 1910.1048(n) (3) ] .
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RESPONSE
COMMENTS
162) Confirm that formaldehyde exposure
measurements include:
a) Date of measurement
b) Operation monitored
c) Methods of sampling and
analysis and evidence of their
accuracy and precision
d) Number, duration, time, and
results of samples
e) Type(s) of protective devices
worn
f) Names, job classifications,
social security numbers, and
exposure estimates of the
employees whose exposures are
represented by the monitoring
results.
[29 CFR 1910.1048(0)(I)].
163) Verify that a record of objective
data supporting the determination of
no employee exposure to formaldehyde
at or exceeding the action level is
maintained for employers determining
that no monitoring is required [29
CFR 1910.1048(0)(2)].
164) Evaluate the formaldehyde medical
surveillance records to determine
whether they include:
a) Name and social security
number of the employee
b) Physician's written opinion
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c) List of employee health
complaints attributed to
formaldehyde exposure
d) Medical examination results,
including medical disease
questionnaire and results of
medical tests
[29 CFR 1910.1048(0)(3)].
Bloodborne Pathogens
165) Determine through observation,
review of documentation and
interviews with selected personnel
whether employees have an
anticipated occupational exposure to
blood or other potentially
infectious material. If so, evaluate
the effectiveness of the facility's
bloodborne pathogens program by
examining the following procedures.
166) Confirm that the facility has
established an Exposure Control Plan
to minimize employee exposure. The
plan should contain the following
elements:
a) Exposure determination
b) Universal precautions
c) Hepatitis B Vaccination and
Post-Exposure Evaluation and
Follow-Up
d) Communication of hazards
e) Recordkeeping
RESPONSE
COMMENTS
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RESPONSE
COMMENTS
f) Procedure for the evaluation
of exposure incidents
[29 CFR 1910.1030 (c)]
167) Verify that the Exposure Control
Plan is available to employees, and
reviewed and updated no less than
annually or modified as appropriate
to reflect new or revised employee
positions [29 CFR 1910.1030(c)
(1) (C)] .
168) Confirm that the facility's exposure
determination contains:
a) List of occupational exposure
job classifications
b) List of tasks and procedures
in which occupational exposure
occurs
[29 CFR 1910.1030 (c)(2)].
169) Verify that universal precautions
are observed to prevent contact with
blood or other potentially
infectious material [29 CFR
1910.1030(d)(1)]-
170) Confirm that engineering and work
practice controls are used to
minimize employee exposure. (Note:
Engineering controls should be
maintained regularly to ensure
effectiveness) [29 CFR 1910.1030(d)
(2)] .
171) Confirm that contaminated reusable
sharps are placed in containers that
are:
a)
Leak proof
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b) Puncture resistant
c) Labeled or color-coded
d) Easily accessible, maintained
upright and replaced routinely
[29 CFR 1910.1030(d) (2) (viii)] .
172) Confirm that eating, drinking,
smoking, applying cosmetics and
handling contact lenses are
prohibited in areas where there is a
likelihood of occupational exposure
[29 CFR 1910.1030 (d)'(2) (ix) ].
173) Verify that food and drink are not
maintained in areas where blood or
other potentially infectious
material are present [29 CFR
1910.1030(d)(2)(xi)].
174) Confirm that mouth
pipetting/suctioning of blood or
other potentially infectious
material is prohibited [ 29 CFR
1910.1030(d)(2)(xii)].
175) Verify that specimens of blood or
other potentially infectious
material are placed in containers
which prevent leakage during
collection, handling, processing,
storage, transport, or shipping [29
CFR 1910.1030(d)(2)(xiii)].
176) Confirm that personal protective
equipment (gloves, gowns, laboratory
coats, face shields, etc.) is
accessible, used and provided [29
CFR 1910.1030(d)(3)].
177) Verify that when personal protective
equipment is removed it is placed in
a designated area for storage,
RESPONSE
COMMENTS
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washing, decontamination, or
disposal [29 CFR 1910.1030(d)(3)
(viii)].
178) Confirm that receptacles intended
for reuse which have a likelihood of
becoming contaminated with
infectious material are inspected
and decontaminated on a regularly
scheduled basis and also cleaned and
decontaminated upon visible
contamination [29 CFR 1910.1030
(d) (4) (ii) (C) ] .
179) Verify that Hepatitis B vaccine and
vaccination series are available for
personnel who have an occupational
exposure, post-exposure evaluation
and follow-up to an exposure
incident [29 CFR 1910 .1030 (f)].
180) Confirm that a confidential medical
evaluation is immediately available
following an exposure incident [29
CFR 1910.1030(f)(3)].
181) Verify that warning labels are
affixed to containers of regulated
waste, refrigerators and freezers
containing potentially infectious
material, and other containers used
to store or transport potentially
infectious material with the
following exceptions:
a) Red bags or red containers
b) Containers of blood or blood
products that are labeled and
have been released for
clinical use
c) Individual containers of
potentially infectious
material that are placed in a
RESPONSE
COMMENTS
XIII-51
OCCUPATIONAL HEALTH
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labeled container during
storage, transport or disposal
[29 CFR 1910.1030(g)(1)]
182) Confirm that personnel with an
occupational exposure participate in
a training program at the time of
initial assignment to tasks where
occupational exposure may take
place, annually thereafter, and when
modifications of tasks or new tasks
affect the employee's exposure. The
training program should include:
a) Copy of the Bloodborne
Pathogens Standard and an
explanation of its content
b) Epidemiology and symptoms of
bloodborne disease
c) Modes of transmission of
bloodborne pathogens
d) Exposure control plan
e) Methods of recognizing tasks
that may involve potentially
infectious material
f) Engineering controls, work
practices and personal
protective equipment
g) Hepatitis B vaccine
h) Emergency procedures
i) Reporting and post-exposure
evaluation
j) Signs and labels
[29 CFR 1910.1030(g)(2)]
RESPONSE
COMMENTS
XIII-52
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PROTOCOL
RESPONSE
COMMENTS
183) Verify that training records
include:
a) Date of training session
b) Summary of training session
c) Names and qualifications of
persons conducting the
training
d) Names and job titles of
persons attending the training
session.
[29 CFR 1910.1030(h) (2)]
.Recommended Practices
The following recommended biohazard safety
practices reference the Duke University
Biohazard Science Program, National
Biohazard Risk Management Program
Presentation.
184) If personnel conduct activities such
as the following, determine if the
facility has assessed and
established a risk management
strategy that includes: engineering
and work practices, personal
protective equipment, training, and
medical surveillance to control
risks associated with potential
biohazards:
a) Bioremediation
b) Marine operations
c) Wild animal collection
d) Hazardous waste site
activities
XIII-53
OCCUPATIONAL HEALTH
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PROTOCOL
e) Diving in potentially polluted
waters
f) Spill and disaster control
h) Foreign assignments.
The biohazard risk management strategy
should be in addition to the facility's
Bloodborne Pathogens program (if
applicable).
Hazard Communication (Non-Laboratory
Areas)
Determine through observation and a review
of documentation whether hazardous
chemicals are present at the facility. If
so, evaluate the effectiveness of the
program by completing steps 185 through
189 of this protocol. If hazardous
chemicals are not present at the facility,
proceed to step number 190 of the
protocol.
185) Confirm that a written hazard
communication program containing the
following elements has been
established:
a) List of hazardous chemicals
known to be present
b) Methods used to inform
employees of chemical hazards
of non—routine tasks
c) Methods used to inform
contractor employees of
hazardous chemicals of which
they may be exposed
d) Chemical labeling system
RESPONSE
COMMENTS
XIII-54
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PROTOCOL
RESPONSE
COMMENTS
e) Employee information and
training program on the
hazards if chemicals are
routinely used
f) List of warning methods
[29 CFR 1910.1200 (e)].
186) Review records to determine whether
they document that all employees
have received information and
training on hazardous chemicals in
their workplace at the time of their
initial assignment or when a new
chemical hazard is introduced [29
CFR 1910.1200 (h)]
187) Evaluate the training program to
determine whether it addresses:
a) Methods or observations used
to detect the presence or
release of a hazardous
chemical
b) Physical and health hazards of
the chemicals
c) Employee protection measures
d) Detail of the hazard
communication program
e) Labeling system
f) MSDS explanation, availability
and location
[29 CFR 1910.1200(h) (2)] .
188) Verify that each hazardous chemical
container is labeled with the
identity of the hazardous chemical
and the appropriate hazard warning
XIII-55
OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
or precaution. For containers pre-
labeled by the manufacturer,
additional labels are not required.
If chemicals are transferred from
one container to another, labeling
is required unless the chemical is
used immediately by the employee who
performed the transfer [29 CFR
1910.1200(f) (5) and (7) ] .
189) Verify that copies of MSDSs or
similar comprehensive information
are maintained for each hazardous
chemical in the workplace. This
information should be accessible to
employees during each work shift [29
CFR 1910.1200(g) (8) ] .
G. Hazardous Chemicals in Laboratories
If the facility does not perform
laboratory activities, proceed to step
number 201 of this protocol.
190) Verify that the facility implements
a Chemical Hygiene Plan that
contains the following elements:
a) Safety and health standard
operating procedures
b) Criteria to determine and
implement control measures to
reduce employee exposure to
hazardous chemicals (e.g.,
engineering controls, personal
protective equipment and
hygiene practices)
c) Methods to ensure fume hoods
and other protective equipment
are functioning properly
XIII-56
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PROTOCOL
RESPONSE
COMMENTS
d) Circumstances under which
laboratory operations require
prior approval from the
employer
e) Employee information and
training
f) Medical consultations and
medical examinations
g) Chemical Hygiene Officer
h) Additional employee protection
for work involving
particularly hazardous
substances (e.g., select
carcinogens, reproductive
toxins and substances with a
high degree of toxicity)
[29 CFR 1910.1450(6)(3)].
191) Verify that the employer updates the
Chemical Hygiene Plan and evaluates
its effectiveness at least annually
[29 CFR 1910.1450(6)(4)].
192) Review the facility's chemical
inventory for substances that appear
to be significant based on exposure
limits, quantity present, operations
and degree of toxicity. Based on
knowledge of laboratory chemical
exposures and available monitoring
data, determine if the Chemical
Hygiene Plan is capable of keeping
exposures below the action level or,
in the absence of an action level,
the PEL [29 CFR 1910.1450
(e) (1) (ii) ] .
XIII-57
OCCUPATIONAL HEALTH
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PROTOCOL
(RESPONSE
COMMENTS
193) Verify that initial employee
monitoring has been conducted for
any substance regulated by a
standard which requires monitoring
if there is reason to believe that
exposure levels for that substance
routinely exceed the action level
or, in the absence of an action
level, the PEL. If initial
monitoring data demonstrate employee
exposure levels over the action
level or the PEL, ensure the
employer is complying with exposure
monitoring provisions of the
relevant standard [29 CFR 1910.1450
(d) (1) and (2) ] .
194) Review records to verify that all
employees handling toxic substances
have received 24 hours of safety and
health training at the time of their
initial assignment and four hours of
annual refresher training thereafter
[EPA Occupational Health and Safety
Manual, 1440, Chapter 8].
195) Evaluate the training program
through interviews of selected
employees and a review of facility
records to determine if the program
effectively addresses:
a) Methods of observation used to
detect the presence or release
of a hazardous chemical
b) Physical and health hazards of
the chemical
c) Employee protection measures
d) Details of the Chemical
Hygiene Plan
XIII-58
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PROTOCOL
RESPONSE
COMMENTS
e) Signs and symptoms of
hazardous chemical exposure
f) PELs for hazardous chemicals
g) Location and availability of
the chemical hygiene plan and
reference material
[29 CFR 1910.1450(f)(4)].
196) Verify that labels on incoming
containers of hazardous chemicals
are not removed or defaced [29 CFR
1910.1450(h) (1) (i)] .
197) Verify through selected employee
interviews and a review of facility
records that copies of MSDSs are
maintained from incoming shipments
of hazardous chemicals and are
readily accessible to employees [29
CFR 1910.1450(h) (1) (ii) ] .
198) Verify the development of a
laboratory safety manual and
laboratory safety plans before toxic
substances are used [EPA
Occupational Health and Safety
Manual, 1440, Chapter 8].
199) Verify that the quantity of toxic
substances in the work area does not
exceed the amount required for use
in one week (Note: This does not
include substances located in a
specific storage area or cabinet.)
[EPA Occupational Health and Safety
Manual, 1440, Chapter 8].
200) Determine through facility tours and
MSDS review that a current inventory
of hazardous substances is
maintained [EPA Order 1440.7].
XIII-59
OCCUPATIONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
H.
201) Verify that entrances to work areas
where toxic substances are located
are posted "Caution - Toxic
Substances - Authorized Persons
Only" [EPA Occupational Health and
Safety Manual, 1440, Chapter 8].
Medical Surveillance*
202) Confirm that a pre-assignment health
assessment is provided to employees
who will work with or work in areas
where toxic substances are regularly
used [EPA Occupational Health and
Safety Manual, 1440, Chapter 8].
203)
Confirm that periodic health
assessments are provided to
employees who work with or work in
areas where toxic substances are
regularly used. The assessment
should include:
a) Names of toxic substances that
employee is exposed to
b) Probability, frequency and
extent of exposure
c)
Exposure sampling results
[EPA Occupational Health and Safety
Manual, 1440, Chapter 8].
*SHEMD is currently reviewing the Agency's Medical
Surveillance Program
XIII-60
/-"TTn IV t»T^\VTR T HE* R T Ttl
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PROTOCOL
RESPONSE
COMMENTS
I. Health Service Program
If the facility maintains a Health Service
Program, complete the applicable portions
of the protocol, steps 204 through 212.
If not, proceed to step number 213 of the
protocol.
204) Confirm that a Health Service
Program is established in localities
where there are a sufficient number
of employees to warrant providing
the service [5 U.S. Code
7901(b) (2)] .
205) Verify that the facility's Health
Service Program is limited to:
a) Treatment of on-the-job
illness and dental conditions
requiring emergency attention
b) Preemployment and other
examinations
c) Referral of employees to
private physicians and
dentists
d) Preventive programs relating
to health.
[5 U.S. Code 790KO ] .
Recommended Practices
The following recommended Health Services
Program practices reference the Department
of Health and Human Services (DHHS),
Public Health Service (PHS), Availability
of Occupational Health Services for
Federal Employees document.
XIII-61
OCCUPATZONAL HEALTH
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PROTOCOL
RESPONSE
COMMENTS
206) Determine whether the Health Service
Program provides promotion/
prevention-oriented chemical
assessment and intervention services
appropriate to the needs of the
population served [DHHS/PHS
Availability of Occupational Health
Services for Federal Employees,
Appendix 1, Table 1] .
207) Confirm that the Health Service
Program provides education-related
activities directed toward behavior
modification/risk reduction
[DHHS/PHS Availability of
Occupational Health Services for
Federal Employees, Appendix 1, Table
1] -
208) Verify that the Health Service
Program has established procedures
for assuring that its providers are
qualified and remain current in
their fields [DHHS/PHS Availability
of Occupational Health Services for
Federal Employees, Appendix 1, Table
1] .
209) Confirm that the Health Service
Program is reviewed regularly and is
appropriate and effective in meeting
the needs of the population serviced
[DHHS/PHS Availability of
Occupational Health Services for
Federal Employees, Appendix 1, Table
1] -
210) Determine whether the scope of
health services provided is made
known to facility personnel and
consistent with program-specific
goals and objectives [DHHS/PHS
Availability of Occupational Health
Services for Federal Employees,
Appendix 1, Table 1].
XIII-62
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PROTOCOL
RESPONSE
COMMENTS
211) Verify that the Health Service
Program assures access to high
quality health care services aimed
at preventing further harm to
employees who experience injury or
illness while at work, or who are
urgently in need of assistance
[DHHS/PHS Availability of
Occupational Health Services for
Federal Employees, Appendix 1, Table
1] -
212) Confirm that the Health Service
Program provides services to
evaluate and appropriately assist
employees in returning to and
remaining effective in their jobs
following illness or injury
[DHHS/PHS Availability of
Occupational Health Services for
Federal Employees, Appendix 1, Table
1] -
J. Evaluation of Findings
213) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
214) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in
working papers.
215) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
trends or identify overall patterns
or trends.
XIII-63
OCCUPATIONAL HFAt.TH
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FIRE AND LIFE SAFETY AUDIT PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA fire and life safety audit program. It is intended
to serve as a guide for planning and conducting an evaluation of operating unit-level fire
and life safety management systems and internal controls. The protocol may require additions
or revisions to meet the needs of specific operating unit assessments. The purpose of
assessing EPA facility fire and life safety management programs is to confirm that
appropriate systems are in place and functioning effectively to achieve and sustain continued
compliance with applicable fire and life safety regulations and to minimize EPA's risks.
Applicable Laws, Regulations, Policies, and Recommended Practices
The Williams-Steiger Occupational Safety and Health Act of 1970 was enacted to ensure that
employees are provided with a place of employment that is free from recognized hazards that
are likely to cause physical harm. Pursuant to the Act, the Occupational Safety and Health
Administration codified fire and life safety regulations within Title 29 Code of Federal
Regulations (CFR) 1910 - Occupational Safety and Health Standards. Title 29 CFR 1910
establishes fire and life safety standards for general industry — specifically in the areas
of hazardous material handling and storage, means of egress, and fire protection.
The EPA Facilities Safety Manual, 4870 (Draft, September 30, 1991), establishes the Agency's
fire and life safety requirements in the areas of, fire extinguishing systems, hazardous
material storage, emergency power, and means of egress.
SECTION XIV - FIRE AND LIFE SAFETY
-------
In addition, EPA, as agency policy, has chosen to comply with the National Fire Protection
Association (NFPA) Codes. In addition, individual states and local authorities may also
adopt NFPA. NFPA establishes fire and life safety standards in the areas of means of egress,
hazardous material handling and storage, and fire protection systems.
-------
FIRE AND LIFE SAFETY AUDIT PROTOCOL
Table of Contents
Section Page Number
A. Introduction XIV-1
B. Means of Egress XIV-2
C. Hazardous Materials XIV-12
D. Fire Protection XIV-14
E. Elevators XIV-24
F. Material Handling and Storage XIV-25
G. Welding, Cutting, and Brazing XIV-26
H. Evaluation of Findings XIV-27
Attachment A - Egress Capacity A-l
Attachment B - Maintenance, Testing, and Inspection Schedule for
Water-Based Sprinkler Systems B-l
SECTION XIV - FIRE AND LIFE SAFETY
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PROTOCOL
XIV. FIRE AND LIFE SAFETY MANAGEMENT
A. Introduction
Background Information
1) Review the following background
information before arriving at the
operating unit (If it is not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Facility diagrams and
floorplans
b) Descriptions of primary
facility activities/operations
c) Previous fire and life safety
audit reports or reports on
inspections of the facility
2) Review the following background
information related to fire and life
safety management programs and
activities prior to the on-site
visit (If it is not available prior
to conducting the field work, review
the information as early in the
field visit as possible):
a) EPA and facility-specific fire
and life safety directives and
orders
b) EPA and facility-specific fire
and life safety operating
manuals and procedures
c) Organizational charts and
staffing tables
RESPONSE
COMMENTS
XIV-1
FIRE AND LIFE SAFETY
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PROTOCOL
RESPONSE
COMMENTS
d) Training and employee
orientation documents
e) Emergency Action Plan
f) Applicable Federal, State and
local regulations
g) Completed facility safety,
health and environmental pre-
audit questionnaire.
Opening Meeting
3) The EPA Team Leader will meet with
the facility management and staff to
provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Audit Planning
4) Based on your initial understanding
of the facility and operations as
well as a review of the completed
pre-audit questionnaire, develop a
plan for conducting the audit.
Information Gathering and Finding
Development
5) Using the fire and life safety audit
protocol, perform the review of the
facility for compliance with
applicable policies, regulations and
recommended professional practices.
B. Means of Egress
Evaluate whether sufficient exits and
other safeguards are provided to permit
prompt escape of building occupants in
case of fire or other emergency by
verifying the following.
XIV-2
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PROTOCOL
General Requirements
6) Verify that the facility has not
installed locks or fastenings on a
means of egress that would prevent
free escape from the inside of the
building [29 CFR 1910 . 36 (b) (4) , NFPA
101, 5-2.1.5.1] .
7) Assess whether exits are provided
with due regard to the character of
the building occupancy, the number
of persons exposed, fire protection
equipment available, and the height
and type of construction of the
building to afford all occupants
convenient facilities for escape.
[29 CFR 1910.36 (b) (3) , NFPA 101,
2-3] .
8) Verify that at least two means of
egress, remotely located from each
other, are provided to minimize the
possibility that both may be blocked
by a fire or other emergency
condition [29 CFR 1910 . 36 (b) (8) ,
NFPA 101, 5-4.1.1 and 5-5.1.3].
9) Verify that exits connecting three
stories or less above or below the
level of exit discharge have a fire
resistance rating of at least 1 hour
[29 CFR 1910.37 (b) (1) , NFPA 101, 5-
10) Verify that exits connecting four or
more stories above or below the
level of exit discharge have a fire
resistance rating of at least 2
hours [29 CFR 1910 . 37 (b) (2) , NFPA
101, 5-1. 3. Kb) ] .
11) Verify that exits are protected by
approved self-closing fire doors
with fire resistance rating
RESPONSE
COMMENTS
XIV-3
FIRE AND LIFE SAFETY
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PROTOCOL
RESPONSE
COMMENTS
equivalent to the exit enclosures to
prevent the spread of fire and smoke
[29 CFR 1910. 37 (b) (3) , NFPA 101
12) Determine whether exit enclosures
have openings only for access to the
enclosure from normally occupied
space and for egress from the
enclosure [29 CFR 1910 . 37 (b) (4) ,
NFPA 101, 5-1.3.1(d) ] .
13) Determine whether exit access
requires occupants to travel through
a bathroom or other room subject to
locking except where the exit is
required to serve only the room
subject to locking [29 CFR
1910. 37(f) (3) , NFPA 101, 5-5.2.1].
14) Determine whether exit access and
the exit doors to which they lead
are designed and arranged so that
they are clearly recognizable (i.e.,
no drapery or mirrors should be
placed on or in front of the doors)
[29 CFR 1910. 37(f) (4) , NFPA 101, 5-
5.2.2] .
15) Evaluate whether exit access is
arranged so that it is not necessary
for occupants to travel toward any
area of higher hazard to reach the
nearest exit [29 CFR 1910 . 37 (f ) (5) ,
NFPA 101, 5-5.1.7] .
16) Verify that the minimum width of any
exit access is not less than 28
inches (32 inches for new
construction post-1991) and that the
maximum width is 48 inches [29 CFR
1910. 37(f) (6) , NFPA 101, 5-2.1.3.1
and 5-2.1.3.2] .
XIV-4
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PROTOCOL
17) Determine whether any exterior means
of egress (i.e., corridor outside of
a room) has dead ends in excess of
20 feet [29 CFR 1910.37(g)(5), NFPA
101, 5-5.3.5] .
18) Determine whether all exits
discharge directly to a safe access
that leads to a public way (i.e.,
street, yard, court) [29 CFR 1910.37
(h) (1), NFPA 101, 5-7.1] .
19) Evaluate whether adequate headroom
of at least 7 feet from the floor
with no projections below a 6 feet 8
inches nominal height is provided in
all means of egress [29 CFR
1910.37(i), NFPA 101, 5-1.5].
20) Determine whether stairs or ramps
are provided for any means of egress
not substantially level and having
an elevation difference exceeding 21
inches [29 CFR 1910.37 (j), NFPA 101,
5-1.6.1]
21) Verify that all doors, stairs,
ramps, passages, signs, and all
other means of egress components are
of substantial, reliable
construction and installed in a
workman-like manner (i.e., properly
installed and maintained) [29 CFR
1910.37(k)(1), NFPA 101, 5-1.7.1].
22) Determine whether means of egress
are continuously maintained free of
all obstructions or impediments to
allow instant use in the event of
fire or other emergency [29 CFR
1910.37(k)(2), NFPA 101, 5-1.7.3].
23) Verify that devices and alarms
installed on doors to restrict the
improper use of an exit are designed
RESPONSE
COMMENTS
XIV-5
FIRE AND LIFE SAFETY
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PROTOCOL
RESPONSE
COMMENTS
and installed so that they can not
impede or prevent emergency use of
the exit [29 CFR 1910 . 37 (k) (3) , NFPA
101, 5-1.7.2].
24) Evaluate whether furnishings and
decorations obstruct exits, access
thereto, egress therefrom, or
visibility thereof [29 CFR
1910.37 (1) (1) , NFPA 101, 31-
1.2.2.1] .
25) Confirm that the exit capacity for
the expected occupant load is
adequate by completing the following
evaluation for all high density
occupancies (i.e., offices,
conference rooms, dining areas, and
public assembly areas)
a) Calculate square feet per
person per floor
b) Measure the width of the means
of egress using the narrowest
point of the exit component
under consideration [NFPA 101,
5-3.2] .
c) Divide the width in inches by
the exit capacity factors (see
Attachment A) [NFPA 101, 5-
3.3.1] .
d) Compare the occupant load to
the exit capacity to verify
that adequate egress capacity
is provided. In addition,
ensure that the main exit is
capable of accommodating at
least 50 percent of the total
occupant load on that level.
[NFPA 101, 5-7.2] .
XIV-6
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PROTOCOL
Signs
26) Verify that exits and access to
exits are marked with readily
visible exit signs [29 CFR
1910.37(q)(1), NFPA 101, 5-10.1.2].
27) Verify that all doors, passageways,
or stairways which are neither exits
nor access to exits and which could
be mistaken for an exit are
identified by signs reading "NOT AN
EXIT" or similar designation [29 CFR
1910.37(q)(2), NFPA 101, 5-10.4.2].
28) Verify that all exit signs are
distinctive in color and provide
contrast with other decorations,
interior finish, or other signs [29
CFR 1910.37(q)(4), NFPA 101, 5-
10.1.5] .
29) Verify that signs with the word
"EXIT" having an arrow indicating
the appropriate direction of travel
are provided in locations where the
direction of travel to reach the
nearest exit is not immediately
apparent [29 CFR 1910.37(q) (5) ,
NFPA 101, 5-10.4.1.1].
30) Verify that exit signs are
illuminated by a reliable light
source that provides at least 5-foot
candles on the illuminated surface
[29 CFR 1910.37(q)(6), NFPA 101, 5-
10.2] .
31) Verify that exit signs have the word
"EXIT" in plainly legible lettering
at least 6 inches high with the
width of lettering at least 3/4-inch
[29 CFR 1910.37(q)(8), NFPA 101, 5-
10.2] .
RESPONSE
COMMENTS
XIV-7
FIRE AND LIFE SAFETY
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PROTOCOL
Corridors and Enclosures
32) Evaluate whether corridors used as
exit access and serving an area with
an occupant load of more than 30 are
separated from other parts of the
building by a one hour fire barrier
which extends from floor slab to
floor slab or the underside of the
roof [NFPA 101, 5-1.3.4].
33) Evaluate whether enclosing walls of
exits are arranged to provide a
continuous protected path of travel,
including landings and passageways,
to an exit discharge [NFPA 101, 5-
1.3.2] .
34) Verify that exit enclosures are not
used for any purpose that could
interfere with their use as an exit
and, if so designated, as an area of
refuge [NFPA 101, 5-1.3.3].
35) Verify that exits or exit access
doors that swing into an aisle or
passageway do not restrict the
effective minimum exit width (44-
inch) clearance [EPA, FSM, 4870, FS
1-04(6)] .
36) Verify that all doors in the means
of egress leading to an exit or exit
access are side-hinged or pivoted-
swinging type and swing in the
direction of exit travel when
serving a room or area with an
occupant load of 50 or more or a
Class A and B laboratory [29 CFR
1910.37 (f) (2) , NFPA 101, 5-2.1.4.1,
and NFPA 45, 3-4.2] .
RESPONSE
COMMENTS
XIV-8
A KIT* T-TIPI7
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PROTOCOL
Doors
37) Verify that every stair enclosure
door allows for re-entry from the
stair enclosure to the interior of
the building for fire fighting
purposes and to exit the stairway
should the fire render the lower
part of the stair unusable during
egress [NFPA 101, 5-2.1.5.2].
38) Evaluate whether doors are provided
with a knob, handle, panic bar, or
other simple type of releasing
device having an obvious method of
operation under all lighting
conditions [NFPA 101, 5-2.1.5.3].
39) Evaluate whether doors designed to
normally be kept closed in a means
of egress (e.g., door to a stair
enclosure or horizontal exit) are
self-closing and not secured in the
open position unless maintained open
by a hold-open mechanism which upon
release the door becomes self-
closing. The device should be
released upon activation of the
smoke detection system or any other
fire detection system [NFPA 101,
Sec. 5-2.1.8] .
40) Verify that power-operated doors
(actuated by sensing devices upon
the approach of a person) or doors
with power-assisted manual operation
are capable of being opened manually
to permit exit travel or closed
where necessary to safeguard the
means of egress [NFPA 101, 5-2.1.9].
41) Verify that revolving doors are not
used within 10 feet of the foot of
or top of stairs or escalators and
are capable of being collapsed into
RESPONSE
COMMENTS
XIV-9
FIRK AND MFF SAFETY
-------
PROTOCOL
a book-fold position with an
aggregate width of 36 inches [NFPA
101, 5-2.1.10.1 (b) and (c)].
RESPONSE
COMMENTS
Stairs
42) Evaluate whether stairs serving as
required means of egress are of
permanent fixed construction [NFPA
101, 5-2.2.3.1] .
43) Verify that stairs and intermediate
landings serving an exit or exit
access continue with no decrease in
width along the direction of exit
travel [NFPA 101, 5-2.2.3.3].
44) Verify that stair treads are of
uniform size, slip resistant and
free of projections or lips that
could cause occupants to trip or
fall [NFPA 101, 5-2.2.3.4].
45) Verify that activation of the
mechanical ventilation or
pressurized stair enclosure system
in a smoke proof enclosure is
initiated by a smoke detector
installed within 10 feet of the
entrance to the smoke proof
enclosure [NFPA 101, 5-2.3.10.1].
46) Verify that activation of an
automatic closing device on any door
in the smoke proof enclosure will
activate all other automatic closing
devices on doors in the smoke proof
enclosure [NFPA 101, 5-2.3.11].
47) Verify that fire barriers forming
horizontal exits are not penetrated
by ducts [NFPA 101, 5-2.4.3.3].
XIV-10
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PROTOCOL
48) Verify that handrails are installed
on both walls in stairs and ramps
with a slope exceeding 1 in 15. In
addition, handrails should be within
30 inches of all portions of the
required stair egress. [NFPA 101, 5-
2.2.4.2] .
Illumination
49) Evaluate whether floors of means of
egress are illuminated during
emergencies at all points including
angles and intersections of
corridors and passageways,
stairways, landings of stairs, and
exit doors to values of an average
of 3-foot candles measured at the
floor. During non-emergency
situations average illumination
should measure at least 5-foot
candles [EPA, FSM 4870, FS 1-06(17),
and 1-07(11)] .
50) Evaluate whether illumination in a
means of egress is arranged so that
the failure of any single lighting
unit will not leave any area in
darkness [NFPA 101, 5-8.1.4].
51) Verify that no battery operated
electric light nor any type of
portable lamp or lantern is used for
primary illumination of means of
egress [NFPA 101, 5-8.2.2].
52) Verify that emergency lighting can
be provided for a period of 1-1/2
hours in the event of failure of
normal lighting [NFPA 101, 5-
9.2.1] .
RESPONSE
COMMENTS
XIV-11
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PROTOCOL
RESPONSE
COMMENTS
53) Verify that the emergency lighting
system can be continuously in
operation or capable of repeated
automatic operation without manual
intervention [NFPA 101, 5-9.2.5].
54) Verify that emergency lighting in
laboratories provides at least 10
foot candles measured at the face of
the fume hood and at the exit door
[EPA, FSM, 4870, FS 1-06(17)].
Emergency Procedures
55) Review the facility's emergency
action plan to determine whether the
facility has established and
communicated designated actions to
ensure employee safety from fire and
other emergencies [29 CFR
1910.38 (a) (1), NFPA 101, 31-1.5.2].
56) Determine whether the types of
evacuation to be followed during
emergency circumstances have been
included in the emergency action
plan [29 CFR 1910.38(a) (4) ].
57) Verify that designated employees are
provided training on how to assist
in the safe and orderly emergency
evacuation of the building [29 CFR
1910.38 (a) (5), NFPA 101, 31-1.5.4].
C. Hazardous Materials
Evaluate the facility's program for
managing hazardous materials by performing
the following procedures.
Flammable or Combustible Materials
58) Verify that only Underwriters'
Laboratory (UL) listed or Factory
Mutual (FM) approved containers and
XIV-12
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PROTOCOL
RESPONSE
COMMENTS
portable tanks are used to store
flammable or combustible liquids [29
CFR 1910.106(d), NFPA 30, 4-2].
59) Verify that flammable liquid storage
cabinets contain not more than 60
gallons of Class I or Class II
liquids or not more than 120 gallons
of Class III liquid [29 CFR
1910.106(d)(3)(i), NFPA 30, 4-3.1].
60) Verify that storage cabinets are
labeled, "Flammable - Keep Fire
Away" [29 CFR 1910.106(d)(3)(ii),
NFPA 30, 4-3.2].
61) Verify that laboratory storage
cabinets are vented by mechanical
exhaust at a rate of 5 to 20 cubic
feet per minute (CFM). Air should be
supplied at the top of the cabinet
and exhausted from the bottom.
(Note: This requirement is waived
where prohibited by local
jurisdiction.) [EPA, FSM, 4870, FS1-
07(4) ] .
62) Verify that the quantity of liquid
outside a storage room or cabinet in
a fire area (one hour fire
resistance rating) of a building
does not exceed:
a) 25 gallons of Class IA liquids
b) 120 gallons of Class IB, 1C,
II or III liquids in
containers
c) 660 gallons of Class IB, 1C,
II or III liquids in a single
portable tank
[29 CFR 1910.106(e)(2)(ii)(b)].
XIV-13
FIRE AND LIFE SAFETY
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PROTOCOL
RESPONSE
COMMENTS
63) Verify that inside flammable liquid
storage rooms are provided with 2-
hour fire resistance construction
and are mechanically vented at a
rate of 1-CFM per square foot of
floor area. (Note: The location of
supply and exhaust ducts should be
within 12 inches of the floor on
opposite walls of the room.) [EPA
FSM, 4870, FS1-07(4), NFPA 30, 4-
4.1.4 and 4-4.1.6] .
64) Verify that the control switch for
the inside flammable storage room's
ventilation system is located
outside of the room [29 CFR
1910.106(d)(4)(iv)].
65) Verify that hazardous location
electrical wiring and equipment
within an inside storage room
containing Class I liquids is Class
I, Division II. General use wiring
is permitted where Class II and III
liquids are stored. Class I,
Division I wiring and equipment
should be provided if Class I
liquids are dispensed in the room.
[29 CFR 1910.106(d)(4)(iii), NFPA
30, 4-4.1.5].
66) Verify that adequate precautions are
taken to prevent the ignition of
flammable vapors from chemical
reactions, mechanical sparks,
smoking, and hot surfaces [29 CFR
1910.106(6)(6)(i), NFPA 30, 4-7.2].
D. Fire Protection
Using information generated from the
facility and the facility tour, verify
that the facility's fire protection system
meets applicable standards by completing
the following investigation.
XIV-14
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PROTOCOL
Portable Fire Extinguishers
67) Verify that portable fire
extinguishers are mounted and
located so that they are readily
accessible to employees [29 CFR
1910.157 (c) (1) , NFPA 10, 1-6.3].
68) Verify that no portable fire
extinguishers containing carbon
tetrachloride or chlorobromomethane
extinguishing agents are provided in
the building [29 CFR 1910.157
(c) (3)] .
69) Determine whether portable fire
extinguishers are maintained in a
fully charged and operable condition
and kept in their designated
locations [29 CFR 1910.157 (c) (4),
NFPA 10, 1-6.2] .
70) Evaluate how portable fire
extinguishers were selected and
distributed based on the classes and
size of anticipated workplace fires
[29 CFR 1910.157(d)(1), NFPA 10, 3-
2.1 and 3-3.1] .
71) Verify that the travel distance for
any employee to reach a Class A
portable fire extinguisher is not
more than 75 feet, unless approved
uniformly spaced standpipe systems
or hose stations connected to a
sprinkler system are provided for
emergency use by employees [29 CFR
1910.157(d)(2) and (3), NFPA 10, 3-
2.4] .
72) Verify that annual maintenance
checks are performed on all portable
fire extinguishers [29 CFR
1910.157(e) (3) , NFPA 10, 4-4.1].
RESPONSE
COMMENTS
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PROTOCOL
RESPONSE
COMMENTS
73) Evaluate the employee educational
program on the general principles of
fire extinguisher use and the
hazards involved with incipient
stage fire fighting if required in
the emergency action plan. Verify
that only trained personnel are
allowed to use portable fire
extinguishers. Determine whether
fire extinguisher refresher training
is provided annually to designated
employees [29 CFR 1910.157(g), NFPA
10, Appendix D-l-1] .
74) Verify that portable fire
extinguishers are inspected when
initially placed in service and
thereafter on a monthly basis. Note
whether personnel making inspections
of portable fire extinguishers
maintain records of extinguishers
identified as requiring corrective
action. Dates of portable fire
extinguisher inspections and the
initials of the person performing
the inspections should be recorded
[29 CFR 1910.157(e), NFPA 10, 4-3.1
and 4-3.4] .
75) Verify that cabinets housing
portable fire extinguishers are not
locked [NFPA 10, 1-6.4].
76) Verify that portable fire
extinguishers are not obstructed or
obscured from view [NFPA 10, 1-6.5].
77) Verify that portable fire
extinguishers are equipped with
either a label, tag, stencil, or
other form of identification to
inform the user of the contents
inside the extinguisher [NFPA 10, 1-
7] .
XIV-16
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PROTOCOL
78) Verify that portable fire
extinguishers out-of-service for
maintenance or recharge are replaced
with spare, fully operational
extinguishers of the same type and
of at least equal rating [NFPA 10,
4-4.1.4] .
79) Verify that information indicating
the month and year of inspection,
maintenance, and recharging of
portable fire extinguishers is
attached to each extinguisher on a
label or tag [NFPA 10, 4-4.3].
80) Verify that rechargeable portable
fire extinguishers are recharged
after any use or as indicated by an
inspection or when performing
maintenance [NFPA 10, 4-5.1.1].
81) Verify that support personnel
trained in inspection, testing and
maintenance of the building's fire
protection systems are available to
assist when the authorized
individual is unavailable [NFPA 13A,
1-5.5] .
Automatic Sprinkler Systems
Evaluate the effectiveness of the
facility's automatic sprinkler system by
performing the following investigation.
82) For sprinkler systems having more
than 20 sprinklers, verify that a
local waterflow alarm is provided
which sounds an audible signal on
the premises upon water flow through
the system equal to the flow from a
single sprinkler [NFPA 13, 4-
6.1.1.1]
RESPONSE
COMMENTS
XIV-17
FIRE AND LIFE SAFETY
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PROTOCOL
83) Evaluate sprinkler spacing to
determine if it provides a maximum
protection area per sprinkler with a
minimum vertical clearance between
sprinklers and materials below of at
least 18 inches [NFPA 13, 4-2.2 and
4-4.1.6]
84) Verify that the automatic sprinkler
system is continuously maintained in
reliable operating condition and
periodically inspected and tested to
assure proper maintenance [29 CFR
1910.37(m), NFPA 13, 9-1.1, NFPA 25-
2].
85) Verify that water flow tests are
performed quarterly from water
supply test pipes (main drain
valves). Note readings that vary
substantially from those previously
established or from normal readings
[NFPA 13A, 2-6.1] .
86) Determine whether the automatic
sprinkler system is provided with at
least one automatic water supply
capable of providing design water
flow for the minimum duration [NFPA
13, 5-2.2.1 and 5-2.3.1] .
87) Verify wet pipe automatic sprinkler
system piping is protected against
freezing and exterior surfaces are
protected against corrosion (where
applicable) [NFPA 13, 4-5.4.1, 4-
5.4.2] .
88) Verify that sprinklers are
(visually) checked regularly to
ensure that they are free from
corrosion, foreign material, paint,
and damage [29 CFR 1910. 37(m), NFPA
13A, 3-1.1] .
RESPONSE
COMMENTS
XIV-18
XKTTt T TW O »E»1?«PV
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PROTOCOL
89) Verify that sprinklers that are
exposed to mechanical injury are
protected with approved sprinkler
guards [NFPA 13A, 3-4].
90) Verify that sprinkler protection is
provided for all:
a) Laboratories
b) Buildings more than 75 feet in
height
c) Below grade areas
d) Group IV occupancies
e) Group II occupancies more than
1000 square feet
f) Windowless areas exceeding
1000 square feet
g) Cooling towers of combustible
construction
h) Areas reoccupied with a higher
hazard operation that exceeds
fire separation design
i) Open office plans exceeding
six pounds per square feet of
fuel load
j) Electronic equipment areas
[EPA FSM 4870, FS1-05(6)].
Fixed Extinguishing Systems (General)
Audit steps 91 through 105 apply only to
fixed systems not installed to meet an
OSHA requirement (e.g., 1910.106,.107,
.108,.109), but where the extinguishing
RESPONSE
COMMENTS
XIV-19
FIRE AND LIFE SAFETY
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PROTOCOL
RESPONSE
COMMENTS
agent may expose employees to adverse
health consequences.
91) Verify that Halon 1301 fire
extinguishing systems are not
installed in EPA facilities [EPA,
FSM, 4870 FS1-05(7)] .
92) Evaluate the procedures used when
the fixed extinguishing system
becomes inoperable. Verify that
employees are notified and
appropriate precautions are taken to
assure employee safety until the
system is restored to operating
condition [NFPA 101, 31-1.3.6].
93) Verify that threads provided for
fire department connections, hose
outlets or other threads used for
the connection of fire hoses comply
with local fire department
specifications [NFPA 13, 2-8.1].
94) Verify that a distinctive alarm
capable of being perceived above
ambient noise levels is provided to
warn building occupants of a fire
[NFPA 101, 7-6.3.6] .
95) Evaluate whether effective
safeguards are provided to warn
employees against entry into
extinguishing system discharge areas
where the atmosphere could be or
remains potentially hazardous to
employee safety and health [29 CFR
1910.160(b)(4); carbon dioxide
systems, NFPA 12, 1-5.1; dry
chemical systems, NFPA 17, 2-4.1;
halon systems, NFPA 12A, 1.5.1.2 or
12B, 1-6.1.2] .
XIV-20
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PROTOCOL
96) Verify that hazard warning or
caution signs are posted at the
entrance and inside areas protected
by fixed extinguishing systems known
to use agents in concentrations
hazardous to employee safety and
health [29 CFR 1910 .160(b) (5) ;
carbon dioxide systems, NFPA 12, 1-
5.1.2; dry chemical systems, NFPA
17, 2-4.1; halon systems, NFPA 12A,
1-5.1.2, or 12B, 1-6.1.2] .
97) Verify that carbon dioxide and foam-
water fixed extinguishing systems
are inspected and maintained
annually by a person knowledgeable
of the system [29 CFR 1910.160
(b)(6); carbon dioxide systems, NFPA
12, 1-10.3.2; foam-water systems,
NFPA 16, 7-1.1, NFPA 16A, 7-1.1].
98) Verify that dry chemical
extinguishing systems are inspected
monthly and maintained semi-annually
by a person knowledgeable of the
system [NFPA 17, 2-11.1, 2-11.3.1].
99) Verify that halon extinguishing
systems are inspected semi-annually
by trained, competent personnel
[NFPA 12A, 4-1.1, or 12B, 1-11.1].
100) Verify that the weight and pressure
of refillable extinguishing system
containers are checked at least
semi-annually [29 CFR
1910.160(b)(7); carbon dioxide
systems, NFPA 12, 1-10.3.5; halon
systems, NFPA 12A, 4.1.3, or 12B, 1-
11.1.6] .
101) Determine whether factory charged
nonrefillable containers with no
means of pressure indication are
weighed at least semi-annually
RESPONSE
COMMENTS
XIV-21
FIRE AND LIFE SAFETY
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PROTOCOL
[carbon dioxide systems, NFPA 12, 1-
10.3; halon systems NFPA 12A, 4-1.3
and 12B, 1-11.1.7].
102) Verify that inspection and
maintenance dates are recorded on
all containers by a tag attached to
the container, or in a central
location [dry chemical systems, NFPA
17, 2-11.2.1; for halon systems,
NFPA 12A, 4-1.6 or 12B, 1-11.1.8].
103) Determine whether employees
designated to inspect and maintain
fixed extinguishing systems are
trained in the functions they
perform, [carbon dioxide systems,
NFPA 12, 1-10.4; foam-water systems,
NFPA 16, 7-2, and 16A, 7-2; dry
chemical systems, NFPA 17, 2-11.1;
halon systems, NFPA 12A, 4-6] .
104) Verify that there is at least one
manual station provided for
discharge activation of each fixed
extinguishing system [carbon dioxide
systems, NFPA 12, 1-7.3.7; foam-
water systems, NFPA 16, 4-4.1 and 4-
4.2; dry chemical systems, NFPA 17,
2-6.3.4; halon systems, NFPA 12A, 2-
3.3.7 or 12B, 1-8.3.7] .
105) Verify that manual fire
extinguishing system operating
devices are identified for the
hazard which they provide protection
[carbon dioxide, NFPA 12.1-7.3.9;
dry chemical systems, NFPA 17, 2-
6.3.9; halon systems, NFPA 12A, 2-
3.3.10 or 12B, 1-8.3.10] .
RESPONSE
COMMENTS
XIV-22
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PROTOCOL
Fire Detection Systems
106) Verify that smoke detectors are
installed in the following areas:
a) Essential electronic equipment
b) Air handling systems:
1. Downstream of fan filter
in the main supply duct
if system is more than
2000 cfm
2. Return air ducts on each
floor or fire area if
air handling supplies
multiple floors
3. Elevator lobbies
(exception: sprinkled
buildings where elevator
recall is activated by
automatic fire alarms).
[EPA, FSM 4870, FS1-06(16), NFPA
90A, 4-4.2, and 72E,4-5]
Emergency Power
107) Verify that emergency power is
provided by battery generator or a
diesel powered generator and an
automatic switching scheme. Verify
that emergency power is supplied to
emergency lighting, fire safety
systems and elevators. [NFPA 72, 5-
3.3] .
Ventilation
108) Evaluate the adequacy of cooking
equipment exhaust systems. The
exhaust systems should be:
RESPONSE
COMMENTS
XIV-23
FIRK AND LIFE SAFFTY
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PROTOCOL
RESPONSE
COMMENTS
E.
a) Exhausted directly to the
outside and not contact
combustible construction
b) Manufactured of non-
combustible materials
c) Filtered, regularly
[NFPA 96, 3-5.1, 3-7.1.3, 3-1.2, 4-
2.4] .
109) Verify that automatic fire dampers
are provided in air return and
exhaust systems to maintain fire
separation areas (e.g., computer
rooms) [EPA, FSM 4870, FS1-05O),
NFPA 90A, 3-3.4.4].
Boiler/Furnace Rooms
110) Verify that the fire-rated
construction of boiler or furnace
rooms is no less than one hour fire
rating [EPA, FSM 4870, FS1-05U1)].
Ill) Verify that no flammable or
combustible materials are used in
the boiler or furnace rooms unless
the room is provided with automatic
sprinkler protection [EPA, FSM 4870,
FS1-05U1) ] .
Elevators
112) Verify that elevators with a travel
distance of 25 feet or greater are
recalled upon initiation of any fire
alarm initiating device [EPA, FSM
4870, FS1-05U5), NFPA 72, 3-7.3.1].
113) Verify that elevator lobbies and
elevator machine rooms are provided
with an approved smoke detector
(Note: Fully sprinklered buildings
XIV-24
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PROTOCOL
do not require smoke detectors in
the lobby) [EPA, FSM 4870, FS1-
05(15)] .
114) Verify that standby power is
provided to at least one elevator in
each bank and is capable of being
manually transferable to all
elevators in each bank. Confirm
that a generator located in a
separate room enclosed by at least a
2 hour fire resistive separation is
provided to supply standby power
automatically whenever there is a
loss of electrical power in the
building [NFPA 70, 620-101]
115) Verify that all elevator machine
rooms and hoist ways in government
owned buildings are vented directly
to the outside if the elevator
serves at least three floors. A
remote means should operate the
vents, and exhaust fans should be
included when serving six or more
levels. Exhaust fans should be
initiated by any area fire
detection system (sprinkler, smoke
detector, etc.) [EPA, FSM 4870,
FS1-05U5) ] .
116) Verify that elevator lobbies have
access to at least one exit which
does not require the use of a key,
tool, special knowledge, or effort
[NFPA 101, 5-4.1.5] .
F. Material Handling and Storage
117) Verify that the storage areas are
free from fire and explosion hazards
[29 CFR 1910.176(c)] .
RESPONSE
COMMENTS
XIV-25
FIRE AND LIFE SAFETY
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PROTOCOL
RESPONSE
COMMENTS
Powered Industrial Trucks
118) Verify that facilities for battery
charging include spill control, fire
protection, ventilation and
protection from physical damage [29
CFR 1910.178(g)(2), NFPA 70, 503-
14] .
119) Verify that only approved powered
industrial trucks are designated to
enter hazardous atmosphere locations
[29 CFR 1910.178(c)(2), NFPA 505, 1-
5] -
G. Welding, Cutting and Brazing
120) Verify that welding and cutting is
only conducted in fire-safe areas
[29 CFR 1910.252(a)(2)(xv), NFPA
51B, 3-1].
121) Verify that before cutting or
welding is permitted, the area is
inspected by the individual
responsible for authorization and a
written permit completed. The hot
work permit should be written and
signed by the authorizing supervisor
[29 CFR 1910.252(a)(2)(iv)].
122) Verify that oxygen-fuel gas welding
cylinders stored inside a building
are stored in a dry, protected,
ventilated area and are separated by
at least 20 feet from
combustible material [29 CFR
1910.253(b)(2)(ii), NFPA 51, 2-2.1,
2-2.2].
123) Verify that oxygen gas welding
cylinders in storage are separated
from fuel gas cylinders or
combustible materials by 20 feet or
by a noncombustible barrier at least
XIV-26
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124)
PROTOCOL
5 feet in height with a one-half
hour fire resistance rating. [29 CFR
1910.253(b) (4) (iii), NFPA 51, 2-
4.3] .
Verify that empty oxygen-fuel gas
cylinders have their valves closed
[29 CFR 1910.253(b) (2) (iii)].
H. Evaluation of Findings
125) Review actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
facility's status.
126) Review and discuss any unresolved
issues with appropriate facility
personnel. Note explanations and
the disposition of issues in working
papers.
127) Develop a written list of exceptions
and observations. Discuss this list
at a team meeting prior to the exit
conference to substantiate the
trends or identify overall patterns
or trends.
RESPONSE
COMMENTS
XIV-27
FIRE AND LIFE SAFETY
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ATTACHMENT A
EGRESS CAPACITY
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EGRESS CAPACITY
Egress capacity for approved components of means of egress shall be based on the
following:
Use
High Hazard
All Others
Stairways
inch per person
[cm per person]
0.7 [1.8]
0.3 [0.8]
Level Components and
Class A Ramps
inch per person
[cm per person]
0.4 [1.0]
0.2 [0.5]
For class B ramps used for ascent, the width per person shall be increased by 10 percent
beyond what is required for Class A ramps. Widths for Class B ramps used for decent shall
be calculated the same as for Class A ramps.
The required capacity of a corridor is the occupant load utilizing the corridor for exit
access divided by the required number of exits to which the corridor connects but shall
not be less than the required capacity of the exit to which the corridor leads.
Source: NFPA 101,5-3.3.1
1
ATTACHMENT A
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ATTACHMENT B
Maintenance, Testing and Inspection
Schedule For Water Based Fire Protection Systems
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Maintenance, Testing and Inspection
Schedule For Water Based Fire Protection Systems
Item
Gauges (dry, Pre-action deluge
systems)
Control Valves
Alarm Devices
Gauges (wet pipe systems)
Hydraulic Nameplate
Buildings
Hanger/Seismic Bracing
Piping
Sprinklers
Fire Department Connections
Valves (all types)
Alarm Devices
Main Drain
Antifreeze Solution
Gauges
Sprinklers— High Temperature
Sprinklers-Fast Response
Sprinkler
Valves (all types)
Obstruction Investigation
Activity
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Inspection
Test
Test
Test
Test
Test
Test
Test
Maintenance
Maintenance
Frequency
Weekly/Monthly
Weekly/Monthly
Monthly
Monthly
Quarterly
Annually (prior to freezing weather)
Annually
Annually
Annually
Quarterly
Quarterly
Annually
5 years
5 years
20 years and every 10 years thereafter
50 years and every 10 years thereafter
Annually or as needed
5 years or as needed
Source: NFPA 25, Table 2-1
1
ATTACHMENT B
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DIVING AND SMALL BOAT SAFETY AUDIT PROTOCOL
OPERATING UNIT: DATES OF REVIEW:
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA diving and small boat program. It is intended to
serve as a guide for planning and conducting an evaluation of operating unit-level diving and
small boat management systems and internal controls. The protocol may require additions or
revisions to meet the needs of specific operating unit assessments. The purpose of assessing
EPA diving and small boat management programs is to confirm that appropriate systems are in
place and functioning effectively to achieve and sustain compliance with applicable diving
and small boat regulations and to minimize EPA's risks.
Applicable Agency Policy and Recommended Practices
The EPA Occupational Health and Safety Manual, 1440 (March 18, 1986), establishes Agency
policy regarding commercial diving operations. This policy applies to open circuit self-
contained underwater breathing apparatus (SCBA) diving operations including: research
projects, monitoring projects, sample collection, and equipment maintenance.
To ensure that diving operations are performed safely, the EPA Diving Safety Board
established a Checklist for Inspecting Diving Programs within the Agency. This checklist
delineates recommended practices in the areas of dive equipment, dive plan, dive operations,
and postdive procedures.
The EPA Environmental Research Laboratory - Narragansett (ERL-N) Procedures for Small Boats
can be used in developing facility-specific procedures for small boat operations.
SECTION XV - DIVINC ANT TMAI.L BOAT SAFETY
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DIVING AND SMALL BOAT SAFETY PROTOCOL
Table of Contents
Section Page Number
A. Introduction XV-1
B. Diving XV-2
C. Small Boats XV-12
D. Evaluation of Findings XV-15
CMAT.T. TV1AT
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PROTOCOLS
XV. DIVING AND SMALL BOAT SAFETY PROTOCOL
A. Int roduct ion
Background Information
1) Review the following background
information before arriving at the
dive site or facility (if not
available before conducting the
field work, review the information
as early in the visit as possible):
a) Diving safety plan and/or dive
plan
b) Dive logs
c) Previous diving or small boat
safety audit reports or
reports on inspections of the
activity
2) Review the following background
information related to diving and
small boat safety management
programs prior to the site visit (if
not available prior to conducting
the field work, review the
information as early in the field
visit as possible):
a) Chapter 10 of EPA's
Occupational Health and Safety
Manual
b) Organizational staffing charts
c) Training documents
d) Medical monitoring documents
e) Draft EPA Safe Vessel
Specification Manual
RESPONSE
COMMENTS
XV-1
DIVING AND SMALL BOAT SAFETY
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PROTOCOLS
Opening Meeting
3) The EPA audit team leader will meet
with the safety and health personnel
and/or the unit diving officer and
divers to provide an overview of the
objectives, scope, methodology,
approach and reporting for the
review.
Information Gathering and Finding Development
4) Using the diving and small boat
safety audit protocol perform the
review of the diving and small boat
operations for compliance with
applicable policies and recommended
professional practices.
B.
Diving
5)
Verify that the Unit Diving Officer,
Dive Supervisor and individual
divers have been certified by the
EPA Diving Safety Committee
Chairperson [EPA Occupational Health
and Safety Manual, 1440, Chapter
10] .
6) Verify that divers participate in an
annual diving physical examination
[EPA Occupational Health and Safety
Manual, 1440, Chapter 10] .
7) Verify that working divers
(completed at least 15 dives),
senior divers (completed at least
100 dives) and diving instructors
have attended the National Oceanic
and Atmospheric Administration
(NOAA) "Diving Accident Management"
Class [EPA Occupational Health and
Safety Manual, 1440, Chapter 10].
RESPONSE
COMMENTS
XV-2
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PROTOCOLS
8) Verify that the following personal
and support equipment are available
for each dive site:
a) Flotation compensation device
b) Tank harness and weight belt
c) Tank pressure gauge
d) Diving watch
e) Decompression meter
f) Compass
g) Dive flag
h) First aid kit
i) Safety plan
j) Underwater communicator
k) Support tanks
[EPA Occupational Health and Safety
Manual, 1440, Chapter 10].
9) Verify that all dives are logged
[EPA Occupational Health and Safety
Manual, 1440, Chapter 10].
10) Verify through facility records that
all regulator valves, depth gauges
and decompression meters are
calibrated and inspected by an
appropriate specialist every 18
months [EPA Occupational Health and
Safety Manual, 1440, Chapter 10].
RESPONSE
COMMENTS
XV-3
DIVING AND SMALL BOAT SAFETY
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PROTOCOLS
RESPONSE
COMMENTS
Project Specific Information
The following recommended diving safety
practices reference the EPA Checklist for
Inspecting Diving Programs. This document was
prepared by the EPA Diving Safety Board.
11) Verify that the dive plan accurately
describes the proposed dive project.
[EPA Checklist for Inspecting Diving
Programs, 1].
12) Confirm that the objectives of the
proposed dive project are clearly
delineated. [EPA Checklist for
Inspecting Diving Programs, 1].
13) Verify that the potential hazards of
the dive are identified including
sources of pollution. [EPA Checklist
for Inspecting Diving Programs, 1].
14) Confirm that environmental
conditions are identified and
discussed in the dive plan:
a) Tidal heights
b) Water currents
c) Maximum expected water depth
during dive
d) In-water visibility
e) Weather
f) Boat/vessel traffic
[EPA Checklist for Inspecting Diving
Programs, 1].
XV-4
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PROTOCOLS
15) Verify that divers, boat operators,
and support personnel are identified
in the plan [EPA Checklist for
Inspecting Diving Programs, 1].
16) Confirm that the dive plan is
approved by the Unit Diving Officer
[EPA Checklist for Inspecting Diving
Programs, 1].
Predive Briefing And Activities
17) Verify that the following topics are
discussed prior to diving
operations:
a) Emergency evacuation
b) Accident management and
emergency equipment
c) Diver-to-diver and diver-to-
tender communications
d) Decontamination for polluted
water operations
e) Specialized diving equipment.
[EPA Checklist for Inspecting Diving
Programs, 2].
18) Verify that diving safety protocols
are reviewed (e.g. safety stop at 15
feet when repetitive diving)[EPA
Checklist for Inspecting Diving
Programs, 2].
19) Verify that the project's
description and objectives are
reviewed [EPA Checklist for
Inspecting Diving Programs, 2].
RESPONSE
COMMENTS
XV-5
DIVING AND SMALL BOAT SAFETY
-------
PROTOCOLS
20) Verify that dive teams are
identified (i.e. divemaster,
alternate divemaster, tender, and,
if needed, standby diver) during
predive activities [EPA Checklist
for Inspecting Diving Programs, 2].
21) Confirm that tank pressures are
inspected and documented before
divers enter the water [EPA
Checklist for Inspecting Diving
Programs, 2].
22) Verify that personal emergency
information (e.g., medical history)
is available for each diver [EPA
Checklist for Inspecting Diving
Programs, 2].
23) Verify that vessel traffic control
is notified during predive
activities (if necessary) [EPA
Checklist for Inspecting Diving
Programs, 2].
Operations During The Dive
24) Confirm that tenders monitoring the
divers are not performing other
functions that may interfere with
tending responsibilities [EPA
Checklist for Inspecting Diving
Programs, 3].
25) Verify that support vessels are
clear of the diving area [EPA
Checklist for Inspecting Diving
Programs, 3].
26) Confirm that appropriate dive flags
are displayed on vessels tending
divers:
RESPONSE
COMMENTS
XV-6
-------
PROTOCOLS
a) Red and white "diver down"
flag in internal or coastal
waters.
b) Red and white "diver down" and
blue and white code flag Alpha
in waters with international
vessel traffic.
c) Wire stiffeners supporting
small flags
[EPA Checklist for Inspecting Diving
Programs, 3].
27) Confirm that standby divers are
equipped and ready to provide
immediate assistance [EPA Checklist
for Inspecting Diving Programs, 3].
28) Confirm that a tender-to-diver
communication system is deployed
during diving operations (i.e.,
diver recall unit) [EPA Checklist
for Inspecting Diving Programs, 3].
29) Verify that the emergency first aid
and oxygen kits are readily
available [EPA Checklist for
Inspecting Diving Programs, 3] .
Postdive Procedures
30) Confirm that the divemaster and/or
tender monitors each diver exiting
the water for signs or symptoms of
"bubble trouble" [EPA Checklist for
Inspecting Diving Programs, 4] .
31) Verify that divers are protected
from hypothermia or hyperthermia
[EPA Checklist for Inspecting Diving
Programs, 4].
RESPONSE
COMMENTS
XV-7
DIVING AND SMALL BOAT SAFETY
-------
PROTOCOLS
32) Verify that freshwater is available
to ensure that divers can avoid
dehydration [EPA Checklist for
Inspecting Diving Programs, 4].
33) Confirm that each diver's water
depths, bottom times, and tank
pressures are documented [EPA
Checklist for Inspecting Diving
Programs, 4]
34) Confirm that a postdive report is
prepared that includes information
specific to the diving operation
(e.g., dive water depths and bottom
times, tank pressures, achievement
of objectives, hazards encountered,
malfunctions and lost equipment)
[EPA Checklist for Inspecting Diving
Programs, 4].
35) Verify that decontamination
procedures are followed when diving
in polluted water [EPA Checklist for
Inspecting Diving Programs, 4].
36) Confirm that divers clean and store
dive equipment [EPA Checklist for
Inspecting Diving Programs, 4].
Diving Personnel
37) Verify that divers are certified in
cardiopulmonary resuscitation and
first-aid training [EPA Checklist
for Inspecting Diving Programs, 5].
38) Confirm that divers receive training
in oxygen administration [EPA
Checklist for Inspecting Diving
Programs, 5].
RESPONSE
COMMENTS
XV-8
uvu-i CUKT.T. nnaT
-------
PROTOCOLS
39) Confirm that divers maintain diving
proficiency (i.e., performed a dive
within the past three months) [EPA
Checklist for Inspecting Diving
Programs, 5].
40) Verify that divers are experienced
with anticipated project conditions
(e.g. water depths, sea conditions,
water currents, or reduced in-water
visibility) [EPA Checklist for
Inspecting Diving Programs, 5].
41) Verify that divers using air
compressors are trained in safe
operating procedures [EPA Checklist
for Inspecting Diving Programs, 5].
SCUBA Equipment
42) Confirm that SCUBA cylinders have
been hydrostatically tested within
the past five years [EPA Checklist
for Inspecting Diving Programs, 6].
43) Verify that all SCUBA cylinders have
been visually inspected within the
past 12 months [EPA Checklist for
Inspecting Diving Programs, 6].
44) Verify that valves and hoses are
critically examined and replaced or
overhauled as necessary [EPA
Checklist for Inspecting Diving
Programs, 6].
45) Verify that belts and buckles are in
proper working condition [EPA
Checklist for Inspecting Diving
Programs, 6].
46) Confirm that buoyancy compensators
are maintained in proper condition
and in accordance with manufacturer
RESPONSE
COMMENTS
XV-9
DIVING AND SMALL BOAT SAFETY
-------
PROTOCOLS
specifications [EPA Checklist for
Inspecting Diving Programs, 6].
47) Confirm that buoyancy compensators
are capable of being inflated by no
less than two methods (one other
than oral) [EPA Checklist for
Inspecting Diving Programs, 6].
48) Confirm that diver communication
equipment is inspected prior to use
[EPA Checklist for Inspecting Diving
Programs, 6] .
49) Verify that a dive ladder is
available on boats (required to have
a dive ladder) to ensure that divers
can safely enter the tending vessel
[EPA Checklist for Inspecting Diving
Programs, 6].
50) Confirm that full-face masks and
dive equipment are free of corrosion
and maintained in proper operating
condition [EPA Checklist for
Inspecting Diving Programs, 6].
51) Confirm that head harnesses and
buckles are maintained in proper
operating condition [EPA Checklist
for Inspecting Diving Programs, 6].
52) Verify that manufacturer maintenance
manuals are available for the
specialized dive equipment (e.g.,
communication equipment and full-
face masks) [EPA Checklist for
Inspecting Diving Programs, 6] .
53) Verify that adequate spare parts and
repair materials are available at
the dive site [EPA Checklist for
Inspecting Diving Programs, 6].
RESPONSE
COMMENTS
xv-io
-------
PROTOCOLS
Air Compressors
54) Confirm that air compressors are
operated by experienced personnel in
accordance with manufacturer
specification [EPA Checklist for
Inspecting Diving Programs, 6 (B)].
55) Verify that maintenance is performed
and documented in an operation and
maintenance log that is maintained
with the compressor [EPA Checklist
for Inspecting Diving Programs,
6(B)].
56) Confirm that compressor relief
values are tested annually [EPA
Checklist for Inspecting Diving
Programs, 6(B)] .
First Aid Equipment
57) Confirm that emergency oxygen kits
are capable of simultaneously
serving two divers with demand
second stage regulators [EPA
Checklist for Inspecting Diving
Programs, 6(C)].
58) Verify that emergency oxygen kits
include an oxygen cylinder that is
no less than size "E" (626 liters)
[EPA Checklist for Inspecting Diving
Programs, 6 (C)] .
59) Confirm that the oxygen cylinder
regulators are maintained in
accordance with manufacturer's
specifications [EPA Checklist for
Inspecting Diving Programs, 6 (C)] .
60) Verify that oxygen kits contain a
cylinder wrench for manipulating
tank valves [EPA Checklist for
Inspecting Diving Programs, 6(C)].
RESPONSE
COMMENTS
XV-11
DIVING AND SMALL BOAT SAFETY
-------
PROTOCOLS
RESPONSE
COMMENTS
61) Verify that oxygen kit hoses,
valves, and regulators are
maintained in proper condition free
from oil and grease [EPA Checklist
for Inspecting Diving Programs,
6(0] .
62) Confirm that oxygen cylinders have
been hydrostatically tested within
the past five years [EPA Checklist
for Inspecting Diving Programs,
6(0] .
63) Confirm that the oxygen cylinder O-
rings are maintained in proper
condition [EPA Checklist for
Inspecting Diving Programs, 6 (C) ] .
64) Verify that oxygen cylinders are
stored in areas that do not exceed
125 degrees Fahrenheit [EPA
Checklist for Inspecting Diving
Programs, 6 (C) ] .
65) Verify that a fully-equipped medical
(first-aid) kit is available for
divers [EPA Checklist for Inspecting
Diving Programs, 6 (C) ] .
66) Verify that spare oxygen cylinder O-
rings are available [EPA Checklist
for Inspecting Diving Programs,
6(C) ] .
67) Confirm that an emergency use
backboard is available on the vessel
[EPA Checklist for Inspecting Diving
Programs, 6 (C) ] .
C. Small Boats
Evaluate the effectiveness of the
facility's Small Boat Safety Program by
performing the following procedures.
XV-12
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PROTOCOLS
Recommended Practices
The following recommended small boat
safety practices reference procedures
developed by the EPA Environmental
Research Laboratory - Narragansett (ERL-
N) .
68) Verify that the facility has
designated a boat safety officer to
ensure that boat safety
considerations are met.
69) Confirm that the boat safety officer
is informed of the intended work,
personnel involved, date(s) of boat
field work and expected time of
return.
Boat Trailering
70) Confirm that when trailering a boat
the vehicle operator ensures that:
a) A properly equipped towing
vehicle is employed
b) Trailer safety chains are
attached to the towing vehicle
c) Trailer tires are prop*erly
inflated
d) Trailer lights are properly
operating
e) The boat is attached to the
trailer at the bow and across
the stern
f) Loose equipment is properly
stowed aboard the boat or
carried in the towing vehicle
RESPONSE
COMMENTS
XV-13
DIVING AND SMALL BOAT SAFETY
-------
PROTOCOLS
RESPONSE
COMMENTS
Boat Operation
71)
Verify that boat operators are
experienced and knowledgeable of
boat safety.
72) Verify that the following safety
equipment is located on board the
boat:
a) Life jackets
b) Fire extinguisher
c) Anchor
d) Horn
e) Flares
f) Lights (for night use)
g) First aid kit
73)
74)
75)
Boat Return
76)
Confirm that the boat operator is
knowledgeable in its use and
maintains a working radio on board
the boat.
Verify that the boat operator
considers current weather conditions
and weather predictions before
commencing boat activities.
Confirm that personnel wear non-slip
footwear and dress for the
appropriate weather conditions.
Verify that boats, motors and
trailers are cleaned after use.
XV-14
-------
PROTOCOLS
77) Confirm that any deficiencies,
malfunctions, or damage of boat
equipment are reported to the boat
safety officer.
D. Evaluation of Findings
78) Review the actions taken to complete
each step of the audit protocol and
summarize conclusions as to the
program's status.
79) Review and discuss any unsolved
issues with appropriate facility or
diving personnel. Note explanations
and disposition in working papers.
80) Develop a written list of exceptions
and observations. Discuss the list
at a team meeting prior to the exit
conference to substantiate trends or
identify overall patterns.
RESPONSE
COMMENTS
XV-15
DIVING AND SMALL BOAT SAFETY
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