PROTOCOL FOR
CONDUCTING ENVIRONMENTAL
AUDITS OF FEDERAL FACILITIES
EPA $300-6-95-002
FEB95
2nd Edition
Prepared
by the member
agencies of the
Federal Audit
Protocol Workgroup
for the Federal
Community
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Section 11
Storage Tank Management
Appendices
Philadelphia, PA 19103
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Appendix 11-1
UST Applicability Guide
'Afr^gftfi'^P ••#:
*•'•?*••'•$*, 5i/
Underground Storage Tanks
as defined in 40 CFR 280.12
(see definitions)
Excluded USTs (see
definitions)
Deferred USTs (see
definitions)
USTs storing fuel for
emergency generators
Applicable tJFR; Citation
40 CFR 280
none
40 CFR 280.11
40 CFR 280.20 through
280.22
280.30 through 280.34
280.50 through 280.53
280.60 through 280.67
280.70 through 270.74
ChttCfcflif «» „ / /<;- - '/;
,•* , • ' f • ' "., : 9,
ST.14 through ST.46
none
ST.37
ST.14 through ST.19,
ST.21 through ST.24.
ST.29 through ST.36,
ST.38 through ST.46
A11-1
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Appendix 11-2
Schedule for Phase-In of Release Detection
(40 CFR 280.40(C))
Year system was installed
Before 1965 or date unknown
Year when release detection is required
(by December 22 of the year indicated)
RD
1965-69
P/RD
1970-74
RD
1975-79
RD
1980-86
RD
P- - must begin release detection for all pressurized piping as defined in 40 CFR 260.41 (b)(1).
RD - must begin release detection for tanks and suction piping.
A11-2
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Appendix 11-3
Release Detection Requirements for USTs and Underground Piping
(40 CFR 280.41 through 280.43)
A. UST Options (see NOTE for additional guidance)
1. Inventory control
Product inventory control must be conducted monthly to detect a release of at least 1.0 percent of
flow-through plus 130 gal on a monthly basis in the following manner
a. Inventory volume measurements for regulated substance inputs, withdrawals, and the amount
still remaining in the tank are recorded each operating day,
b. The
tanks
c. The regulated substance inputs are reconciled with delivery receipts by measurements of die
tank inventory volume before and after delivery;
d. Deliveries made through a drop tube that extends to within 1ft of the tank bottom;
e. Product dispensing is metered and recorded within the local standards of product withdrawn;
and
f. The measurement of any water level in the bottom of the tank is made to the nearest 1/8 in. at
least once a month.
2. Manual gauging
Manual tank gauging must meet the following requirements:
a. Tank liquid level measurements are taken at the beginning and end of a period of at least 36
hours during which no liquid is added to or removed from the tank;
b. Level measurements are based on an average of two consecutive stick readings at both the
beginning and end of the period;
c. The equipment used is capable of measuring die level of product over the full range of the
tank's height to the nearest 1/8 in.;
d. A leak is suspected and subject to the requirements of subpart E if die variation between
beginning and ending measurements exceeds the weekly or mondily standards of Table A
below;
e. Only tanks of 550 gal or less nominal capacity may use this as a sole method of release
detection. Tanks of 551 to 2000 gal may also use inventory control See paragraph 1 in this
appendix. Tanks of greater than 2000 gal nominal capacity may not use this method to meet
release detection requirements.
550 gal or toss
551-1000 gal
1001-2000 gal
10 gal
13 gal
26 gal
5 gal
7 gal
13 gal
A11-3
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Appendix 11-3
Release Detection Requirements for USTs and Underground Piping
(40 CFR 280.41 through 280.43)
3. Tank Tightness Testing
Tank tightness testing must be capable of detecting a 0.1 gal/hour leak rate from any portion of the
tank that routinely contains product while accounting for the effects of thermal expansion or
contraction of the product, vapor pockets, tank deformation, evaporation or condensation, and the
location of the water table.
4. Tank Automatic Gauging
Equipment for automatic tank gauging that tests for the loss of product and conducts inventory
control; must meet the following requirements:
a. The automatic product level monitor test can detect a 0.2 gal/hour leak rate from any portion of
die tank diat routinely contains product; and
b. Inventory control is conducted according to requirements (see paragraph 1 above).
5. Vapor Monitoring
Testing or monitoring for vapors within the soil gas of the excavation zone must meet the
following requirements:
a. The materials used as backfill are sufficiently porous (e.g., gravel, sand, crushed rock) to
easily allow diffusion of vapors from releases into the excavation area;
b. The stored regulated substance, or a tracer compound placed in me tank system, is sufficiently
volatile (e.g., gasoline) to result in a vapor level that is detectable by the monitoring devices
located in the excavation zone in the event of a release from the tank;
c. The measurement of vapors by the monitoring device'is not rendered inoperative by the
ground water, rainfall, or soil moisture or other unknown interferences so mat a release could
go undetected for more man 30 days;
d. The level of background contamination in the excavation zone will not interfere with the
method used to detect releases from the tank;
e. The vapor monitors are designed and operated to detect any significant increase in
concentration above background of the regulated substance stored in the tank system, a
component or components of that substance, or a tracer compound placed in the tank system;
f. In die UST excavation zone, the site is assessed to ensure compliance with the requirements of
' ' ' \ithroughivaboveandtoestablishtheniiinberandpositioriingof
monitor wells that will detect any releases within the excavation zone from any portion of the
tank that routinely contains product; and
g. Monitoring wells are clearly marked and secured to avoid unauthorized access and tampering.
6. Groundwater Monitoring
Testing or monitoring for liquids in the ground water must meet the following requirements:
a. The regulated substance stared is immiscible in water and has a specific gravity of less dian
one;
b. Groundwater is never more than 20 ft from the ground surface and the hydraulic conductivity
of the soil(s) between the UST system and the monitoring wells or devices is not less than
A11-4
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Appendix 11-3
Release Detection Requirements for USTs and Underground Piping
(40 CFR 280.41 through 280.43)
0.01 cm/s (e.g., the soil should consist of gravels, coarse to medium sands, coarse silts or
other permeable materials;
c. Hie slotted portion of die monitoring well casing must be designed to prevent migration of
natural soils or filter pack into the well and to allow entry of regulated substance on the water
table into the well under both high and low ground water conditions;
d. Monitoring wells should be sealed from the ground surface to the top of the filter pack;
e. Monitoring wells or devices intercept the excavation zone or are as close to it as is technically
f. The continuous monitoring devices or manual methods used can detect the presence of at least
1/8 in. of free product on tip of die ground water in die monitoring wells;
g. Within and immediately below the UST system excavation zone, the site is assessed to ensure
compliance with the requirements of paragraphs 6 i-v above and to establish the number and
positioning of monitoring wells or devices that will detect releases from any portion of the
tank that routinely contains product; and
h. Monitoring wells are clearly marked and secured to avoid unauthorized access and tampering.
7. Interstitial Monitoring
Interstitial monitoring between the UST system and a secondary banier immediately around or
beneath it may be used, but only if the system is designed, constructed and installed to detect a leak
from any portion of the tank that routinely contains product and also meets one of the following
requirements:
a. For double-walled systems, die sampling or testing method can detect a release through the
inner wall in any portion of the tank that routinely contains product;
b. For UST systems with a secondary barrier within die excavation zone, the sampling or testing
method used can detect a release between the UST system and the secondary barrier;
c. The secondary banier around or beneath the UST system consists of artificially constructed
material that is sufficiently thick and impermeable (at least 10-6 cm/s for the regulated
substance stored) to direct a release to the monitoring point and permit its detection;
d. The banier is compatible with the regulated substance stored so that a release from the UST
system will not cause a deterioration of the banier allowing a release to pass through
undetected;
e. For cathodically protected tanks, the secondary banier must be installed so diat it does not
interfere with die proper operation of the cathodic protection system;
f. The ground water, soil moisture, or rainfall will not render the testing or sampling method
used inoperative so mat a release could go undetected for more than 30 days;
g. The site is assessed to ensure that the secondary banier is always above the ground water and
not in a 25 year floodplain, unless the banier and monitoring designs are for use under such
conditions; or
A11-5
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Appendix 11-3
Release Detection Requirements for USTs and Underground Piping
(40 CFR 280.41 through 280.43)
h . Monitoring wells are clearly marked and secured to avoid unauthorized access and tampering.
i. For tanks with an internally fitted liner, an automated device can detect a release between the
inner wall of the tank and the liner. The liner is compatible with die substance stored
8. Other Methods
Any other type of release detection method, or combination of methods, can be used if:
a. It can detect a 0.2 gal/hour leak rate or a release of 150 gal within a month with a probability
of detection of 0.95 and a probability of false alarm of 0.05; or
b. The imlementing agency may approve another method, if it can be demonstrated that this
releases
can detect releases as effectively as the methods listed in dus appendix.
NOTE: The following are alternatives on the above listings for UST release detection options:
• USTs meeting the requirements in 40 CFR 280.20 for new tanks and die mpndily inventory
requirements in A 1 and A2 above can use tank tightness testing as outlined in A3 at least every
5 yr until 22 December 1998, or until 10 yr after the tank is installed or upgraded under 40
CFR 280.21(b),
• USTs that do not meet die standards of 40 CFR 280.20 or 280.21 may use monthly inventory
as outlined in A 1 or A2 and annual tank tightness testing done according to A3 until 22
December 1998 when the tank must be upgraded or permanently closed.
• USTs with a capacity of 550 gal or less may use weekly tank gauging done according to A2.
B. Underground Piping Options
1. Automatic Line Detectors
Methods which alert die operator to die presence of a leak by restricting or shutting off the flow of
regulated substances through piping, or triggering an audible or visual alarm may be used only if
they detect leaks of 3 gal/hour at 10 Ih/in2 tine pressure within 1 hour. An annual test of the
operation of the teak detector must be conducted in accordance with the manufacturer's
requirements.
2. Line Tightness Testing
A periodic test of piping may be conducted only if it can detect a 0. 1 gal/hour leak one and one-half
times the operating pressure.
3. Applicable Tank Methods
The methods outlined in A2 through A4 may be lused if they are designed to detect a release from
any portion of the underground piping that routinely contains regulated substances.
A11-6
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Appendix 11-3
Release Detection Requirements for USTs and Underground Piping
(40 CFR 280.41 through 280.43)
NOTE: The following is additional information on the above listings for underground piping
release detection options:
• Pressurized piping must meet both of the following:
Be equipped with an automatic line leak detector as outlined in B1
Have an annual line tightness test done according to B2 or have monthly monitoring done
in accordance with B3.
• Underground suction piping must either have a line tightness test done according to B2 at least
every 3 years or use a monthly monitoring method in accordance with B3. No release
detection is required for suction piping that is designed and constructed to meet the following
standards:
- The below-grade piping operates at less than atmospheric pressure
The below-grade piping is sloped so that the contents of the pipe will drain back into the
Storage tank is the suction is released
Only one check valve is included in each suction line
The check valve is located directly below and as close as practical to the suction pump
A method is provided that allows compliance with these standards to be readily
determined.
A11-7
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Phase 1
Section 12
Drinking Water Management
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A. Applicability
This section identifies rules, regulations, and requirements for any facility that has jurisdiction
over any public water supply system. A public water system is defined as a system for
providing piped water to the public for human consumption, if such system has at least IS
service connections or regularly serves an average of at least 25 individuals daily at least 60
days out of the year. This term includes:
1. Any collection, treatment, storage, and distribution facilities under control of the operator
of such system.
2. Any collection or pretreatment storage facilities not under such control that are used
primarily in connection with such system.
A public water system is either a community water system or a noncommunity water system
(40 CFR 141.2).
Facilities that meet all the criteria listed below are not required to comply with the
requirements of the Safe Drinking Water Act (SDWA) since, by definition, they are not
public water systems (40 CFR 141.3):
1. System consists only of distribution and storage facilities and does not have any
collection and treatment facilities.
2. The facility gets all of its water from a public water system that is owned or operated by
another party.
3. The facility does not sell water to any party.
Assessors are required to review agency, federal, state and local regulations in order to
perform' a comprehensive assessment.
This section also identifies rules, regulations, and requirements for facilities that have
underground injection control (UIC) activities. There are five classes of UIC wells:
B. Federal Legislation
1. The Safe Drinking Water Act (SDWA)
This Act, Public Law (PL) 99-339, 42 U.S. Code (USC) 201, 300f-300j-25, 6939b, 6979a,
6979b, 7401-7402, etc., is the Federal legislation which regulates the safety of drinking water
in the country. Each department, agency, and instrument of the executive, legislative, and
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12-1
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judicial branches of the Federal Government having jurisdiction over any potential source of
contaminants identified by a state program must be subject to and observe all requirements of
the state program applicable to such potential source of contaminants, both substantive and
procedural, in the same manner, and to the same extent, as any other person, including
payment of reasonable charges and fees (42 USC 300h-7(h)).
If a Federal agency has jurisdiction over any Federally owned or maintained public water
system, or is engaged in any activity resulting, or which may result in, underground water
injection which endangers drinking water, it is subject to, and must observe, any Federal,
state, and local regulations, administrative authorities, and process and sanctions respecting
the provision of safe drinking water and respecting any underground injection program in the
same manner, and to the same extent as any nongovernmental entity. This requirement
applies (42 USC 300j-6(a)):
a. To any rules, substantive or procedural (including any recordkeeping or reporting,
permits, and other requirements);
b. To the exercise of any Federal, state, or local authorities; and
c. To any process or sanction, whether enforced in Federal, state, or local courts or in any
other manner.
National primary drinking water regulations apply to each public water system in each state.
However, such regulations do not apply to a public water system (42 USC 300g):
a. Which consists only of distribution and storage facilities (and does not have any
collection and treatment facilities).
b. Which obtains all its water from, but is not owned or operated by, a public water system
to which such regulations apply;
c. Which does not sell water to any person; and
d. Which is not a carrier which conveys passengers in interstate commerce.
2. Executive Order (EO) 12088, Federal Compliance with Pollution Standards
This EO, dated 13 October 1978, requires Federally owned and operated facilities to comply
with applicable Federal, state, and local pollution control standards. It makes the head of
each executive agency responsible for seeing to it that the agencies, facilities, programs, and
Phase 1 - Section 12
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12-2
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activities the agency funds meet applicable Federal, state, and local environmental
requirements or to correct situations that are not in compliance with such requirements. In
addition, the EO requires that each agency ensure that sufficient funds for environmental
compliance are included in the agency budget.
C. State/Local Regulations
States have primary responsibility to enforce compliance with national primary drinking water
standards and sampling, monitoring, and notice requirements in conformance with 40 CFR
Part 141. U.S. Environmental Protection Agency (USEPA) executes the enforcement
responsibilities until individual state programs are approved.
States that have primacy may establish drinking water regulations, monitoring schedules and
reporting requirements more stringent than, or in addition to, those in the Federal regulations.
Generally speaking, most states who have primacy adopt drinking water regulations which
closely reflect the Federal requirements. Almost all states have achieved authorization from
USEPA to administer drinking water compliance programs including underground injection
control (UIC) programs. Some states also require certification of operators of public water
systems. Furthermore, some states require operators to receive approval of plans and
specifications prior to constructing or modifying a. public drinking water system.
D. Key Compliance Requirements
1. Plans and Records
The drinking water facility manager must keep records of actions taken to correct or repair
any part of the treatment and distribution system for at least 3 years. Plans for water system
modifications should be reviewed. Facilities are required to survey public water systems and
maintain records of those reviews (MP, 40 CFR 141.21(d) and 141.33(b)).
2. Physical Requirements for Drinking Water Systems
There will not be any cross-connection, open or potential, between a system furnishing
potable water and a system furnishing nonpotable water. All water systems shall install and
operate optimal corrosion control treatment and/or comply with corrosion control requirements
specified by the state (40 CFR 141.80(d)).
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3. Maximum Contaminant Level (MCL) Standards
Drinking water is to be supplied from sources approved by Federal, State, or local health
authorities, or treated to specific standards. Community water systems, noncommunity water
systems, except as defined under exempted water systems, and community and nontransient,
noncommunity water systems are required to meet specific MCLs for organic, inorganic, and
microbiological contaminants. These are outlined in Appendices 11-1 and 11-2 (40 CFR
141.11 (a) through 1141.1 l(c), 141.12, 141.15, 141.16(a), and 141.60 through 141.63).
4. Monitoring
The monitoring schedule and what constituents are to be monitored is based on what type, of
drinking water facility is being operated. Facilities with community water systems and/or
nontransient, non-community water systems are required to monitor for inorganic
contaminants. All public water systems are required to conduct monitoring to determine
compliance for nitrate and nitrite levels. Monitoring for Endrin is required to be done
according to specific schedules. Community and non-community water systems are required
to monitor for total coliforms and facilities are required to monitor for radioactivity in
community water systems (40 CFR 141.21 (a), 141.23, 141.24, and 141.26).
5. Total ColHorm and Turbidity Sampling
Total coliform samples are required to be collected at regular intervals throughout the month
except at systems that use only groundwater and serve 4900 people or fewer. Public water
systems that use surface water or groundwater under the direct influence of surface water and
do not practice filtration are required to collect at least one total coliform sample near the
first service connection each day the turbidity level of the source water exceeds 1
nephelometric turbidity unit (NTU). When a routine sample is total coliform-positive, the
public water system must collect a set of repeat samples within 24 hours of being notified of
the positive result. Sampling for turbidity is required to be done at public water systems that
use water obtained in whole or part from surface water sources according to a specific
schedule and any excesses reported (40 CFR 141.21 and 141.22).
6. Water Analysis
Facilities with community water systems that add a disinfectant to the water are required to
analyze for total trihalomethanes (TTHM). 'Suppliers of water for community public water
systems are required to analyze for sodium and collect samples from representative entry
points to the water distribution system and analyze for corrosivity. Bacteriological analysis of
samples used to determine compliance with MCLs must be performed in a state-approved lab
or by a state-approved individual (40 CFR 141.28, 141.30, 141.41 and 141.42).
Phase 1 - Section 12
Drinking Water Management
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7. Filtration and Disinfection
Facilities that have a public water system that uses surface water sources or groundwater
sources under direct influence of a surface water source, must provide filtration as a treatment
technique for microbiological contaminants which meets specific standards, provide
disinfection treatment by 29 June 1993, and report •specific information monthly to the state
starting 29 June 1993, or when filtrating.
8. Notification and Reporting Requirements
Records of chemical analyses are required to be kept for not less than 10 years. When
primary drinking water standards are exceeded, public notifications must be made. Facilities
that operate public water systems must send reports to the state on any failure to comply with
the applicable biological, turbidity, radioactivity, and chemical standards, and on any failure
to comply with monitoring requirements that apply (40 CFR 141.31, 141.32, and 141.33(a)).
9. Lead and Copper in Drinking Water Systems
Facilities with community or nontransient, noncommunity water systems must notify their
users about lead in drinking water systems and must meet specific standards for lead and
copper action levels and reporting requirements when these levels are exceeded. Facilities
with water systems exceeding the lead action level after the implementation of corrosion
control and source water treatment requirements are required to replace lead service lines.
Monitoring for lead and copper is required to start on a specified date, be done at a specified
number of sites. The facility is required to fulfill specific reporting requirements and retain
onsite all the original records of sampling data, analysis, reports, surveys, letters, evaluations,
state determinations, and any other pertinent documents for at least 12 years (40 CFR 141.80
through 141.90).
E. Key Compliance Definitions
1. Action Level
The concentration of lead -or copper in the water specified in 40 CFR 141.80(c) which
determines, in some cases, the treatment requirements that a water system is required to
complete (40 CFR 141.2).
2. Best Available Technology (BAT)
The best technology treatment techniques, or other means which the administrator finds,
examined for efficacy under field conditions and not solely under lab conditions that are
available (taking cost into consideration). For the purposes of setting MCLs for synthetic
organic chemicals, any BAT must be at least as effective as granular activated carbon (40
CFR 141.2).
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Drinking Water Management
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3. Coagulation
A process using coagulant chemicals and mixing by which colloidal and suspended materials
are destabilized and agglomerated into floes (40 CFR 141.2).
4. Community Water System
A public water system that serves at least IS service connections used by year round residents
or regularly serves at least 25 year-round residents (40 CFR 141.2).
5. Contaminant
Any physical, chemical, biological, or radiological substance or matter in water (40 CFR
141.2).
6. Conventional Filtration Treatment
A series of processes including coagulation, flocculation, sedimentation, and filtration
resulting in substantial paniculate removal (40 CFR 141.2).
7. Diatomaceous Earth Filtration
A process resulting in substantial paniculate removal in which (40 CFR 141.2):
a. A precoat cake of diatomaceous earth filter media is deposited on a suppon membrane
(septum), and
b. While the water is filtered by passing through, the cake on the septum, additional filter
media known as body feed is continuously added to the feed water to maintain the
permeability of the filter cake.
8. Direct Filtration
A series of processes including coagulation and filtration but excluding sedimentation
resulting in substantial paniculate removal (40 CFR 141.2).
9. Disinfectant
Any oxidant, including but not limited to chlorine, chlorine dioxide, chloramines, and ozone
added to water in any pan of the treatment or distribution process that is intended to kill or
inactivate pathogenic micro-organisms (40 CFR 141.2).
10. Disinfection
A process which inactivates pathogenic organisms in water by chemical oxidants or
equivalent agents (40 CFR 141.2).
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11. Domestic or Other Non-Distribution System Plumbing Problem
A colifomi contamination problem in a public water system with more than one service
connection that is limited to the specific service connection from which the coliform-positive
sample was taken (40 CFR 141.2).
12. Exempted Public Water Systems
The following are public water systems which are not required to meet the standards outlined
in 40 CFR 141 (40 CFR 141.3):
a. Systems which consist only of distribution and storage facilities and do not have any
collection and treatment facilities;
b. Systems that obtain all of their water from, but is not owned by or operated by, a public
water system to which 40 CFR 141 applies;
c. Systems that do not sell water to any person; and
d. Systems that are not a carrier that conveys passengers in interstate commerce.
13. Filtration
A process for removing paniculate matter from water by passage through porous media (40
CFR 141.2).
14. Flocculation
A process to enhance agglomeration or collection of smaller floe particles into larger, more
easily settleabie particles through gentle stirring by hydraulic or mechanical means (40 CFR
141.2).
15. Gross Alpha Particle Activity
The total radioactivity due to alpha particle emissions as inferred from measurements on a dry
sample (40 CFR 141.2).
16. Groundwater Under the Direct Influence of Surface Water
Refers to any water beneath the surface of the ground with:
a. Significant occurrence of insects or other macro-organisms, algae, or large-diameter
pathogens such as Giardia lamblia, or
b. Significant and relatively rapid shifts in water characteristics such as turbidity,
temperature, conductivity, or pH which closely correlate to climatological or surface
water conditions.
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Direct influence must be determined for individual sources in accordance with criteria
established by the state (40 CFR 141.2).
17. Halogen
One of the chemical elements chlorine, bromine, or iodine (40 CFR 141.2).
18. Initial Compliance Period
The first full 3 year compliance period which begins at least 18 months after promulgation,
except for Dichloromethane, 1,2,4-Trichlorobenzene, 1,1,2-Trichloroethane, Benzo(a)pyrene,
Dalapon, Di(2-ethythexyl) adipate, Di(2-ethythexyl) phthalate, Dinoseb, Diquat, Endrin,
Endothall, Glyphosate, Hexachlorobenzene, Hexachlorocyclopentadiene, Oxamyl (Vydate),
Picloram, Simazine, 2,3,7,8,-TCDD (Dioxin), Antimony, Beryllium, Cyanide (as free
Cyanide), Nickel, and Thallium, the initial compliance period means the first full 3 year
compliance period after promulgation for systems with 150 or more service connections
(January 1993 December 1995), and first full 3 year compliance period after the effective date
of the regulation (January 1996 December 1998) for systems having fewer than 150 service
connections (40 CFR 141.2).
19. Large Water System
In reference to lead and copper in.systems, this refers to a water system that serves more than
50,000 persons (40 CFR 141.2).
20. Lead Service Line
A service line made of lead which connects the water main to the building inlet and any lead
pigtail, gooseneck, or other fitting which is connected to such a lead line (40 CFR 141.2).
21. Leglonella
A genus of bacteria, some species of which have caused a type of pneumonia called
Legionaries Disease (40 CFR 141.2).
22. Management Practice (MP)
Practices that, although not mandated by law, are encouraged to promote safe operating
procedures.
23. Maximum Contaminant Level (MCL)
The maximum permissible level of a contaminant in water that is delivered to any user of a
public water system (40 CFR 141.2).
24. Maximum Contaminant Level Goal (MCLG)
Refers to the maximum level of a contaminant in drinking water at which no known or
anticipated adverse effect on the health of persons would occur, and which allows an adequate
margin of safety. MCLGs are nonenforceable health goals (40 CFR 141.2).
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25. Maximum Total Trlhalomcthane Potential
Means the maximum concentration of total trihalomethanes produced in a given water
containing a disinfectant residual after 7 days at a temperature of 25°C or above (40 CFR
141.2).
26. Medium Size Water System
In reference to lead and copper in systems, this refers to a water system that serves greater
than 3300 and less than or equal to 50,000 persons (40 CFR 141.2).
27. Near the First Service Connection
Means at one of the 20 percent of all service connections in the entire system that are nearest
the water supply treatment facility as measured by water transport time within the distribution
system (40 CFR 141.2).
28. Noncommunity Water System
A public water system that is not a community water system (40 CFR 141.2).
•
29. Nontransient, Noncommunity Water System
A public water system that is not a community water system and that regularly serves at least
25 of the same persons over 6 months per year (40 CFR 141.2).
30. Person
An individual, corporation, company, association, partnership, municipality, or state, Federal, .
or tribal agency (40 CFR 141.2).
31. Picocurie (pCi)
Quantity of radioactive material producing 2.22 nuclear transformations/nun (40 CFR 141.2).
32. Point of Disinfectant Application
The point where the disinfectant is applied and water downstream of that point is not subject
to recontamination by surface water runoff (40 CFR 141.2).
33. Point-of-Entry Treatment Device
A treatment device applied to the drinking water entering a house or building for the purpose
of reducing contaminants in the drinking water distributed throughout the house or building
(40 CFR 141.2).
34. Point-of-Use Treatment Device
A treatment device applied 'to a single tap used for the purpose of reducing contaminants in
drinking water at that one tap (40 CFR 141.2).
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35. Public Water System
A system for providing piped water to the public for human consumption, if such system has
at least IS service connections or regularly serves an average of at least 25 individuals daily
at least 60 days out of the year. This term includes:
a. Any collection, treatment, storage, and distribution facilities under control of the operator
of such system, and
b. Any collection or pretreatment storage facilities not under such control that are used
primarily in connection with such system.
A public water system is either a community water system or a noncommunity water system
(40 CFR 141.2).
36. Rent
The unit of dose equivalent from ionizing radiation to the total body or any internal organ or
organ system. A millirem (mrem) is 1/1000 of a rem (40 CFR 141.2).
37. Residual Disinfectant Concentration
("C" in CT calculations) is the concentration of disinfectant measured in mg/L in a
representative sample of water (40 CFR 141.2).
38. Sanitary Survey "
An onsite review of the water source, facilities, equipment, operation ad maintenance of a
public water system for the purpose of evaluating the adequacy of such source, facilities,
equipment, operation and maintenance for producing and distributing safe drinking water (40
CFR 141.2).
39. Sedimentation
A process for removal of solids before filtration by gravity or separation (40 CFR 141.2).
40. Slow Sand Filtration
A process involving passage of raw water through a bed of sand at low velocity (generally
less than 0.4 m/hr [1.31 ft/hr]) resulting in substantial paniculate removal by physical and
biological mechanisms (40 CFR 141.2).
41. Standard Sample
The aliquot of finished drinking water that is examined for the presence of coliform bacteria
(40 CFR 141.2).
Phase 1 - Section 12
Drinking Water Management
12-10
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42. State
The agency of the state or tribal government that has jurisdiction over public water systems.
During any period when a state or tribal government does not have primary enforcement
responsibility pursuant to Section 1413 of the SDWA (42 USC 300g-2), the term "state"
means the Regional Administrator of the USEPA (40 CFR 141.2).
43. Supplier of Water
Any person who owns or operates a public water system (40 CFR 141.2).
44. Surface Water
All water that is open to the atmosphere and subject to surface runoff (40 CFR 141.2).
45. System with a Single Service Connection
A system which supplies drinking water to consumers via a single service line (40 CFR
141.2).
46. Total Trihalomethanes (TTHM)
The sum of the concentration in mg/L of the trihalomethane compounds rounded to two
significant figures (40 CFR 141.2).
47. Trihalomethane (THM)
One of the family of organic compounds, named as'derivatives of methane, wherein three of
the four hydrogen atoms in methane are each substituted by a halogen atom in the molecular
structure (40 CFR 141.2).
48. Virus
Means a virus of fecal origin which is infectious to humans by waterbome transmission (40
CFR 141.2).
49. Waterbome Disease Outbreak
The significant occurrence of acute infectious illness, epidemiologically associated with the
ingestion of water from a public water system which is deficient in treatment, as determined
by the appropriate local or state agency (40 CFR 141.2).
Phase 1 -Section 12
Drinking Water Management
12-11
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F. Records To Review
• Bacterial and chemical analyses of drinking water, including sampling dates and
locations, dates of analyses, analytical methods used, and results of analyses
• Monthly operating reports (flow, chlorine residual, etc.)
• State and public notification of non-compliance with primary drinking water regulations
• Action taken by the facility to correct violations of primary drinking water regulations
• Sanitary surveys of the water system conducted by the installations/CW facility itself, a
private consultant, or any local, state, or Federal agency
• Public notification of non-compliance with secondary MCL for fluoride
• Variance or exemption granted to the facility for its water supply system
G. Physical Features to Inspect
• Laboratory analysis facilities
• Drinking water treatment facility
• Well sites
Phase 1 • Section 12
Drinking Water Management
12-12
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H. Guidance For Checklist Users
All Facilities
General Requirements
Standards
Monitoring/Sampling
Disinfecting and Filtration
Notification and Reporting
Lead and Copper in Drinking
Water Systems
Sole Source Aquifer
Refer To ,
Checklist Hens
DW.1 through DW.3
DW.4 through DW.6
DW.7 through DW.9
DW.1 0 through DW.29
DW.30 through DW.37
DW.38 through DW.41
DW.42 through DW.53
DW.54
Page Numbers
12-14
12-15
12-16
12-17
12-29
12-33
12-35
12-40
Phase 1 - Section 12
Drinking Water Management
12-13
-------
Compliance Category:
Drinking Water Management
Regulatory Requirements
nBViawor checks
All Facilities
DW.1. The current status of
any ongoing or unresolved
Consent Orders, Compliance
Agreements, Notices ol Violation
(NOV), Interagency Agreements,
or equivalent state enforcement
actions is required to be
examined. (A finding under this
checklist Hem will have the
enforcement action/identifying
information as the citation.)
Determine if noncomplianca issues have been resolved by reviewing a copy of the
previous report, Consent Orders, Compliance Agreements, NOVs, Interagency
agreements or equivalent State enforcement actions.
For those open items, indicate what corrective action is planned and milestones
established to correct problems.
DW.2. Facilities are required to
comply with all applicable
Federal regulatory requirements
not contained in this checklist.
(A finding under this checklist
item will have the citation of the
applied regulation as a basis of
finding.)
Determine if any new regulations have been issued since the finalization of the guide.
If so, annotate checklist to include new standards.
Determine if the facility has activities or facilities which are Federally regulated, but
not addressed in this checklist.
Verify that the facility is in compliance with all applicable and newly issued
regulations.
DW.3. Facilities are required to
comply with state and local
drinking water regulations (EO
12088, Sect. 1-1 and42USC
300h-7(h)).
Verify that the facility is abiding by state and water air quality requirements.
Verify that the facility Is operating according to permits issued by the state or local
agencies.
(NOTE: Issues typically regulated by state and local agencies include:
- more stringent contaminant level requirements certification and training
requirements
- water system surveys
• reporting requirements
• monitoring frequency
- use of groundwater
• use and maintenance of wells
- wellhead protection programs
- cross connection control and backflow prevention
• O & M practices such as: maintenance of a disinfectant residual throughout the
distribution system; proper maintenance of the distribution system; proper
disinfection of replaced or repaired mains: main flushing.)
Phase 1 - Section 12
Drinking Water Management
12-14
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Compliance Category:
Drinking Water Managame
Regulatory Requirements
Reviewer
-------
Compliance Category:
Drinking Water Management
Regulatory Requirements
Reviewer Checks
Standards
DW.7. Community water
systems, except as defined
under exempted water systems
in the definitions, are required to
meet specific MCLs for
inorganic and organic chemicals,
fluorides, radium 228, radium-
228, gross alpha particle
radioactivity, beta particles and
photon radioactivity from man-
made radionuclides (40 CFR
141.11 (a) through 141.11(c),
141.12, 141.15, and 141.16{a)).
Verify that combined radium-226 and radium-228 do not exceed 5 pCi/L
Verify that gross alpha particle radioactivity does not exceed 15 pCi/L
Verify that the average annual concentration of beta particles and photon radioactivity
from man-made radionuclides does not produce an average dose rate equal to the
total body or any internal organ greater than 4 millirems/yr.
Verify that the MCL of 4.0 mg/L for fluoride is not exceeded.
Verify that the MCLs outlined in Appendix 12-1 and 14-2 are met.
DW.8. Non-community water
systems, except as defined
under exempted water systems,
will not exceed a MCL for nitrate
of 10 mg/L (40 CFR 141.11(a)).
Verify that the nitrate level at non-community water systems does not exceed 10 mg/
L
DW.9. Community and non-
transient, non-community water
systems, except as defined
under exempted water systems,
are required to meet specific
MCLs for organic contaminants,
inorganic contaminants and
microbiological contaminants (40
CFR 141.60 through 141.63).
Verify that the standards outlined in Appendix 12-1 and 14-2 are met.
Verify that systems which collect at least 40 bacteriological samples per month ha*'
no more than 5 percent of the samples collected during a month that are total
coliform positive.
Verify that systems which collect less than 40 bacteriological samples per month have
no more than 1 sample collected per month that is total coliform positive.
Verify that there are no fecal collform-positive repeat sampling or E. coll positive
repeat samples, or any total coliform-positive repeat samples following a fecal
cotiform-positive or E coli-positive routine sample.
Phase 1 - Section 12
Drinking Water Management
12-16
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Compliance Category:
Drinking Water Management
•guMoryftequirami
Reviewer Checks
Monitoring/Sampling
DW.10. Facilities with
community water systems
and/or non-transient.
noncommunity water systems
are required to meet specific
monitoring requirements for
inorganic contaminants (40 CFR
141.23(a)).
Verify that groundwater systems:
• Take a minimum of one sample at every entry point to the distribution system which
is representative of each well after treatment beginning in the compliance period
starting 1 January 1993
- Take each sample at the same sampling point unless conditions make another
sampling point more representative of each source or treatment plant.
Verify that surface water systems:
- Take a minimum of one sample at every entry point to the distribution system after
any application of treatment or in the distribution system at a point that is
representative of each source after treatment beginning in the compliance period
starting 1 January 1993
• Takes each sample at the same sampling point unless conditions make another
sampling point more representative of each source or treatment plant.
(NOTE: In relation to these requirements, surface water systems include systems
with a combination of surface and ground sources.)
Verify that if the system draws water from more than one source and the sources are
combined before distribution, the system samples at an entry point to the distribution
system during periods of normal operating conditions.
(NOTE: The state may reduce the total number of samples which must be analyzed
by allowing the use of compositing. Composite samples from a maximum of five
sampling points are allowed if the detection limit of the method used for analysis is
less than one fifth the MCL and compositing is done In a laboratory.)
Verify that If the concentration in a composite sample is greater than or equal to one-
fifth of the MCL of any inorganic chemical, a follow-up sample is analyzed within 14
days from each sampling point included in the composite and analyzed for the
contaminants which exceeded one fifth of the MCL in the composite sample.
(NOTE: Detection limits for each analytical methods and MCLs for each inorganic
contaminant are listed in Appendix 12-3.)
Verify that for groundwater systems, inorganic monitoring is repeated at least once
every compliance period (every 3 years), and samples are taken quarterly lor at least
two quarters if a MCL is violated.
Verify that for surface water systems, inorganic sampling is repeated annually and
samples are taken quarterly for at least four quarters if a MCL is violated.
(NOTE: The state may issue a waiver reducing the required monitoring.)
Phase 1 - Section 12
Drinking Water Management
12-17
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CompHsncs Category:
Drinking Water Managarmnt
Regulatory Requirement*
Reviewer CiMCfcft
DW.11. Facilities with
community and non-transient,
non-community water systems
are required to meet specific
monitoring requirements for
asbestos (40 CFR I4i.23(b)).
Verify that asbestos is monitored during the first 3 years compliance period of each 9
years compliance cycle starting 1 January 1993.
(NOTE: The facility may apply to the state for a waiver of monitoring if they believe
that asbestos is not an issue.)
Verify that If the system is vulnerable to asbestos contamination only because of
corrosion of asbestos-cement pipe, one sample is taken at a tap served by asbestos
cement pipe and under conditions where asbestos contamination is most likely to
occur.
Verify that if the system is vulnerable to asbestos contamination due to both its
source water supply and corrosion of asbestos-cement pipe, one sample is taken at a
tap served by asbestos-cement pipe and under conditions where contamination is
most likely to occur.
Verify that when the MCL is exceeded, monitoring is done quarterly.
DW.12. Facilities with
community water systems
and/or non-transient.
noncommunity water systems
are required to meet specific
monitoring requirements for
antimony, barium, beryllium,
cadmium, chromium, cyanide,
fluoride, mercury, selenium, and
thallium (40 CFR 141.23(0).
Verify that monitoring is done as follows:
• Groundwater systems: take 1 sample at each sampling point every 3 years
- Surface water systems (or combined surface/ground): take 1 sample annually at
each sampling point
- When MCLs are exceeded, monitoring is done quarterly.
Phase 1 - Section 12
Drinking Water Management
12-16
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Compliance Category:
Drinking Water Manage
Regulatory Requirements
Reviewer Checks
DW.13. All public water
systems are required to conduct
monitoring to determine
compliance for nitrate and nitrite
levels according to specific
parameters (40 CFR 141.23(d)
and 141.23(e)).
Verify that the following schedules are met for monitoring of nitrate:
• Community and non-transient, non-community water systems served by
groundwater monitor annually starting 1 January 1993
- Community and non-transient, non-community water systems served by surface
water monitor quarterly starting 1 January 1993
- Transient non-community water systems monitor annually starting 1 January 1993.
Verify that when the MCL for nitrate are exceeded community and non-transient, non-
community water systems do repeat monitoring quarterly for at least 1 year following
any one sample in which the concentration exceeds more than 50 percent of the
MCL
(NOTE: After the initial round of quarterly sampling is completed, each community
and non-transient non-community system which is monitoring annually shall take the
subsequent samples during the quarters which previously resulted in the highest
analytical result.)
Verify that public water systems take one sample at each sampling point in the
compliance period beginning 1 January 1993 and ending 31 December 1995 for
nitrite.
(NOTE: After the initial sample, systems where an analytical result for nitrite is less
than 50 percent of the MCL will monitor at the frequency specified by the state.)
Verify that community, non-transient, non-community and transient non-community
systems repeat monitoring for nitrites quarterly for at least 1 year after any one
sample is greater than 50 percent of the MCL.
Verify that systems which are monitoring annually for nitrites take each subsequent
sample during the quarters which previously resulted in (he highest analytical result.
Verify that when nitrate or nitrite samples indicate an exceedence of the MCL, a
confirmation sample is taken within 24 hours of receipt of the results.
(NOTE: If the system is unable to take a confirmation sample within 24 hours, it must
notify consumers of the exceedence.)
Phase 1 - Section 12
Drinking Water Management
12-19
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CompUanc* Category:
Drinking Water Management
Regulatory
into
Reviewer ClMCKS
DW.14. Monitoring for Endrin is
required to be done according to
specific schedules (40 CFR
141.24(8) through I4l.24(d)).
Verify that community water systems using surface water sources'have completed
endrin analyses by 30 July 1993.
(NOTE: For community water systems, samples will be taken during the time of the
year designated by the State as most likely for pesticide contamination and the
analyses repeated at intervals specified by the state but no less frequently than every
3 years.)
Verify that when the MCL. is exceeded the State is notified within 7 days and three
additional analyses are initiated within 1 month.
Verify that when an average of four analyses exceeds the MCL level, the facility
reports to the State and gives notice to the public and continues to monitor at a
frequency designated by the State.
(NOTE Instead of the initial analyses, data for surface water acquired within one year
prior to 30 July 1992 and data for groundwater acquired within 3 years of 30 July
1992 may be substituted at the discretion of the State.)
Phase 1 - Section 12
Drinking Water Management
12-20
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Compliance Category:
Drinking Water Management
Regulatory Requirements
Reviewer Checks
DW.15. Beginning with the
initial compliance period,
monitoring of the contaminants
listed in Table 2 of Appendix 12-
1 at community and
nontransient, non-community
water systems is required to be
done according to specific
parameters (40 CFR 141.24(f)).
Verify that groundwater systems take a minimum of one sample at every entry point
of the distribution system which is representative of each well after treatment.
Verify that surface water systems (or combined surface/ground) take a minimum of
one sample at points in the distribution system that are representative of each source
or at each entry point to the distribution system after treatment.
(NOTE: For both groundwater and surface water systems, each sample must be
taken at the same sampling point unless conditions make another sampling point
more representative of each source, treatment plant, or within the distribution
system.)
Verify that if the system draws water from more than one source and the sources are
combined before distribution, the system samples at an entry point to the distribution
system during periods of normal operating conditions.
Verify that each community and non-transient non-community water system takes 4
consecutive quarterly samples for each contaminant, except vinyl chlorides.
(NOTE: If the initial monitoring for contaminants is completed by December 1992 and
none of the contaminants listed are found, then each system shall take one sample
annually starting with the initial compliance period.)
(NOTE: After a minimum of 3 years of sampling, the State may reduce the number
of samples to one each compliance period.)
Verify that If a contaminant, except vinyl chloride, is detected at a level exceeding
0.0005 mg/L in any sample, the system monitors quarterly at each sampling point
which resulted in a detection.
Verify that groundwater systems which have detected one or more of the following
two-carbon organic compounds; trichloroethylene, tetrachloroethylene, 1,2-
dichloroethane, 1.1,1-tnchloroethane, cts-1,2-dichloroethylene, trans-1,2-
dichloroethylene, or 1,1-dichloroethylene monitor quarterly for vinyl chlorides at each
sampling point at which one or more of the two-carbon organic compounds was
detected.
Verify that when the MCLs are exceeded, monitoring is conducted quarterly until the
State determines that the system is reliably and consistently below the MCL
Phase 1 • Section 12
Drinking Water Management
12-21
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Compliance Category:
Drinking Water Managemont
Regulatory Requirements
DW.16. Monrtoring for organic
contaminants listed in Table-3 of
Appendix 12-1 at community
water systems and non-
transient, noncommunity water
systems is required to be done
according to specific parameters
(40 CFR 141.24(h)).
Verify that groundwater systems take a minimum of one sample at every entry point
to the distribution system which is representative of each well after treatment.
Verify that surface water systems (or surface/ground).take a minimum of one sample
at points in the distribution system that are representative of each source or at each
entry point to the distribution system after treatment.
(NOTE: For both groundwater and surface water systems, each sample must be
taken at the same sampling point unless conditions make another sampling point
more representative of each source, treatment plant, or within the distribution
system.)
Verify that if the system draws water from more than one source and the sources are
combined before distribution, the system samples at an entry point to the distribution
system during periods of normal operating conditions.
Verify that each community and non-transient, non-community water system takes
four consecutive quarterly samples for each contaminant during each compliance
period starting 1 January 1993.
(NOTE: Systems serving more than 3300 persons which do not detect a contaminant
in the initial compliance period may reduce sampling to two quarterly samples in one
year during each repeat compliance period.)
(NOTE: Systems serving less than or equal to 3300 person that do not detect a
contaminant in the initial compliance period may reduce sampling to one sample
during each repeat compliance period.)
Verify that when an organic contaminant is detected (see Appendix 12-4), the system
monitors quarterly at each sampling point that resulted in a detection.
Verify that if monitoring results in detection of one or more of aldicarb, aidicarb
sulfone, aldicarb sulfoxide, and heptachlor, heptachlor epoxide then subsequent
monitoring analyzes for all related contaminants.
(NOTE: The State may reduce the number of samples required and/or the frequency
of sampling.)
Phase 1 - Section 12
Drinking Water Management
12-22
-------
Compliance Category;
Drinking'
Regulatory Requirements
Reviewer Checks
DW.17. Community and non-
transient, noncommunity water
systems are required to monitor
lor specific organic and
inorganic contaminants (40 CFR
141.35 and 141.40(a) through
141.40(m)).
Verify that monitoring is being done for the following contaminants: Chloroform;
Bromodlchloromethane; Bromoform; Chlorodibromomethane; Chlorobenzene; n>
Dichlorobenzene; 1,1-Dichloropropene; 1,1-Dichloroethane; 1,1,2,2-Tetrachlofoethane;
1,3-Dichloropropane; Chloromethane; Bromomethane; 1,2,3-Trichloropropane;
1,1,1.2-Tetrachtoroethane; Chloroethane; 2,2,-Dichloropropane; o-Chlorotoluene; p-
Chtorotoluene; Bromobenzene; 1,3-Dichloropropene.
Verify that surface water systems sample at points in the distribution system that are
representative of each water source or at entry point to the distribution system after
any application of treatment.
Verify that for surface water systems, the minimum number of samples taken is one
year of quarterly samples per water system.
Verify that groundwater systems sample at points 'of entry to the distribution system.
representative of each well after any application of treatment.
Verify that for groundwater systems the minimum number of samples taken is one
sample taken per entry point to the distribution system.
Verify that initial monitoring was done by the dates specified in the following, and that
all community and non-transient, non-community water systems repeat the monitoring
every 5 years after the specified dates:
Number of persons served
Over 10,000
3300 to 10,000
less than 3300
Monitoring to Begin No Later Than:
1 January 1988
1 January 1389
1 January 1991
(NOTE: Public water systems may use monitoring data collected any time after 1
January 1983 to meet the requirements for unregulated monitoring, provided the
monitoring program was consistent with these requirements. Additionally the results
of USEPA's Groundwater Supply Survey may be used in a similar manner for
systems supplied by a single well.)
(NOTE: The State may require monitoring of additional contaminants.)
(NOTE: Instead of doing the monitoring required here, a community water system or
non-transient, non-community water system serving fewer than 150 service
connections may send a letter to the State by 1 January 1991 stating that the system
is available for sampling.)
Verify that the facility notifies the systems users of the availability of the results of
sampling.
Verify that the facility sends copies of the monitoring results within 30 days after
public notification.
Phase 1 - Section 12
Drinking Water Management
12-23
-------
Compliance Cstecfoiy;
Drinking Water Management
Regulatory Requirement*
GfWClCtt
DW.18. Monitoring of specific
contaminants must be
completed by 31 December
1995 (40 CFR 141.35 and
141.40(n)).
Verify that the substances listed in Appendix 12-5 are monitored for by 31 December
1995.
Verify that each community and non-transient, non-community water systems takes
four consecutive quarterly samples for the unregulatedjOrgante contaminants listed in
Appendix 12-5 at each sampling point and reports the results to the State.
Verify that each community and non-transient non-community water system takes one
sample at each sampling points for the unregulated inorganic compounds listed in
Appendix 12-5 and reports the results to the State.
Verify that groundwater systems take a minimurp of one sample at every entry point
to the distribution system which is representative of each well after treatment and that
each sample is taken from the same sampling point unless conditions make another
sampling point more representative of each source or treatment.
Verify that surface water systems, including systems with a combination of surface
and ground sources, take a minimum of one sample at points in the distribution
system that are representative of each source or at each entry point to the distribution
system after treatment and that each sample is taken from the same sampling point
unless conditions make another sampling point more representative of each source or
treatment.
Verify that if the system draws water from more than one source and the sources are
combined before distribution, the system samples at the entry point to the distribut'
system during periods of normal operating conditions.
Verify that the facility notifies the systems users of the availability of the results of
sampling.
Verify that the facility sends copies of the monitoring results within 30 days after
public notification.
DW.19. Community water
systems, except as defined as
exempted water systems, are
required to monitor for total
coliforms at a frequency based
on the population served by the
system (40 CFR I41.2l(a)(2».
Verify that the facility's community water systems is sampling according to the
schedule in Appendix 12-5.
Phase 1 - Section 12
Drinking Water Management
12-24
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Compliance Category:
Drinking Water Management
Regulatory Requirements
Reviewer Checks
DW.20. Non-community water
systems, except as defined
under exempted water systems,
are required to monitor for total
conforms according to a specific
schedule (40CFR 141.21(a)(3)).
Verify that non-community water systems using only groundwater (except
groundwater under the direct influence of surface water) and serving 1000 persons or
less, monitors each calendar quarter the system provides water to the public.
Verify that the following non-community water systems are monitoring for total
coliforms according to the schedule outlined in Appendix 12-6:
- Systems using only groundwater (except groundwater under the direct influence of
surface water) and serving more than 1000 persons during any month
• Systems using surface water, in total or in part
- Systems using groundwater under the direct influence of surface water.
DW.21. Total conform samples
are required to be collected at
regular time intervals throughout
the month except at system
which use only groundwater and
serves 4900 person or fewer (40
CFR 14
Verify that total colrform samples are collected at regular intervals.
(NOTE: Systems which use groundwater (except groundwater under the influence of
surface water) and serves 4900 persons or fewer may collect all required samples on
a single day il they are being taken from different sites.)
DW.22. Public water systems
that use surface water or
groundwater under the direct
influence of surface water that
do not practice filtration are
required to collect at least one
total coliform sample near the
first service connection each
day the turbidity level of the
source water exceeds 1 NTU
(40CFR 141.21(a)(5)).
Verify that when the turbidity exceeded 1 NTU, total colrform samples were taken
within 24 hours of the first exceedence by reviewing the records on turbidity levels.
Phase 1 - Section 12
Drinking Water Management
12-25
-------
Compliance Category:
Drinking Water Manasammt
Regulatory Requirements
ROVWWttT CROCKS
DW.23. When a routine sample
is total coliformpositive, the
public water system must collect
a set of repeat samples within
24 hours of being notified of the
positive result (40 CFR
141.21 (b)(l) through
141.21(b)(4), and 141.21(e)(1)).
Verify that if more than one routine sample per nionth is collected, at least three
repeat samples are taken for each total coliform-positive sample found.
Verify that if one or less routine sample per month is collected, no less than four
repeat samples are collected for each total coliform-positive sample found.
Verify that at least one of the repeat samples is collected from the sampling tap
where the original total col'rfomn positive sample was taken.
Verify that at least one repeat sample was taken at a tap within five service
connections upstream and at least one repeat sample at a tap within five service
connections downstream of the original sampling site.
Verify that the sampling process is repeated until either total coliforms are not
detected in one complete set of repeat samples or the system determines that the
MCL for total coliforms is exceeded and the State is notified.
Verify that all repeat samples are collected on the same day.
Verify that if one or more of the repeat samples is total coliform-positive, an additional
set of repeat samples is collected within 24 hours of notification of the positive result.
Verify that if a repeat sample Is total coliform-positive it is also analyzed for fecal
coliforms.
(NOTE: The system may test for E. coli instead of fecal coliforms.)
DW.24. Sampling for turbidity is
required to be done at public
water systems which must
install filtration according to a
specific schedule until the time
at which the systems installs
filtration (40 CFR 141.22).
Verify that suppliers of water for both community and non-community water systems
sample for turbidity at a representative entry point to the water distribution system at
least once daily.
Verify that when the turbidity levels are exceeded immediate resampling is done.
Verily that the state is notified within 48 hours.
(NOTE: These systems must monitor for turbidity according to 40 CFR 141.73 and
141.74.)
Phase 1 - Section 12
Drinking Water Management
12-26
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Compliance Category:
Drinking
er Manage
ent
Regulatory Requirements
Reviewer Checks
DW.25. Facilities are required
to monitor for radioactivity in
community water systems (40
CFR 14126).
Verify that compliance for standards of gross alpha particle activity, radium-226 and
radium-228 are based on an annual composite of 4 consecutive samples that are
obtained at quarterly intervals or the average of the analyses of 4 samples obtained
at quarterly intervals.
(NOTE: A gross alpha particle activity measurement may be substituted for the
required radium-226 and radium-228 analysis if the measured gross alpha particle
activity does not exceed 5 pCi/L at a confidence level of 95 percent.)
Verify that when the gross alpha particle activity exceeds 5 pCi/l the same or an
equivalent sample is analyzed for radium-226 and if the concentration of radium-226
exceeds 3 pCi/L, the same or equivalent sample is analyzed for radium-228.
Verify that suppliers of water monitor for gross alpha particle activity, radium-226 and
radium-228 every 4 years and within 1 year of the introduction of a new water source
for a community water system.
(NOTE: The State has the power to order additional samples, waive required
samples and impose additional requirements.)
Verify that if the MCL for gross alpha particle activity or total radium is exceeded and
the facility is the supplier of a community water system, the installation notifies the
State and the public of the exceedence.
Verify that systems using surface water sources and serving more than 100,000
persons are initially monitored quarterly for compliance with man-made radioactivity
limitations and after the initial analysis, monitoring is done at least every 4 years.
Verify that suppliers of any community water system using waters contaminated by
nuclear facilities initiate quarterly monitoring for gross beta particle and todine-131
radioactivity and annual monitoring for strontium-90 and tritium.
DW.26. Facilities with
community water systems that
add a disinfectant to the water
are required to analyze for
TTHM (40 CFR 141.30).
(NOTE: The minimum number of samples that is required is based on the number of
treatment plants used by the system.)
Verify that community water systems serving a population of 10,000 or more
individuals that adds a disinfectant to the water and uses surface water sources or
only groundwater sources analyze for total TTHM on a quarterly basis on at least 4
samples.
DW.27. Suppliers of water for
community public water systems
are required to analyze for
sodium (40 CFR 141.41).
Verify that one sample is taken per plant at the entry point of the distribution system
annually for systems using surface water in whole or in part and every 3 years for
systems using solely groundwater sources.
Verify that the results of the sampling were reported to the USEPA and/or state within
10 days following the end of the required monitoring period or within the first 10 days
of the month following the month in which the sample was taken.
Phase 1 - Section 12
Drinking Water Management
12-27
-------
Compliance Category?
OrtnUng Water
Regulatory Requirement*
Reviewer Choc KB
DW.28. Suppliers of water for
community water systems shall
collect samples from
representative entry points to
the water distribution system
and analyze for corroshrity (40
CFR 141.42).
Verify that the supplier collects 2 samples per plant for analyses for each plant using
surface water sources wholly or in part.
Verify that the samples are taken one in mid-winter and one during mid-summer.
Verify that one sample per plant Is collected for each plant using groundwater
sources.
(NOTE: Determination of corrosivity includes measurement of pH, calcium, hardness,
alkalinity, temperature, total dissolved solids, and calculation of the Langelier Index.)
Verify that the results for the analyses of corrosivity are reported to the USEPA
and/or state within the first 10 days of the month following the month in which the
sample results were received.
(NOTE: The state might require monitoring for additional parameters which may
indicate corrosivity, such as sulfates and chlorides.)
DW.29. Analysis for inorganic
chemicals, volatile organic
contaminants, pesticides, and
bacteria to determine
compliance with MCLs must be
performed in a state-approved
laboratory or by a state-
approved individual (40 CFR
141.23(k)(5). 141.24(f)(17).
141.24(l)(19). and 141.28).
Verify that laboratory is approved by reviewing documentation of state certification for
laboratory analysis.
Phase 1 - Section 12
Drinking Water Management
12-28
-------
Compliance Category:
Drinking Water Management
Regulatory Requirements
Reviewer Checks
Disinfection And Filtration
DW.30. Facilities that have a
public water system that uses
surface water sources or
groundwater sources under
direct influence of a surface
water source must provide
filtration as a treatment
technique for microbiological
contaminants unless certain
criteria are met (40 CFR
141.71(a) and 141.71(b)).
(NOTE: Public water systems that use a groundwater source under the direct
influence of surface are not required to meet these conditions to avoid filtration until
18 months after the state has determined mat the system is under the direct influence
of surface water.)
Verify that filtration of drinking water is performed unless all of the following conditions
for surface water are met:
• The fecal coliform concentration is less than or equal to 20/100 mL or total cotiform
concentration is equal to or less than 100/100 mL in representative samples of the
source water immediately prior to the first or only point of disinfectant application in
at least 90 percent of the measurements made in the last 6 months that the system
served water to the public on an ongoing basis
• The turbidity level does not exceed 5 NTU In representative samples of the source
water immediately prior to the first or only point of disinfectant application the
unless state determines otherwise and there has not been more than 2 events in
the past 12 months the system served water to the public or more than 5 events in
the past 120 months the system served water to the public.
Verify that filtration of drinking water Is done unless all the following site specific
conditions are met:
- Meets the requirements of 40 CFR 141.72(a)(1) for disinfection treatment of Giardia
lamblia for at least 11 of the 12 previous months
• Meets 40 CFR 141.72(a}(2) through 141.72(a)(4) at all times.
- Maintains a watershed control program for Giardia lamblia in the source water.
including:
identification of watershed characteristics
monitoring occurrence of activities that have adverse effects
demonstrates through ownership and/or written agreements that the control of
adverse effects of human activities are regulated
submits annual reports to the state
subject to annual onsite inspection by the state or a party approved by the
state, to assess watershed control program
has not been identified as a source of waterbome disease or threat or has
been modified sufficiently to prevent recurrence
• Complies with MCL for total coliforms as defined in 40 CFR 141.63 for at least 11
of the previous 12 months (see Appendix 12-1)
• Complies with requirements for trihalomethanes as listed on 40 CFR 141.12 and
141.13 (see Appendix 12-1).
Phase 1 • Section 12
Drinking Water Management
12-29
-------
Compliance Category;
Drinking Water Managnraflt
Regulatory Requirement*
Reviewer Checks
DW.31. Systems that do not
meet the criteria necessary for
exclusion from filtration for
public water systems that use a
surface water source or a
groundwater source under the
direct influence of surface water
must provide filtration that meets
specific standards by 29 June
1993. or within 18 months after
being required to provide
filtration, whichever is later (40
CFR 141.73 and 141.74(c)(2)J.
Verify that if conventional or direct filtration is used the following are met:
- A turbidity level of 0.5 MTU or less in 95 percent of measurements taken each
month
• The turbidity level of representative samples of filtered water at no time exceeds 5
NTU.
Verify that if slow sand filtration is used the following are met:
• The turbidity level of representative samples of a systems filtered water is 1 NTU or
less in 95 percent of the monthly measurements
- The turbidity level of representative samples of a systems filtered water at no time
exceeds 5 NTU.
Verify that if diatomaceous earth filtration is used the following is met:
- The turbidity level of representative samples of a systems filtered water is less than
or equal to 1 NTU in at least 95 percent of the measurements taken each month
- The turbidity level of representative samples of a systems filtered water at no time
exceeds 5 NTU.
Verify that if other filtration technologies are used, they have been approved by the
state.
Verify that, starting 29 June 1993, or when filtration is installed, turbidity
measurements are performed on representative samples of the systems filtered water
every 4 hours that the system serves water to the public.
Verify that as of 29 June 1993, or whenever filtration is installed, the residual
disinfectant concentration of water entering the distribution system is monitored
continuously and the lowest value recorded each day.
Verify that if there is a failure in the continuous monitoring equipment, grab sampling
is done every 4 hours.
(NOTE: Grab sampling can be done for no more than 5 working days following the
failure of the continuous monitoring system.)
(NOTE: Systems serving 3300 or fewer person can use grab sampling instead of
continuous monitoring If the following daily frequencies are met:
System size by population
501 1000
1001 2500
2501 3300
Samples/day
1
2
3
4
Verify that any time the residual disinfectant concentration falls below 0.2 mg/L in a
system using grab sampling, the system takes a grab sample every 4 hours until the
residual disinfectant concentration is equal to or greater then 0.2 mg/L.
Phase 1 - Section 12
Drinking Water Management
12-30
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Compliance Category:
Drinking Water Management
Regulatory Requirements
Reviewer Checks
OW.32. Facilities, with public
water systems that use a
surface water source or a
groundwater source under direct
influence of a surface water
source that is not required to
provide filtration are required to
provide disinfection treatment by
30 December 1891 (40 CFR
141.72(a)).
Verify that the following requirements for disinfection are met:
- It ensures 99.9 percent (3-log) inadivation of Giardia lamblia cysts every day
except for once per month by meeting the required CT applicable to the systems
particular drinking water parameters as outlined in 40 CFR 141.74
• It ensures 99.99 percent (4-log) inadivation of virus every day except for once per
month by meeting the required CT applicable to the systems particular drinking
water parameters as outlined in 40 CFR 343.74
• The CT values are calculated daily as specified in 40 CFR 141.74(b)(3)
• Throughout the disinfection system there is either
- automatic startup and alarm for insuring continuous disinfection application
while water is delivered through the distribution system
automatic shutoff when there is less than 0.2 mg/L residual disinfectant
- The residual disinfectant concentration in water entering distribution system is not
less than 0.2 mg/L for more than 4 hours
- The residual disinfectant concentration, measured as total chlorine, combined
chlorine, or chlorme dioxide is not undetectable in more than 5 percent of samples
each month for more than 2 consecutive months.
(NOTE: Water in a distribution system with a heterotrophic bacteria concentration
less than or equal to 500 mL, measured as Heterotrophic Plate Count (HPC) is
deemed to have a detectable disinfectant residual.)
DW.33. Facilities with public
water systems that use a
surface water source or a
groundwater source under direct
influence of a surface water
source that provide filtration or
that are required by the state to
install filtration must meet
specific disinfection
requirements by 29 June 1993
or within 18 months of being
required to install filtration (40
CFR 141.72(6) and 141.73).
Determine if the facility provides filtration for drinking water.
Verify that the following requirements for disinfection are provided:
- It ensures 99.9 percent (3-log) inactivation of Giardia lamblia cysts
- It ensures 99.99 percent (4-log) inactivation of viruses
- The residual disinfectant concentration in water entering distribution system is not
less than 0.2 mg/L for more than 4 hours.
- The residual disinfectant concentration throughout the distribution system is not
undetectable in more than 5 percent of samples each month for any 2 months the
system serves water to the public
- Analytical methods as specified in 40 CFR 141.74 are used to demonstrate
compliance with the requirements for filtration and disinfection.
(NOTE: Systems which fitter are given an inactivation credit dependant on the type
of filtration used.)
Phase 1 - Section 12
Drinking Water Management
12-31
-------
Compliance Category:
Drinking Water Managam
Regufatoiy Requirements
Reviewer Chaeka
DW.34. Facilities with public
water systems that use a
surface water source and do not
provide filtration are required to
report specific information
monthly to the state beginning
31 December 1990 (unless the
state has determined that
filtration is not required) until
filtration is in place (40 CFR
141.75(a)).
Verify that the following listed information is reported to the state at the indicated
times:
- Source drinking water information within 10 days after the end of each month the
system serves water to the public
• Disinfection information within 10 days after the end of each month the system
serves water to the public
- A report summarizing compliance with all watershed control programs no later than
10 days after the end of each Federal FY
- A report on the onsite inspection conducted during that year, unless it was
conducted by the state, no later than 10 days after the end of the Federal FY
- The occurrence of a waterbome disease outbreak potentially attributable to that
water system as soon as possible, but no later than by the end of the next
business day
• When turbidity exceeds 5 NTU, as soon as possible, but no later than the end of
the next business day
- Any time the residual falls below 02 mg/L in the water entering the distribution
system as soon as possible, but no later than by the end of the next business day.
(NOTE: See the complete text of 40 CFR 14175(a) for more details on how this
information is to be reported.)
DW.35. Facilities with public
water systems that use a
groundwater source under the
direct influence of surface water
and does not provide filtration
treatment must report specific
information to the state monthly
starting 31 December 1990, or 6
months after the state
determines that the groundwater
source is under the direct
influence of surface water,
whichever is later (40 CFR
141.75(a)).
Verify that the following listed information is reported to the state at the Indicated
times:
- Source drinking water information within 10 days after the end of each month the
system serves water to the public
- Disinfection information within 10 days after the end of each month the system
serves water to the public
- A report summarizing compliance with all watershed control programs no later than
10 days after the end of each Federal FY
- A report on the onsite inspection conducted during that year, unless it was
conducted by the state, no later than 10 days after the end of the Federal FY
- The occurrence of a waterbome disease outbreak potentially attributable to that
water system as soon as possible, but no later than by the end of the next
business day
- When turbidity exceeds 5 NTU, as soon as possible but no later than the end of the
next business day
- Any time the residual falls below 0.2 mg/L in the water entering the distribution
system as soon as possible, but no later than by the end of the next business day.
(NOTE: See the complete text of 40 CFR 14l.75(a) for more details on how this
information is to be reported.)
Phase 1 - Section 12
Drinking Water Management
12-32
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Compliance Category:
Drinking Water Managoment
Regulatory Requirements
Reviewer Checks
DW.36. Facilities with public
water systems that use a
surface water source or a
groundwater source under the
direct influence of surface water
that provide filtration must report
specific information monthly to
the state starting 29 June 1993
or when filtration is installed.
whichever is later (40 CFR
I4l.75(b)).
Verify that by 29 June 1993, or whenever filtration Is installed, the following
information is provided to the state in the indicted time frame:
• Turbidity measurements within 10 days after the end of. each month the system
serves water to the public
- Disinfection information within 10 days after the end of each month the system
serves water to the public
- Notice of an occurrence of a waterbome disease outbreak, as soon as possible but
no later than by the end of the next business day
- When the turbidity exceeds 5 NTU, as soon as possible, but no later than the end
of the next business day
- Any time the residual falls below 0.2 mg/L in the water entering the distribution
system, as soon as possible, but no later thao by the end of business the next day.
(NOTE: See the complete text of 40 CFR 141.75(b) for more details on how this
information is to be reported.)
DW.37. USEPA has set certain
standards for analytic
procedures that must be used
and followed to demonstrate
compliance with disinfection and
filtration requirements (40 CFR
141.74).
Verify that analytic methods as specified in 40 CFR 141.74 are used to demonstrate
compliance with the requirements for filtration and disinfection.
Notification and Reporting Requirements
DW.36. Public water systems
are required to maintain on the
premises, or at a convenient
location specific records (40
CFR 141.33(a). 141.33(b) and
141.33(d)).
Verify that records of bacteriological analyses are kept for a minimum of 5 years.
Verify that records of chemical analyses are kept for a minimum of 10 years.
Verify that records of actions taken to correct violations of primary drinking water
regulations are kept for a minimum of 3 years after the last action taken for a
particular violation.
Verify that records concerning a variance or exemption granted to the system are
kept for a period ending not less than 5 years following the expiration of the variance
or exemption.
Phase 1 - Section 12
Drinking Water Management
12-33
-------
Compliance Cetogtwy:
Drinking Water Managwmnt
Regulatory Requirements
Reviewer Checks
DW.39. Whan primary drinking
water standards are exceeded,
public notifications must be
made (40 CFR 141.32).
Verify that if there was an excess the following public notification procedures were
followed:
• Notices were placed in a daily newspaper of general circulation in the area served
by the system as soon as possible, but no later than 14 days after the violation or
failure
• Notices were placed in a weekly newspaper of general circulation if there is no daily
newspaper
• Notices were issued by mail delivery, by direct mail or with the water bill, or by
hand delivery within 45 days after the violation or failure.
(NOTE: The State may waive mail or hand delivery if rt is determined that the
violation or failure is corrected within the 45 day period.)
Verify that if it was an acute violation, the public radio and tv stations were notified.
Verify that if public notification was made, it was made according to USEPA
guidelines.
Verify that following the initial notice, additional notice is given at least once every 3
months by mail delivery, or by hand delivery, for as long as the violation exists.
(NOTE: Instead of the requirements outlined here, community water systems in an
area that is not served by a daily or weekly newspaper of general circulation must
give notice by hand delivery or by continuous posting in conspicuous places within
the area served by the system. Notice must be given within 72 hours for acute
violations and 14 days for other violations.)
DW.40. Community water
systems that exceed the
secondary MCL of 2.0 mg/L for
fluoride but not the MCL of 4.0
mg/L are required to notify
specific individuals (40 CFR
143.5).
Verify that notice has been provided to the following:
- All billing units annually
• All new billing units at the time service begins
- The state public health officer.
(NOTE: A copy of the text of the notice is found in 40 CFR 243.5(b).)
DW.41. Facilities that operate
public water systems must send
reports to the state on any
failure to comply with applicable
biological, turbidity, radioactivity,
and chemical standards, and on
any failure to comply with
monitoring requirements that
apply (40 CFR 141.31).
Verify that, in general, reports are sent within the first ten days following the month in
which the result is received or the first ten days following the end of the required
monitoring period whenever standards are not met.
Verify that the facility reported failure to comply with any national primary drinking
water regulations to the state within 48 hours.
Phase 1 - Section 12
Drinking Water Management
12-34
-------
Compliance Category:
Drinking Water Harassment
Regulatory Requirement*
Lead and Copper in Drinking Water Systems
DW.42. The use of pipe, solder,
or flux that contains lead is not
allowed in specific situations (40
CFR 141 43(a)(l) and
141.43(d)).
Verify that lead pipe, solder, or flux is not used in the installation or repair of either of
the following:
• Any public water system
- Any plumbing in a residential facility providing water for human consumption which
is connected to a public water system.
(NOTE: This does not apply to leaded joints necessary for the repair of cast iron
pipes.)
(NOTE: Lead-free is defined as not more than 0.2 percent content for solders and
flux and not more than 8.0 percent lead In reference to pipes and pipe fittings.)
DW.43. Community waters
systems and each non-transient,
non-community water systems
were required to issue a notice
by 19 June 1988 to persons
served by the system that might
be affected by lead
contamination (40 CFR 141.34
and 141.43(a)(2)).
Verify that the notice was issued by one of the following methods:
- 3 newspaper notices
- A notice included with the water bill
- A hand delivered notice.
(NOTE: For non-transient, non-community water systems notice may be given by
continuous posting.)
(NOTE: The notice is not required if the system can demonstrate to the State that
the water system, including the non-residential and residential portion connected to
the water system, are lead free.)
(NOTE: Notice must be provided even if there is no violation of the national primary
drinking water standards. The required wording of the notice is outlined in 40 CFR
141.34.)
Phase 1 - Section 12
Drinking Water Management
12-35
-------
Compliance Category:
DrlnMng Water Management
Regulatory Raquirementa
DW.44. Facilities with
community or non-transient,
non-community water systems
must notify their users about
lead in drinking water systems
(40 CFR 141.85 and 141.91(0).
Verify that public education materials are distributed in the following manner when a
water system exceeds the lead action level based on tap water samples:
- The material is in the appropriate languages where languages other than English
are spoken by a significant proportion of the population
- Within 60 days after exceeding the lead action level:
notices are insert in each customer's water utility bill
information is provided to the editorial departments of the major dairy and
weekly newspapers circulated in the community
pamphlets or brochures are delivered to pertinent facilities, organizations.
schools and medical centers
public service announcements are submitted to at least 5 of the radio and
television stations broadcasting to the community.
Verify that the notification tasks are repeated every 6 months for as long as a
community water system exceeds the lead action level.
Verify that a non-transient, non-community water system delivers the public education
materials by posting informational posters and distributing brochures.
Verify that a non-transient, non-community water system repeats distribution of
information at least once each calendar year In which the system exceeds the lead
action level.
(NOTE: The text of written materials and broadcast materials can be found in 40
CFR 141,85{a) and 141.85(b).)
Verily that by December 31st any water system that has had to issue public
education materials submits a letter to the state indicating that the system has
delivered the public education materials as required each year that the levels are
exceeded.
OW.45. Community water
systems and nontransient, non-
community water systems are
required to meet specific
standards for lead and copper
action levels and reporting
requirements when these levels
are exceeded (40 CFR
I41.80(a)(1), I4l.80(c),
141.80(e), 141.86(b)and
14l.90(e)j.
Verify that the concentration of lead does not exceed 0.015 mg/L in more than 10
percent of tap water samples collected during any monitoring period.
Verify that the concentration of copper does not exceed 1.3 mg/L in more than 10
percent of tap water samples collected during any monitoring period
Phase 1 - Section 12
Drinking Water Management
12-36
-------
Compliance Category,
Drinking Waiter Management
Regulatory Rw
ante
Reviewer Cheeks
DW.46. All water systems are
required to install and operate
optimal corrosion control (40
CFR 141.80{d}).
Verify that the water system has corrosion control that minimizes the lead and copper
concentrations at users' taps while insuring that the treatment does not cause the
water system to violate any of the national primary drinking water standards.
(NOTE: See 40 CFR 181 and 40 CFR 183 for design details for corrosion control
systems in relationship to the size of the water system.)
DW.47. Systems that exceed
the lead or copper action level
are required to implement
applicable source water
treatment standards (I41.80(e)
and 141.83).
Verity that systems exceeding the lead or copper action level do lead and copper
source water monitoring and make a treatment recommendation to the State within 6
months after exceeding the lead or copper action rate.
Verify that if the State requires the installation of source water treatment, the
installation is done within 24 months after the State's initial response.
Verify that follow-up tap water monitoring and source water monitoring is completed
within 36 months after the States initial response.
DW.48. Facilities with water
systems exceeding the lead
action level after implementation
of corrosion control and source
water treatment requirements
are required to replace lead
service lines (40 CFR 141.80(f)
and 141.84).
Verify that lead service line replacement is done according to the schedules and
parameters outlined in 40 CFR 141.84.
(NOTE: A system is not required to replace an individual lead service line if the lead
concentration in all service line samples from that line is less than 0.015 mg/L)
(NOTE: Replacement of lead service lines can stop when the first draw samples that
are collected meet the lead action levels during two consecutive monitoring periods
and the system submits the results to the state.)
Phase 1 - Section 12
Drinking Water Management
12-37
-------
Compliance Category:
Drinking Water Mungamnt
Regulatory Rwpdrenrwntp
IraVfeWOr CIMCKS
DW.49. Monitoring for lead and
copper is required to start on a
specified date and be done at a
specified number of sites
according to the chart in
Appendix 12-7 (40 CFR
141.80(g), 141.86(a)(1),
141.86(c). and 141.86{d)).
Verify that sample sites have been selected and sampling started as of the dates
indicatedm Appendix 12-7.
Verify that monitoring is done according to the schedules outlined in 40 CFR 141.86
and as required by the state.
Verify that the procedures for sampling and granting of variances found in 40 CFR
141.86 are followed
Verify that for the initial tap sample, all large water systems monitor during two
consecutive 6 month periods and all small and medium-size water systems monitor
during each 6 month period until:
- The system exceeds the lead or copper action levels and is then required to
implement corrosion control treatment
- The system meets the lead and copper action levels during two consecutive 6
month monitoring periods.
(NOTE: A small or medium-sized water system that meets the lead and copper action
levels during each of two consecutive 6 month monitoring periods can reduce the
frequency of sampling to once a year. If action levels are met during three
consecutive years of monitoring, the frequency may be reduced to once every 3
years.)
Verify that for monitoring after the installation of corrosion control and source water
treatment, large systems with optimal corrosion control by 1 January 1997 monitor
during two consecutive 6 month periods by 1 January 1988.
Verify that for monitoring after the installation of corrosion control and source water
treatment, small or medium-size systems that install optimal corrosion control within
24 months after being required to do so by the State, monitor during two consecutive
6 month periods within 36 months after being required to install optimal corrosion
control treatment.
Verify that for monitoring after the installation of corrosion control and source water
treatment required by the State, all systems that install State required systems
monitor during two consecutive months within 36 months after the initial State
requirement.
Verify that after the State has specified drinking water parameter values for optimal
corrosion control that monitoring is done during each subsequent 6 month monitoring
period beginning when the State specified the optimal values.
Phase 1 - Section 12
Drinking Water Management
12-38
-------
iptlance Cateoory!
Drinking Water Manage
Regulatory Requirements
Reviewer Checks
DW.50. All large water systems
and all small and medium size
systems that exceed the lead or
copper action level are required
to monitor for drinking water
parameters in addition to lead
and copper (40 CFR 141.40(h)
and 141.87).
Verify that monitoring for drinkmg water parameters is done according to
Appendix 12-6.
DW.51. Water systems that fail
to meet the lead or copper
action levels are required to
meet specific monitoring
requirements (40 CFR 141.80(h)
and 141.88).
Verify that systems that exceed lead or copper action levels at the tap collect one
source water sample from each entry point to the distribution system within 6 months
after the exceedence.
Verify that systems which install source water treatment as required by the State
collects an additional source water sample from each entry point to the distribution
system during two consecutive 6 month monitoring periods.
Verify that the system monitors as follows when the State specifies maximum
permissible source water levels:
• Once during the 3 year compliance period for water systems using only
groundwater
• Annually for water systems using surface water or a combination of surface and
groundwater.
(NOTE: Frequency of monitoring may be reduced by the State upon request.)
DW.52. In reference to lead
end copper In water systems, all
water systems are required to
fulfill specific reporting
requirements (40 CFR 141.90(a)
and I4i.90(b)).
Verify that waste systems report sampling results for all tap water samples within the
first 10 days following the end of each monitoring period.
Verify that water systems report the sampling results for all source water samples
within the first 10 days following the end of each source water monitoring period.
DW.53. All systems subject to
the lead and copper
requirements are required to
retain onsite all the original
records of sampling data,
analysis, reports, surveys,
letters, evaluations, state
determinations, and any other
pertinent documents for at least
12 years (40 CFR 141.80Q),
141.91).
Verify that records are kept onsite for 12 years.
Phase 1 - Section 12
Drinking Water Management
12-39
-------
CompUanee Category.
Drinking Water Manage
Regulatory Requirements
Reviewer Checks
Sole Source Aquifer
DW.54. Projects that may affect
the recharge zone or stream
flow source zone of a
designated sole source aquifer
are regulated (40 CFR 149.103
and 149.104).
(NOTE: Currently the only Federally designated sole source aquifer is the Edwards
Aquifer in the San Antonio, Texas area.)
Determine if the facility is located near a designated sole source aquifer.
Verify that the facility maintains a list of projects for which environmental impact
statements will be prepared.
Verify that if any projects may potentially cause direct or indirect contamination
through its recharge zone a petition has been submitted to the USEPA Regional
Administrator.
Phase 1 - Section 12
Drinking Water Management
12-40
-------
Section 12
Drinking Water Management
Appendices
A12-1
-------
Appendix 12-1
Primary Drinking Water Standards for Organic Contaminants
Table 1
Maximum Contaminant Levels Applicable to Community Water Systems
(40 CFR 141.12)
Contaminant - • •
Total Trihatomethanes (TTHM)
(the sum of the concentrations of
bromodichloromethane.
dibromochloromethane, tribromomethane
(bromoform) and trichloromethane
{chloroform)
Mfl/L
0.10
(NOTE: The standard for TTHM only applies to community water systems serving greater than 10,000
individuals which add a disinfectant during treatment).
A12-2
-------
Appendix 12-1 (continued)
Primary Drinking Water Standards for Organic Contaminants
Table 2
Maximum Contaminant Levels Applicable to Community and Non-Transient,
Non-Community Water Systems (40 CFR 141.61 (a))
^^^S^^^l^^^^^^^^^-i fe^MI^
*§S^^*S8?i*F^^^^w^^^^^RP^feS
1,1-Dichtoroethylene
1.1,1-Trtehloroethane
1 ,2-Dlchloroelhane
1 ,2-Dichloropropane
Benzene
Carbon Tetrachtoride
cis-1 ,2-Dichloroethylene
Ethylbenzene
Monochlorobenzene
0-DichloFobenzene
para-Dichtorobenzene
Styrene
Tetrachtoroethylene
Toluene
trans- 1 ,2-Dichloroethylene
Trichloroethylene
Vinyl chloride
Xylenes (total)
Dichloromethane
1 ,2,4-Trichlorobenzene
1.1,2-Trich(oro8thane
0.007
0.20
0.005
0.005
0.005
0.005
0.07
0.7
0.1
0.6
0.075
0.1
0.005
1.0
0.1
0.005
0.002
10.0
0.005*
.or
.005*
The effective date for these MCLs is 17 January 1994
A12-3
-------
Appendix 12-1 (continued)
Primary Drinking Water Standards for Organic Contaminants
Table 3
Maximum Contaminant Levels For Synthetic Organic Contaminants Applicable to
Community Water Systems and Non-Transient, Non-Community Water Systems
(40 CFR 141.61(C))
Alachlor
AMicarb
AUicarb sulfoxide
AUicarb suffone
Atrazine
Carbofuran
Chlordane
Oibromochloropropane
2,4-D
Ethylene dibromide
Heptachtor
Heptachlor epoxide
Lindane
Methoxychtor
Pentachlorophenol
Polychtorinated biphenyls
Toxaphene
0.002
0.003"
0.004"
0.003"
0.003
0.04
0.002
0.0002
0.07
0.00005
0.0004
0.0002
0.0002
0.04
0.001
0.0005
0.003
2.4,5-TP
Benzo(a)pyrene
Delapon
Di(2-ethythexyl) adlpate
Di(2-ethythexyl) phthalate
Dinoseb
Diquat
Endothall
Endrin
Glyphosate
Hexachlorobenzene
Hexachlorocyclopentadlene
Oxamyt(Vydate)
Picbram
Simazln
2.3.7,8,-TCOD (Dtoxin)
•The effective date for these MCLs is 17 January 1994.
"The MCLs for these substances have been postponed by the USEPA.
0.05
0.0002*
0.2*
0.4*
0.006*
0.007*
0.02*
0.1*
0.002*
0.7*
0.001*
0.05*
0.2*
0.5*
0.004*
3. x 10*
A12-4
-------
Appendix 12-2
Primary Drinking Water Standards for Inorganic Contaminants
Table 1
Maximum Contaminant Levels Applicable to Community Water Systems
(40 CFR 141.11,141.12(c) and 141.62(b)(1))
Cofttanim*ftt ,-. ^A-,. .V
Arsenic
Fluoride
Total Trihalomethanes
Mg/L
0.05
4.0
0.10*
* This MCL only applies to community water systems which serve a population of 10,000 individuals or
more and which add a disinfectant (oxidant) to the water in any part of the drinking water treatment
process.
Table 2
Maximum Contaminant Levels Applicable to Community Water Systems and
Non-Transient, Non-Community water Systems
(40 CFR 141.62(b)(2) through141.62(b)(6) and 141.62(b)(10) through 141.62(b)(l5))
£oiiti £ liliSiRt^B^K^^^S^^18® ^
m:3m %s$$^wm SWM&^&^^fcv
Asbestos
Barium
Cadmium
Chromium
Mercury
Selenium
Antimony
Beryllium
Cyanide (as free Cyanide)
Nickel
Thallium
S53&$H!®
7 million
fibers/L
(longer than
10
micrometers)
2.0
0.005
0.1
0.002
0.05
0.006
0.004
0.2
0.1
0.002
A12-5
-------
Appendix 12-2 (continued)
Primary Drinking Water Standards for Inorganic Contaminants
Tabled
Maximum Contaminant Levels Applicable to Community, Non-Transient,
Non-Community and Transient Non-Community Water Systems
(40 CFR 141.62(b)(7) through 141.62(b)(9))
Nitrate (as N)
10.0
Nitrite (as N)
1.0
Total Nitrate and Nitrite (as N)
10.0
A12-6
-------
Appendix 12-3
Detection Limitations for Inorganic Contaminants
(40 CFR 141.23(8))
Contaminant
*.
Antimony
Asbestos
Barium
Cadmium
Chromium
Cyanide
Mercury
Nickel
Nitrate
Nitrite
Selenium
Thallium
find*.-*, *< ,
(w«/M
0.005
7 million
fibers/L
2.0
0.005
0.1
0.2
0.002
0.1
10asN
1asN
0.05
0.002
Analytical Method ,;...,;
Atomic Absorption Furnace
ICP Mass spectrometry
Hydride Atomic Absorption
Transmission Electron Microscopy
Atomic Absorption; furnace technique
Atomic Absorption; direct aspiration
Inductively Coupled Plasma
Atomic Absorption; furnace technique
Inductively Coupled Plasma
Atomic Absorption; furnace technique
Inductively Coupled Plasma
Distillation.Spectrophotometric4
Distillation. Automated. Spectrophotometric*
Distillation, Selective Electrode*
Distillation, Amenable, Spectrophotometrics
Manual CoU Vapor Technique
Automated Cold Vapor Technique
Atomic Absorption, Furnace
Inductively Coupled Plasma3
ICP Mass Spectrometry
Manual Cadmium Reduction
Automated Hydrazine Reduction
Automated Cadmium Reduction
ton Selective Electrode
ton Chromatography
Spectrophetometric
Automated Cadmium Reduction
Manual Cadmium Reduction
ton Chromatography
Atomic Absorption; furnace
Atomic Absorption; gaseous hydride
Atomic Absorption Furnace
ICP-Mass Spectrometry
Detection Unit
(mg7L)
0.003
0.00088
0.0004
0.001
0.01 million fibers/L.
0.002
0.1
0.002(0.001')
0.0001
0.001^
0.001
0.007
(0.001)*
0.02
0.05
0.02
0.0002
0.0002-
0.001
0.00068
0.005
0.0005
0.01
0.01
0.05
1.0
0.01
0.01
0.05
0.01
0.004
0.002
0.002
0.001
0.00078
0.0003
1 Using concentBiion tecrriques n Appendbc A to EPA Method 200.7
SWiQ^fimwHtoato^esZu&nMahoiiymi. LoM«rMDLirnaybBacrie\^byusinQa4xpreeonoBntrat)on.
4 Screening mottwd for total cyanitos
5 Measures tree* cyanides
6 Lower MOLs era reported using suUiad temperaure graphite tumBceat
absorption.
A12-7
-------
Appendix 12-4
Detection Limitations
(40CFR141.24(h)(18))
Alachlor
AWfcarb
Aldicarb sutfoxide
AUicarb sulfone
Atrazine
Benzo[a]pyrene
Carbofuran
Chlordane
Dalapon
Dtoromochtoropropane
(DBCP)
Dl (2-ethyDiexyl) adipate
Di (2-ethylhexyl) phthatate
Dinoseb
Dlqual
2,4-D
Endothall
0.0002
0.0005
0.0005
0.0008
0.0001
0.00002
0.0009
0.0002
0.001
0.00002
0.0006
0.0006
0.0002
0.0004
0.0001
0.009
Endrin
Elhylene dibromide (EOB)
Heptachlor
Heptachlor epoxlde
Hexachlorobenzene
Hexachtorocyclopentadiene
Lindane
Methoxychtor
Gxamyl
Pidoram
Pentachlorophenol
Potychlorinated biphenyls
Simazine
Toxaphene
1.3.7,8-TCDD(Dioxin)
2,4,5-TP
0.00001
0.00001
0.00004
0.00002
0.0001
0.0001
0.00002
0.0001
0.002
0.0001
0.00004
0.0001
0.00007
0.001
0.000000005
0.0002
A12-8
-------
Appendix 12-5
Unregulated Organic and Inorganic Contaminants
(40 CFR 141.40(n)(11) and 141.40(n){12))
AJdrin
Butachlor
Caibaryl
Dfcamba
DiekJrin
3-Hydroxycarfaofuran
Methomty
Metolachtor
Metribuzin
Propachtor
Sulfate
A12-9
-------
Appendix 12-6
Collform Bacteria Sampling Frequency
(40 CFR 141.21 (a)(2))
Population Served Minimum Number of
Per Month Samples Per Month
25 to 1000 i '• 1
1001 to 2500 2
2501 10 3300 3
3301 to 4100 4
4101 to 4900 5
4901 to 5800 6
5801 10 6700 7
6701 to 7600 8
7601 to 8500 9
8501 to 12,900 10
12.901 to 17,200 15
17,201 to 21,500 20
21,501 to 25,000 25
25.001 to 33,000 30
33,001 to 41,000 40
41.001 to 50,000 50
50,001 to 59,000 . . 60 .
59,001 to 70,000 70
70,001 to 83.000 80
83,001 to 96.000 90
96,001 to 130,000 100
130,001 to 220,000 120
220,001 to 320,000 150
320,001 to 450,000 180
450,001 to 600,000 210
600.001 10 780,000 240
780,001 to 970,000 270
970,001 to 1,230,000 300
1,230,001 to 1,520,000 330
1,520,001 to 1,850,000 360
1,850,001 to 2,270,000 390
2,270,001 to 3,020,000 420
3,020,001 to 3,960,000 450
3.960,001 or more 480
A12-10
-------
Appendix 12-7
Monitoring and Sampling Parameters for Lead and Copper In Drinking Water
(40 CFR 141.86(c) and I41.86(d))
naroror ot swmiwnfi 9m»9 Heqwrea
C *fim ^tflM*
(people served}
> 100,000
10,001 - 100,000
3301 - 10,000
501-330
101 -500
£100
Ho. of sites
monitoring)
100
60
40
20
10
5
Mo. of sites
(reduced
monitoring}
50
30
20
10
5
5
>50,000
1 Jan 1992
3301 - 50.000
&3300
1 July 1992
1 July 1993
A12-11
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Phase 1
Section 13
PCB Management
-------
A. Applicability
This section is used to determine the cpmpliance status of the management activities
associated with PCBs and in-service and out-of-service PCB items.
Assessors are required to review agency, federal, state and local regulations in order to
perform a comprehensive assessment.
B. Federal Legislation
1. The Toxic Substances Control Act (TSCA)
This Act. as last amended in 1986 (IS U.S. Code (USC) 2601-2671), is the federal legislation
which deals with the control of toxic substances. The Act consists of three subchapters, one
of which regulates the control of toxic substances (such as PCBs), another governs asbestos
hazard emergency response, and another subchapter regulates indoor radon abatement. The
policy developed in TSCA on chemical substances is as follows (15 USC 260 l(b)):
a. Adequate data should be developed with respect to the effect of chemical substances and
mixtures on health and the environment and that the development of such data should be
the responsibility of those who manufacture and those who process such chemical
substances and mixtures;
b. Adequate authority should exist to regulate chemical substances and mixtures which
present an unreasonable risk of injury to health or the environment, and to take action
regarding chemical substances and mixtures; and
c. Authority over chemical substances and mixtures should be exercised in such a manner as
not to impede unduly or create unnecessary economic barriers to technological innovation
while fulfilling the primary purpose of this Act to assure that such innovation and
commerce in such chemical substances and mixtures do not present an unreasonable risk
of injury to health or the environment.
Upon request by the U.S. Environmental Protection Agency (USEPA), each Federal
department and agency is authorized to (IS USC 2625(a)):
a. Make its services, personnel, and facilities available (with or without reimbursement) to
the USEPA to assist the USEPA in the administration of this Act; and
Phase 1 - Section 13
PCB Management
13-1
-------
b. Furnish the USEPA with information, data, estimates, and statistics, and allow the
USEPA access to all information in its possession as the USEPA may reasonably
determine to be necessary for the administration of this Act.
2. Executive Order (EO) 12088, Federal Compliance with Pollution Standards
This EO, dated 13 October 1978, requires Federally owned and operated facilities to comply
with applicable Federal, state, and local pollution control standards. It makes the head of
each executive agency responsible for seeing to it that the agencies, facilities, programs, and
activities it funds meet applicable Federal, state, and local environmental requirements or to
correct situations that are not in compliance with such requirements. In addition, the EO
requires that each agency ensure that sufficient funds for environmental compliance are
included in the agency budget.
C. State/Local Regulation
1. PCBs
According to the general structure of Federal regulatory programs, any state regulations must
adopt the Federal regulations as a minimum set of requirements. In some cases, state
regulations have been developed which regulate PCBs more stringently than the Federal
program. State PCB regulations may provide additional regulatory requirements beyond the
Federal program to address a specific concern or activity sensitive in' that state. State
regulations may supersede the Federal regulations in areas including the following:
a. PCBs may be regulated as a hazardous waste;
b. PCBs may be regulated, to a lower concentration. For example, regulated PCBs in one
state are defined to be materials and fluids which contain PCBs at a concentration greater
than 7 ppm;
c. Shipments of PCBs may require manifest documents;
d. Analysis may be required to quantify the PCB concentration in all PCB items;
e. Additional inspections of select PCB items and specific disposal requirements for PCBs
and PCB items may also be required; and
f. Generators of PCBs and PCB items may be required to obtain disposal permits.
Phase 1 - Section 13
PCB Management
13-2
-------
D. Key Compliance Requirements
1. Personnel and PCBs
Certain regulations and practices should be followed to ensure the health of personnel who
come in contact with PCBs. These include provision of protective work-clothing, shower
facilities, and facilities for washing hands during shift. Airborne contaminations of PCBs
should be assessed and certain precautionary practices followed to protect personnel, which
include the wearing of respirators if contamination is above a certain level. Certain records
and practices should be maintained for employees exposed to PCBs, including medical
histories and physical examinations emphasizing liver and skin condition.
2. PCB Equipment Marking
The following equipment is required to be marked indicating that they contain PCBs (40
CFR 761.40 and 761.45):
a. PCB Containers with PCBs in concentrations of 50 to 500 parts per million (ppm);
b. PCB Transformers (500 ppm or greater);
c. PCB Large High Voltage Capacitors;
d. Equipment containing a PCB Transformer (500 ppm or greater) or a PCB Large High
Voltage Capacitor at the time of removal from service;
e. PCB Large Low Voltage Capacitors at the time of removal from service;
f. Electric motors using PCB coolants with a concentration of 50 to 500 ppm;
g. Hydraulic systems using PCB hydraulic fluid with concentrations of 50 to 500 ppm;
h. Heat transfer systems (other than PCB Transformers) using PCB concentrations of 50 to
500 ppm;
i. PCB Article Containers containing any of the above;
j. Each storage area used to store PCBs and PCB Items for disposal;
Phase 1 - Section 13
PCB Management
13-3
-------
k. Transport vehicles loaded with PCS Containers that contain more than 45 kg (99.4 Ib) of
PCBs in the liquid phase with PCB concentrations of 50 to 500 ppm or one or more PCB
Transformers with PCB concentrations of greater than 500 ppm: mark on each end and
side; and-
1. Vault doors, machinery room doors, fences, hallways, or means of access, other than a
manhole or grate cover, to a PCB Transformer (500 ppm or greater).
3. Records for PCBs
A written annual document log must be prepared by 1 July of each calendar year, covering
the previous year for all facilities that use or store at any time at least 45 kg (99.4 Ib) of
PCBs contained in PCB Containers, or one or more PCB Transformers. Owners and
operators of PCB chemical waste landfills shall keep records on water analysis and
operational records, including burial coordinates for 20 years after disposal has ceased.
Generators of PCBs shall keep copies of manifests and certificates of disposal for 3 years.
i
4. PCB Transformers
PCB Transformers with PCBs of 500 ppm or greater that are in use or in storage for reuse,
must not pose an exposure risk to food and feed and are subject to registration requirements.
Combustible materials, including, but not limited to, paints, solvents, plastics, paper, and sawn
wood, must not be stored by a PCB Transformer. PCB transformers are required to be
properly serviced, and inspections must be performed once every 3 months for all in-service
transformers. If the transformer is found to be leaking, it must be repaired or replaced to
eliminate the source of the leak. When a PCB transformer is involved in a. fire, the facility is
required to immediately report the incident to the National Response Center (NRC) (40 CFR
761.120(a), 761.120(b), 761.120(c), 761.123(d)(2), and 761.125).
5. PCB Spills
Facilities are required to report spills of more than 10 Ib [4.56 kg] of PCBs of concentrations
of 50 ppm to the USEPA regional office. Spills of greater than 1 Ib [0.45 kg] must be
cleaned up. The criteria for cleanup is based on whether the spill is of high or low
concentration of PCBs (40 CFR 761.120, 761,123, 761.125).
6. PCB Items
The use of PCBs in electromagnetic switches, voltage regulators, capacitors, heat transfer and
hydraulic systems, circuit breakers, reclosers, and cable is -allowed if applicable restrictions
are met and precautions taken (40 CFR 761.30).
Phase 1 - Section 13
PCB Management
13-4
-------
7. PCB Storage .
PCBs and PCB Items at concentrations greater than SO ppm that are to be stored before
disposal must be stored in a facility that will assure the containment of PCBs. Storage prior to
disposal is not to exceed 1 year. Nonleaking and structurally undamaged PCB Large, High-
Voltage Capacitors and PCB Contaminated Electric Equipment that have not been drained of
freeflowing dielectric fluid may be stored on pallets next to a storage area that complies with
the storage area requirements. Containers used for the storage of PCBs must comply with
the shipping container specification of the Department of Transportation (DOT) (40 CFR
761.65).
8. PCB Transportation
A generator who offers a PCB waste for transport to commercial offsite storage or offsite
disposal must prepare a manifest. If the generator does not receive a signed copy of the
manifest with 35 days from the date the waste was accepted by the initial transporter, the
generator must immediately contact the transporter and/or owner or operator of the designated
facility to determine the status of the PCB waste (40 CFR 761.207 through 761.210, 761.215).
9. PCB Disposal
For each shipment of manifested PCB waste that a disposal facility accepts, the owner or
operator of the disposal facility must prepare a Certificate of Disposal (COD). PCB
contaminated fluids of concentrations greater than 50 ppm, but less than 500 ppm, are
required to be disposed of in a USEPA approved incinerator, or chemical waste landfill, or a
high efficiency boiler. PCB liquids and Transformers with concentrations of 500 ppm or
greater must be disposed of in a USEPA approved PCB incinerator. PCB Capacitors must be
disposed of either a solid waste landfill or an approved incinerator depending on the
concentration of PCBs. PCB hydraulic machines containing PCBs at concentrations greater
than 50 ppm may be disposed of as municipal solid waste when drained. PCB-contaminated
Electrical Equipment, except capacitors, shall be disposed of by draining off the free-flowing
liquid. PCB Articles and Containers shall be disposed of in a USEPA approved incinerator or
chemical waste landfill if all free-flowing liquids have been removed (40 CFR 761.60,
761.218).
E. Key Compliance Definitions
1. ' Capacitor
A device for accumulating and holding a charge of electricity and consisting of conducting
surfaces separated by a dielectric. Types of capacitors are as follows (40 CFR 761.3):
a. Small Capacitor - a capacitor which contains less than 1-36 kg (3 Ib) of dielectric fluid;
Phase 1 - Section 13
PCB Management
13-5
-------
b. Large High-voltage Capacitor - a capacitor which contains 1.36 kg (3 Ib) or more of
dielectric fluid and which operates at 2000 volts (a.c. or d.c.) or above; and
c. Large Low-voltage Capacitor - a capacitor which contains 1.36 kg (3 Ib) or more of
dielectric fluid and which operates at 2000 volts (a.c. or d.c.).
2. Chemical Waste Landfill
Landfill at which protection against risk of injury to health or the environment from
mitigation of PCBs to land, water, or the atmosphere is provided from PCBs and PCB Items
deposited therein by locating, engineering, and operationing the landfill as required (40 CFR
761.3).
3. Commercial Storer of PCB Waste
The owner or operator of each facility that is subject to the PCB storage facility standards of
40 CFR 761.65, and who engages in storage activities involving PCB waste generated by •
others, or PCB waste that was removed while servicing the equipment owned by others and
brokered for disposal. The receipt of a fee or any other forms of compensation for services is
not necessary to qualify as a commercial storer of PCB waste. It is sufficient under this
definition that the facility stores PCB waste generated by others or the facility removed the
PCB waste while servicing equipment owned by others. If a facility's storage of PCB waste
at no time exceeds 500 gal [1892.71 L] of PCBs, the owner or operator is not required to
seek approval as a commercial storer of PCB waste (40 CFR 761.3).
4. Disposal
Intentionally or accidentally to discard, throw away, or otherwise complete or terminate the
useful life of PCBs and PCB Items (40 CFR 761.3).
5. Double Wash/Rinse
A minimum requirement to cleanse solid surfaces (both impervious and nonimpervious) two
times with an appropriate solvent or other material in which PCBs are at least 5 percent
soluble (by weight) (40 CFR 761.123).
6. Emergency Situations
For continuing use of a PCB transformer exists when (40 CFR 761.3):
a. Neither a non-PCB transformer nor a non-PCB contaminated transformer is currently in
storage for reuse or readily available within 24 hours for installation, or
b. Immediate replacement is necessary to continue service for power users.
Phase 1 - Section 13
PCB Management
13-6
-------
7. High Concentration PCBs
PCBs that contain 500 ppm or greater PCBs, or those materials which the USEPA requires to
be assumed to contain 500 ppm or greater PCBs in the absence of testing (40 CFR 761.123).
8. In or Near Commercial Buildings
Within the interior of, on the roof of, attached to the exterior wall of, in the parking area
serving, or within 30 meters of a non-industrial, non-substation building (40 CFR 761.3).
9. Industrial Building
A building directly used in manufacturing or technically productive enterprises (40 CFR
761.3).
10. Leak or Leaking
Any instance in which a PCB article, PCB container, or PCB equipment has any PCBs on any
portion of its external surface (40 CFR 761.3).
11. Low Concentration PCBs
PCBs that are tested and found to contain less than 500 ppm PCBs or those PCB-containing
materials which USEPA requires to be assumed to be at concentrations below 500 ppm (e.g.,
untested mineral oil dielectric fluid) (40 CFR 761.123).
12. Management Practice (MP)
Practices that, although not mandated by law, are encouraged to promote safe operating
procedures.
13. Mark
The descriptive name, instructions, cautions, or other information applied to PCBs and PCB
items, or other objects subject to these regulations (40 CFR 761.3).
14. Marking
The marking of PCB items and PCB storage areas and transport vehicles by means of
applying a legible mark by painting, fixation of an adhesive label,- or by any other method
that meets the requirements of these regulations (40 CFR 761.3).
15. Mineral OH PCB Transformers
Any transformer originally designed to contain mineral oil as the dielectric fluid and which
has been tested and found to contain 500 ppm or greater PCBs (40 CFR 761.3).
Phase 1 - Section 13
PCB Management
13-7
-------
16. Non-PCB Transformers
Any transformer that contains less than 50 ppm PCB except any transformer that has been
converted from a PCB transformer or a PCB-contaminated transformer cannot be classified as
a non-PCB transformer until rectification has occurred in accordance with the requirements
of 40 CFR 761.30(a)(2)(v) (40 CFR 761.3).
17. PCBorPCBs
An chemical substance that is limited to the biphenyl molecule that has been chlorinated to
varying degrees or any combination of substances which contains such substance (40 CFR
761.3).
18. PCB Article
Any' manufactured article, other than a PCB container, that contains PCBs and whose
surface(s) has been in direct contact with PCBs. This includes capacitors, transformers,
electric motors, pumps, and pipes (40 CFR 761.3).
19. PCB Article Container
Any package, can, bottle, bag, barrel, drum, tank, or other device used to contain PCB articles
or PCB equipment, and whose surface(s) has not been in direct contact with PCBs (40 CFR
761.3).
20. PCs-Contaminated Electrical Equipment
Any electrical equipment, including but not limited to transformers, capacitors, circuit
breakers, reclosers, voltage, regulators, switches, electromagnets, and cable, that contain SO
ppm or greater PCB, but less than 500 ppm PCB (40 CFR 761.3).
21. PCB Equipment
Any manufactured item, other than a PCB container or a PCB article container, which
contains a PCB article or other PCB equipment, and includes microwave ovens, electronic
equipment, and fluorescent light ballasts and fixtures (40 CFR 761.3).
22. PCB Item
Any PCB Article, PCB Article Container, PCB Container, or PCB Equipment that deliberately
or unintentionally contains or has as a part of it any PCB or PCBs (40 CFR 761.3).
23. PCB Transformer
Any transformer that contains 500 ppm PCB or greater (40 CFR 761.3).
24. PCB Waste
Those PCBs and PCB Items that are subject to the disposal requirements of Subpait D of 40
CFR 761 (40 CFR 761.3).
Phase 1 - Section 13
PCB Management
134
-------
25. Posing an Exposure 'Risk to Food .or Feed
Being in any location where human food or animal feed products could be exposed to PCBs
released from a PCB item (40 CFR 761.3).
26. Retroflll
To remove PCB or PCB contaminated dielectric fluid and replace it with either PCB, PCB
contaminated, or non-PCB dielectric fluid (40 CFR 761.3).
27. Rupture of a PCB Transformer
A violent or non-violent break in the integrity of a PCB Transformer caused by an
overtemperature and/or overpressure condition that results in the release of PCBs (40 CFR
761.3).
F. Records to Review
• Inspection, storage, maintenance, and disposal records for PCBs/PCB Items
• PCB Equipment inventory and sampling results
• Correspondence with regulatory agencies concerning noncompliance situations
• Annual reports
• Spill Prevention Control and Countermeasure (SPCC) Plan
• Manifests
• Certificates of Disposal
G. Physical Features to Inspect
• PCB storage areas
• Equipment, fluids, and other items used or stored at the facility containing PCBs
Phase 1 - Section 13
PCB Management
13-9
-------
H. Guidance For Checklist Users
All Facilities
PCB Management
PCB Records
PCB Transformers
PCB Spills
PCB Items
PCBs in Research
PCB Storage
PCB Transportation
PCB Disposal
Refer To
Checklist Items
PCB.1 through PCB.3
PCB.4 through PCB.5
PCB.6 through PCB.8 •
PCB.9 through PCB.1 7
PCB. 18 through PCB.20
PCB21 through PCB.24
PCB.25
PCB.26 through PCB.31
PCB.32 through PCB.33
PCB.34 through PCB.45
Page Numbers
13-11
13-12
13-14
13-15
13-19
13-21
13-23
13-23
13-25
13-26
Phase 1 - Section 13
PCB Management
13-10
-------
Compliance Category:
PCB Management
Regulatory Requirement!
Reviewer Cheeks:
All Facilities
PCB.1. The current status of
any ongoing or unresolved
Consent
Orders. Compliance
Agreements. Notices of Violation
(NOV), Interagency Agreements,
or equivalent state enforcement
actions is required to be
examined. (A finding under this
checklist item will have the
enforcement action/identifying
information as the citation).
Determine if noncompliance issues have been resolved by reviewing a copy of the
previous report, Consent Orders. Compliance Agreements, NOVs, Interagency
agreements or equivalent State enforcement actions.
For those open items, indicate what corrective action is planned and milestones
established to correct problems.
PCB.2. Facilities are required to
comply with all applicable
Federal regulatory requirements
not contained in this checklist.
(A finding under this checklist
item will have the citation of the
applied regulation as a basis of
finding.)
Determine if any new regulations have been issued since the finalization of the guide.
If so,'annotate checklist to include new standards.
Determine if the facility has activities or facilities which are Federally regulated, but
not addressed in this checklist.
Verify that the facility Is in compliance with all applicable and newly issued
regulations.
PCB.3. Facilities are required to
comply with state and local
regulations concerning PCB
management (EO 12088, Sect
1-1).
Verify that the facility is abiding by state and local requirements.
Verify that the facility is operating according to permits issued by the state or local
agencies.
(NOTE: Issues typically regulated by state and local agencies Include:
- definitions of RGB-contaminated
• PCB storage, labeling, and disposal requirements.)
Phase 1 - Section 13
PCB Management
13-11
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Compliance Category:
PCB Management
Regulatory Requirements: I Reviewer Checks:
PCB Management
PCB.4. Certain equipment that
contains PCBs must be marked
with an ML marking (40 CFR
761.40 and 761.45).
(NOTE: Marking Format Large PCB Mark (ML) letters and striping, on a white or
yellow background, sufficiently durable to equal or exceed the life of the PCB Article.
The size shall be 15.25 cm (6 in.) on each side. If the article is too small to
accommodate this size, a smaller label (Ms) may be used.)
Verify that equipment containing PCBs is .marked with an ML marking that can be
easily read by any person inspecting or servicing the equipment (see Appendix 13-1
for a sample of the marking):
• PCB Containers with PCBs in concentrations of 50 to 500 ppm
- PCB Transformers (500 ppm or greater)
- PCB Large High Voltage Capacitors
- Equipment containing a PCB Transformer (500 ppm or greater) or a PCB Large
High Voltage Capacitor at the time of removal from service
- PCB Large Low Voltage Capacitors at the time of removal from service
- Electric motors using PCB coolants with a concentration of 50 to 500 ppm
- Hydraulic systems using PCB hydraulic fluid with concentrations of 50 to 500 ppm
- Heat transfer systems (other than PCB Transformers) using PCB concentrations of
50 to 500 ppm
- PCB Article Containers containing any of the above
• Each storage area used to store PCBs and PCB Items for disposal
- Transport vehicles loaded with PCB Containers that contain more than 45 kg (99.4
Ib) of PCBs in the liquid phase with PCB concentrations of 50 to 500 ppm or one or
more PCB Transformers with PCB concentrations of greater than 500 ppm are
marked on each end and side
- Vault doors, machinery room doors, fences, hallways, or means of access, other
than a manhole or grate cover, to a PCB Transformer (500 ppm or greater).
Verify that rf one or more PCB Large High Voltage Capacitors is installed in a
protected location such as a pole, structure, or behind a fence, the pole, structure, or
fence is marked and a record or procedure identifying the PCB Capacitor is
maintained by the
facility.
(NOTE: Marking of PCB Contaminated electrical equipment (50 500 ppm) is not
required.)
(NOTE: Appendix 13-2 contains a list of manufacturers that produced PCB
contaminated dielectric fluid.)
(NOTE: The annual document tog should contain a list of all PCB equipment at the
site.)
Phase 1 - Section 13
PCB Management
13-12
-------
Compliance Category:
PCS Management
Regulatory Requirements:
Reviewer Cheeks:
PCB.5. Generators,
transporters, and disposers of
PCB waste are
required to have an USEPA ,
identification number (40 CFR
761.202 through 761.205).
(NOTE: Some facilities are exempt from the notification requirement and do not have
a specified PCB storage area as regulated by 40 CFR 761.65 and just temporarily
store before they transport for disposal.)
Determine if the facility is a generator, transporter, or disposer of PCB waste.
Verify that facilities which generate PCB waste have an USEPA identification number
before processing, storing, dispensing, transporting, or offering for transport PCB
waste.
Verify that facilities which transport or dispose of PCB waste have an USEPA
identification number.
Verify that if an facility must file. Form 7710-53, Notification of PCB Waste Activity, it
was filed with USEPA by 4 April 1990 and a USEPA identification number was
obtained.
Phase 1 - Section 13
PCB Management
13-13
-------
Compliance Category:
PCS Management
Regulatory Requirements: I Reviewer Chocks:
PCB Records
PCB.6. A written annual
document log must be prepared
by July 1 of each calendar year,
covering the previous year for
all facilities that use or store at
any time at least 45 kg (99.4 Ib)
of PCBs contained in PCB
Containers or one or more PCB
Transformers (500 ppm or
greater), or 50 or more PCB
Large. High, or Low Voltage
Capacitors (40 CFR
761.180(a)J.
Verify that the annual document log and annual records (manifests certificates ol
disposal) are kept for at least 5 years after the facility stops using or storing PCBs
and PCB items in the listed quantities.
Review the written annual document log for the following:
- Identification of facility
- Calendar year covered
- Manifest number for every manifest generated
- Total number (by type) of PCB Articles, PCB Article Containers, and PCB
Containers placed into storage for disposal or disposed of during the calendar year
• Total weight placed mto storage for disposal or disposed of during the calendar
year of:
- PCBs in PCB Articles
- contents of PCB Article Container
- contents of PCB Containers
- bulk PCB Waste
- A list of PCBs and PCB Items remaining in-service at the end of the calendar-year.
The total weight of any PCBs and PCB Items in containers including identification
of container contents and the total number of PCB Transformers, PCB Large, High-
and Low-Voltage Capacitors, and the total weight of PCBs in PCB Transformers
- A record of each telephone call or other form of verification to confirm the receipt of
PCB Waste transported by independent transport.
Verify that the annual document log contains the following for each manifest, for
unmanifested waste, and for any PCBs or PCB Items received from or shipped fro
another facility owned or operated by the generator
- Date removed from service for disposal (first date material placed in PCB
Container)
- Date placed into transport for offsrte storage/disposal
• Date of disposal (if known)
• Weight of PCB Wastes:
- total bulk for PCB wastes
- In each article for PCB Transformers or Capacitors
- total in each container for PCB Containers
- total weight of contents and of the PCB Article (in kg) in each PCB Article
Container
- Serial number or other unique identification number (except for bulk wastes)
- Description of the contents for PCB Containers and Article Containers.
Determine if the following information is provided by reviewing the annual document
log:
- All signed manifests generated or received at the facility during the calendar year
- All CODs that have been generated or received during the calendar year.
Phase 1 - Section 13
PCB Management
13-14
-------
Compliance Category:
PCB Management
Regulatory Requirements:
Reviewer Checks:
PCB.7. Owners and operators
of PCB chemical waste landfills
shall keep records on water
analysis and operational
records, including burial
coordinates, for 20 years after
disposal has ceased (40 CFR
761.1BO(d)>.
Verify that records on water analysis and operations are being kept for the required
20 years.
PCB.8. Storage and disposal
facilities for PCBs shall maintain
specific records for 3 years (40
CFR 761.180(f)).
Verify that facilities which store or dispose of PCBs
collect and maintain the following records for 3 years:
- All documents, correspondence, and data thaj have been provided by any state or
local government
- All documents, correspondence, and data provided to the state or local
governments by the facility
- Any applications and related correspondence concerning wastewater discharge
permits, solid waste permits, building permits, or other permits and authorizations.
PCB Transformers
PCB.9. PCB Transformers with
PCBs of 500 ppm or greater
that are in use or in storage for
reuse shall not pose an
exposure risk to food and feed
(40CFR761.30(a)(1)(i)).
Determine if there are any PCB Transformers on the rnstallation/CW
facility, in use or in storage for reuse, that pose an exposure risk to
food and feed by reviewing the inventory.
PCB. 10. PCB Transformers
with concentrations of PCBs of
500 ppm or greater are subject
to certain registration
requirements (40 CFR
Verify that all PCB Transformers, including those in storage for reuse, are registered
with the facility fire department, or the fire department with jurisdiction, with the
following information:
- Physical location of PCB Transformer(s)
- Principle constituent of dielectric fluid (e.g., PCBs, mineral oil, silicone oil, etc.)
- Name and telephone number of contact person knowledgeable of PCB
Transform er(s).
PCB. 11. Railroad transformers
must not contain dielectric fluid
with greater than 1000 ppm
PCB and must be serviced
according to specific
requirements
(40 CFR 761.30(b)((1)(vi),
761.30(b)(2)(iii)and
761.30(b)(2)(iv)).
Verify that railroad transformers do not exceed 1000 ppm PCB.
Verify that servicing of a railroad transformer is only done with dielectric fluid
containing less than 1000 ppm PCB.
Verify that if the coil is removed from the casing of a railroad transformer, It Is refilled
with dielectric fluid containing 50 ppm or less PCB.
(NOTE: Dielectric fluid may be filtered through activated carbon or otherwise
industrially processed for the purpose of reducing the PCB concentration In the fluid.)
Phase 1 - Section 13
PCB Management
13-15
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CompUaiioo
PCS
Regulatory Requirements:
Reviewer Checks:
PCB.12. Combustible materials,
including but not limited to
paints, solvents, plastics, paper.
and sawn wood, must not be
stored by a PCB Transformer
(40CFR761.30(a)(1)(vih)).
Verify that all combustible materials have been removed from the area within a PCB
transformer enclosure (e.g.. vault or partitioned area) and the area within 5 meters
(16.40 ft] of a PCB transformer or PCB transformer enclosure.
PCB. 13. PCB Transformers of
concentrations of 500 ppm or
greater in use in or near
commercial buildings are subject
to certain requirements (40 CFR
761.30(a)(1)(ii) through
761.30(a)(1)(v) and
Determine if there are any transformers located in or near commercial buildings by
reviewing the inventory.
Verify that procedure/policy exists prohibiting installation of PCB Transformers which
have been placed into storage for reuse or which have been removed from another
location.
Verify that there are no network PCB Transformers with higher secondary voltages
(equal to or greater than 430 V. including 480/277 V systems) in or near commercial
buildings
Determine where any of the following PCB Transformers are in use in or near
commercial buildings or located in sidewalk vaults and if a plan exists to equip such
PCB Transformers with electrical protection to avoid transformer failure that would
result in release of PCBs:
- Radial PCB Transformers and lower secondary voltage network PCB Transformers
(voltage less than 460 V)
- Radial PCB Transformers with higher secondary voltages (greater than or equal to
480 V including 480/277 V system).
Determine if lower secondary voltage network PCB Transformers which have not
been electrically protected are registered with the USEPA Regional Administrator ana
plans are being made to remove them from service by 1 October 1993.
Verify that all higher secondary voltage radial PCB Transformers, in use in or near
commercial buildings, and lower secondary voltage network PCB Transformers not
located in sidewalk vaults in or near commercial buildings are equipped with:
- Electrical protection such as current-limiting fuses to avoid transformer ruptures
• Disconnect equipment to insure complete de-energization of the transformer in case
of a sensed abnormal condition.
Verify that all lower secondary voltage radial PCB Transformers, in use in or near
commercial buildings, are equipped with electrical protection such as current limiting
fuses or equivalent technology and provide for the complete de-energization of the
transformer or complete de-energization of the faulted phase of the transformer within
several hundredths of a second.
Phase 1 - Section 13
PCB Management
13-16
-------
Compliance Category:
PCB Management
Regulatory Requirements:
Reviewer Checks!
PCB.14. PCB transformers are
required to be properly serviced
(40 CFR 761.30(a}(2)).
Verify that servicing activities are properly conducted as follows by reviewing
servicing records:
- Transformers classified as PCB-contaminated electrical equipment (50-500 ppm
PCBs) are only serviced with dielectric fluid containing less than 500 ppm PCB
- The transformer coil is not removed during servicing of PCB Transformers with
PCB concentrations of 500 ppm or greater
• PCBs removed during servicing are captured and are either reused as dielectric
fluid or disposed of property
- The PCBs from a PCB Transformer with PCB concentrations of 500 ppm or greater
are not mixed with or added to dielectric fluid from PCB-contaminated electrical
equipment (50-500 ppm PCBs)
• Dielectric fluids containing less than 500 ppm PCBs that are mixed with fluids
containing 500 ppm or greater are not used as dielectric fluid in1 any transformers
classified as PCB-contaminated electrical equipment (50-500 ppm PCBs).
(NOTE: PCB Transformers may be serviced with dielectric fluid at any
concentration.)
PCB. 15. Inspections must be
performed once every 3 months
for all in-service PCB
Transformers with greater than
500 ppm PCB (40 CFR
761.30(a) (1)(ix) and
761.30(a)(1)(xii) through
761,30(a)(1)(xiv)).
Verify that applicable transformers are Inspected at least once every 3 months by
reviewing inspection records.
Determine whether any PCB Transformers have been leaking.
Verify that the following information is recorded for each PCB Transformer Inspection:
- Location of transformer
- Dates of each visual inspection
• Date when any teak was discovered
- Name of person conducting inspection
• Location and estimate of the dielectric fluid quantity for any leaks
• Data and description of any cleanup, containment, or repair performed
- Results of any daily inspections for transformers with uncorrected active leaks.
(NOTE: Reduced visual inspections of at least once every 12 months is allowed for
PCB Transformers with impervious, undrained secondary containment capacity of 100
percent of dielectric fluid and for PCB Transformers tested and found to contain less
than 60.000 ppm PCBs.)
(NOTE: Increased visual inspections of once a week is required for any PCB
Transformer in use or stored for reuse which poses an exposure risk to food or feed.)
Verify that records of inspection and maintenance are kept for 3 years after disposal.
Phase 1 - Section 13
PCB Management
13-17
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Cotnpll&rice Category:
PCS Management
Regulatory Requirements:
Reviewer Checks:
PCB.16. PCB Transformers
with PCB concentrations of 500
ppm or greater found to be
leaking during an inspection
must be repaired or replaced to
eliminate the source of the leak
(40 CFR 761.30(a)(1)(x)).
Determine if cleanup and/or containment of released PCBs has been initiated within
48 h of its detection or as soon as possible.
Verity that leaking PCB Transformers are inspected daily.
Determine if plans exist to repair or replace transformers to eliminate the source of
the leak.
Verify that cleaned up material is disposed of according to appropriate requirements.
PCB.17. When a PCB
Transformer with concentrations
of PCBs 500 ppm or greater is
involved in a fire, the facility is
required to immediately report
the incident to the NRC (40
CFR76l.30(a)(1)(xi)).
Determine if any PCB Transformers have been involved in any incident where
sufficient heat and/or pressure was generated to result in the violent or nonviolent
rupture of a PCB Transformer and the release Of PCBs.
Verify that the NRC was notified and the following measures were taken':
• Floor drains were blocked
• Water runoff was contained.
Phase 1 - Section 13
PCB Management
13-18
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Compliance Category:
PCB Management
Regulatory Requirements:I Reviewer Checks:
PCB Spills
PCB. 18. Facilities are required
to report spills of more than 10
Ib [4.53 kg] of PCBs of
concentrations of SO ppm or
greater (40 CFR 761.120(a)(1),
761.123(d}(2). and 761.125(a)).
Verify that when a spill of 10 Ib [4.53 kg] or more directly contaminates surface water.
sewers, or drinking water the facility notifies the regional USEPA office within 24
hours after discovery of the spill and acts on the guidance given by the USEPA.
Verify that if a spill of 10 Ib [4.53 kg] or more directly contaminates grazing land or a
vegetable garden the facility notifies the USEPA regional office within 24 hours after
discovery and begins the cleanup of the spill.
Verify that when a spill of 10 Ib [4.53 kg] or more occurs which does not directly
contaminate surface waters, sewers, drinking water supplies, grazing land, or a
vegetable garden the facility notifies the USEPA Regional office within 24 hours after
discovery of the spill and begins decontamination of the spill area.
(NOTE: Spills of greater than 1 Ib [0.45 kg] must be reported to the NRG under 40
CFR 302.1 through 302.6, see appropriate checklist items in Hazardous Materials
•Management protocol.)
PCB. 19. Cleanup of low
concentration spills of less than
1 Ib [0.45 kg] of PCBs (less than
270 gal [1022.26 L] of untested
mineral oil) must be done
according to specific
requirements (40 CFR
761.120(a)(2}, 761.120(b),
761.120(c), and761.125(b)).
Verify that solid surfaces are double washed/rinsed and all indoor, residential
surfaces other than vault areas are cleaned to 10 mg/100 cm1 by standard
commercial wipe tests.
Verify that all soil within the spill area (visible traces of soil and buffer of 1 lateral foot
[3.28 lateral meters] around the visible traces) is excavated and the ground restored
to its original status by backfilling with clean soil (soil with less than 1 ppm PCBs).
Verify that the above cleanup requirements are done within 48 hours after identifying
the spill unless an emergency or adverse weather delays the process.
Verify that the cleanup is documented with records and certification of
decontamination and the records are maintained for 6 years.
(NOTE- The finat numerical cleanup standards do not apply to spills directly into
surface waters, drinking water, sewers, grazing lands, and vegetable gardens.)
(NOTE: The USEPA may impose more stringent or less stringent cleanup
requirements on a case by case basis depending on conditions such as possibility of
groundwater contamination.)
Phase 1 - Section 13
PCB Management
13-19
-------
PCS Management
Regulatory Requirements:
Revtemr Checks?
PCB.20. Cleanup of high
concentration spills and low
concentration spills involving 1
Ib [0.45 kg] or more of PCBs by
weight (270 gal [1022.64 L] or
more of untested mineral oil)
must be done according to
specific requirements (40 CFR
761.120(a)(2),761.120(b),
76l.120(c), and 761.125(c)).
Verify that the following actions are taken within 24 hours (or within 48 hours for PCB
Transformer with PCB concentrations of greater than 500 ppm) of discovery of the
spill:
- Notification of the USEPA regional office and the NRC
- The area of the spill is cordoned off or otherwise identified to include the area with
visible traces of the spill and a 3 ft [0.91 m] buffer zone. If there are no visible
traces the area of the spill may be estimated
- Clearly visible signs are placed advising persons to avoid the area
- The area of visible contamination is recorded and documented, identifying the
extent and center of the spill
- Cleanup of visible traces of the fluid from hard surfaces is initiated
- Removal of all visible traces of the spill on soil and other media such as gravel,
sand, etc. is started.
Verity that if the spill occurs in an outdoor substation:
- Contaminated solid surfaces are cleaned to a PCB concentration of 100 mg/cm* (as
measured by standard wipe tests)
- Soil contaminated by the spill is cleaned to either 25 ppm PCBs by weight or 50
ppm PCBs by choree of the facility if a label to notice is placed in the area
indicating the level of cleanup
- Post-cleanup sampling is done.
Verify that If the spill occurs in a restricted access area other than an outdoor
substation:
- High-contact solid surfaces are cleaned to 10 mg/100 cm2 (as measured by
standard wipe tests)
- Low-contact, Indoor, impervious solid surfaces are decontaminated to 10 mg/10T
cm*
- Low contact, indoor, nonimpervious surfaces are cleaned to either 10 mg or 100
mg/100 cm2 and encapsulated at the option of the facility
- Low-contact, outdoor surfaces (both impervious and non-impervious) are cleaned to
100 mg/100 cm2
• Soil contaminated by the spill is cleaned to 25 ppm PCBs by weight
• Post-cleanup sampling is done.
Verify that spills in nonrestncted access locations are decontaminated as follows:
- Furnishings, toys, and other easily replaceable household items are disposed of
and replaced
- Indoor solid surfaces and high-contact outdoor solid surfaces are cleaned to 10 mg/
100 cm* (as measured by standard wipe tests)
- Indoor vault areas and low-contact, outdoor, impervious solid surfaces are
decontaminated to 10 mg/100 cm1
- At the option of the facility, tow-contact, outdoor, nonimpervious solid surfaces are
cleaned to either 10 or 100 mg/100 cm* and encapsulated
- Soil is decontaminated to 10 ppm PCBs by weight provided that the soil is
excavated to a minimum depth of 10 in. [25 cm] and replaced with clean soil
• Post-cleanup sampling is done.
Phase 1 - Section 13
PCB Management
13-20
-------
Compliance Category:
PCB Management
Regulatory Requirements:
Reviewer Checks!
PCB.20. Continued
Verify that records documenting all cleanup and decontamination are maintained for 5
years.
(NOTE: The occurrence/discovery of the spill on the weekend or overtime costs are
not considered acceptable reasons to delay response.)
(NOTE: The final numerical cleanup standards do not apply to spills directly into
surface waters, drinking water, sewers, grazing lands, and vegetable gardens.)
(NOTE: The USEPA may impose more stringent or less stringent cleanup
requirements on a case by case basis depending on conditions such as possibility of
groundwater contamination.)
o/tp •*_—,„
PCB items
PCB.21. PCBs may be used in
heat transfer and hydraulic
systems in a manner other than
a totally enclosed manner at
concentrations less than 50 ppm
if specific requirements are met
(40 CFR 761.30(d) through
761.30(e)).
Determine if testing has been conducted to demonstrate that heat transfer or
hydraulic systems that formerly contained PCBs at a concentration greater than 50
ppm now contain less than 50 ppm PCB.
Verify that no fluid containing greater than 50 ppm PCB is added to heat transfer or
hydraulic systems.
Verify that results from analyses which are performed to demonstrate presence of
less than 50 ppm PCB. are retained for confirmation for at least 5 years.
Verify that heat transfer or hydraulic systems are free from leaks of dielectric PCBs.
PCB.22. Electromagnets,
switches, and voltage regulators
may contain PCBs at any
concentration if certain
requirements are met (40 CFR
761.30(h».
Verify that no electromagnets are used or stored at the facility that contain greater
than 500 ppm PCB and pose an exposure risk to food or feed.
Verify that electromagnets that contain greater than 500 ppm PCB and which pose an
exposure risk to food or feed are inspected at least weekly to determine if they are
leaking.
Verify that electromagnets, switches, and voltage regulators that contain 500 ppm or •
greater PCB are not rebuilt and no removal or reworking of internal components is
done during servicing.
Verify that electromagnets, switches, and voltage regulators which contain between
50 and 500 ppm PCB (PCB Contaminated Electrical Equipment) are only serviced
with dielectric fluid which that less than 500 ppm PCB.
Verify that PCBs removed or captured are either reused as dielectric fluid or disposed
of properly.
Verify that dielectric fluid containing a mixture of fluids with less than 500 ppm PCBs
are not used as dielectric fluid in any electrical equipment.
Phase 1 - Section 13
PCB Management
13-21
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CompOance Category:
PCB
Regulatory Requirements:
Reviewer Checka:
PCB.23. Capacitors may
contain PCBs at any
concentration subject to certain
requirements (40 CFR
761.30(1)).
Verify that all PCB Large, High- and Low-Voltage Capacitors that pose an exposure
risk to food and feed have been removed.
Verify that all PCB Large, High- and Low-Voltage Capacitors are in use only in
restricted-access electrical substations, or in a contained and restricted-access indoor
area.
Verify that capacitors are free from leaks of dielectric PCBs.
PCB-24. Circuit, breakers.
reclosers, and cable may
contain PCBs at any
concentration for remainder of
their useful lives subject to
certain conditions (40 CFR
76l.3(m)J.
Verify that any circuit breakers, reclosers, and cables used at the facility are serviced
using only dielectric fluid which contains less than SO ppm PCB and have been free
from leaks.
Phase 1 - Section 13
PCB Management
13-22
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Compliance Category:
PCB Management
Regulatory Requirements: I Reviewer Cheeke:
PCBs In Research
PCB.25. The use of pigments
containing PCBs in research or
microscopy or in miscellaneous
items is subject to certain
conditions (40 CFR 761.30(g),
761.30(j), and 761.30(k)).
Verify that pigments used at the facility contain PCBs in concentrations less than 50
ppm.
Verify that pigments are handled in enclosed conditions.
PCB Storage
PCB.26. PCBs and PCB Items
at concentrations greater than
50 ppm that are to be stored
before disposal must be stored
in a facility that will assure the
containment of PCBs (40 CFR
761.65(a) through 761.65(b) and
761.65(c)(8)).
Verify that the following provisions are present by inspecting the PCB storage area:
- The roof and walls of the building in which the PCBs are stored are constructed so
as to exclude rainfall from contacting PCBs and PCB items
• A 6 in. [15.24 cm] tall containment curb circumscribes the entire area in which any
PCBs or PCB Items are stored. Such curbing shall effectively provide containment
for twice the internal volume of the largest PCB Article or 25 percent of the total
internal volume of all PCB Articles or Containers stored, whichever is greater
- Drains, valves, floor drains, expansion joints, sewer lines or other openings that
would allow liquids to flow from the curbed area are not present
• Floors and curbing are constructed of continuous, smooth, and impervious material
- Location is not below a 100-year flood water elevation.
Verify that PCB Articles or PCB Containers are removed from storage and disposed
of within 1 year from the date they were placed in storage.
PCB.27. PCB Items may also
be stored in other areas that do
not comply with the storage
area requirements when such
storage is for a period of less
than 30 days and when any
such PCB items are marked
with the date of removal from
service (40 CFR 761.65(c)(1)).
Venfy that only the following items are stored and are property marked in areas used
as a 30 day storage area:
- Nonleaking PCB Articles and PCB Equipment
• Leaking PCB Articles and PCB Equipment placed in a non-leaking PCB Container
which contains sufficient sorbent material to absorb liquid contained on the PCB
Article or equipment
- PCB Containers in which nonhquid PCBs have been placed
- PCB Containers in which liquid PCBs at a concentration between 50-500 ppm have
been placed when containers are marked to indicate less than 500 ppm PCB.
Verify that area has been included in the facility Spill, Prevention, Control, and
Countermeasure (SPCC) Plan.
PCB.28. Nonleaking and
structurally undamaged PCB
Large, High-Voltage Capacitors
and PCB Contaminated Electric
Equipment that have not been
drained of freeflowing dielectric
fluid may be stored on pallets
next to a storage area that
complies with the storage area
requirements (40 CFR
761.65(0(2)).
Determine if available unfilled storage space in the storage area is equal to at least
10 percent of the volume of capacitors and electrical equipment stored outside.
Verify that capacitors and equipment stored outside the storage facility are on pallets
and inspected at least weekly.
Phase 1 - Section 13
PCB Management
13-23
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Compliance Category:
PCB Management
Regulatory Requirement*:
Reviewer Checks;
PCB29. Specific operational
procedures are required at PCB
storage areas (40 CFR '
761.65(c)(4). 761.65(c)(5), and
761.65(c)(8)).
Verify that the following practices are conducted at any area where RGBs or PCB
Items are stored:
- Movable equipment used for handling PCBs and PCB Items that directly contact
PCBs is not removed from storage area unless decontaminated
- Inspections for leaks of all PCB Articles and PCB Containers in storage are done at
least once every 30 days
- Any leaked PCBs are immediately cleaned up and any spill absorbent material
properly disposed
- PCB Articles and Containers are marked with the date when placed into storage
- PCB Articles and PCB Containers are positioned so that they can be located by the
date they were placed into storage
- Containers in which PCBs are accumulated have a record that includes quantity
and date of each batch.
PCB.30. Containers used for
the storage of PCBs must
comply with the shipping
container specification of the
DOT (40 CFR 761.65(c)(6) and
761.65(c)(7J).
Verify that DOT specifications are on drums/containers. Typical specifications are 5,
SB. 17C.
(NOTE: Containers larger than those specified in DOT Specs 5. SB. or 17C may be
used for nonliquid PCBs when such containers will provide as much protection
against leaking and exposure to the environment as the DOT specified containers.)
Verify that containers used for storage of liquid PCBs are containers without
removable heads.
Verify that If the facility uses containers larger than DOT approved containers it has
prepared a SPCC Plan covering its containers storing PCBs.
PCB.31. Commercial storers of
PCB Waste must have final
storage approval (40 CFR
761.65(d)).
Determine if the facility is a commercial storer of PCB or has a commercial storer >
PCB waste at the facility.
Verify that the commercial storer has final storage approval from the USEPA Regional
Administrator for PCB waste.
(NOTE: Commercial storers were required to file for final storage approval by 2
August 1990. After filing for final approval, they will operate under interim approval
until the a final decision is made on approval.)
(NOTE: The following storage facilities may be exempt from this requirements for
storage approval:
- Storage areas at transfer facilities unless the PCB waste is stored at the transfer
facility for more than 10 consecutive days between destinations
- Storage areas at RCRA-permitted facilities if the facility proves to the Regional
Administrator that the facility's existing RCRA closure plan substantially meets the
requirements for a TSCA closure plan
- Storage areas ancillary to a TSCA approved disposal facility if the disposal
approval contain an expiration date and the current disposal approval's closure and
financial responsibility conditions specifically extend to storage areas ancillary to
disposal.)
Phase 1 - Section 13 ,
PCB Management
13-24
-------
Compliance Category:
PCB
Regulatory Requirement*: I Reviewer Checks:
PCB Transportation
PCB.32. A generator who offers
a PCB waste for transport for
commercial offsite storage or
offsite disposal must prepare a
manifest (40 CFR 761.207
through 761.210).
(NOTE: This applies to PCB wastes as defined in 40 CFR 761.3, and that contain
greater than 50 ppm PCB unless the concentration was reduced below 500 ppm by
dilution.)
Verify that a manifest has been prepared when needed and that it contains (use
USEPA Form 8700-22):
- The identity of PCB Waste, the earliest date of removal from service for disposal
and the weight in kg of the waste for bulk load of PCBs
- The unique identifying number of each PCB Article Container or PCB Container.
the date of removal from service, type of waste, and the weight of PCB waste
contained
- The serial number if available or other identification for each PCB Article not in a
PCB Container or PCB Article Container, the date of removal from service for
disposal, and weight in kg of the PCB waste in each PCB Article.
Verify that sufficient copies are prepared to supply the generator, the initial
transporter, each subsequent transporter, and the owner or operator of the disposal
facility with one legible copy each for their records, and one additional copy to be
signed and returned to the generator by the owner or operator of the disposal facility.
Verify that the generator maintains a copy of the signed manifest for at least 3 years
after receipt of waste by the initial transporter.
PCB.33. If the generator does
not receive a signed copy of the
manifest within 35 days of the
date the waste was accepted by
the initial transporter, the
generator is required to
immediately contact the
transporter and/or owner or
operator of the designated
facility to determine the status of
the PCB Waste (40 CFR
761.215(a) and 761.215(b)).
Verify that a procedure is in place so that if the generator does not receive a copy
within 35 days of the date the waste was accepted by the initial transporter, an
Exception Report is filed with the USEPA containing the following information:
- A legible copy of the manifest for which the generator does not have confirmation
of delivery
- A cover letter signed by the generator or his authorized representative explaining
the efforts taken to locate the PCB Waste and the results of those efforts.
Phase 1 - Section 13
PCB Management
13-25
-------
Compliance Category:
PCB Management
Regulatory Requirements: I Reviewer Checks:
PCB Disposal
PCB.34. For each shipment of
manifested PCB waste that a
disposal facility accepts, the
owner or operator of the
disposal facility must prepare a
COO (40 CFR 761.218).
Verify that a COD has been prepared containing the following information:
• The identity of the disposal facility by name, address, and USEPA identification
number
• The identity of the PCB Waste affected by the COD including reference to the
manifest number for the shipment
• A certification as defined in 40 CFR 761.3.
Verify that a copy of the COD was:
• Sent to the generator identified on the manifest within 30 days of the date that
disposal of the PCB waste was completed
- Retained at the facility with the annual report.
Phase 1 - Section 13
PCB Management
13-26
-------
Compliance Category:
PCB Management
Regulatory Requirements:
HBVWW0T wvlOdltt*
PCB.35. PCB contaminated
fluids other than mineral oil
dielectric fluid of concentrations
greater than SO ppm but less
than 500 ppm are required to be
disposed of according to specific
requirements (40 CFR
761.60(a)(3».
Determine if any PCB fluids meetrng these criteria were processed for disposal in the
last year.
Verify that disposal was done at:
- A USEPA-approved incinerator
- A USEPA-approved chemical waste landfill
- A high efficiency boiler.
Verify that if the fluid is burned in an high efficiency boiler:
- The boiler is rated at a minimum of 50 MBtu/h [14.65 MW)
- The CO concentration in the stack is 50 ppm or less and the excess O, is at least 3
percent when PCBs are being burned and the boiler uses natural gas or oil as the
primary fuel
• The CO concentration in the stack is 100 ppm or less and the 02 content is at' least
3 percent when PCBs are being burned and the boiler uses coal as the primary fuel
• The waste does not compromise more than 10 percent (on a volume basis), of the
total fuel feed rate
- The waste Is not fed into the boiler unless the boiler is operating at its normal
operating temperature the operator of the boiler does one of the following:
- continuously monitors and records the CO concentrations and excess 02
percentages in the stack gas while burning the waste fluid
- measure and records the CO concentration and excess O, percentage in the
stack gas at regular intervals of no longer than 60 min if the boiler will bum less
than 30.000 gal/yr [113,562.36 L/yr] of waste fluid
- measures and records the primary fuel feed rates, the waste fluid feed rates,
and total quantities of both primary fuel and waste fluid fed to the boiler at
regular intervals of no longer than 15 minutes
- checks the CO concentration and the excess O2 percentage at least once every
hour and if either measurement falls below the specified levels, the flow of the
waste fluid to the boiler stops immediately.
Verify that before burning waste fluid, approval has been obtained from the USEPA
Regional Administrator.
Verify that the following information is obtained by persons burning waste fluid in a
boiler and kept at the boiler location for 5 years1
- Emissions data
- The quantity of waste fluid burned in the boiler each month
- A waste analysis.
Verify that such PCB fluids were disposed of by an approved method at a property
licensed facility
Phase 1 - Section 13
PCB Management
13-27
-------
Compliance Category:
PCS Management
Regulatory Requirements:
Reviewer Checks:
PCB.36. PCB liquids greater
than 50 ppm must be disposed
of in an incinerator which is
approved by USEPA to
incinerate PCBs (40 CFR
761.60(a)(1)J.
Verify that all shipments were made to USEPA licensed PCB incinerators by
reviewing manifests for a PCB shipments over the past 3 years.
(NOTE: Other disposal provisions apply to:
- Mineral oil dielectric fluid from PCB-Contaminated Electrical Equipment with a
concentration greater than 50 ppm but less than 500 ppm
- Liquids, other than mineral oil dielectric fluids, with PCB concentrations between 50
and 500 ppm
- Rags, solids, and other debris contaminated with PCB at concentrations greater
than 50 ppm
• PCB Articles.)
Phase 1 - Section 13
PCB Management
19-28
-------
Compliance Category:
PCS
Regulatory Requirements:
Reviewer Checks:
PCB.37. Mineral oil dielectric
fluid from PCB-Contaminated
Electrical Equipment containing
a PCB concentration greater
than 50 ppm but less than 500
ppm is required to be disposed
of according to specific methods
(40 CFR 761.60(a)(2)).
Verify that mineral oil dielectric fluid as described is disposed of in one of the
following ways:
- An USEPA approved incinerator
- An approved chemical waste landfill if written information proves that the fluid is not
contaminated at greater than 500 ppm and is not an ignftable waste
- An approved high efficiency boiler that Is rated at a minimum of 50 MBtu/h {14.65
MW].
Verify that if the fluid is burned in an high efficiency boiler
- The boiler is rated at a minimum of 50 MBtu/h [14.65 MW]
• The CO concentration in the stack is 10 ppm or less and the excess 0, is at least 3
percent when PCBs are being burned and the boiler uses natural gas or oil as the
primary fuel
- The CO concentration in the stack is 100 ppm or less and the O, content is at least
3 percent when PCBs are being burned and the boiler uses coal as the primary fuel
- The mineral oil dielectric fluid does not compromise more than 10 percent (on a
volume basis), of the total fuel feed rate.
• The mineral oil dielectric fluid is not fed into the boiler unless the boiler is operating
at its normal operating temperature
- The operator of the boiler does one of the following:
- continuously monitors and records the CO concentrations and excess 02
percentages in the stack gas while burning mineral oil dielectric fluid
- measure and records the CO concentration and excess O, percentage in the
stack gas at regular intervals of no longer than 60 min if the boiler will burn less
than 30,000 gal [113,562.36 L| of mineral oil dielectric fluid per year •
- measure and record the primary fuel feed rates, the mineral oil dielectric fluid
feed rates, and total quantities of both primary fuel and mineral oil dielectric fluid
fed to the boiler at regular intervals of no longer than 15 mln
- checks the CO concentration and the excess O2 percentage at least once every
hour and if either measurement falls below the specified levels, the flow of the
mineral oil dielectric fluid to the boiler stops immediately.
Verify that 30 days before burning mineral oil dielectric fluid, a written notice of the
burning is given the to USEPA Regional Administrator.
Verify that the following information is obtained by persons burning mineral oil
dielectric fluid in a boiler and kept at the boiler location for 5 years:
• Emissions data
- The quantity of mineral oil dielectric fluid burned in the boiler each month.
PCB.38. Rags, soils, and other
debris contaminated with PCBs
at concentrations greater than
50 ppm must be disposed of In
a PCB incinerator or in a
chemical waste landfill
(40CFR761.60(a)(4)).
Determine if any contaminated soil or debris has been disposed of, and verify that
disposal was conducted at a properly licensed facility.
Phase 1 - Section 13
PCB Management
13-29
-------
Compliance Category:
PCB Management
Regulatory Requirements:
Hovieww Gnedftt!
PCB.39. PCB Transformers
with PCB concentrations of 500
ppm or greater shall be
disposed of in either a USEPA
approved incinerator or a
chemical waste landfill (40 CFR
761.60(b)(1)).
Determine if the PCB Transformers are being disposed of at a USEPA-approved
incinerator or a chemical waste landfill.
Verify that if disposal is being done at a chemical waste landfill the transformer is
drained of all free-flowing liquids, filled with solvent, allowed to stand for at least 18
hours, and than drained thoroughly.
PCB.40. PCB Capacitors must
be disposed of in accordance
with certain requirements (40
CFR761.60(b)(2)).
Verity that disposal of PCB Capacitors was done as follows:
- PCB Small Capacitors (less than 1.36 kg (3 Ib) of PCBs) are disposed of in a solid
waste landfill
- PCB Large, High- or Low-Voltage Capacitors (greater than 1.36 kg (3 Ib) of PCBs)
containing more than 500 ppm are incinerated in a USEPA approved incinerator.
(NOTE: The large, high, or low-voltage capacitors may be disposed of in a chemical
waste landfill upon approval of the USEPA.)
Verify that capacitors in storage are placed in DOT containers with absorbent
material.
PCB.41. PCB hydraulic
machines containing PCBs at
concentrations greater than 50
ppm may be disposed of as
municipal solid waste if specific
conditions are met (40 CFR
761.60(b)(3)).
Verify that the machines are drained of all free-flowing liquid.
Verify that if the machine contained PCB liquid of 1000 ppm PCB or greater, it is
flushed prior to disposal with a solvent containing less than 50 ppm PCB.
PCB.42. PCB contaminated
electrical equipment (50 500
ppm PCB), except capacitors,
shall be disposed of by draining
off the free-flowing liquid (40
CFR761.60(b)(4)).
Verify that the free-flowing liquid is drained from electrical equipment prior to disposa..
PCB.43. PCB Articles shall be
disposed of properly (40 CFR
761.60(b)(5)).
Verify that PCB Articles with concentrations at 500 ppm or greater are disposed of in
either
- A USEPA-approved incinerator
- A chemical waste landfill if all free-flowing liquids have been removed.
Verify that PCB Articles with PCB concentration between 50 and 500 ppm are
drained of all tree-flowing liquid.
PCB.44. PCB Containers shall
be disposed of properly (40
CFR761.60(c)).
Verify that PCB Containers with concentrations of 500 ppm or greater are disposed of
in one of the following ways:
- In a USEPA-approved incinerator
- In a chemical waste landfill If first the container is drained of any liquid PCBs.
Verify that PCB Containers used to contain only PCBs at concentrations less than
500 ppm are drained of PCB liquid prior to disposal as municipal solid waste.
Phase 1 - Section 13
PCB Management
13-30
-------
Compliance Category:
PCB Management
Regulatory Requirements:
Reviewer Checks:
PCB.45. PCB contaminated
fluids other than mineral oil
dielectric fluid of concentrations
greater than 50 ppm but less
than 500 ppm shall be disposed
of properly (40 CFR
761.60(a)(3».
Determine if any PCB fluids meeting these criteria were processed for disposal in the
last year.
Verify that disposal was done at:
• A USEPA-approved incinerator
- A USEPA-approved chemical waste landfill
• A high efficiency boiler, if:
- the boiler is rated at a minimum of 50 MBtu/h
- the boiler uses natural gas or oil.
Verify that such PCB fluids were disposed of by an approved method at a properly
licensed facility.
Phase 1 - Section 13
PCB Management
1W1
-------
Section 13
PCB Management
Appendices
-------
Appendix 13-1
PCB Label Format
vc^^^^^^^^c^v^^xwoc^^^^^^w^^J^cc^
Caution
Contains
S \
I pCBs
pCBs
(Polychlorinated Biphenyls)
S A toxic environmental contaminant requiring special
^ handling and disposal in accordance with U.S.
S Environmental Protection Agency Regulations
§ 40CFR761
^
S For Disposal Information, contact the nearest U.S. EPA
S Office.
$
S In case of accident or spill, call toll free the U.S. Coast
S Guard National Response Center: 800-424-8802
$
S Also Contact _
Tel. No.
A13-1
-------
Appendix 13-2
Dielectric Fluid Trend Names and (Manufacturers
Name ..-V •'••;'// .
Manufacturer , ''-- •"••.•
"• •**£-. . *
1 . U.S. Manufactured Dielectrics
Aroclor
Aroctor B
Sbestol
AskarelHevi-Duty
Askarel*
Askarel
Chtorextol
Chtorinol
Chlorphen
Diador
Dykanol
Elemex
Eucarel
Hyvol
Inerteen
Nc-Flamol
Pyranol
Sal-T-Kuhl
Monsanto
Mallory
American Corporation
Hevi-Duty Corporation
Ferranti-Packard, Ltd.
Universal Mfg. Co.
Allis-Chalmers
^nararmA Ftarirv*
Jard Company
Sangamo Electric
Cornell Dubilier
McGraw Edison
Electric Utilities Co.
Aerovox
Westinghouse Electric
Wagner Electric
General Electric
Kuhlman Electric
* Generic name used for insulating liquids in capacitors and transformers.
&$?$&& s> ?.™£ ' ^j.^/£ '*(2^-.i'.*?s fV''.. '.f'v^'i ^,
jM^nuracTurer>j^ f^J -••&,, t- '^ ^^v^^***^^
2. Foreign Manufactured Dielectrics
Clophen
Fenclo
Kennechlor
Phenoclor
DK
Pyralene
Solvol
Santotherm
Bayer (Germany)
Caffaro (Italy)
Mitsubishi (Japan)
Prodelec (France)
CafTaro (Italy)
Prodelec (France)
USSR
Mitsubishi (Japan)
A13-2
-------
Appendix 13-2 (continued)
Dielectric Fluid Trend Names and Manufacturers
3. Transformers that list other dielectrics or do not bear a manufacturer's identification or service plate
on the transformer: if the transformer contains any of the dielectrics (commonly referred to as
askarels), it is to be certified as a PCB transformer containing in excess of 500 ppm PCB and no
laboratory testing is necessary.
A13-3
-------
Phase 1
Section 14
Pesticide Management
-------
Table of Contents
Section 14
Pesticide
A. Applicability 14-1
B. Federal Legislation 14-1
C. State/Local Regulations 14-1
D. Key Compliance Requirements 14-2
E. Key Compliance Definitions 14-3
F. Records to Review 14-5
G. Physical Features to Inspect 14-5
H. Guidance for Checklist Users 14-6
-------
A. Applicability
This section applies to facilities which use, store or handle pesticides. Pesticides are regulated
on the Federal and state levels.
Assessors are required to review agency, federal, state and local regulations in order to
perform a comprehensive assessment.
It must be noted that pesticides by nature are hazardous materials and are subject to
hazardous materials management regulations. Please see Section 8, Hazardous Materials
Management. In this manual, the term pesticides includes herbicides and fungicides.
B. Federal Legislation
1. The Federal Insecticide, Fungicide, and Rodentlcide Act (FIFRA)
This Act, as last amended in December 1991 (7 U.S. Code (USC) 136-136y), deals with the
sale, distribution, transportation, storage, and use of pesticides. It requires the registration of
new pesticides and, when pesticides are reregistered, requires that they will not present any
unreasonable risks to human health or the environment if used according to label directions.
2. Executive Order (EO) 12088, Federal Compliance with Pollution Standards
This EO, dated 13 October 1978, requires Federally owned and operated facilities to comply
with applicable Federal, state, and local pollution control standards. It makes the head of
each executive agency responsible for seeing to it that the agencies, facilities, programs, and
activities it funds meet applicable Federal, state, and local environmental requirements or to
correct situations that are not in compliance with such requirements. In addition, the EO
requires that each agency ensure that sufficient funds for environmental compliance are
included in the agency budget.
C. State/Local Requirements
State pesticide regulatory programs are to be at least as stringent as FIFRA. State and local
programs typically contain regulations which are tailored to an industry or activity which is
prevalent or particularly sensitive in a state. State and local pesticide regulations in many
cases provide more stringent standards or specifically identify a requirement which may be
qualitatively regulated under the Federal program. State and local pesticide programs
generally include regulations which address the following topics:
1. Restrictions or requirements for the sale, distribution, or use of selected pesticides;
2. Disposal requirements for excess pesticides and pesticide wastes such as pesticide
containers;
Phase 1 - Section 14
Pesticide Management
14-1
-------
3. Restrictions on the control of specific animal or insect species;
4. Specifications for bulk pesticide storage tanks, storage facilities;
5. Operational requirements for selected application methods; and
6. Recordkeeping and applicator certification requirements. This may require that
applicators practice Integrated Pest Management (IPM) techniques.
D. Key Compliance Requirements
1. Pesticide Application
People applying restricted use pesticides must be certified to purchase and apply restricted use
pesticides. Contractors used for pest management must have current certification for the
types of applications to be performed. The application of pesticides must not jeopardize the
existence of threatened or endangered species. (40 CFR 171.9 and SO CFR 402).
2. Pesticide Storage, Mixing, and Preparation Facilities
Pesticide storage, mixing, and preparation activities must provide facilities and procedures to
ensure safety of personnel. Facilities such as a ventilation system for all indoor pesticide
mixing/preparation areas and an emergency deluge shower and eyewash station located to
provide immediate access to all personnel performing mixing. Personal protective clothing
and equipment need to be provided and used by pest management personnel. Pesticides,
pesticide container, and/or pesticide residues are to be stored such that it is not inconsistent
with labeling (40 CFR 165.7).
3. Highly Toxic and Moderately Toxic Pesticide Storage and Use
Storage facilities for pesticides and excess pesticides classed as highly toxic or moderately
toxic that are labeled DANGER, POISON, or with the skull and crossbones symbol, must
meet specific structural, operational (e.g., ventilation) and storage requirements. These
include pesticides being kept in a dry, separate room (building) with fire protection and not
near food or feed, and in containers in good condition with plainly visible labels. There
should be a decontamination facility, the area must be placarded and the local fire department,
hospitals, public health officials, and police departments should be notified in writing that the
pesticides are being stored (MP).
4. Pesticide and Container Disposal
Facilities are required to dispose of any excess pesticide, pesticide container, or pesticide
residue in a manner consistent with labeling, not including open dumping or burning. Organic
pesticides other than organic mercury, lead, cadmium, and arsenic compounds, must be
disposed according to specific procedures. Options include incineration at an incinerator that
meets air quality standards for gaseous emissions. Metallo-organic pesticides must be
disposed of in a manner that facilities the recovery of heavy metals (40 CFR 165.7, 165.8 and
165.9).
Phase 1 - Section 14
Pesticide Management
14-2
-------
5. Recordkeeping
Regardless of the regulatory requirements concerning the length of time which records must
be kept, it is advisable to maintain application and disposal records beyond the regulated
periods of time in order to support facility compliance.
E. Key Compliance Definitions
1. Acute LDW
A statistically derived estimate of the concentration of a substance mat would cause 50
percent mortality to the test population under specified conditions (40 CFR 152.3).
2. Caution
The human hazard signal word required on the front panel of a pesticide container determined
by the Toxicity Category of the pesticide. All pesticide products meeting the criteria of
Toxicity Category III or IV must bear on the front panel the signal word CAUTION (see
Toxicity Category (40 CFR 156.10(h)).
3. Commercial Applicator
A certified applicator, other than a private applicator, who uses or supervises the use of any
pesticide, for any purpose, on any property, or performs other pest control related activities
(40 CFR 171.2).
4. Crisis Exemption
This is utilized in an emergency condition when the time from discovery of the emergency to
the time when the pesticide use is needed is insufficient to allow for the authorization of a
specific quarantine exemption or public health exemption (40 CFR 166.2).
5. Danger
The human hazard signal word required on the front panel of a pesticide container determined
by the Toxicity Category of the pesticide. All pesticide products meeting the criteria of
Toxicity Category I must bear on the front panel the signal word DANGER (see Toxicity
Category) (40 CFR 156.10(h».
6. Imminent Hazard
A situation that exists when the continued use of a pesticide during the time required for
cancellation proceedings would be likely to result in unreasonably adverse effects on the
environment or will involve unreasonable hazard to the survival of a species declared
endangered by the Secretary of the Interior (SOI) under PL 91-135 (40 CFR 165.1).
Phase 1 • Section 14
Pesticide Management
-------
7. Management Practice (MP)
Practices that, although not mandated by law, are encouraged to promote safe operating
procedures.
8. Pesticide
Any substance or mixture of substances intended for preventing, destroying, repelling, or
mitigating any pest, or intended for use as a plant regulator, defoliant, or disinfectant; and is
further categorized into the following (40 CFR 165.1):
a. Excess pesticides means all pesticides that cannot be legally sold pursuant to the Act or
that are to be discarded.
b. Organic pesticides means carbon-containing substances used as pesticides, excluding
metallo-organic compounds.
c. Inorganic pesticides means noncarbon-containing substances used as pesticides.
d. Metallo-organic pesticides means a class of organic pesticides containing one or more
metal or metalloid atoms in the structure.
9. Pesticide Product
A pesticide in the particular form (including composition, packaging, and labeling) in which
the pesticide is, or is intended to be, distributed or sold. This includes any physical apparatus
used to deliver or apply the pesticide if distributed or sold with the pesticide (40 CFR 152.3).
10. Public Health Exemption
This may be authorized in an emergency condition to control a pest that will cause a
significant risk to human health (40 CFR 166.2).
11. Quarantine Exemption
This may be authorized in an emergency condition to control the introduction or spread of
any pest hew to or not theretofore known to be widely prevalent or distributed within and
throughout the United States and its territories (40 CFR 166.2).
12. Restricted Use Pesticides
Pesticides designated for restricted use under the provisions of Section 3(d)(l)(c) of FIFRA
(40 CFR 171.2).
Phase 1 - Section 14
Pesticide Management
14-4
-------
13. Specific Exemption
This exemption may be authorized in an emergency condition to avert (40 CFR 166.2):
a. A significant economic loss
b. A significant risk to endangered species, threatened species, beneficial organisms, or the
environment.
14. Toxicity Category
Required warnings and precautionary statements are based on the Toxicity Category of the
pesticide. The category is assigned on the basis of the highest hazard shown in the table
listed in 40 CFR 156.10 (40 CFR 156.10(h)).
15. Warning
The human hazard signal word required on the front panel of a pesticide container determined
by the Toxicity .Category of the pesticide. All pesticide products meeting the criteria of
Toxicity Category II shall bear on the front panel the signal word WARNING (see 40 CFR
156.10 for listing of indicators necessary to meet specific criteria of toxicity categories) (40
CFR 156.10(h)).
F. Records to Review
• Records of pesticides purchased by the facility (purchase orders, inventory)
• Pesticide application records and annual reports
• Description of the management of the facility's pest control program
• Certification status of pesticide applicators
• Pesticide disposal manifests and records
• Contract files
• Respiratory protection program (qualification, medical monitoring and respirator
maintenance/cartridge replacement)
• Any emergency exemption granted to the Federal agency by the USEPA
• Disposal of pesticide containers
• Monitoring of applicator's health status
G. Physical Features to Inspect
• Personnel protection equipment
• Pesticide application equipment
• Pesticide storage areas, including storage containers
• Observation of pesticide applications, procedures and protective equipment
• Disposal of used containers and pesticide waste (if any)
Phase 1 - Section 14
Pesticide Management
14-5
-------
H. Guidance for Checklist Users
All facilities
Pesticide application
Storage, mixing, or preparation
areas
Disposal
Agricultural pesticides
Refer To
Checklist Hems
PM.1 through PM.5
PM.6 through PM.1 2
PM.1 3 through PM.27
PM.28 through PM.33
PM.34 through PM.35
Page Numbers
14-7
14-10
14-11
14-17
14-20
Phase 1 - Section 14
Pesticide Management
14-6
-------
Compliance Category:
Pesticide Management
Regulatory Requir
All Facilities
PM.1. The current status of
any ongoing or unresolved
Consent Orders. Compliance
Agreements, Notices of
Violation (NOV), Interagency
Agreements, or equivalent state
enforcement actions is required
to be examined. (A finding
under this checklist item will
have the enforcement
action/identifying information as
the citation.)
Determine if noncompliance issues have been resolved by reviewing a copy of the
previous report, Consent Orders, Compliance Agreements, NOVs, interagency
agreements or equivalent State enforcement actions. For those open items, indicate
what corrective action Is planned and milestones established to correct problems.
PM.2. Facilities are required to
comply with all applicable
Federal regulatory requirements
not contained in this checklist.
(A finding under this checklist
item will have the citation of the
applied regulation as a basis of
finding.)
Determine if any new regulations have been issued since the finalization of the guide.
If so, annotate checklist to include new standards.
Determine if the facility has activities or facilities which are Federally regulated, but
not addressed in this checklist.
Verify that the facility is in compliance with all applicable and newly issued
regulations.
PM.3. Facilities are required to
comply with state and local
pesticide regulations concerning
pesticide management (EO
12088, Section 1-1).
Verify that the facility is abiding by state and local requirements.
Verify that the facility is operating according to permits issued by the state or local
agencies.
(NOTE: Issues typically regulated by state and local agencies include-
• applicator certification
- restricted use pesticides
- application procedures
- banned pesticides
• disposal methods
• emergency application of pesticides due to public health threats
- annual reporting of usages
- application health monitoring
- record of each application including target pest).
Phase 1 - Section 14
Pesticide Management
14-7
-------
Compliance Category:
Pertclcto Management
Regulatory Requirements:
Reviewer Checks:
PM.4. All pesticides present on
the facility must be registered or
ruled exempt from the
registration requirements (40
CFR 152.15 through 152.30).
Verify that pesticide products at the facility are registered unless the facility or product
is considered exempt, such as the following:
- Certain biological control agents
- Certain human drugs
- Treated articles or substances such as paint treated with a pesticide
• Pheromones and pheromone traps
- Preservatives for biological specimens
- Vitamin hormone products
- Pesticide transferred between registered establishments operated by the same
producer
- A pesticide distributed or sold under an experimental use permit
- A pesticide transferred solely for export
- A pesticide distributed or sold under an emergency exemption.
Phase 1 - Section 14
Pesticide Management
14-8
-------
CompBanoe Category.
Revtowi
PM.5. All facilities must comply
with pesticide use requirements
unless an emergency
exemption has been granted by
the USEPA (40 CFR 166.1.
166.2. 166.20. 166.28, 166.32.
166.45, 166.50).
Verify that pesticide use requirements are followed unless one or more of the
following emergency conditions exist:
- Specific exemptions may be authorized to avoid conditions of:
- Significant economic loss
- Significant risk to threatened or endangered species
- Significant risk to beneficial organisms
- Significant risk to the environment
• Quarantine exemptions may be authorized to control the introduction or spread of
any pest new to or unknown to be widespread throughout the United Slates and its
territories
- Public health exemptions may be authorized to control a pest that imposes
significant risk to human health
- Crisis exemptions may be utilized when the time constraint between discovery, and
implementation of pesticide use will not allow a specific, quarantine, or public health
exemption to be issued.
Verify that applications for exemptions are submitted to the Regional Administrator in
writing and include:
• A description of the pesticide
- The proposed use
- Target organism
- Any alternative means of control and why those means are not feasible.
Verify that exemptions are issued for a specific length of time, as follows:
- No more than 1 year for specific and public health exemptions
- For no longer than 3 years for a quarantine permit, but it may be renewed
- No longer than 15 days (unless an application for another type of exemption has
been submitted) for an crisis exemption.
Verify that any unexpected adverse affects from the use of a pesticide under
exemption conditions are be reported to the USEPA.
Verify that a report summarizing the use of a pesticide under an exemption was
submitted within 6 months after the expiration of the exemption to the agency (3
months for a crisis exemption).
Phase 1 - Section 14
Pesticide Management
14-9
-------
Reviewer Checks:
Pesticide Application
PM.6. Persons applying
restricted use pesticides must
be certified to apply restricted
use pesticides (40 CFR 171.9).
Determine if facility personnel apply restricted use pesticides (see Appendix 14-1).
Determine if pesticide applicators are trained and/or certified.
Verify that training recertification is scheduled and performed as required to maintain
certification and that certification is relevant to the pest management activities
undertaken.
Verify the certification status of contractors used for pest management through
interviews or contract review.
PM.7. Personnel routinely
applying any pesticides should
be trained in safety procedures
and application procedures
(MP).
Determine if personnel at the facility routinely apply pesticides.
Verify that personnel are trained in appropriate handling and use procedures.
PM.8. Health monitoring should
be provided for government
personnel applying restricted
use pesticides (MP).
Verify that all pest management personnel have received baseline physical
examinations within 30 days of starting pest management work.
Verify that pest management personnel receive additional physical examinations once
each year.
Verify that cholinesterase tests are given to pest management personnel working
regularly with pesticides which contain organophosphates or N-alkyl-carbamates.
PM.9. Public safety should be
ensured when applying or using
pesticides (MP).
Verify the elimination of hazardous exposure to the general public by checking for the
following:
• Appropriate signs for treatment area are posted
• Scheduling for low use periods or restricted usage for a number of days
• Water use restrictions and reentry times are followed according to the pesticide
labels.
PM.10. Records should be
maintained of each application
of a pesticide, whether
performed by facility staff or
contract labor, and retained at
the facility (MP).
Verify that records are kept on file for a minimum of 3 years.
Verify that the record of each application includes information (e.g.. target organism,
compound applied, dilution, quantity applied, notification/posting done, etc)., based on
individual state requirements.
Phase 1 - Section 14
Pesticide Management
14-10
-------
Pesticide Management
Regulatory naqulNMnsntK
PM.11. Facilities must ensure
that the use of pesticides does
not jeopardize the existence of
threatened or endangered
species (50 CFR 402.01). •
• •-. • :- v •••..-*£
-• •"•-: >v^;
Reviewer Checks: ' •- '
Determine if surveys have been conducted to identify the presence of threatened or
endangered species in areas where pesticides are used.
Determine what measures are taken to ensure that threatened or endangered species
are not impacted.
Verify that applications are made according to label Instructions regarding the
protection of endangered species.
(NOTE: Refer to the checklist items on endangered species in Natural Resources
Management.)
Dining Facilities
PM.12. Dining facilities should
be notified at least 24 hours in
advance of a pesticide
application (MP).
Storage/Mlxlno/Preparatlon Are
(NOTE: Storage areas must also
1910.106. see Hazardous Materu
PM.13. Facilities are required
to store any pesticide, pesticide
container, or pesticide residue
according to specific restrictions
(40 CFR 165.7).
Verify that food services personnel are notified of scheduled applications and that
only compounds and procedures labelled for food service are used by applications
certified in the food processing category.
as
meet the general requirements for the storage of hazardous materials found in 29 CFR
its Management protocol.)
Verify that pesticides, pesticide containers, and/or pesticide residues are stored such
that they are consistent with labeling.
Phase 1 - Section 14
Pesticide Management
14-11
-------
PM.14. Pesticide storage,
mixing and preparation facilities
must provide structures and
procedures to ensure safety of
personnel (29CFR 1910.133).
Determine if a ventilation system is specifically provided for all indoor pesticide
mixing/preparation areas.
Verify that an emergency deluge shower and eyewash station are located to provide
immediate access to all personnel performing mixing.
Verify that personal protective clothing and equipment is provided and used by pest
management personnel. The following equipment depends upon magnitude and type
of operations:
- Respirators •
• Masks
- Gloves (appropriate kinds)
- Safety shoes
- Coveralls
- Barrier aprons
- Specialized personal protective equipment for fumigation.
Verify that operations include health and safety procedures emphasizing good work
habits, reduction or elimination of hazards (through the use of engineering controls),
and use of personal protective equipment.
PM.15. A spill containment
system constructed of
impervious materials should
provide containment for
pesticide storage, mixing.
preparation and management
areas (MP).
Verify that there is curbing around the required areas.
Determine if there are drains or cracks in floors.
Determine tf pest management shop personnel are familiar with spill response
procedures.
Verify that spill response procedures are written and understood by staff.
PM.16. Storage facilities for
pesticides should have
ventilation at a rate of 10 air
changes/hour (MP).
Verify that storage facilities for pesticides have ventilation at a rate of 10 air changes/
hour.
PM.17. Storage facilities for
pesticides should have separate
drainage systems and fire
suppression/extinguishers (MP).
Verify that fire extinguishers are installed near the door of pesticide storage room or
an automatic fire suppression system is in place and working.
Verify that the drainage systems are separated from the regular systems.
PM.18. Pesticide storage areas
should be inspected quarterly
by certified applicator personnel
(MP).
Verify that pesticide storage areas are inspected.
Phase 1 - Section 14
Pesticide Management
14-12
-------
ReVwVflfrf CiMCKBC
Highly And Moderately Toxic Pesticides
PM.19. Storage facilities for
pesticides classified as highly
toxic or moderately toxic which
are required to be labeled with
DANGER, POISON,
WARNING, or the skull and
crossbones symbol should meet
specific structural requirements
-------
Rapitstoty ftftquJrtmenti
Revtamtr Check*:
PM.21. Pest management
programs which use pesticides
classified as highly toxic or
moderately toxic and are
required to bear the signal
words DANGER, POISON.
WARNING, or the skull and
crossbones symbol on the label
should have decontamination
facilities (MP).
Determine if facilities are available for personnel decontamination and where they are
located.
Determine if facilities are available for the decontamination of equipment, including
vehicles which have been used for pesticide applications.
Verify that berms, curbing, surfaces, and catchment drains which are used to
impound washwater resulting from decontamination are impervious.
Verify that drains impound washwater and do not connect to sanitary sewer or
stormwater systems.
Verify that the procedure for disposal of washwater resulting from decontamination
activities is the same as for excess pesticides.
(NOTE: These MPs are based on recommendations found in 40 CFR 165.10(c)(3)
and 165.10(c)(4).)
PM.22. Equipment used for
pesticides applications may not
be removed from a
decontamination site unless
thoroughly decontaminated
(MP).
Verify that prior to removal from a site, vehicles are decontaminated.
(NOTE: This MP is based on recommendations found in 40 CFR 165.10(c){2) and
Phase 1 - Section 14
Pesticide Management
14-14
-------
CompBanee Category:
PM.23. Storage of pesticides
and excess pesticides that are
classified as highly toxic or
moderately toxic and are
required to be labeled
DANGER, POISON.
WARNING, or the skull and
crossbortes should meet
specific requirements (MP).
Verify that the site location, where possible, is in an area where flooding is unlikely
and where hydrogeotogic conditions prevents contamination of any water system by
runoff or percolation by.
- Inspecting area surrounding facilities and determine proximity to surface water
- Noting location relative to floodplains, depth of groundwater. and general soil types
and typical permeabilities
• Verifying that the spill management system is in existence.
Verify that an environmental monitoring system exists for facilities which do not have
spill management system when the facility handles large quantities of pesticides and
is located near sensitive environmental receptor. The reviewer should:
- Note approximate quantity of pesticides and location of sensitive environmental
receptors
- Check whether groundwater, or surface water, or air monitoring program exists to
determine any effects caused by pesticide storage, mixing and preparation
• Inspect facility operations and layout to determine if operations are likely to allow
runoff of water which may have contacted pesticides.
(NOTE: The Clean Water Act specifies certain pesticides which may trigger
additional monitoring/reporting requirements (Aldrin/Dieldrin, DDT, Endrin,
Toxaphene) (40 CFR 129).)
Verify that, when needed, drainage from the site is contained fay natural or artificial
barriers or dikes.
(NOTE: These MPs are based on recommendations found in 40 CFR 165.10(b).)
Phase 1-Section 14
Pesticide Management
14-15
-------
Compliance Category
PM.24. Facilities which
store/use pesticides that are
classified as highly toxic or
moderately toxic and are
required to bear the signal
words DANGER, POISON.
WARNING, or the skull and
crossbones symbol should
provide facilities and
procedures to ensure the safety
of personnel (MP).
Verify that no food consumption, drinking, smoking, or tobacco use is undertaken in
any area where pesticides are present.
Verify that the following practices are performed in pest management operations:
• Persons handling pesticides keep hands away from mouths and eyes and wear
rubber gloves during all pesticide handling
• Persons handling pesticides wash hands immediately upon completion of working
with pesticides and always prior to eating, smoking or using toilet facilities
- Persons handling concentrated pesticides wear protective clothing which is
removed If found to be contaminated
• A stock of dean protective clothing and respirators is available
• Self-contained breathing apparatus and impermeable suits are available when
handling pesticides which present the potential of being absorbed through the skin
• Inspections are made once a month to determine if any pesticide containers are
leaking
- Pesticide containers are inspected for leakage prior to handling
- Unauthorized persons are not allowed in storage areas.
Verify that the following accident prevention measures are done:
- Containers are not manhandled
- Unauthorized persons are not allowed in the storage area
• Pesticides are not stored next to food or feed or other articles intended (or
consumption by humans or animals
• All vehicles are inspected prior to departure.
(NOTE: These MPs are based on recommendations found in 40 CFR 165.10(e) and
165.10(f).)
PM.25. Pesticide storage
facilities and equipment which
contain or use pesticides
classified as highly toxic or
moderately toxic and are
labeled DANGER, POISON.
WARNING, or the skull and
crossbones symbol should have
signs and safety procedures
posted (MP).
Verify that signs which read DANGER POISON, PESTICIDE STORAGE, are placed
on or near entries to storage facilities.
Verify that safely precautions and accident prevention measures are posted.
Verify that an inventory of pesticides is displayed outside of the storage facility
identifying all chemicals in storage.
Verify that mobile equipment used for pesticide applications is labeled
CONTAMINATED WITH PESTICIDES.
(NOTE: These MPs are based on recommendations found in 40 CFR 165.10(c)(2)
through 165.10(c)(3), 165.10(e). and 165.10(g)(2).)
Phase 1 - Section 14
Pesticide Management
14-16
-------
Compliance Category: "'"_ • ' ' ': . •'.' {:•(*'&
Portable Uanagament , • . ' . ••";.'?'£<
Regulatory Requirements:
PM.26. Where large quantities
of pesticides classified as highly
toxic or moderately toxic and
are labeled DANGER, POISON.
WARNING, or the skull and
crossbones symbol are being
stored, or other conditions
warrant the local fire
department, hospitals, public
health officials, and police
department should be notified in
writing that pesticides are being
stored in the event of a fire
-------
PM.30. Metallo-organic
pesticides, except organic
mercury, lead, cadmium, or
arsenic compounds should be
disposed of according to
specific procedures (MP).
Determine if the facility uses metallo-organic pesticides.
Verify that metaflo-organic pesticides are subjected to an appropriate chemical or
physical treatment to recover the heavy metals from the hydrocarbon structure prior
to disposal.
Verify that metallo-organic pesticides are disposed of through incineration at an
approved incinerator, or in a specially designated landfill, or by another approved
method.
(NOTE: These MPs are based on guidelines found in 40 CFR 165.8 and 165.9.)
PM.31. Organic mercury, lead,
cadmium, arsenic, and all
inorganic pesticides should be
disposed of according to
specific procedures (MP).
Determine if the facility uses organic mercury, lead, cadmium, arsenic, or any
inorganic pesticides.
Verify that these pesticides are converted to a nonhazardous compound and the
heavy metal resources are recovered.
Verify that, if chemical deactivation facilities are not available, these pesticides are
encapsulated and buried in a specially designated landfill and records sufficient to
permit location and retrieval are maintained.
Determine if an alternate method of disposal has been approved.
(NOTE: These MPs are based on guidelines found in 40 CFR 165.8 and 165.9.)
Phase 1 - Section 14
Pesticide Management
14-18
-------
Compliance Categor
*.
vr*
•*.*" -,'
nOYUMfvf irffiBCKB*
PM.32. Containers should be
disposed of according to their
classification as either a Group
I, Group II, or Group III
container (MP).
Determine which of the following types of containers the facility has ensile:
- Group I Containers: combustible containers which formerly contained organic or
metallo-organic pesticides
- Group II Containers: noncombustible containers which formerly held organic or
metallo-organic pesticides
• Group lit Containers: containers (both combustible and noncombustible) which
formerly held organic mercury, lead, cadmium, or arsenic or inorganic pesticides.
Verify that Group I containers are disposed of in an incinerator or buried in a specially
designated landfill.
(NOTE: Small quantities of Group I containers may be burned in open fields by the •
user of the pesticide when allowed by the state.)
Verify that Group II containers are triple rinsed.
Verify that Group II containers in good condition are returned to the manufacturer,
formulator, or drum reconditioner to reuse with the same chemical class of pesticides.
Verify that Group II containers which are going to be transported to a facility for
recycling as scrap metal or for disposal are punctured.
Determine if rinsed Group II containers are crushed and disposed of in a landfill
according to state or local requirements.
Verify that unrinsed Group II containers are disposed of In a specially designated
landfill or incinerated.
Verify that Group III containers which are not rinsed are encapsulated and disposed
of in a specially designated landfill.
(NOTE:
• Group III containers which are rinsed may be disposed of in a sanitary landfill.
- These MPs are based on guidelines found in 40 CFR 165.8 and 165.9.)
PM.33. Pesticide residues and
rinse liquids should be added to
spray mixtures or disposed of
according to their pesticide type
(MP).
Verify that pesticide residues or rinse liquids are reused.
Verify that if they are not reused they are disposed of according to their pesticide
type-
(NOTE: These MPs are based on guidelines found in 40 CFR 165.8 and 165.9.)
Phase 1 - Section 14
Pesticide Management
14-19
-------
Reviewer Checks:
.'r*
Agricultural Pesticides
PM.34. Agricultural pesticides
must be applied in a manner
that workers or other persons,
except those knowingly involved
in the application, are not
exposed either directly or
through drift (40 CFR 170.3(a)
and I70.4(c)).
Determine if the facility applies agricultural pesticides.
Verify that the area being treated is vacated by unprotected persons.
(NOTE: These requirements do not pertain to:
• mosquito abatement treatment and related public pest control programs
- greenhouse treatments which are applied in accordance with labeling directions
and restrictions
• livestock and other animal treatments which are applied In accordance with labeling
directions and restrictions
• treatment of golf courses and similar non-agricultural areas which are applied in
accordance with labeling directions and restrictions.)
Verify that workers are warned when a field is to be treated and when a field has
been treated.
PM.35. Workers not wearing
protective clothing shall not be
allowed to enter a field treated
with sprays until specific
conditions are met (40 CFR
170.3(b) and I70.4(c)).
Verify that workers without protective clothing do not enter fields that have been
sprayed until the labelled reentry times have elapsed.
Verify that if the following pesticides are used, the indicated reentry times are
observed:
- Ethyl parathton: 48 hours
• Methyl parathion: 48 hours
- Guthion: 24 hours
- Demeton: 48 hours
- Azodrin: 48 hours
- Phosalone: 24 hours
- Carbophenothion: 48 hours
• Metasystox-R: 48 hours
- EPN: 24 hours
• Bidrirv. 48 hours
• Endrin: 48 hours
- Ethion: 24 hours
(NOTE: Check labels to verify these reentry times have not changed.)
(NOTE: These requirements do not pertain to:
- mosquito abatement treatment and related public pest control programs
- greenhouse treatments which are applied in accordance with labeling directions
and restrictions
- livestock and other animal treatments which are applied in accordance with labeling
directions and restrictions
- treatment of golf courses and simitar non-agricultural areas which are applied in
accordance with labeling directions and restrictions.)
Phase 1 - Section 14
Pesticide Management
14-20
-------
Section 14
Pesticide Management
Appendices
-------
Appendix 14-1
Restricted Use Pesticides
(40 CFR 152.175)
The following uses of pesticide products containing the active ingredients specified below have been
classified for restricted use and are limited to use by or under the direct supervision of a certified
applicator.
NOTE: These may vary from state to state. The auditor must check each state, some compounds are
not permitted and for others, the trigger concentrations may be lower.
NOTE: Any applications made by a certified applicator must be recorded and done in accordance with
the labelled instructions, even if the compounds are not restricted use pesticides.
^''^PS4
Acrolein
Acrytonrtrile
Aldtearb
Ally! alcohol
Aluminum
phosphide
.
Azinpnosmethyl
Calcium cyanide
Carbofuran
*5t 'v'^jsj^t .^\*v &* •fe^
L * ** -^'^ ' * **Sf t . ^^ ~ ,
As sole active ingredient.
No mixtures registered.
In combination with carbon
tetrachloride. No
registrations as the sole
active ingredient.
As sole active ingredient.
No mixtures registered.
All formulations.
As sole active ingredient.
No mixtures registered.
All liquids with a
concentration greater than
13.5%.
All other formulations.
As sole active ingredient.
No mixture registered.
and wettable powders 40%
and greater
All granular formulations.
All granular and fertilizer
formulations.
•Mjtigjf**,
*;**• "•*<** ^"?',> ".'
T •*•.;;,•* x,' ;,"'.'..
All uses.
•do
Ornamental uses
(indoor and
outdoor).
Agricultural crop
uses.
All uses.
do
do
do
do
do
Rice
All uses except rice.
^^a^Eflcatlon^
* v' * ' ( * "• ' f
"^ ***••*.
Restricted
do
do
Under further
evaluation.
Restricted
do
do
Under further
evaluation.
Restricted
do
Under evaluation.
do
KCrlte/^-frif^obiglf
tRAsfrictioftr * ^V^:fe
, .'' r~-'4t,.f ": X SIT' '^^
Inhalation hazard to
humans Residue effects
on avian species and
aquatic organisms
Other hazards-accident
history of acrytonitrile and
carbon tetrachbride
products.
Other hazards-accident
history.
Acute dermal toxicity.
Inhalation hazard to
humans.
do
do
Acute inhalation toxicity.
'do - same as above.
A14-1
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
Ac4Jy» ,*".
tegitotNnt
. .
Crnortenvirtpnos
Chbropfcrin
Ctonitralid
Cydohaximhia
Demeton
'Dicrotophos
Formtifeiitm
oremulsifiabteor
concentrates 21% and
greater.
All formulations greater
than 2%.
All formulations.
All formulations 2% and
toss.
AD wettable powders 70%
and greater.
All granulars and wettable
powders.
Pressurized sprays 0.55%
and lass.
AD formulations greater
than 4%.
AD formulations 0.027% to
4%.
All formulations 0.027%
and less.
1% fertilizer formulation,
1.985% granular.
AH granular formulations
emulsiflable concentrates
and concentrated
solutions.
All liquid formulations 8%
and greater.
Use Pattern
AD uses (domestic
and non-domestic).
All uses.
Rodent control.
Outdoor uses
(other than
rodent control).
All uses.
Mollusoide uses.
Hospital
antiseptics.
All uses.
All uses.
Domestic uses.
All uses including
domestic uses.
All uses.
All uses.
Cl***l
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
Ml^Hf^
angwdtoqipx^
Dtoxalhton
Disulfoton
Endrin
EPN
FoVnitilaVion . i*$iffl
'**£*?'**!?: • * > •:?&£
"'y-/ -L* • *vWWw
•„;•>» 5 ->- ' -JiT-
AH concentrate solutions
or emulsffiable
concentrates2 greater than
30%.
_
concentrate solutions or
emulsion concentrates2
30% and less and wettabte
powders 25% and less.
All solutions2 3% and
greater.
3% and greater 23%
solutions2 with toxaphene
and malathion.
Afl emubifiable
concentrates 65% and
greater, all emutsifiable
concentrates and
concentrate solutions 21%
and greater with
fensulfothion 43% and
greater, all emuteifiable
concentrates 32% and
greater in combination with
32% fensulfothion and
greater.
Non-aqueous solution 95%
and greater-
Granular formulations 10%
and greater.
All emulsions, dusts,
wettable powders, pastes,
and granular formulations
2% and above.
AD concentrations less
than 2%.
All liquid and dry
formulations greater than
4%.
^tifsprtm^-S
' , .,' ^ v ,'
All uses.
Livestock and
agricultural uses
(nondomestic uses
oniy).
Domestic.
All uses.
do
Commercial
seed treatment.
Indoor uses
(greenhouse).
All uses.
do
All uses.
Aquatic uses.
Classification'
v, • ' • • : ' '" -A '
-,••' '-•.-'.
•<,,.•*",
Restricted
Unclassified
Restricted
Under evaluation.
Restricted
Restricted
do
Restricted
do
Restricted
Restricted
{Irttmttiv'ftnt&kiniitrirti^x
,V"**'>'*?' WlflMHHJWtB'O'' 2
.*t*w^!^s
Acute dermal toxicity.
do
do
Acute inhalation toxicity.
Acute dermal
toxicity.
Acute inhalation
toxicity.
Acute dermal toxicity.
Hazard to nontaiget
organisms.
Hazard to non-target
organisms.
Acute dermal toxicity;
acute inhalation toxicity;
residue effects on avian
species.
Effects on aquatic
organisms.
•do - same as above.
A14-3
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
Adfv*
Etnoprop
Ethyl parathicn
Fenamiphos
FensuHothbn
Ruoroacetamide
/1 081
Fonofos
Formulation
Emulsifiable concentrates
40% and greater.
All granular and fertilizer
formulations.
A!! granuiar and dust
formulations greater than
2% fertilizer formulations,
wettable powders.
emulsifiable concentrates,
concentrated
suspensions,
concentrated solutions.
Smoke f umkjarrts.
Dust and granular
formulations 2% and
below.
Emulsifiable concentrates
35% and greater.
Concentrate solutions 63%
and greater, all
emulsifiable concentrates
and concentrate solutions
43% and greater with
disuHbton 21% and greater
all emulsifiable
' concentrates 32% and
greater in combination with
disuHbton 32% and
greater.
Granular formulations 10%
and greater.
As sole active ingredient in
bate. No mixtures
registered.
Emulsifiable concentrates
44% and greater.
Emulsifiable concentrates
12.6% and less with
pebulate 50.3% and less.
Uw Pattern
do
do
do
do
do
do
do
indoor usos
(greenhouse).
All uses.
All uses.
Tobacco.
OMMM.
do
Under evaluation.
Restricted
do
do
do
Restricted
do
Restricted
do
Unclassified
Criteria trtfto«*ctec
Restriction
Acute dermal toxttity.
humans. Acute dermal
toxkaty. Residue effects
or mammalian, aquatic.
avian species. Inhalation
hazard to humans.
Other hazards-accident
history.
Acute dermal toxkaty.
do
Acute inhalation toxitity.
Acute oral toxiciry.
Acute dermal toxttity.
*do - same as above.
A14-4
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
> » "ft - W vf frvf y *
Active — vtj*
MgUMItnOv..
. ./*%
Hydrocyanic
acid
Melhamidaphos
Methidathion
Methomyl
Mtf&Mm'^ *1X /*•
As sola active ingredient.
No mixtures registered.
Liquid formulations 40%
and greater.
Dust formulations 2.5%
and greater.
All formulations.
Ad formulations.
As sole active ingredient in
1% to 2.5 baits (except 1%
fly baft).
All concentrated solution
formulations. •
90% wettabte powder
formulations (not in water
soluble bags).
90% wettabb powder
formulation in water soluble
bags.
All granular formulations.
25% wettabte powder
formulations.
In 1.24% to 2.5% dusts as
sole active ingredient and
in mixtures with
fungicides and chlorinated
hydrocarbon, inorganic
phosphate and biological
insecticides.
?Ua»l Pattern' ' '
. x, - r
**.
do
All uses.
All uses.
All uses except
stock saffbwer and
sunfbwer.
Nursery stock,
safflower, and
sunfbwer.
Nondomestic
outdoor agricultural
crops, ornamental
and turf. All other
registered uses.
do
do
do
do
do
do
&as9itlcatlon*"
•>, "" ^' '
do
Restricted
*
Restricted
Restricted
Unclassified
Restricted
do
do
Unclassified
do
do
do
<$rVfc1^»l*fd
.itoMrtoMw^ J:v,
r- . *-. -IT "" '\fv
Inhalation hazard to
humans.
Acute dermal toxicity;
residue effects on avian
species.
Residual effects on avian
species.
Residue effects on avian
species.
Residue effects on avian
species.
Residue effects on
mammalian species.
Other hazards-accident
history.
Other hazards-accident
history.
do
*do - same as above.
A14-5
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
Acilv*
tegrwif+n*
Methylbromide
•
Methyl parathkm
Mevinphos
.. t_
Monocrotophos
Formulation
AH formulations in
containers greater than 1.5
to.
Containers with not more
than 1.5 Ib of methyl
bromide with O25% to
chtoropicrin as an
indicator.
Containers with not more
than 1 5 Ib having no
indicator.
All dust and granular
formulations less than 5%.
Micraencapsulated. All
dust and granular
formulations 5% and
greater and all wettaUe
powders and liquids.
All emulsifiable
concentrates and liquid
concentrates.
PsycodkJ filler fly liquid
formulations.
2% dusts.
Uquid formulations 19*
and greater.
Liquid formulations 55%
and greater.
Uw Pattern
All uses.
Single applications
(nondomestic use)
for soil treatment in
dosed systems.
Ml uses.
do
do
do
do
do
do
do
OhM»i«c»tlan'
Restricted
Unclassified
Restricted
do
do
/
do
do
do
do
do
Crfterf* Inftamcfep
RmfcteUan
Other hazards-accident
history.
do
Other hazards-accident
history. M foliar
applications restricted
based on residue effects
on mammalian and avian
species.
Residue effects on avian
species. Hazard to bees.
Acute dermal toxicity.
Residue effects on
mammalian and avian
species.
do
Acute dermal toxicity.
Residue effects on
mammalian and avian
species.
Residue effects on avian
species. Residue effects
on mammalian spades.
Acute dermal toxicity.
Residue effects on avian
species. Residue effects
on mammalian ifp^?*0*
*do - same as above.
A14-6
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
Active ;
ingredient .
* •** '
Nicotine
(alkaloid)
Paraquat
(dichloride) and
paraquat
bis(m
ethylsulfate)
Phorate
Phosaoetim
{'Formulation^ ' ' *%
•*•" -;• -
f ' - :--- :•- :'•"•
"*fft
Liquid and dry formulations
14% and above.
All formulations.
Liquid and dry formulations
1.5% and less.
All formulations and
concentrations except
those listed below.
Pressurized spray
formulations containing
0.44% Paraquat bis(methyl
suHate)and15%
petroleum distillates as
active ingredients.
Liquid fertilizers containing
concentrations of 0.025%
paraquat dichloride and
0.03% atrazine; 0.03%
paraquat dichloride and
0.37% atrazine, 0.04%
paraquat dichloride and
0.49% atrazine.
Liquid formulations 65%
and greater.
All granular formulations.
Baits 0.1% and greater.
U«* Pattern - •
' «•' i *. *«*' " •*
f • . Xl' ' * '
Indoor
(greenhouse).
Aoolications to
cranberries.
All uses (domestic
and non-domestic).
AQ uses.
Spot weed and
grass control.
All uses.
do
Rice
All uses.
Cta«MUc«tio(»'
* , • * '**
i
Restricted
Restricted
Unclassified
Restricted
do
Unclassified
Restricted
Restricted
Restricted
CrftWfe frtfMHMteoV:
R»»frtetlon '^-\. ?-.
**' . . *
Acute inhalation toxtety.
Effects on aquatic
organisms.
Other hazards. Use and
accident history, human
lexicological data.
i
Acute dermal toxkaty.
Residue effects on avian
species (applies to foliar
Residue effects on
mammalian species
(applies to foliar
application only).
Effects on aquatic
organisms.
Hazard to non-target
species. Residues effects
on mammalian species.
Residue effects on avian
species.
•do - same as above.
A14-7
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
AcllV»
,ift0FMMeitt
Phosphamidon
•Pictorarn
Sodium
cyanides
SodiumfluoiD-
acetate
Strychnine
SuHotapp
Tepp
ForirwfsMan
i >» • • f *
1 1 *• m r j + rf r
Liquid formulations 75%
and greater.
Dust formulations 1.5%
and greater.
AD formulations and
concentrations except
tordon101R.
TordonlOl R forestry
herbicide containing 5.4%
picbram and 20.9% 2. 4-D.
All capsules and ball
formulations.
All solutions and dry baits.
All dry bate pellets and
powder formulations
greater than 05%.
All dry bails pellets and
powder formulations.
AH dry baits, and pellets.
and powder formulations
0.5% and below.
do
Sprays and smoke
generators.
cffluiSui&DiB concentrate
formulations.
Use Pattern
do
do
do
Control of unwanted
trees by cut surface
treatment.
All uses.
do
do
Ail uses calling for
burrow builders.
All uses except
subsoil.
All subsoil uses.
All uses.
do
Classification*
do
do
do
Unclassified
Restricted
do
do
do
do
Unclassified
Restricted
do
* • r^t *
Cfftwis- fetfilM&ebtg
Jtartrteilan : ,. -
Acute dermal toxichy.
Residue effects on
mammalian species.
Residue effects on avian
species.
Residue effects on
mammalian species.
Hazard to non-target
organisms (specifically
nontarget plants both crop
and noncrop).
Inhalation hazard to
humans.
Acute oral toxtoty. Hazard
to nontarget organisms.
Use and accident history.
Acute oral toxteJty. Hazard
to non-target avain
history.
Hazard to non-target
organisms.
do
do
Inhalation hazard to
humans.
Inhalation hazard to
humans. Dermal hazard to
humans. Residue effects
on mammalian and avian
species.
"do - same as above.
A14-8
-------
Appendix 14-1 (continued)
Restricted Use Pesticides
(40 CFR 152.175)
. • ' , ' V1
* * **£.!V. ..". .*.."« v
Zinc Phosphide
Formulation • - ^ , ( '.
^^Sn- . " vx*fr?A, v* ':** /'^*tV%
,7-, ^T*^ : "$LA'-VV -
«, *«* v . *w> •k
All formulations 2% and
less.
All dry formulations 60%
and greater.
AD bait formulations.
An dry formulation 10% and
greater.
Use Pattern
">''* :..<•' ;~y;
All domestic uses
and non-domestic
uses in and around
buildings.
All uses.
Nondomestic
outdoor uses (other
than around
buildings).
Domestic uses.
Classification' <
*r& ^ -•?<
Unclassified
Restricted
Restricted '
Restricted
Criteria'' irtflwtefpsk • '
iBMlrtJIw:-^^^
Acute inhalation toxicity.
Hazard to nontarget
organisms.
Acute oral toxicity.
1. "Under evaluation* means no classification decision has been made and the use/formulation Is stiH under active
review within EPA.
2. Percentages given are the total of dioxathion plus related compounds.
3. (NOTE: M44 sodium cyanide capsules may only be used by certified applicators who have also taken the required
additional training.)
•do - same as above.
A14-9
-------
Phase 1
Section 15
Groundwater Protection
-------
Table of Contents
Section 15
Groundwater Protection
A. Applicability 15-1
B. Federal Legislation 15-1
C. State/Local Regulations 15-2
D. Key Compliance Requirements 15-2
E. Key Compliance Definitions 15-7
F. Records to Review 15-12
G. Physical Features to Inspect 15-12
H. Guidance for Checklist Users 15-13
-------
A. Applicability
This section applies to facilities that have solid waste management units (SWMUs), and/or
hazardous waste treatment, storage, or disposal facilities (TSDFs), and/or underground
injection control (UIC) activities. It includes a discussion of the relevant statutes, regulations,
and procedures for determining applicability of groundwater protection and UIC requirements
and it includes reviewing procedures for determining the facilities' compliance status with
respect to these requirements.
B. Federal Legislation
1. Resource Conservation and Recovery Act (RCRA), Subtitle C and D
This Act, Public Law (PL) 98-616, 42 U.S. Code (USC) 6921-2939b, establishes standards for
groundwater protection and monitoring at hazardous waste treatment, storage, and disposal
facilities, and solid waste disposal facilities.
Under the Underground Storage Tank (UST) rules of RCRA, USTs containing petroleum
products or hazardous substances must have a release detection program That program can
include a shallow groundwater monitoring program. The UST shallow groundwater
monitoring, program for USTs is only appropriate for tanks storing materials, immiscible in
and with a density less than water, located where the water table is less than 20 feet below
ground surface, backfill soils are similar to natural soils and monitoring wells are properly
constructed, placed, marked and secured.
2. The Safe Drinking Water Act (SDWA)
This Act, Public Law (PL) 99-339, 42 U.S. Code (USC) 201, 300f--300j-25, 6939b, 6979a,
6979b, 7401-742, etc., is the Federal legislation which regulates the safety of drinking water
in the country.
The SDWA also established a program to ensure that underground injection will not endanger
drinking water sources and empowers each .state to develop a UIC program.
Under die SDWA, regulations were promulgated concerning the use of underground injection
as a means of disposing wastes. The regulations require an Underground Injection Control
Program permit and establishment of an Underground Injection Control Program. The
program must contain procedures for sampling, recordkeeping, reporting, well construction,
well plugging and abandonment, and outline financial assurances for the underground
injection control program.
Phase 1 - Section 15
Groundwater Protection
15-1
-------
C. State/Local Regulations and Other State Regulations
The UIC program within each state is administered directly by the state (Primary Program) or
EPA (where states do not administer the program), or a combination of the state and EPA.
The overall Wellhead Protection Program for a state is administered by the state but is
developed and implemented on a local (e.g., municipal, water district) level.
D. Key Compliance Requirements
1. Classification of Wells. There are five classes of UIC wells:
Class I.
a. Wells used by generators of hazardous waste or owners or operators of hazardous
waste management facilities to inject hazardous waste beneath the lowermost
formation containing, within one-quarter mile of the well bore, an underground
source of drinking water.
b. Other industrial and municipal disposal wells which inject fluids beneath the
lowermost formation containing, within one-quarter mile of the well bore, an
underground source of drinking water.
Class II. Wells which inject fluids:
a. Which are brought to the surface in connection with natural gas storage operations,
or conventional oil or natural gas production and may be commingled with waste
waters from gas plants which are an integral part of production operations, unless
those waters are classified as a hazardous waste at the time of injection.
b. For enhanced recovery of oil or natural gas.
c. For storage of hydrocarbons which are liquid at standard temperature and pressure.
Class III. Wells which inject for extraction of minerals including:
a. Mining of sulfur by the Frasch process.
b. In-situ production of uranium or other metals; this category includes only in-situ
production from ore bodies which have not been conventionally mined. Solution
mining of conventional mines such as slopes leaching is included in Class V.
c. Solution mining of salts or potash.
Phase 1 - Section 15
Groundwater Protection
15-2
-------
Class IV.
a. Wells used by generators of hazardous waste or of radioactive waste, by owners or
operators of hazardous waste management facilities, or by owners or operators of
radioactive waste disposal sites to dispose of hazardous waste' or radioactive waste
into a formation which within one-quarter mile of the well contains an underground
source of drinking water.
b. Wells used by generators of hazardous waste or of radioactive waste, by owners or
operators of hazardous waste management facilities, or by owners or operators of
radioactive waste disposal sites to dispose of hazardous .waste or radioactive waste
above a formation which within one-quarter mile of the well contains an
underground source of drinking water.
c. Wells used by generators of hazardous waste or owners or operators of hazardous
waste management facilities to dispose of hazardous waste, which cannot be
classified under l.a or 4.a and b above (e.g., wells used to dispose of hazardous
waste into or above a formation which contains an aquifer which has been exempted
pursuant to 40 CFR 146.04).
Class V. Injection wells not included in Classes I, II, HI, or IV.
2. Exempted Aquifers
Under 40 CFR 144.7(b), EPA has identified "exempted aquifers" which cannot be used as
sources of drinking water because they: (1) contain minerals, hydrocarbons, or geothermal
energy expected to be commercially producible; (2) are situated at a depth or location which
makes recovery for drinking water purposes economically or technologically impractical; (3)
are contaminated; (4) are located over a Class in well or mining area subject to subsidence or
catastrophic collapse; or (S) contain between 3,000 and 10,000 mg/1 of total dissolved solids.
These aquifers are exempted from the protection afforded by the UIC regulations (40 CFR
144.7).
3. Indian Lands
EPA may promulgate an alternative UIC program for Class II wells on any Indian reservation
or Indian lands (40 CFR 144.2).
4. Prohibition of Unauthorized Discharge
Any underground injection, except as authorized by permit or rule issued under the UIC
program is prohibited (40 CFR 144.11).
Phase 1 - Section 15
Groundwater Protection
15-3
-------
5. Prohibition of Class IV Wells
The following activities relating to Class IV wells are prohibited, unless the conditions in 40
CFR 144.13(c) are met (40 CFR 144.13):
1. The construction of any Class IV well.
2. The operation or maintenance of any Class IV well not in operation prior to July 18,
1980.
3. The operation or maintenance of any Class IV well that was in operation prior to July 18,
1980, after six months following the effective date of a UIC program approved or
promulgated for the state.
4. Any increase in the amount of hazardous waste or change in the type of hazardous waste
injected into a Class IV well.
6. Prohibition of Movement
The construction, operation, maintenance, conversion, plugging, abandonment, or conduct of
other injection activities must not cause movement of fluid containing contamination into
underground sources of drinking water if the presence of that contaminant may cause a
violation of any primary drinking water regulation or otherwise adversely affect the health of
persons (40 CFR 144.12).
7. Injection of Hazardous Waste Under the UIC Program
Each facility using any class of well to inject hazardous waste must comply with (40 CFR
144.14):
1. The notification requirements of Section 3010-of RCRA.
2. The identification number requirements of 40 CFR 264.11.
3. The recordkeeping, reporting, and manifest requirements in 40 CFR 264.71-264.72.
4. The operation record requirements in 40 CFR 264.73(a), (b)(l), and (b)(2).
5. The annual report requirements of 40 CFR 264.75.
6. The unmanifested waste report requirements in 40 CFR 264.75.
Phase 1 - Section 15
Groundwater Protection
15-4
-------
7. The applicable training requirements of 40 CFR 264.16.
8. The closure certification requirements of 40 CFR 144.52(a)(6).
8. Inventory Requirements
Owners/operators of all injection wells authorized by rule must submit an inventory to the
Director (40 CFR 144.26).
9. Financial Responsibility
Owners/operators of Class I hazardous waste injection wells must establish financial
assurance. A written estimate, in current dollars, of the cost of plugging and abandoning each
injection well-is required. Owners/operators of each facility must establish financial
assurance for the plugging and abandonment of each existing and new Class I hazardous
waste injection well, choosing from the following options: plugging and abandonment trust
fund; surety bond guaranteeing payment into a plugging and abandonment trust fund; surety
bond guaranteeing performance of plugging and abandonment; plugging and abandonment
letter of credit; plugging and abandonment insurance; or financial test and corporate guarantee
for plugging and abandonment (40 CFR 144 Subpart F).
Owners/operators of hazardous and solid waste landfills have similar responsibilities defined
in Subpart H of 40 CFR 258, 264 and 265. A written estimate of costs for closure, post-
closure care, liability and sudden and non-sudden occurrences is required. The options for
establishing financial assurance are the same as those for the UIC program. These estimates
are to be updated annually; some states may require a more frequent update.
10. RCRA Permit Programs
RCRA regulations under 40 CFR 258.50-258.58 outline the requirements of a groundwater
monitoring and corrective action program. RCRA regulations under 40 CFR 264 and 265
require that any facility that treats, stores or disposes of hazardous waste must apply to the
State for an operating permit. If the State has not yet given final approval or denial of the
permit application, then the facility is considered an "interim status" facility, and the
temporary permit issued by the state is called a "Part A permit." If a final permit, called a
"Part B permit" has been issued, then the facility is considered a treatment, storage, and
disposal facility (TSDF). The facility RCRA permit, whether it is Part A or B, will have
requirements in it for groundwater programs and those requirement tend to differ from state to
state.
In the Federal regulations, there are basic requirements for both interim status facilities and
TSDFs including the development and maintenance of a groundwater monitoring program.
The programs generally have different levels of requirements depending on the potential level
of groundwater contamination at the facility, and proximity to sensitive receptors.
Phase 1 - Section 15
Groundwater Protection
15-5
-------
11. Imminent and Substantial Endangerment
Federal environmental laws, including CERCLA, RCRA, the Safe Drinking Water Act
(SDWA), the Clean Air Act (CAA) and, to some extent, the Clean Water Act (CWA), rely on
the concept of immediate response action when an actual or threatened release poses an
imminent and substantial endangerment to public health, welfare or the environment. Site
inspectors must have a full understanding of this concept to properly interpret and take
immediate and appropriate action if situations that present an imminent and substantial
endangerment to human health, welfare, or the environment are encountered. The following
definitions provide clarification:
"Actual or threatened release" applies not only to actual releases or discharges, but also to
potential releases or discharges as well. However, the release or discharge must be actual or
probable not merely speculative.
"Imminent" is defined as existing now or likely to exist in the near future. "Imminent" refers
to endangerment, it does not require that actual harm be imminent.
"Substantial" is defined both in relation to the potential for risk (that is, harm is very likely to
occur) and the degree of harm that may occur (that is, the harm will be very serious).
"Endangerment" is defined broadly as the risk of harm to human health, welfare, or the
environment. Risk of harm to human health includes the potential for acute/chronic illness or
injury caused by exposure to hazardous substances, wastes, contaminants, or pollutants
including contaminated public or private water supplies. Risk of harm to welfare includes the
potential for economic loss due to damage to property, livestock, crops, resources, fish, or
other harm to livelihood. Risk of harm to the environment includes the direct physical
destruction or alteration of an ecosystem, (e.g., harm to flora and fauna). The harm need not
have already occurred for the endangerment to exist.
Consideration of these terms simultaneously suggests a complex interaction between the
material released or threatened to be released, the amount of material released, the potential
pathways of migration, the proximity of such pathways, the potential for human, animal, or
environmental exposure, the nature of harm caused by exposure, and the severity of harm.
12. Clean Water Act - Discharges to Groundwater
Frequently, state NPDES equivalent programs will contain regulations controlling the
discharge of pollutants to groundwater. These programs generally require permitting,
monitoring, and reporting activities.
Phase 1 - Section 15
Groundwater Protection
15-6
-------
E. Key Compliance Definitions
1. Approved State Program
a. UIC program administered by the State or Indian Tribe that has been approved by
EPA according to SDWA Sections 1422 and/or 1425 (40 CFR 144.3).
b. A RCRA program administered by the State or Indian Tribe that has been approved
by EPA according to 40 CFR 271.
2. Aquifer
Geological "formation," group of formations, or part of a formation that is capable of yielding
a significant amount of water to a well or spring (40 CFR 144.3, 40 CFR 260.10).
3. Area of Review
The area surrounding an injection well described according to the criteria set forth in 40 CFR
146.06 or in the case of an area permit, the project area plus a circumscribing area the width
of which is either 1/4 of a mile or a number calculated according to the criteria set forth in 40
CFR 146.06 (40 CFR 144.3).
4. Contaminant/Pollutant
a. Any physical, chemical, biological, or radiological substance or matter in water (40
CFR 144.3).
b. As defined by section 101(33) of CERCLA, this term includes, but is not limited to,
any element, substance, compound or mixture, including disease-causing agents,
which after release into the environment and upon exposure, ingestion, inhalation, or
assimilation into any organism, either directly from the environment or indirectly by
ingestion through food chains, will cause death, disease, behavioral abnormalities,
cancer, genetic mutation, physiological malfunctions, or physical deformations, in
such organisms or their offspring. The term does not include petroleum, including
crude oil or any fraction thereof which is not otherwise specifically listed or
designated as a hazardous substance under section 101(14)(A) through (F) of
CERCLA (40 CFR 300.5).
5. Corrective Action Management Unit (CAMU)
An area within a facility that is designated by the Regional Administrator under 40 CFR 264
Subpart S, for the purpose of implementing corrective action requirements under 40 CFR
264.101 and RCRA section 3008(h), A CAMU shall only be used for the management of
remediation wastes pursuant to implementing such corrective action requirements at the
facility.
Phase 1 - Section 15
Groundwater Protection
16-7
-------
6. Discharge
As defined by section 311(a)(2) of the CWA, includes, but is not limited to, any spilling,
leaking, pumping, pouring emitting, emptying, or dumping of oil but excludes discharges in
compliance with a permit under section 402 of the CWA. For purposes of the NCR, discharge
also means threat of discharge.
7. Drilling Mud
A heavy suspension used in drilling an "injection well," introduced down the drill pipe and
through the drill bit (40 CFR 144.3).
8. Exempted Aquifer
An "aquifer" or its portion that meets the criteria in the definition of "underground source of
drinking water" but which has been exempted according to the procedures in 40 CFR 144.7
(40 CFR 144.3).
9. Facility or Activity
a. Any UIC "injection well," or another facility or activity that is subject to regulation
under the UIC program (40 CFR 144.3).
b. Any building, structure, installation, equipment, pipe or pipeline (including any pipe
into a sewer or publicly owned treatment works), well, pit pond, lagoon,
impoundment, ditch, landfill, storage container, motor vehicle, rolling stock or
aircraft, or any site or area where a hazardous substance has been deposited, stored,
disposed of, or placed, or otherwise come to be located; but does not include any
consumer product in consumer use or any vessel.
10. Fluid
Any material or substance which flows or moves whether in a semisolid, liquid, sludge, gas,
or any other form or state (40 CFR 144.3).
11. Formation
A body of consolidated or unconsolidated rock characterized by a degree of lithologic
homogeneity which is prevailingly, but not necessarily, tabular and is mappable on the earth's
surface or traceable in the subsurface (40 CFR 144.3).
12. Formation Fluid
"Fluid" present in a "formation" under natural conditions as opposed to introduced fluids,
such as "drilling mud" (40 CFR 144.3).
Phase 1 - Section 15
Groundwater Protection
16-8
-------
13. Generator
Any person, by site location, whose act or process produces hazardous waste identified or
listed in 40 CFR Part 261 (40 CFR 144.3).
14. Groundwater
Water below the land surface in a zone of saturation (40 CFR 260.10, 144.3).
15. Hazardous Waste
Hazardous waste as defined in 40 CFR 261.3 (40 CFR 144.3).
16. Hazardous Waste Management Facility
"HWM facility" means all contiguous land, and structures, other appurtenances, and
improvements on the land used for treating, storing, or disposing of hazardous waste. A
facility may consist of several treatment, storage, or disposal operational units (for example,
one or more landfills, surface impoundments, or combination of them) (40 CFR 144.3).
17. Indian Lands
"Indian country" as defined in 18 U.S.C. 1151. That section defines Indian country as (40
CFR 144.3):
a. All land within the limits of any Indian reservation under the jurisdiction of the United.
States government, notwithstanding the issuance of any patent, and, including rights-of-
way running through the reservation.
b. All dependent Indian communities within the borders of the United States whether within
the original or subsequently acquired territory thereof, and whether within or without the
limits of a State.
c. All Indian allotments, the Indian titles to which have not been extinguished, including
rights-of-way running through the same.
18. Indian Tribe
Any Indian Tribe having a Federally recognized governing body carrying out substantial
governmental duties and powers over a defined area (40 CFR 144.3).
19. Injection Well
A "well" into which "fluids" are being injected (40 CFR 144.3).
20. Injection Zone
Geological "formation" group of formations, or part of a formation receiving fluids through a
"well" (40 CFR 144.3).
Phase 1 - Section 15
Groundwater Protection
15-9
-------
21. Landfill
A disposal facility or part of a facility where hazardous waste is placed in or on land and
which is not a pile, a land treatment facility, a surface impoundment, an underground
injection well, a salt dome formation, a salt bed formation, an underground mine, a cave, or a
corrective action management unit (40 CFR 260.10).
22. Management Practice (MP)
Practices that, although not mandated by law, are encouraged to promote safe operating
procedures.
23. Owner or Operator
The owner or operator of any "facility or activity" subject to regulation under the UIC
program (40 CFR 144.3).
24. Permit
An authorization, license, or equivalent control document issued by EPA or an approved State
to implement the requirements of 40 CFR Parts 144, 145, 146 and 124. "Permit" includes an
area permit (40 CFR 144.33) and an emergency permit (40 CFR 144.34). Permit does not
include UIC authorization by rule (40 CFR 144.21), or any permit which has not yet been the'
subject of final agency action, such as a "draft permit" (40 CFR 144.3).
25. Person
An individual, association, partnership, corporation, municipality, State, Federal, or Tribal
agency, or an agency or employee thereof (40 CFR 144.3).
26. Plugging
The act or process of stopping the flow of water, oil or gas into or out of a formation through
a borehole or well penetrating that formation (40 CFR 144.3).
27. Project
A group of wells in a single operation (40 CFR 144.3).
28. Radioactive Waste
Any waste which contains radioactive material in concentrations which exceed those listed in
10 CFR Part 10, Appendix B, table II, Column 2 (40 CFR 144.3).
29. Site
The land or water area where any "facility or activity" is physically located or conducted,
including adjacent land used in connection with the facility or activity (40 CFR 144.3).
Phase 1 -Section 15
Groundwater Protection
15-10
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30. Underground Injection Control (UIC)
Underground Injection Control program under Part C of the Safe Drinking Water Act,
including an "approved State program" (40 CFR 144.3).
31. Underground Source of Drinking Water (USDW)
An aquifer or its portion (40 CFR 144.3):
a. Which supplies any public water system; or
b. Which contains a sufficient quantity of ground water to supply a public water system;
and
c. Currently supplies drinking water for human consumption; or
d. Contains fewer than 10,000 mg/1 total dissolved solids; and
e. Which is not an exempted aquifer.
32. Uppermost Aquifer
The geologic formation nearest the natural ground surface that is an aquifer, as well as lower
aquifers that are hydraulically interconnected with this aquifer within the facility's property
boundary (40 CFR 144.3).
33. USDW
Underground source of drinking water .(40 CFR 144.3).
34. Well
A bored, drilled or driven shaft, or a dug hole, whose depth is greater than the largest surface
dimension (40 CFR 144.3).
35. Well Injection
The subsurface emplacement of "fluids" through a bored, drilled, or driven "well;" or through
a dug well, where the depth of the dug well is greater than the largest surface dimension (40
CFR 144.3).
Phase 1 - Section 15
Groundwater Protection
15-11
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F. Records to Review
• Approved underground injection well permits
• Injection well planning and construction records
Injection well monitoring results
UlJbVUVd TTVil ILlWUUVUlUg 1&JU1US
Facility records, or petitions, for review records, for projects that may potentially cause
contamination of a sole source aquifer through its recharge zone
State waivers
Groundwater monitoring results, reports (for more detail, see checklist)
G. Physical Features to Inspect
• Underground injection wells
• Groundwater monitoring well system
• Surrounding environment for signs of stress
Phase 1 - Section 15
Groundwater Protection
15-12
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H. Guidance for Checklist Users
All Facilities
Site Reconnaissance and
Inspections
Records Review
State-Specific Regulatory
Requirements
Groundwater Pollution and
Hydrogeology
Groundwater Protection Program
Hazardous Waste Site
Groundwater Monitoring -
Permitted Facilities
Hazardous Waste Site
Groundwater Monitoring - Interim
Status Facilities
Sampling and Analytical Practices
Underground Injection
Refer To
Checklist Hems
GW.1 through GW.2
GW.3
GW.4
GW.5
GW.6
GW.7
GW.8 through GW.13
GW.14 through GW.16
GW.17 through GW.18
GW.1 9 through GW.29
Page Number*
15-14
15-15
15-15
15-16
15-17
15-18
15-18
15-22
15-24
15-28
Phase 1 - Section 15
Groundwater Protection
15-13
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All Facilities
GW.1. The current status of
any ongoing or unresolved
Consent Orders, Compliance
Agreements. Notices of Violation
(NOV). Interagency Agreements,
or equivalent state enforcement
actions must be examined. (A
finding under this checklist Hem '
will have the enforcement
action/identifying information as
the citation.)
Determine if noncompliance issues have been resolved by reviewing a copy of the
previous report, Consent Orders, Compliance Agreements, NOVs, Interagency
agreements or equivalent State enforcement actions.
For those open items, indicate what corrective actions are planned and milestones
established to correct problems.
OW.2. Facilities are required to
comply with all applicable
Federal regulatory requirements
not contained in this checklist.
(A finding under this checklist
item will have the citation of the
applied regulation as a basis of
finding.) . • •
Determine if any new regulations have been issued since the fmalization of the guide.
If so. annotate checklist to include new standards.
Determine if the facility has activities or facilities which are Federally regulated, but
not addressed in this checklist.
Verify that the facility is in compliance with all applicable and newly issued
regulations.
Phase 1 - Section 15
Groundwater Protection
15-14
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RWMWK Cracks
Site Reconnaissance and Inspections
GW.3. The facility must renew
all of its operations In an effort
to identify any possible areas of
concern with respect to
groundwater protection. Creating
inventories of potential sources
of groundwater contamination
(e.g., USTs. ASTs. past spills
and leaks, etc.), allows the
facility to determine its
compliance status (MP).
Determine whether the facility has developed an inventory of potential sources of
groundwater contamination.
Determine whether the following potential contaminant sources are present at the
facility:
- Petroleum products, hazardous material, and non-RCRA wastes stored in
underground storage tanks which could negatively affect groundwater. If yes,
complete Appendix 15-3, Inventory of Existing and Former Underground Storage
Tanks
• Petroleum products and oil-filled dielectric transformers stored in aboveground
storage tanks which could negatively affect groundwater. If yes, complete Appendix
15-3, Inventory of Existing and Former Aboveground Storage Tanks
- Facility operations (e.g., soil column discharges, SWMUs) that caused cm-site soil
or groundwater contamination. If yes. complete Appendix 15-5, Inventory of Spills
and Leaks or Suspected Areas of Contamination
- Operation of any off site locations (e.g., warehouses, garages, storage units,
specialty experiments shops, etc.) that could negatively affect
- Groundwater monitoring or supply wells, etc. If yes, complete Appendix 15-2,
Inventory of Groundwater Wells, Appendix 15-6, Inventory of Aquifers, and
Appendix 15-7, Inventory of Lithologies
- Any known or suspected spill events with the potential for causing soil or
groundwater contamination. If yes, complete Appendix 15-5, Inventory of Spills and
Leaks or Suspected Areas of Contamination
- Property abettors capable of causing groundwater contamination. If yes, complete
Appendix 15-1, Inventory of Neighboring Facilities
- The facility discharges pollutants into water bodies. If yes, complete Appendix 15-9,
Inventory of Water Discharges
- Operation of wastewater treatment facilities
Recoios Review
GW.4. The facility must keep
records of all past groundwater
problems and all facility
programs and procedures in
place to prevent groundwater
pollution. This will help the
facility compare the types of
problems they may be
susceptible to with the control
techniques they use to prevent
and remediate those problems
to ensure there is a contingency
for all potential problems (MP).
Evaluate whether the facility been subject to any regulatory action (e.g., lawsuits,
consent decrees, investigations, etc.) during the period of review.
Determine if the facility documented any internal audits, appraisals, or reviews during
the period of review.
Determine if the facility evaluated the potential effect past operations may have had
on groundwater.
Determine if the facility has been the subject of groundwater complaints or lawsuits
by third parties (e.g., neighbors, environmental organizations, etc.) during the period
of review.
Identify and evaluate any formal groundwater protection programs in place.
Phase 1 - Section 15
Groundwater Protection
15-15
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Groundwater Protection
Regulatory Requirements:
fWVwWBF GIMClHI
State Specific Regulatory Requirements
GW.5. Groundwater is normally
considered "waters of the
State" and is regulated by
individual States. The specialist
should obtain and review State
groundwater related regulations
and laws. Below are some State
regulated issues the specialist
should keep in mind (MP).
Determine if the state has any groundwater regulations covering the following:
- Groundwater well plugging and abandonment procedures
- Groundwater discharge permits
• Monitoring well security requirements
- Wellhead protection (often regulated and implemented at the local level)
- Groundwater contamination reporting requirements and cleanup standards
• Other State regulatory requirements.
Phase 1 - Section 15
Groundwater Protection
15-16
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Compliance Category:
Groundwater Pollution and Hydrogeology
GW.6. The facility must
consistently monitor the
groundwater at the site for
evidence of contamination. It is
imperative to understand how
the contaminants are
discharged, how they would
react if discharged to the
groundwater, as well as the
hydrologic regime at the site to
properly evaluate the
groundwater monitoring system.
Verify that facility programs are adequate to detect leaks from underground storage
tanks before groundwater resources are degraded.
Determine if there is groundwater contamination on-site. (NOTE: Primary types of
contamination include volatile organic compounds, inorganic compounds and
radiological compounds.) (If groundwater contamination exists, and if possible.
determine its state (e.g.. non-aqueous phase, dissolved.)
Determine if soil gas studies and/or other programs for contamination within the
unsaturated zone or vadose zone have been conducted to characterize volatile
organic compounds and/or radiological contaminants.
Verify that facility formal site assessment procedures exist to address groundwater
contamination if It Is Identified. Determine that applicable state environmental
regulations and/or CERCLA requirements are met
Determine if there Is groundwater contamination at the site. If contamination is
present, has the facility:
- Identified and removed the source
- Characterized the nature and extent (e.g., determined the types of contamination
present, the state (dissolveoVhon-aqueous) the contamination is in, and the limits of
• the contaminant plume).
- Taken necessary steps with the regulators to determine if cleanup is necessary?
Determine if soil base studies and/or other investigations have been performed to
identify and characterize contamination in the unsaturated zone.
Verify that the facility has characterized the groundwater system and determined the
aquifer properties that control groundwater flow; and that the facility has characterized
groundwater quality, flow direction and rate. Methods for assessing aquifer properties
include: slug tests, aquifer pump tests, geophysical methods, tracer testing, and
laboratory soil/sediment property measurements. The aquifer characteristics of
importance include transmissivrty, storage coefficient anisotropy. infiltration rates.
organic carbon content, fracture spacing and aperture, degree of interconnection
between aquifer and other water bearing units and surface water, leakage rates,
groundwater velocity, porosity, gradients, and dispersion.
Phase 1 • Section 15
Groundwater Protection
15-17
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Compliance Category:
-*fc • * ftM- •JB-af»^
uraunawaisf rmeciion ,
HeguiatOfy ntXfamnuaK
ft J. * •• - - -• n
Groundwater protection Prograi
GW.7. The facility should
develop a formal groundwater
protection program which
includes groundwater
monitoring, documentation.
recordkeeping and standard
operating procedures for
groundwater related activities
(e.g., drilling, well inspection and
maintenance, etc.) (MP).
| Reviewer Checka
n
Confirm that facility standard operating procedures exist for:
- Drilling
- Well construction
- Management and disposal of investigation derived waste (e.g., borehole cuttings,
development water and purge water, and drilling fluid)
- Well inspection and maintenance
• Groundwater and soil sampling, preservation and shipment and chain of custody
control
- Well abandonment
- Data management.
Verify that the facility developed and maintains documentation relating to
hydrogeologic characterization which includes the definition and description of site
geology and hydrology Including identification of aquifers, and surface
water/groundwater relationships.
Hazardous Waste She Groundwater Monitoring - Permitted Facilities
(NOTE: GW.8 through GW.13 describe the requirements for groundwater programs pursuant to 40 CFR 264 Subpart F,
Releases from Solid Waste Management Units, such as surface impoundments, waste piles, land treatment units,
received waste after Jury 26, 1982 (40 CFR 264.90).)
GW.8. The facility must comply
with the conditions specified in
the facility permit meant to
ensure that hazardous
constituents under 40 CFR
264.93 detected in the
groundwater do not exceed the
concentration limits under 40
CFR 264.94 in the uppermost
aquifer underlying the waste
management area beyond the
point of compliance under 40
CFR 264.95 (40 CFR 264.92).
Review the facility Part B permit and determine whether the groundwater protection
standards set forth are addressed in the facility's groundwater protection program.
The groundwater protection standards should include at least the following parts:
- The identification of hazardous constituents listed in Appendix VIII of 40 CFR 261
that have been detected in the groundwater from the facility
- Concentration limits for the hazardous constituents identifieD
- The point of compliance at which monitoring must be conducted
• The compliance period during which the groundwater protection standard applies.
Phase 1 - Section 15
Groundwater Protection
15-18
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CompBanee Category:
GrounitMtef Protection
Regulatory Requb
Reviewer Checks
GW.9. Facilities are required to
conduct a monitoring program
(40 CFR 264.91).
Verify that the facility conducts the following monitoring and response activities as
applicable:
- At a minimum, the facility must institute a detection monitoring program as
. described in Step GW. 11
- Whenever hazardous constituents are detected at statistically significant
concentrations at a compliance point, the facility must institute a compliance
monitoring program as described in GW.12
- Whenever the groundwater protection standard is exceeded or hazardous
constituents exceed concentration limits beyond the point of compliance, the facility
must institute a corrective action program as described in Step GW.13.
GW.10. Facilities must comply
with the requirements in 40 CFR
264.97 for any groundwater
monitoring program developed
to satisfy 40 CFR 264.98.
264.99, or 264.100 (40 CFR
264.97).
If there is a possibility of hazardous constituents In the groundwater, ensure that the
following activities are added to the groundwater monitoring plan:
- For each hazardous constituent In each well, one of the statistical methods
described In 40 CFR 264.97(h) for evaluating monitoring data has been chosen by
the facility, approved by the Regional Administrator, and complies with the
performance standards in 40 CFR 264.97(i)
- All groundwater monitoring data collected is maintained in the facility operating
record and submitted for review as required by the Regional Administrator
- The program includes sampling and analytical procedures that are appropriate and
accurately measure hazardous constituents in groundwater samples
-' An appropriate method for determining background water quality has'been selected
and background groundwater quality has been determined.
Phase 1 - Section 15
Groundwater Protection
15-19
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Compliance Category:
Groundwater Protection
Regulatory Requirement!
Reviewer Checks
GW.11. Facilities required to
establish a detection monitoring
program under 40 CFR 264
Subpart F must, at a minimum,
comply with 40 CFR 264.98 (40
CFR 264.98).
ff the facility is required by the Regional Administrator to establish a detection
monitoring program, ensure that the following activities are included in the
groundwater monitoring plan:
- Monitoring for indicator parameters (e.g., specific conductance, total organic
carbon, or total organic halogen), waste constituents, or reaction products that
provide a reliable indication of the presence of hazardous constituents In the
groundwater
(NOTE: The Regional Administrator will specify the parameters or constituents to
be monitored and their frequency for collection and statistical analysis in the facility
permit (40 CFR 264.98(d).)
- Determination of the groundwater flow rate and direction in the uppermost aquifer,
at least annually
- Determination of whether statistically significant evidence of contamination exists
and if it does exist, the following steps are taken:
(NOTE: H statistically significant evidence of contamination exists but, may have
been caused by contamination from another source or by an error in sampling, then
the facility must demonstrate that to the Regional Administrator.)
The Regional Administrator is notified In writing within seven days
The groundwater is immediately sampled In all monitoring wells to determine If
any constituents in Appendix IX of 40 CFR 264 are present, and if so, in what
concentration.
(NOTE: If Appendix IX constituents are present in the sample then the following
activities are required:
- An application for a permit modification to establish a compliance monitoring
program is submitted within 90 days to the Regional Administrator
- An engineering feasibility plan for corrective action and all data necessary to justify
any alternative concentration limits are submitted to the Regional Administrator
within 180 days.)
GW.12. Facilities required to
establish a compliance
monitoring program under CFR
264 Subpart F must, at a
minimum, comply with 40 CFR
264.99 (40 CFR 264.99).
If the facility is required to establish a compliance monitoring plan, verify that the plan
contains procedures for the following activities to be done in conjunction with the
groundwater monitoring plan:
• Determination of whether any significant evidence of increased contamination exists
and if it does exist, the following steps are taken:
- The Regional Administrator is notified in writing which limits are exceeded
within seven days
An application for a permit modification to establish a corrective action
program is submitted to the Regional Administrator within 180 days.
(NOTE: If statistically significant evidence of increased contamination exists but, may
have been caused by contamination from another source or by an error in sampling,
then the facility must demonstrate that to the Regional Administrator.)
Phase 1 - Section 15
Groundwater Protection
15-20
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CompBance Category:
Protection
Regulatory toqtdnmwnta
GW.13. Facilities required to
establish a corrective action
program under 40 CFR 264
Subpart F must, at a minimum,
comply with 40 CFR 264.100
(40 CFR 264.100).
If the facility is required to establish a corrective action program, determine whether
the following procedures are in place in addition to the groundwater monitoring plan:
- The facility either removes hazardous waste constituents or treats them in place to
prevent the constituents from exceeding their respective concentration limits. The
permit will specify the specific measures that will be taken
- The facility establishes a groundwater monitoring program to evaluate the
effectiveness of the corrective action program and submits the results of the
evaluation semi-annually in a written report to the Regional Administrator.
Phase 1 - Section 15
Groundwater Protection
15-21
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Compliance Category:
Groundffater Protection
Regulatory Requirement*:
Raviswer. Cnecke
Hazardous Waste Site Groundwater Monitoring - Interim Status Facilities
(NOTE: GW.14 through GW.16 describe the requirements for groundwater programs pursuant to 40 CFR 265 Subpart F,
Interim Status lor Owners and Operators of Treatment. Storage, and Disposal Facilities (40 CFR 265.90).)
GW. 14. The facility must have
a groundwater monitoring
program capable of determining
the facility's impact on the
uppermost aquifer unless they
have demonstrated and certified
that a program is not necessary
(40 CFR 265.90(0, (e».
The program must include a
groundwater monitoring system
consistent with the requirements
of 40 CFR 265.91 and a
sampling and analysis plan
consistent with 40 CFR 265.92.
Verify that the facility has developed a groundwater sampling and analysis plan.
Review the plan and verify that it includes procedures and techniques for:
- Sample collection
- Sample preservation and shipment
- Analytical procedures
'- Chain of custody control.
Verify that the facility determines the background concentration or value of the
following parameters in the groundwater samples at least annually:
• Parameters characterizing the suitability of groundwater as a drinking water supply,
as specified in 40 CFR 265 Appendix III.
- The following parameters establishing groundwater quality:
- Chloride
Iron
Manganese
— Phenols
Sodium
- Sulfate.
- The following parameters used as indicators of groundwater contamination:
- pH
Specific conductance
- Total organic carbon
Total organic halogen.
Verify that the facility maintains records of all borings advanced and well construction
details for all wells installed. Review records to determine if wells are capable of
determining the facility's impact on the uppermost aquifer.
Phase 1 - Section 15
Groundwater Protection
15-22
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Compliance Category:
Grow dwater Protection
Regulatory Requirements:
GW.tS. The facility must
resample and provide notice if a
downgradient monitoring wall
sample shows a significant
increase (or pH decrease) in
constituent concentration (40
CFR 265.93(c)).
If the facility determines that a monitoring well sample shows a significant increase
(or pH decrease) in constituent concentration, confirm that the facility conducts the
following activities:
- Duplicate resampling of the well(s) that showed the difference and separate
analysis of the two sets of samples to determine whether the difference was a
result of sampling or laboratory error
• If it is determined that the difference was not a result of sampling or laboratory
error, the facility must conduct the following activities:
Written notice is given to the Regional Administrator within seven days
A groundwater quality assessment plan has been approved by a qualified
geologist or geotechnical engineer and is submitted to the Regional
Administrator within 15 days
An assessment report is submitted to the Regional Administrator within 15
days of its completion.
GW.16. Groundwater
monitoring program records
must be maintained (40 CFR
265.94).
Unless the groundwater is monitored to satisfy 40 CFR 265.93(d)(4), verify that the
facility:
- Maintains records of the analyses required in 40 CFR 265.92(c) and (d), the
associated groundwater surface elevations required in 40 CFR 265.92(e), and the
evaluations required in 40 CFR 265.93(b)
(NOTE: These records must be kept throughout the active life of the facility, and, for
disposal facilities, throughout the post-closure care period as well.)
- Reports information specified in 40 CFR 265.94(a)(2) to the Regional Administrator
i
If the groundwater Is maintained to satisfy the requirements of 40 CFR 265.93(d)(4),
verify that the facility:
- Maintains records of the analyses and evaluations specified in the plan
(NOTE: These records must be kept throughout the active life of the facility, and, for
disposal facilities, throughout the post-closure care period as well.)
• Annually submits a report to the Regional Administrator containing the results of the
groundwater quality assessment program.
(NOTE: This report Is required annually until final closure of the facility.)
Review facility recordkeeping and reporting procedures to ensure that they include
the following with respect to groundwater monitoring:
- Procedures to keep all analyses and evaluations of groundwater throughout the
active life of the facility, and, for disposal facilities, throughout the post-closure care
period as well
- Procedures to submit (no later than March 1 each year) to the Regional
Administrator, a report containing the results of the groundwater quality
assessment.
Phase 1 - Section 15
Groundwater Protection
15-23
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Compliance Category:
Gfoundwalef Protection
Regulatory Requirements:
Sampling and Analytical Practices
GW.17. Sampling and analysis
requirements are largely
regulated by the individual
states and will be described in
the facility's permit. A review of
the permit requirements and the
groundwater protection program
is necessary to complete this
section. The following steps are
general requirements which
should be coordinated with the
permit requirements when
conducting sampling and
analysis procedures (MP).
Verify that groundwater sampling technicians are properly trained and certified.
Verify that all sampling activities are conducted in accordance with an approved
health and safety plan.
Verify that all sampling and analysis is conducted in accordance with an approved
Quality Assurance Plan.
Verify that samples are submitted to approved laboratories where required.
GW.18. The groundwater
monitoring system must be
capable of yielding
representative groundwater
samples (40 CFR 265.91).
Obtain and review the facility's written groundwater monitoring program and/or
procedures. Test the adequacy of the facility's monitoring system and sampling and
analytical procedures by performing the following:
- Verify compliance with applicable sampling and analytical procedures and
requirements by completing the following:
Verify that the appropriate and up-to-date state certification has been obtained
Verify that representative samples are obtained and that the sampling
frequency and analytical program complies with prescribed requirements
- Note whether or not the monitoring frequency is consistent with regulatory
provisions and good management practices
Review the procedures used in calibrating and maintaining analytical
equipment and review maintenance logs and determine whether the
equipment is routinely maintained and calibrated in conformance with good
management practices
Review the analytical procedures used by the facility to verify compliance with
best management practices or approved test procedures {e.g., confirm that
proper preservation techniques, holding times, and quality control procedures
are used and correct)
- If samples are analyzed by an outside laboratory:
Confirm that the lab is certified or approved to perform the work
Note any provisions for cross-checking or verification by independent analysis
as well as other quality control/assurance procedures.
Phase 1 - Section 15
Groundwater Protection
15-24
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ComptrancB
Gtaundwater Protection
B; I Reviewer Checks
Underground Injection
GW.19. Injection wells are
classified into five classes of
wefls: Class I; Class II; Class
III; Class IV; and Class IV (40
CFR 144.6).
Determine by reviewing engineering records or other documentation ft
• the injection well is property classified according to US EPA requirements
- any injection wells have been installed since July 20,1984.
Confirm by comparing engineering data to regulatory provisions that the design and
construction of those wells meet US EPA standards.
GW.20. Owners/operators of
Class I injection wells are
required to establish financial
assurance for the plugging and
abandonment of the wells using
one of the options specified in
40 CFR 144.63(a)-(f) (40 CFR
144.62 and 144.63).
For any class I injection well, determine whether the facility has established financial
assurance by:
- establishing and keeping current a cost estimate for its plugging and abandonment
plan (P&A)
(NOTE: The cost estimate must be in current dollars, equal to the cost of plugging
and abandonment at the point in the facility's operating life when the extent and
manner of its operation would make plugging and abandonment the most expensive,
and adjusted for inflation annually.)
- keeping financial assurance for its plugging and abandonment plan using at least
one of the specified forms:
- P&A trust
surety bond guaranteeing payment into a P&A trust fund
surety bond guaranteeing performance of P&A
- P&A letter of credit
P&A insurance
financial test and corporate guarantee for P&A.
GW.21. Underground injection
activities must be authorized by
permit. All permit applications
must be complete before the
Director of the UIC program will
Issue a permit (40 CFR 144.31-
144.41).
Obtain and review the permit application for the underground injection control
program.
Confirm that the permit application reflects current operations (complete and
accurate) and has the proper signatories.
Confirm that the facility's permits are up to date and reflect current operations.
GW.22. The permittee must
comply with all conditions of the
permit. Any permit
noncompliance is a violation of
the SDWA and is grounds for
enforcement action; for permit
termination, revocation and
reissuance, or modification; or
for denial of a permit renewal
application (40 CFR 144.51).
Prepare a schedule that includes a representative sample of permit conditions and
regulatory requirements.
Verify that the facility has meet these obligations by observing operations, reviewing
facility records, and interviewing facility personnel.
Note any discrepancies.
Phase 1 - Section 15
Groundwater Protection
15-25
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Compliance Category:
Groundwater Protection
Regutetory Requirements!
Rttvtowsr Checks
GW.23. The permittee must at
all times properly operate and
maintain all facilities and
systems of treatment and
control (and related
appurtenances) necessary to
achieve compliance. Proper
operation and maintenance
includes effective performance,
adequate funding, adequate
operator staffing and training,
and adequate laboratory and
process controls, including
appropriate quality assurance
procedures (40 CFR 144.51 (e)).
Review the facility's maintenance and calibration records and observe operations to
verify that automatic monitoring systems are functioning property.
Evaluate the facility's injection well operation by performing the following:
• Review a representative sample of location monitoring data to verify that permitted
operating limitations (injection pressure, temperature, pH) are being met.
• Verify by interviewing personnel and inspection records that other operating
requirements (receipt control, inspections, etc.) are addressed by the facility and
that they are being met.
GW.24. The permittee is
required to retain all monitoring
information as specified in 40
CFR 144.51 G)).
Verify that samples and measurements taken are representative of the monitored
activity.
Verify by reviewing facility files that the following records have been maintained for a
minimum of three years (or longer if requested by the Director):
- Calibration and maintenance records
- Original strip chart recordings for continuous monitoring instrumentation
- Monitoring reports
- Permit application data
- Nature and composition of all injected fluids.
Review monitoring information to verify that it includes:
- The date, exact place, and time of sampling or measurements
- The individual(s) who performed the sampling or measurements
- The date(s) analyses were performed
- The individual(s) who performed the analyses
- The analytical techniques or methods used
- The results of such analyses.
Determine by interviewing key personnel how the facility will maintain inventory
records of plugged wells for three years after they are taken out of service to ensure
the facility will meet the requirements of 40 CFR 144.51.
GW.25. All applications,
reports, or Information submitted
to the Administrator must be
signed and certified (40 CFR
144.32 and I44.51(k)).
Review all permit applications, reports, and other information to verify that the proper
signature and certification is included.
Phase 1 -Section 15
Groundwater Protection
15-26
-------
Compliance Category:
Greundwater Protection
Regulatory Requirement*:
Reviewer Checks
GW.26. The permittee must
notify the Director of any
planned physical alterations or
additions to the facility, any
anticipated noncompliance,
compliance schedules, and
permit transfers. In addition,
monitoring reports must be
reported as specified in the
permit (see 40 CFR 144.51(j)>.
and 24-hour reporting is
required for any noncompliance
which may endanger health or
the environment (40 CFR
144.51(1)).
Confirm that the facility conducts required reporting activities such as:
• Planned changes, anticipated non-compliance, transfers, or compliance schedules
- Monitoring reports
- 24-hour reporting of any non-compliance which may endanger health or the
environment, including:
Any monitoring or other information which indicates that any contaminant may
cause an endangerment to an underground source of drinking water (USDW)
or
Any noncompliance with a permit condition or malfunction of the Injection
system which may cause fluid migration into or between USDWs.
(NOTE: Information must be provided orally within 24-hours and written submission
must follow within 5 days.)
GW.27. New injection wells
may not commence injection
until construction is complete
and the permittee has submitted
notice of completion of
construction to the Director; and
the Director has inspected or
reviewed the new injection well
an finds it in compliance with
permit conditions (40 CFR
144.51 (m)).
Determine if any new injection wells have commenced construction or injection since
the last audit.
Verity that for each new injection well:
- A notice of completion of construction was submitted to the Director
- The Director has inspected/reviewed the injection well for permit compliance.
GW.28. The permittee must
notify the Director before
conversion or abandonment of
the well or before closure of the
project (40 CFR 144.51(n)).
Determine if any injection wells have been:
- Converted,
- Abandoned, or
- Closed.
Verify that the Director was notified of such activity as specified in the permit.
Phase 1 - Section 15
Groundwater Protection
15-27
-------
»» • „•
Reviewer Chocks
GW.29. A plugging and
abandonment report must be
submitted to the Regional
Administrator for EPA-
admlnistered programs (40 CFR
144.51(o)).
Determine if any plugging and abandonment activities have occurred since the last
audit.
Determine if the facility is located in an EPA-admfnistered program state.
Verify that a plugging and abandonment report was submitted to the Regional
Administrator
- Written 60 days after plugging a well, or
- At the time of the next quarterly report, whichever is less.
(NOTE: If the quarterly report is due less than 15 days before completion of plugging,
the report must be submitted within 60 days.)
Verify that the report is certified as accurate by the person who performed the
plugging operation.
Phase 1 - Section 15
Groundwater Protection
15-28
-------
Section 15
Groundwater Protection
Appendices
-------
Appendix 15-1: Inventory of Neighboring Facilities
Name
Location and
Distance
Operations
Known or Suspected
Contamination
Name and owner of facility
Location: Proximity to reviewed location
Operations: Nature of operations'capable of causing soil or groundwater contamination
Known or Suspected Groundwater Contamination: Nature of groundwater contamination at the neighboring
facility and the extent of any migration
•Neighboring Facility": Facility within 1/2 mile of the reviewed location with a potential for causing groundwater
contamination
Location:.
Prepared by:
Date:
A1S-1
-------
Appendix 15-2: Inventory of Groundwater Wells
Well
Number
Type
Location
Punipinp
Rate
Geologic
Material
In
Screened
Area
Depth
of
SCftMH
Hydraulic
Conductivity
Water
Table
Depth
Average
or Range
Date of
Measurement
PresentYor
N. It Y type
0.9, voc.
BNA.PCB
•
Type: e.g., monitoring, observation, potable water supply, cooling water, injection wells
Hydraulic Conductivity: Indicate value and methods, e.g., based on pump, rising head, or falling head tests
Location: On-site • indicate area of site; Off-site • indicate distance and direction from site
Location:
Prepared by:
Date:
A15-2
-------
Appendix 15-3: Inventory of Existing and Former Aboveground Storage Tanks
Tank
lowitif icanon
•
Contents
Capacity
(gallons)
Age
UjM*Jh«lj»lA mjt
HMienais 01
Construction
Frequency of
Integrity Inspection
lami
Identification
uaiiy
Inspection
lypeoi
Overfill
Protection
inventory
Frequency
Detection
owenowy
containment
Secondary Containment: Nature and adequacy of dikes, barms, etc.
Tanks': Tank, drum, or barrel
Location:.
Prepared by:
Date:
A15-3
-------
Appendix 15-4: Inventory of Prior Operations
Owner
Operations
Hazardous Materials
Used
Dates
Comments
Owner Include all past owners of the site
Operations: Nature of operations capable of causing soil or groundwater contamination
Hazardous Materials Used: Nature and quantities of hazardous materials used
Comments: e.g.. known or potential soil or groundwater contamination and nature of any remedial activities
undertaken
Location:.
Prepared by:
Date:.
A15-4
-------
Appendix 15-5: Inventory of Spills and Leaks or Suspected Ares of Contamination
Location
Number of
Gallons
Leaked/
Spilled
Material
Spilled/Leaked
Date
Area/Volume of
Contamination
Comments
Comments: e.g., nature of any cleanup or remediation undertaken, cost estimates, verification from regulators that
area is 'clean'
Location:
Prepared by:
Date:
A15-5
-------
Appendix 15-6: Inventory of Aquifers
Nairn
type
-
uepin
tnosnenyu ID
necnarge rrom
uiwuem
and
Direction
bonunenw
•
area is 'clean*
Location:
Prepared by:
Date:
A15-6
-------
Appendix 15-7: Inventory of Lithologles
Name
Depth of Top and
Bottom Unit
Composition
Comments
Comments: e.g., grain size, fracturing, faulting, jointing
Location: Prepared by:
Date:
A15-7
-------
Appendix 15-8: Inventory of On-Site Disposal
Unit Type
Location
Waste/
Hazardous
Constituents
Method of
Disposal
Date of
Disposal/
Total
Amount
Regulatory
Status
Comments
Unit Type: e.g., Impoundment, landfill, sump; drain, pit, tank, drum, storage area, treatment unit, incinerator, etc.
Waste: Nature, amount, and ownership of waste disposal of
Regulatory Status: e.g., conformance with applicable permits, compliance orders/agreements, regulations, etc.;
likely future conformance
Comments: e.g.. visible leakage/spillage, nature of spill protection, condition of unit and usable life, potential for
mixing of incompatibles
il: Treatment, storage, or disposal
Location:
Prepared by:
Data*
A15-6
-------
Appendix 15-9: Inventory of Water Discharges
Source
•
Type
Receptor
•
Dally
Discharge
Rate
Pollutants
Length of
Discharge
Piping
Conformance with
Applicable Limitations/
Standards
•
Source: Point of generation
Type: Direct (D) or Indirect (I) discharge. Point Source (P) or Nonpoint Source (N)
Receptor: e.g., surface water body. POTW, deep well. French drain, retention/settling pond
Applicable Limitations/Standards: e.g., nature of permits, compliance orders/agreements. POTW regulations,
sewer use ordinances, pre-treatment standards, etc.
Length of Piping: Length of facility-maintained piping from source to receptor
Conformance with Applicable Limitations/Standards: During preceding twelve-month period and likely future
conformance
Location:.
Prepared by:
Date:
A15-9
-------
Appendix 15-10: Inventory of Existing and Former Underground Storage Tanks
Tank
Identification
Type
Contents
. • •
Capacity
Age
Materials of
Construction
Tank
Piping
Date Last
Leak
Tested
and
Method
Containment
Type of
Leak '
Detection
Type: e.g., product storage tank; sump; pipe; oil/water separator; process tanks; septic tanks, if more than 10% of
volume is below the surface
Location:
Prepared by:
Date:
A1S-10
-------
Phase 1
Section 16
Environmental Radiation Protection
-------
Table of Contents
Section 16
Environmental Radiation Protection
A. Applicability 16-1
B.1 Federal Legislation 16-1
C. State/Local Regulations 16-2
D. Key Compliance Requirements 16-3
E. Key Compliance Definitions 16-4
F. Records to Review 16-7
G. Physical Features to Inspect 16-7
H. Guidance for Checklist Users : 16-7
-------
A. Applicability
This section applies to Federal facilities that use, possess, store, and dispose of radioactive
materials. This section and its associated checklists address activities associated with Federal
research and development laboratories, hospitals, and other facilities where radioactive
material is used, stored, and disposed. Not all checklist items will be applicable to a facility.
Guidance is provided on the checklists to direct the assessor to the regulations concerning the
radioactive material use, storage, and disposal activities at the facility. Information regarding
radioactive waste that also contains a hazardous'waste subject to the requirements of the
Resource Conservation and Recovery Act (RCRA), Subtitle C, are included in the Hazardous
Waste Management checklist.
Assessors are required to review the Federal facility's Radiation Protection Program,
Radioactive Material License and license application, and state and local regulations in order
to perform a comprehensive assessment.
B. Federal Legislation
1. The Atomic Energy Act of 1954, as Amended
This Act established the Nuclear Regulatory Commission (NRC) and empowered the NRC to
regulate the use, possession, storage and disposal of source material, byproduct material and
special nuclear material. Also under the authority of the Atomic Energy Act of 1954, the
NRC has promulgated regulations regarding the packaging of radioactive material for
transport.
2. The Low-Level Radioactive Waste Policy Amendments Act of 1985
This Act required states to establish their own capability for disposal of low-level radioactive
waste generated within their borders.
3. The Federal Water Pollution Control Act
Commonly known as the Clean Water Act (CWA), this is the primary federal statute designed
to "restore and maintain the chemical, physical, and biological integrity" of the Nation's
navigable waterways. The EPA and authorized states regulate point sources of pollutants
through the National Pollutant Discharge Elimination System (NPDES) Permit Program.
4. The Radon Program Development Act of 1987
This Act requires studies to be conducted to determine the extent of radon contamination in
buildings owned by the Department of the Interior, the Department of Agriculture, the
General Services Administration, and the Veterans' Administration, including radon
Phase 1 - Section 16
Environmental Radiation Protection
16-1
-------
contamination of water for Federal buildings using a nonpublic water source (such as a well
or other groundwater). Radon checklist items can be found in the protocol, "Air Pollution
Control" - Section 1.
5. The Safe Drinking Water Act
This Act establishes requirements for sampling drinking water sources for radioactivity.
6. Hazardous Substance Release Reporting
Under CERCLA Section 103, facilities are required to notify the National Response Center
(NRC) immediately if it releases hazardous substances in excess of or equal to reportable
quantities. Facilities with continuous and stable releases have limited notification requirements
(40 CFR 302.1 through 302.6, and 302.8).
7. The National Environmental Policy Act (NEPA)
The purpose of this Act (42 U.S. Code (USC) 4321-4370c), as last amended in November
1990, is to declare and implement a national policy to prevent or eliminate damage to the
environment and biosphere, and stimulate the health and welfare of man (42 USC 4321). Its
underlying intent is to encourage productive and enjoyable harmony between man and his
environment. Under NEPA, the continuing policy of the federal government is to use all
practicable planning, policy, and regulatory means and measures in a manner calculated to
foster and promote the general welfare, and to create and maintain conditions under which
man and nature can exist in productive harmony, and fulfill the social, economic, and other
needs of present and future generations of Americans [42 USC 4331 (a)]. Under NEPA and
related laws, it is the continuing responsibility of the federal government to manage, monitor,
and preserve the important historic, cultural, and natural aspects of our national heritage (42
USC 4331(b)(4)).
C. State/Local Regulations
Many states have met the U.S. Nuclear Regulatory Commission's requirements for
establishing a state agency and management system to regulate users of radioactive material,
and have been granted Agreement State status. Agreement states have promulgated
regulations identical to the NRC, and in some instances, have promulgated regulations that are
more restrictive than those of the NRC. Since differences might exist between regulations of
an Agreement State and the NRC, the assessor must review the regulations of the Agreement
State to ensure that additional restrictions are included in the scope of the assessment and
added to this checklist.
Phase 1 • Section 16
Environmental Radiation Protection
16-2
-------
D. Key Compliance Requirements
1. License Requirements
In order for Federal facilities to possess, use, store, and dispose of radioactive materials, the
facility must obtain a license from the NRG As part of the licensing process, the facility
must submit an application describing the contents of a Radiation Protection Program
designed to ensure that activities meet the regulations of the NRC or Agreement State.
Specific conditions stated in the license imposed by the NRC, and information presented in
the application for the license are enforceable.
2. Radioactivity in Liquid Discharge Requirements
Under the Clean Water Act, discharges of radioactive material cannot exceed specific
quantities specified in a NPDES Permit. In addition, radionuclide discharges to the sanitary
sewer must meet certain discharge limitations presented in Appendix B, Table II of 10 CFR
Part 20.
3. Air Effluent Discharge Requirements
Under the Clean Air Act, the National Emission Standards for Hazardous Air Pollutants
(NESHAPS) requirements specify that discharges of radioactivity in airborne effluents must
not result in an annual effective dose equivalent exceeding 10 millirem to the public for the
airborne pathway. Additionally, airborne effluents containing radioactivity measured at the
point of discharge cannot exceed specific concentrations presented in 10 CFR Part 20
Appendix B, Table Q.
4. Radioactive Waste Management Requirements
Radioactive wastes must be segregated, stored and disposed of according to specific
requirements of the NRC and the state.
5. Decommissioning Funding Plan
Facilities that use, possess, store, and dispose of radioactive materials must establish a
financial instrument to ensure the decontamination and decommissioning of affected facilities.
The facility can establish a bond by either developing a detailed cost estimate for the
decontamination and decommissioning of affected facilities and submitting to the NRC for
approval, or by establishing a bond of predetermined value based on the possession limits
stated in the facility's NRC license.
6. Dose to the Public Requirements
The facility must demonstrate that the radiological dose to the public from activities and
releases to the environment of radioactive materials does not exceed specific values.
Phase 1 - Section 16
Environmental Radiation Protection
16-3
-------
E. Key Compliance Definitions
(NOTE: Definitions taken from "The Health Physics and Radiological Health Handbook",
Revised Edition, Scinta, Inc., 1992.)
1. Agreement State
Any State with which the U.S. Nuclear Regulatory Commission or the U.S. Atomic Energy
Commission has entered into an effective agreement under subsection 274b. of the Atomic
Energy Act of 1954, as amended (73 Stat. 689).
2. ALARA
Acronym for "as low as is reasonably achievable." Making every reasonable effort to
maintain exposures to radiation as far below the dose limits as is practical consistent with the
purpose for which the licensed activity is undertaken, taking into account the state of
technology, the economics of improvements in relation to state of technology, the economics
of improvements in relation to benefits to the public health and safety, and other societal and
socioeconomic considerations, and in relation to utilization of nuclear energy and licensed
materials in the public interest.
3. Annual Limit on Intake (AU)
The derived limit for the amount of radioactive material taken into the body of an adult
worker by inhalation or ingestion in a year. ALI is the smaller value of intake of a given '
radionuclide in a year by the reference man that would result in a committed effective dose
equivalent of 5 reins (0.05 Sv) or a committed dose equivalent of 50 reins (0.5 Sv) to any
individual organ or tissue.
4. Background Radiation
Radiation from cosmic sources; naturally occurring radioactive materials, including radon
(except as a decay product of source or special nuclear material) and global fallout as it exists
in the environment from the testing of nuclear explosive devices. Background radiation does
not include- radiation from source, byproduct, or special nuclear materials.
5. Becquerel
A unit, in the International System of Units (SI) of measurement, of radioactivity equal to one
transformation per second.
6. Byproduct Material
(I) Any radioactive material (except special nuclear material) yielded in, or made radioactive
by, exposure to the radiation incident to the process of producing or. utilizing special nuclear
material; and (2) The tailings or wastes produced by the extraction or concentration of
Phase 1 - Section 16
Environmental Radiation Protection
16-4
-------
uranium or thorium from ore processed primarily for its source material content, including
discrete surface wastes resulting from uranium solution extraction processes. Underground
are bodies depleted by these solution extraction operations do not constitute byproduct
material within this definition.
7. Curie
The basic unit used to describe the intensity of radioactivity in a sample of .material. The
curie is equal to 37 billion disintegrations per second, which is approximately the rate of
decay of 1 gram of radium. A curie is also a quantity of any radionuclide that decays at a
rate of 37 billion disintegrations per second. Named for Marie and Pierre Curie, who
discovered radium in 1898.
8. Decontamination
The reduction or removal of contaminating radioactive material from a structure, area, object,
or person. Decontamination may be accomplished by (1) treating the surface to remove or
decrease the contamination; (2) letting the material stand so that the radioactivity is decreased
as a result of natural decay; and (3) covering the contamination to shield or attenuate the
radiation emitted.
9. Dose Equivalent
The product of the absorbed dose in tissue, quality factor, and all other necessary modifying
factors at the location of interest. The units of dose equivalent are the rem and sievert (Sv).
The ICRP defines this as the .equivalent dose.
10. Effective Dose Equivalent
The sum of the products of the dose equivalent to the organ or tissue (HT) and the weighing
factors (WT) applicable to each of the body organs or tissues that are irradiated (HE =
ZWTHT). The ICRP defines this as the effective dose.
11. Half-life
The time in which half the- atoms of a particular radioactive substance disintegrate to another
nuclear form. Measured half-lives vary from millionths of a second to billions of years. Also
called physical half-life.
12. Hlgh-Level Radioactive Waste
(1) Irradiated reactor fuel, (2) liquid wastes resulting from the operation of the first cycle
solvent extraction system, or equivalent, and the concentrated wastes from subsequent
extraction cycles, or equivalent, in a facility for reprocessing irradiated reactor fuel, and (3)
solids into which such liquid wastes have been converted.
Phase 1 - Section 16
Environmental Radiation Protection
16-5
-------
13. Low-Level Radioactive Waste
Radioactive waste not classified as high-level radioactive waste, transuranic waste, spent
nuclear fuel, or byproduct material.
14. Member of the Public
An individual in a controlled or unrestricted area. However, an individual is not a member of
the public during any period in which the individual receives an occupational dose.
15. Occupational Dose
The dose received by an individual in a restricted area or in the course of employment in
which the individual's assigned duties involve exposure to radiation and to radioactive
material from licensed and unlicensed sources of radiation, whether in the possession of the
licensee or other person. Occupational dose does not include dose received from background
radiation, as a patient from medical practices, from voluntary participation in medical research
programs, or as a member of the general public.
16. Transuranic Waste
Material contaminated with elements that have an atomic number greater than 92, including
neptunium, plutonium, americium, and curium, and that are in concentrations greater than 10
nanocuries per gram, or in such other concentrations as the Nuclear Regulatory Commission
may prescribe to protect the public health and safety.
Phase 1 - Section 16
Environmental Radiation Protection
-------
F. Records to Review
• NRC License
• License application
• Radioactive material inventory
• Records of radioactive material quantities discharged via the sanitary sewer
• Radioactive material receiving procedures
• NESHAP compliance documentation
• Radioactive waste shipping manifests
• Decommissioning funding plan
• Previous audits and inspections
G. Physical Features to Inspect
• Laboratories
• Radioactive waste storage areas
• Radioactive material storage areas
H. Guidance for Checklist Users
Refer To
Checklist terns
Pag»Nimbti*
All facilities
ER.1 through ER.10
16-8
Phase 1 - Sectjon 16
Environmental Radiation Protection
16-7
-------
Compliance Category:
pnvtronmental Radiation PratBctlon
Regulatory Raquto
itt
Reviewer Checks:
ER.4. The NPDES program as
contained in 40 CFR 122.1
requires permits for the
discharge of •pollutants" from
any 'point source* into
•waters of the Untied States.'
The terms •pollutant.* 'point
source," and "waters of the
United States' are defined in 40
CFR 122.2. Requirements for
NPDES permits for storm water
discharges associated with
industrial activity are contained
in 40 CFR 122.26.
Determine whether radionuclide discharge limitations are specified by the Federal
facility's discharge permit.
Verity whether radionuclide discharge limitations, if any, are met.
(Specific requirements regarding implementation of the NPDES program are
addressed in the Water Pollution Control checklist.)
ER.5. Federal facilities
releasing radionuclides into the
sanitary sewer must ensure that
discharge limitations are not
exceeded, and must maintain
records of such releases (10
CFR 20.2003. 20.2103(b)(4)).
Determine whether the Federal facility releases radionuclides into the sanitary sewer
for disposal.
Verify that the facility only disposes of material that is readily soluble, or is readily
disposable biological material, in water.
Verify that the facility maintains records of radionuclides disposed by releasing into
the sanitary sewer.
Verify that the quantity of licensed or other radioactive material released by the
Federal facility into the sanitary sewer in one month divided by the average monthly
volume of water released into the sewer by the facility by the facility does not exceed
the concentration listed in table 3 of Appendix B to 10 CFR Part 20.
Verify that the total quantity of licensed and other radioactive material released into
the sanitary sewer in a year does not exceed 5 Ci of H-3,1 Ci of C-14, and 1 Ci of all
others combined.
ER.6. Federal facilities must
evaluate the potential for
radionuclide emissions tn
airborne effluents, and
demonstrate that the annual
effective dose equivalent for
members of the public does not
exceed 10 million for the
airborne pathway (40 CFR 61
Subpart I).
Verify that the Federal facility has evaluated the potential for releases of radionuclides
via airborne effluents using the COMPLY code.
Verify, if necessary, that the Federal facility has used the AIRDOS-PC or similar EPA
approved computer code to demonstrate that the annual effective dose equivalent to
the public does not exceed 10 million, and submitted the required reports.
Verify that the facility has documented the AIRDOS-PC input parameters, with
justification for those used.
Phase 1 - Section 16
Environmental Radiation Protection
16-9
-------
Compliance Category:
Environmental Radiation Protection
Regulatory Requirements:
Reviewer Checks;
All Facilities
ER.1. The current status of any
ongoing or unresolved Consent
Orders, Compliance
Agreements. Notices of
Violation (NOV). Interagency
Agreements, or equivalent state
enforcement actions is required
to be examined. (A finding
under this checklist item will
have the enforcement
action/identifying information as
the citation.)
Determine if noncompliance issues have been resolved by reviewing a copy of the
previous report. Consent Orders, Compliance Agreements, NOVs. Interagency
agreements or equivalent State enforcement actions.
For those items, indicate what corrective actions are planned and milestones
established to correct problems.
ER.2. Federal facilities are
required to comply with all
applicable Federal regulatory
requirements not contained in
this checklist. (A finding under
this checklist item will have the
citation of the applied regulation
as the citation.)
Determine if any new regulations have been issued since the finalization of this
checklist. If so, annotate checklist to include new standards.
Determine if the Federal facility has activities or facilities which are Federally
regulated, but not addressed in this checklist.
Verify that the Federal facility is in compliance with all applicable and newly issued
regulations.
ER.3. Federal facilities must
meet the requirements provided
in a NRC or Agreement State
issued license for the use,
possession, storage, and
disposal of by-product
materials. Radionuclides,
quantities, and activities
requiring a license are
presented in 10 CFR Part 30
through 35, and 39 or the
equivalent Agreement State
regulations.
Verify that the Federal facility possesses or is operating under a license issued by
NRC or Agreement State where licensable quantities of by-product materials are
used, stored, or disposed.
Phase 1 - Section 16
Environmental Radiation Protection
16-8
-------
Compnanoi Category: ^^^
cftVuonrnwitBi nftdution Protection
Revtewvf CTMCNK
ER.7. Federal facilities must
ensure that the annual average
concentration of radioactive
materials released in gaseous
effluents at the boundary of an
unrestricted area do not exceed
the values specified in table 2
of Appendix B in 10 CFR Part
20.
Verify whether the Federal facility has evaluated releases of radioactive materials and
demonstrated that the concentration does not exceed specified values at the
boundary to unrestricted areas.
Verify whether the techniques used to estimate releases and calculate concentrations
at the boundary to unrestricted areas are appropriate.
Verify whether effluent air sampling techniques used to demonstrate compliance with
the specified limits are performed in accordance with appropriate methodologies (e.g..
ANSI N42.18, ANSI N13.1, Regulatory Guide 8.25).
ER.8. Federal facilities that
generate radioactive waste
must dispose of licensed
material only by transfer to an
authorized recipient, by decay
in-storage. or by release in
effluents (10 CFR Part 20
Subpart K).
Verify whether the Federal facility has identified all radioactive waste streams and that
all liquid wastes disposed of by the sanitary sewer meet the requirements specified in
ER.5., and gaseous effluents meet the requirements specified in ER.7.
Verify whether the Federal facility is licensed to perform decay-in-storage as a means
of disposing of radioactive waste and that all conditions specified in the license
regarding decay-in-storage are met.
Verify that the Federal facility transfers all other radioactive wastes regarding land
disposal to an authorized recipient, and follows all of the recipient's manifesting and
labeling requirements.
ER.9. Federal facilities are
required to develop a
Decommissioning Funding Plan
and file a Statement of Intent
with the NRC or Agreement
State to ensure for
decontamination and
decommissioning of facilities
(10 CFR 30.35. 40.36, 70.25).
Verify the Federal facility has developed a decommissioning cost estimate based on
their Radioactive Material License's possession limits and the extent of the use of
their facilities.
Verify that the Federal facilities have filed a Statement of Intent with the NRC or
Agreement State which states that the funds will be budgeted as needed.
Verify that'the decommissioning cost estimate is reviewed and updated, as significant
changes occur (e.g., change in extent of facility use or addition of radionuchdes. to
the Radioactive Material License) or at least every five years upon renewal.
ER.10. Federal facilities that
possess radioactive material
must conduct operations such
that the annual total effective
dose equivalent to a member of
the public does not exceed 100
millirem, and conduct surveys
of radiation levels and
radioactive materials in effluents
to demonstrate compliance with
the dose limit to the public (10
CFR Part 20, Subpart D).
Verify that the Federal facility has demonstrated that areas where radioactive
materials are used, stored, received, and held for disposal, the radiation levels in
unrestricted areas do not exceed 2 millirem per hour and/or 50 millirem per year.
Verify that the Federal facility has measured or has a system in place to determine
the concentration of radioactive materials disposed of In gaseous and liquid effluents
and that they do not exceed the values listed in 10 CFR Part 20, Appendix B, Table 3
at the boundary to unrestricted areas. (SeeER.2.).
Phase 1 - Section 16
Environmental Radiation Protection
16-10
-------
Phase 2
Assessing the Effectiveness of Specific
Environmental Programs
-------
Table of Contents
Phase 2
Introduction to Assessing the Effectiveness of Specific Environmental Programs
A. Purpose
B. Scope and Format
C. Approach
Protocol Disciplines for Specific Environmental Management Programs
Section 17 Air Pollution Control Systems
Section 18 Water Pollution Control Systems
Section 19 Non Hazardous Waste Management Systems
Section 20 Hazardous Waste Management Systems
Section 21 CERCLA/SARA Management Systems
Section 22 Spill Control and Response Systems
Section 23 Management of Environmental Impacts Systems
Section 24 Hazardous Materials Management Systems
Section 25 Emergency Planning and Community Right to 'Know
Section 26 Cultural and Historic Resources
Section 27 StorageTank Systems
Section 28 Drinking Water Systems
Section 29 PCB Management Systems
Section 30 Pesticides Management Systems
Section 31 Groundwater Protection Systems
Section 32 Environmental Radiation Systems
Appendix - Pollution Prevention Assessment Guide
-------
Introduction
A. Purpose
i1
The primary purpose of a Specific Environmental Discipline Management Systems
Assessment is to provide the Federal facility concise information pertaining to:
• Strengths and weaknesses of program, specific environmental management systems;
• Adherence with program specific Best Management Practices;
• Compliance with agency policies and directives; and
• Identification of underlying causal factors/root causes of compliance deficiencies.
Also, these assessments are also intended to provide Federal facilities feedback on the
effectiveness of their program specific environmental management systems, identify
opportunities for improvement, and benchmark their performance.
B. Scope and Format
The scope of a Specific Environmental Discipline Management System Assessment includes
all of the 16 environmental programs found in Phase 1. Unlike Phase 1, where the status of
environmental compliance is the focal point, Phase 2 centers on reviewing the design and
implementation of the management systems for specific environmental disciplines established
to ensure that compliance obligations are met. Phase 2 consists of 16 sections which mirror
the same environmental disciplines which are found in Phase 1. Each of the 16 programs
within Phase 2 contain key characteristics and elements of effective environmental .
management systems. The 16 disciplines are:
Section 1 Air Pollution Control
Section 2 Water Pollution Control
Section 3 Nonhazardous Waste Management
Section 4 Hazardous Waste Management
Section 5 CERCLA/SARA
Section 6 Spill Control and Response
Section 7 Management of Environmental Impacts (i.e., NEPA, and NEPA components
such on FONSIf As, EISs, etc.)
Section 8 Hazardous Materials Management
Section 9 Emergency Planning and Community Right to Know
Section 10 Cultural and Historic Resources Management
Section 11 Storage Tank Management
Management Systems Assessments Phase 2 - Introduction
i
-------
Section 12 Drinking- Water Management
Section 13 PCB Management
Section 14 Pesticides Management
Section 15 Groundwater Protection
Section 16 Environmental Radiation
Within each of the 16 disciplines are program elements based on key characteristics of
effective environmental management systems as well as an eighth area devoted to Pollution
Prevention. Pollution Prevention is recognized in the Federal Community as a key strategic
initiative to address compliance issues. The following eight disciplines can be used to form an
effective management system:
Organizational Structure
Environmental Commitment
Formality of Environmental Programs
Internal and External Communication
Staff Resources, Training, and Development
Program Evaluation, Reporting, and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
Although a pollution prevention subsection can be found at the end of each of the 16 sections
of Phase 2, a separate appendix on this topic has been added. The appendix details
organizational and technical issues related to pollution prevention programs management and
can serve as a tool for the assessment of a facility's pollution prevention management
activities based on best management practices and relevant executive orders outlining
regulatory guidelines. It contains suggestions or ideas which can serve to enhance a facility's
efforts in managing pollution prevention programs.
Phase 2 is designed for environmental auditors in specific technical disciplines to concentrate
solely upon the management systems supporting a specific environmental program such as the
hazardous waste management or air pollution control program. Each Phase 2 section focuses
upon a "programmatic evaluation" in which the auditor assesses the effectiveness of the
management systems supporting the individual environmental program. As such, a single
auditor could design an evaluation which takes either a representative or a comprehensive
look at the management systems.
Additionally, each Phase 2 section can be used in conjunction with the appropriate Phase 1
section to conduct a joint compliance and programmatic evaluation. Where appropriate,
elements within each Phase 2 section contain specific examples to help guide the auditor in
an evaluation of the specific environmental program.
Management Systems Assessments Phase 2 - Introduction
2
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C. Approach
In assessing environmental management systems for specific programs, the intent is to
evaluate these systems to determine whether they effectively meet the performance objectives
listed in each discipline and whether they have sufficient structure and formality to assure that
activities are conducted in a manner that will guarantee (or exceed) compliance with
environmental regulations and agency policies.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
Management Systems Assessments Phase 2 - Introduction
. 3
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Phase 2
Section 17
Assessing Effectiveness of Air Pollution Control
Program Management
-------
Table of Contents
Section 17
Air Pollution Control
Introduction to Management Systems Assessments 17-1
A. Purpose 17-1
B. Scope 17-1
C. Approach ' 17-2
D. Understanding Management Systems 17-2
1. Organizational Structure . 17-5
A. Management Organization 17-5
B. Roles and Responsibilities . 17-6
2. Environmental Commitment 17-8
A. Top Management Support 17-8
B. Environmental Policy 17-9
C. Line Management Support 17-9
3. Formality of Air Pollution Control Management Program 17-10
A. Regulatory Tracking and Translation 17-10
B. Procedures 17-11
C. Routine Inspections 17-13
D. Recordkeeping and Reporting 17-13
4. Internal and External Communication 17-16
A. Internal Communication 17-16
B. External Communication 17-17
5. Staff Resources, Training, and Development • 17-18
A. Staffing 17-18
B. Job Descriptions and Performance Evaluations 17-19
C. Training Programs 17-19
6. Program Evaluation, Reporting and Corrective Action 17-21
A. Self-Assessment and Appraisal System 17-21
B. Reporting and Follow-up 17-22
7. Environmental Planning and Risk Management 17-23
* A. Environmental Planning and Risk Management 17-23
8. Pollution Prevention 17-24
A. Pollution Prevention Goals 17-24
B. Pollution Prevention Plan 17-24
C. Pollution Prevention Funding 17-25
D. Pollution Prevention Tracking 17-25
E. Pollution Prevention Training 17-25
F. Pollution Prevention Considerations 17-26
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Introduction
A. Purpose
The primary puipose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Actipn
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. 'Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies.
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, air pollution control) will allow the auditor
to obtain an understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., hazardous waste storage areas), the auditor often must talk with other
personnel. This win enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g., air
emergency episode plan, emissions inventory). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
• State and local air pollution control regulations
• Emissions inventory
• All air pollution source permits
• Plans and procedures applicable to air pollution control
• Emission monitoring records
• Opacity records
• Notices of violations (NOVs) from regulatory agencies
• Instrument calibration and maintenance records
• Reports/complaints concerning air quality/odors
• Air emergency episode plan
• State and/or Federal regulatory inspections
• Regulatory inspection reports
• Documentation of preventative measures or actions
• Results of air sampling at the conclusion of response action
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• All air pollution sources (fuel burners, incinerators, VOC sources, heat/steam/energy
production units, firing ranges, tank farms, etc.)
• Air pollution monitoring and control devices
• Air emission stacks
• Air intake vents
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records .or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
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a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central Hie or are they in 250 individual employees'
files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's air pollution control management function is organized.
Determine if the air pollution control management function is characterized by clear lines
of authority and responsibility. For example:
r
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the air pollution control management function and determine
who:
I) Establishes and enforces facility-wide air pollution control programs, policies, and
procedures/practices;
2) Provides air pollution control oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
b. Determine who the air pollution control manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2). Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the air pollution control manager
and person responsible for overall environmental management are open and
effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequently do they talk, etc.).
c. Determine which departments) and individual(s) have authority and
responsibility/accountability for various air pollution control management activities.
For example, determine through interviews and document review who is responsible
for inventorying air emissions, air permitting, monitoring air emissions, process
redesign, maintaining air pollution control equipment, (Linkage with l.B. Roles and
Responsibilities).
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2. Determine if air pollution control managers have sufficient authority to effectively
implement air pollution control programs and to make decisions related to environmental
protection. Interview the air pollution control manager and other air pollution control
personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with air pollution control and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility);
b. Determine who is responsible for approving specific air pollution control projects or
activities and if those personnel have the appropriate background/authority to approve
. these projects; and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for'overall
air pollution control management, who is responsible and accountable for air pollution
control activities, including, but not limited to permitting, monitoring, equipment
maintenance, process redesign, recordkeeping and reporting, etc.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for air pollution control management match those in program manuals
or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the air pollution control functions specified in their job
descriptions?).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall air pollution control management, and determine if this
reporting relationship is clearly and formally defined and understood.
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes air pollution control policy, procedures, and standards;
2) Provides air pollution control oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency air pollution control
policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate air pollution control management responsibilities are defined and are
included in their written performance appraisal.
a. Interview a selection of air pollution control management personnel to determine if
there is accountability for their environmental performance (e.g., if their air pollution
control management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding air
pollution control management performance or reprimands for failure to cany out air
pollution control management responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
air pollution control management, and the facility manager, if top management has
supported air pollution control programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire air pollution control
equipment or redesign chemical processes to reduce toxic air emissions.
1) If financial, technical, and personnel resources are adequate to manage the volume
and toxicity of air emissions at the facility.
b. Whether top management has a .clear set of goals and expectations regarding air
pollution control performance and what they are (e.g., environmental compliance as a
minimum expectation, goals that go beyond compliance, emissions reductions).
2. Review air pollution control management documentation and identify how senior
management communicates its air pollution control goals and expectations to employees;
and, typically, how frequently the goals are communicated. For example, review the
facility's air pollution control mission statements, policies, procedures, orders, directives,
standard operating procedures, etc., and ascertain if they clearly communicate air pollution
control goals.
a. Interview a sample of operating and air pollution control personnel (e.g., engineers,
incinerator operator) to determine if they understand the facility air pollution control
policies, goals, etc.
3. Interview air pollution control management personnel and understand what types of air •
pollution control reports are routinely and periodically provided to top management
a Determine if emissions inventories, toxic release inventories, emission monitoring
records, inspection reports, occurrence/accident reports, etc., are routinely prepared for
top management and to what extent they address the facility's air pollution control
status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of air
pollution control reports or if reports are prepared for "information only."
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B. Environmental Policy
1. Determine through interviews, what air pollution control policies are widely distributed
and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., air pollution
control manager/inspector, environmental manager, line managers, facility manager, etc.)
whose activities may impact air pollution control performance to determine if they take
responsibility and interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in air pollution control
management. Specifically, do they:
1) Routinely observe field level air pollution compliance activities?
2) Participate in audits and self-assessments?
i
3) Write and review air pollution control procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to air pollution control,
line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences involving air emissions.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support air pollution control activities and how they integrate air pollution
control management into the facility operations. For example, do they observe compliance
activities, conduct self-assessments, train employees, etc.
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3. Formality of Air Pollution Control Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging air pollution control
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of air pollution control regulations, and if there
is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging air pollution
control regulations and trends (e.g., BNA, Federal Register updates, professional
societies, contact with regulator/officials, subscriptions to professional publications
related to air pollution control).
c. Determine how new air pollution control regulations are interpreted as to their
applicability and by whom (e.g., air pollution control specialist/manager, legal
department).
d. Note the availability of air pollution control regulatory reference material (for
example, currency of subscription to BNA, automated access via software, CFRs.
Federal and State Registers, state regulations, technical books, and other reference
materials relating to air pollution control management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to air pollution
control program manuals, training courses). Interview selected operating personnel to
obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new air pollution control
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update air
pollution control management programs and procedures to reflect changes in
regulatory requirements, such as new state permitting programs, trip reduction
programs, revised emission limitations, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
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a. Determine how and in what form air pollution control regulatory information is
transmitted to the facility.
b. Interview staff, if any, responsible for regulatory updates to determine whether the
necessary department/people learn of the developments with sufficient lead time to
take appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing air
pollution control programs, policies, and procedures. Note the frequency that air pollution
control programs, policies, and procedures are updated/new ones developed, how often
they are reviewed, and who approves them. Determine if there is a formal system in place
to update air pollution control management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's air pollution control programs, policies, and procedures. Determine their level
of experience and comment on the appropriateness of these individuals to perform
such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new air pollution control regulatory requirement and determine whether a
new procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
air pollution control management policies, programs, or procedures, whether the
organization has a program (e.g., written procedures) for the management of its air
emissions, including, but not limited to:
a. Identification and inventorying of air emissions and sources of air emissions;
b. Permitting of air emission sources;
c. Sampling and monitoring;
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d. Instrument calibration and maintenance;
e. Development, implementation, and review of air episode plans:
f. Procedures for reducing toxic air emissions (e.g., SARA Section 313 chemicals);
g. Procedures of management of specific air emission sources (e.g., incinerators,
VOC/chemical storage tanks, etc.);
h. Reporting permit exceedances to regulatory agencies;
i. Pollution prevention; and
j. Corrective actions to identified problem(s).
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current air
pollution control procedures relevant to their job function. For example, are they easily
accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of air pollution control procedures.
5. Determine whether applicable air pollution control management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
6. Determine if air pollution control management procedures such as those listed above are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review/update.
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C. Routine Inspections
1. Interview the environmental and air pollution control managers and air pollution control
specialists to determine if the facility has a program for routine site and equipment
inspections and compliance checks, including appropriate documentation relating to air
pollution control activities. Specifically, determine if the facility regularly determines
compliance with legal and regulatory requirements such as:'
a. Air emission limitations;
b. Monitoring equipment maintenance and calibration; and
c. Air pollution control equipment maintenance.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
•
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
b. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Air Pollution Control
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of air pollution control activities.
a. Develop an understanding of all systems that are in place for air pollution control
recordkeeping and document control (e.g., does the facility maintain a log or database
of types and sources of air emissions, inspection logs, opacity records, notices of
violations [NOVs] from regulatory agencies, reports/complaints concerning air quality,
•
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air emergency episode plan, results of air sampling, etc.). For example, understand the
systems for:
1) Tracking of key regulatory schedules (e.g., permit renewals, report submissions,
required training);
2) Maintenance of compliance records; and
3) Preparation and submission of required reports (e.g., emissions inventory, NSPS
and NESHAP reports, incinerator reports, exceedance reports, etc.).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
air pollution control records. Determine whether the files are complete, current, and
readily accessible.
c. Determine how the facility ensures that required air pollution control
reports/notifications are routinely prepared and submitted to the appropriate regulatory
agencies in a timely manner. Through interviews with the environmental manager,
identify the person(s) responsible for regulatory reporting and through interviews with
them determine if they have appropriate experience/training to effectively report on air
pollution control activities. Types of reports/notifications include:
1) Notification of new source startup;
2) Exceedance reports; and
3) CERCLA/SARA notification for spills/releases in excess of "reportable quantity".
d. Interview the air pollution controf manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
CAA compliance and other related environmental information. (For example, the
facility may choose to maintain records indefinitely, rather than for the time period
specified in the regulations.)
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities).
c. Verify that the facility maintains air pollution control records for the retention periods
specified by regulation.
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3. Determine how the facility investigates, reports, corrects, tracks, and monitors air
pollution control problems and "incidents" (for example, toxic air releases, permit
exceedances). Interview air pollution control personnel and review procedures to
determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and air pollution control managers, and review internal
memos, newsletters, etc., to understand how environmental information related to the
facility's air emissions is communicated. For example, is air pollution control information
(e.g., incidents, TRI releases) regularly communicated formally or informally throughout
the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover air pollution control issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of air pollution control directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of air pollution control information is
communicated to management:
1) Routine environmental status information;
2) New air pollution control regulations;
3) Incident or major issue information; and
4) Controversial air issues.
b. Determine how quickly new air pollution control requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to air pollution control/air emissions.
a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to air pollution
control. For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the air pollution control status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's air emissions (e.g., odor,
opacity complaints) have been received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
air pollution control management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of air pollution control staff to
determine if staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced air pollution control management staff
• to assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview air pollution control management personnel and review their job descriptions
and applicable regulations to determine what qualifications are necessary for staffing and
other positions with responsibilities (e.g., air pollution specialists, air pollution control
managers).
a. Determine if personnel with air pollution control management responsibilities have the
relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in air pollution control management;
2) Relevant air pollution control work; and
3) Continuing education programs.
3. Based on. the information gathered (interviews, document review, your understanding of
the complexity of air issues at the facility) conclude as to the quality and quantity of air
pollution control personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for air pollution control management staff
(including line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
' b. If appropriate job descriptions are established and maintained for air pollution control
management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if air pollution control management performance
is regularly included in the performance review process.
3. Interview a sample of air pollution control staff (e.g., process engineers, incinerator
9perator, air pollution control specialists) to confirm that they are evaluated on how well
they perform their air pollution control management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing air
pollution control training programs) to determine if the facility has identified specialized
air pollution control training requirements (based on regulatory requirements,
types/volumes of air emissions).
r
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate air pollution control training needs for
all relevant personnel who work with equipment/sources/chemicals that emit air
pollutants?
3) How does the facility ensure that air pollution control training courses are
completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Air emergency episode plan implementation (emergency procedures, equipment, and
systems);
b. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
c. Operation of communications and alarm systems;
d. Response to fire or explosion;
e. Response to leaks or spills;
f. Identification of new air sources;
g. Personnel health and safety and fire safety; and
h. Shutdown procedures.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and air pollution control managers and reviewing air
pollution control program documentation, determine if the facility conducts air pollution
control self-assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all air issues at each self-assessment/appraisal or cover only one topic at a time
(e.g., NSPS, NESHAPs, permits);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies" and track/monitor corrective
actions.
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address air pollution control issues relevant to the
facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessraents/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for air pollution control management performance.
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact air pollution control
management (for example, projects, programs, or activities that may increase the volume
or toxicity of air emissions, require additional personnel or equipment to handle the air
emissions adequately) are carefully reviewed to identify and address environmental,
health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and air pollution
control managers, and a review of project planning documentation, comment on how the
facility balances environmental concerns against production/operational demands when
reviewing proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of air emissions is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of air pollution control management personnel to determine if
they understand the facility goal with regard to pollution prevention/waste
minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to E.O. 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g.. are process redesign, recovery/reuse
systems, product substitution, etc., being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities, and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and .document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submission with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856?
b. Determine if top management receives updates on the facility's pollution prevention
progress.
c. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with air pollution control management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention opportunities. Programs could include seminars, pollution prevention
newsletters, annual training courses, inclusion in environmental meeting agendas, etc.
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F. Pollution Prevention Considerations
1. Based on your understanding of the facility operations and types and volumes of air
emissions, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities. Types of pollution prevention
initiatives may include the following (Linkage with Phase 1 - Section 3 Waste
Minimization Plan):
a. Does the facility employ solvent emissions reduction techniques to limit solvent
emissions due to dragout such as:
1) Withdrawing parts after they have stopped dripping,
2) Holding parts in freeboard zones until they are completely dry, and
3) Using holding fixtures that promote better drainage?
b. Does the facility reduce solvent emissions due to diffusion by:
1) Adding freeboard height to degreasers, and
2) Keeping an idling degreaser covered?
c. Has the facility reduced the use of aerosols where possible and minimized the solvent
emissions due to use of sprays such as:
1) Keeping sprays at temperatures near the boiling point and avoiding cold sprays in
vapor degreasers,
2) Keeping the spray nozzle below the cooling coils, and
3) Using short spray bursts?
d. Has the facility checked joints, connectors and seals in solvent systems with a halon
detector to prevent leakage?
e. Has the facility installed a freeboard refrigeration system for vapor cleaners to reduce
solvent loss to ambient air?
f. Has the facility reduced the air flow around solvent units to reduce solvents loss due
to external drafts?
g. Does the facility substitute sulfite sulfur recovery process for Beavon process to avoid
generation of spent Stretford solution which contains vanadium?
h. Does the facility use floating roofs on wastewater treatment tanks and drains to reduce
air emissions?
i. Does the facility use pressurized air in flotation (wastewater treatment) to reduce air
emissions?
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j. Has the facility consolidated and centralized cold solvent cleaning operations to
prevent vapor loss?
k. Has the facility trained paint operators to minimize unacceptable quality and paint
waste?
1. Does the facility use water soluble emulsified cutting fluid as a coolant and lubricant
in precision machinery or changed to a gas coolant?
m. Does the facility recycle overspray (e.g., powder coatings segregated by color)?
n. Does the facility ensure that lids and bungs are tight fitting on containers to prevent
loss of chemical through evaporation?
o. Does the facility conduct regular maintenance checks to reduce vapor leaks from
drycleaning units?
NOTE: A regular maintenance program includes:
1) Periodically replacing the seals on the dryer deodorizer and aeration valves, the
door gasket on the button trap and the gasket on the cleaning machine door,
2) Repairing holes in air and exhaust ducts;
3) Checking hose connections and couplings:
4) Cleaning lint screens to avoid clogging fans and condensers;
5) Checking the baffle assembly in cleaning machine;
6) Checking air relief valves for proper closure;
7) Monitoring for vapor losses with solvent leak detectors; and
8) Checking to see that water/solvent separator is working correctly.
NOTE: If there is an unusually large amount of "perc" in the collection bucket, it is
not working correctly.
p. Does the facility monitor major vents and valve systems and recover vented products
from storage tanks and tank trucks?
NOTE: Products can be recovered by use of condensers or vent compressors.
q. Does the facility reformulate materials from powder to pellets to reduce dust
emissions?
r. Does the facility avoid sending hot materials to storage to avoid condensation?
s. Has the facility considered the use of steam or ozone as means of sterilization rather
than ethylene oxide?
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Phase 2
Section 18
Assessing Effectiveness of Water Pollution Control
Program Management
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Table of Contents
Section 18
Water Pollution Control
Introduction to Management Systems Assessments 18-1
A. Purpose 18-1
B. Scope 18-1
C. Approach 18-2
D. Understanding Management Systems 18-2
1. Organizational Structure 18-5
A. Management Organization 18-5
B. Roles and Responsibilities 18-6
2. Environmental Commitment 18-8
A. Top Management Support 18-8
B. Environmental Policy 18-9
C. Line Management Support 18-9
3. Formality of Water Pollution Control Management Program 18-10
A. Regulatory Tracking and Translation 18-10
B. Procedures 18-11
C. Routine Inspections 18-12
D. Recordkeeping and Reporting 18-13
4. Internal and External Communication 18-16
A. Internal Communication 18-16
B. External Communication 18-17
5. Staff Resources, Training, and Development 18-18
A. Staffing 18-18
B. Job Descriptions and Performance Evaluations 18-19
C. Training Programs 18-19
6. Program Evaluation, Reporting and Corrective Action 18-21
A. Self-Assessment and Appraisal System 18-21
B. Reporting and Follow-up 18-22
7. Environmental Planning and Risk Management 18-23
A. Environmental Planning and Risk Management 18-23
8. Pollution Prevention 18-24
A. Pollution Prevention Goals 18-24
B. Pollution Prevention Plan 18-24
C. Pollution Prevention Funding 18-25
D. Pollution Prevention Tracking 18-25
E. Pollution Prevention Training 18-25
F. Pollution Prevention Considerations 18-26
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Introduction
A. Purpose
The primary purpose of a. Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, water pollution control) will allow the
auditor to obtain an understanding as to why and how the environmental management systems
work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., hazardous waste storage areas), the auditor often must talk with other
personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation •
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, wastewater treatment plant operation). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
• NPDES permits
• NPDES permit renewal applications
• Discharge monitoring reports for the past year
• Laboratory records and procedures and USEPA QA results
• Monthly operating reports for wastewater treatment facilities
• Flow monitoring calibration certification and supporting records
• Ash pond volume certification and supporting records
• Red water inspection records
• Special reports, certifications, etc., required by NPDES permits
• Spill Prevention Control and Countermeasures (SPCC) Plan
• All records required by SPCC Plan
• All notices of noncompliance
• All notices of violations
• NPDES state or Federal inspection reports
• Sewage treatment plant operator certification
• Administrative Orders
• Sewer and storm drain layout
• Local sewer ordinance
• Local service use permit
• Notification to local POTW
• Old spill reports
• Repair/maintenance records for the wastewater treatment system
• As-built diagrams
• Federal Facility Compliance Agreements
• Stormwater pollution prevention plan
• Pretreatment permits
• Facility response plans
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
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This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
Discharge outfall pipes
Wastewater treatment facilities
Industrial treatment facilities
Streams, rivers, open waterways
Floor and sink drains (especially in industrial areas)
Stormwater collection points (especially in industrial areas)
Oil storage tanks
Oil/water separators
Neutralization tanks
Alarm systems
Wastewater generation points
Sludge application sites
Septic tanks
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central file or are they in 250 individual employees'
files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review'and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's water pollution control management function is organized.
Determine if the water pollution control management function is characterized by clear
lines of authority and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the water pollution control management function and
determine who:
1) Establishes and enforces facility-wide water pollution control programs, policies,
and procedures/practices;
2) Provides water pollution control oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
b. Determine who the water pollution control manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the water pollution control
manager and person responsible for overall environmental management are open
and effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequently do they talk, etc.).
c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various water pollution control management activities.
For example, determine through interviews and document review who is responsible
for inventorying and analyzing wastewater streams, maintaining records relevant to
water pollution control management, training employees; coordinating emergency
response measures (Linkage with l.B. Roles and Responsibilities).
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2. Determine if water pollution control managers have sufficient authority to effectively
implement water pollution control programs and to make decisions related to
environmental protection. Interview the water pollution control manager and other water
pollution control personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with the facility's wastewater and determine if it is sufficient to carry out
their responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific water pollution control projects or
activities and if those personnel have the appropriate background/authority to approve
•these projects, and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
water pollution control management, who is responsible and accountable for wastewater
management activities, including, but not limited to training, coordination of emergency
response measures at the facility, stormwater management, and wastewater treatment
units.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above (e.g., wastewater treatment plant
operator, laboratory manager, plant engineer, stormwater pollution prevention team) to
verify that individual jobs and responsibilities for water pollution control management
match those in program manuals or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the water pollution control functions specified in their job
descriptions?).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall water pollution control management, and determine if this
reporting relationship is clearly and formally defined and understood.
e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
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Management Systems Assessments Water Pollution Control
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1) Establishes water pollution control policy, procedures, and standards;
2) Provides water pollution control oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency water pollution control
policy and/or Federal and state regulations have been assigned (e.g., sewage treatment
plant operator, stormwater pollution prevention team).
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate water pollution control management responsibilities are defined and are
included in their written performance appraisal.
a. Interview a selection of water pollution control management personnel to determine if
there is accountability for their environmental performance (e.g., if their water
pollution control management/field responsibilities are evaluated during performance
reviews).
b. Determine whether there have been any instances of rewards for outstanding water
pollution control management performance or reprimands for failure to carry out water
pollution control management responsibilities.
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2. Environmental Commitment
A. Top Management Support
i •
1. Determine, by interviewing the environmental manager, the person responsible for overall
water pollution control management, and the facility manager, if top management has
supported water pollution control programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire water pollution
control/treatment equipment, to develop and enhance waste minimization programs,
etc.
1) If financial, technical, and personnel resources are adequate to-manage the volume
and toxicity of wastewater generated at the facility.
b. Whether top management has a clear set of goals and expectations regarding water
pollution control performance and what they are (e.g., environmental compliance as a
minimum expectation, goals that go beyond compliance, emissions reductions).
2. Review water pollution control management documentation and identify how senior
management communicates its water pollution control goals and expectations to
employees; and, typically, how frequently the goals are communicated. For example,
review the facility's water pollution control mission statements, policies, procedures,
orders, directives, standard operating procedures, etc. and ascertain if they clearly
communicate water pollution control goals.
a. Interview a sample of operating and water pollution control personnel to determine if
they understand the facility water pollution control policies, goals, etc.
3. Interview water pollution control management personnel and understand what types of
water pollution control reports are routinely and periodically provided to top management.
a Determine if wastewater reduction progress reports, discharge monitoring summary
reports, incident reports, etc., are routinely prepared for top management and to what
extent they address the facility's water pollution control status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of water
pollution control reports or if reports are prepared for "information only."
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B. Environmental Policy
1. Determine through interviews, what water pollution control policies are widely distributed
and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g.,water pollution
control manager/inspector, environmental manager, line managers, facility manager, etc.)
whose activities may impact water pollution control performance to determine if they take
responsibility and interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in water pollution control
management. Specifically, do they:
1) Routinely observe field level water pollution control compliance activities?
2) Participate in audits and self-assessments?
3) Write and review water pollution control procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to water pollution control,
line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences involving wastewater.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support water pollution control activities and how they integrate water
pollution control management into the facility operations. For example, do they observe
compliance activities, conduct self-assessments, train employees, etc.
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i
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3. Formality of Water Pollution Control Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging water pollution control
regulations and trends.
a. .Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of water pollution control regulations, and if
there is a formal system for this function.
i
b. Determine what documents are regularly reviewed for new and emerging water
pollution control regulations and trends (e.g.. BNA, Federal Register-updates.
professional societies, contact with regulator/officials, subscriptions to professional
publications related to water pollution control).
c. Determine how new water pollution control regulations are interpreted as to their
applicability and by whom (e.g., water pollution control manager, legal department).
d. Note the availability of water pollution control regulatory reference material (for
example, currency of subscription to BNA. automated access via software, CFRs,
Federal and State Registers, state regulations, technical books, and other reference
materials relating to water pollution control).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to water pollution
control program manuals, training courses). Interview selected operating personnel to
obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new water pollution control
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update water
pollution control management programs and procedures to reflect changes in
regulatory requirements, such as discharge limitations, compliance dates, monitoring
methods, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form water pollution control regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing water
pollution control programs, policies, and procedures. Note the frequency that water
pollution control programs, policies, and procedures are updated/new ones developed, how
often they are reviewed, and who approves them. Determine if there is a formal system in
place to update water pollution control management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's water pollution control programs, policies, and procedures. Determine their
level of experience and comment on the appropriateness of these individuals to
perform such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new water pollution control regulatory requirement and determine whether a
new procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
water pollution control management policies, programs, or procedures, whether the
organization has a program (e.g., written procedures) for the management of its
wastewater, including, but not limited to:
a. Identification of wastewater streams;
b. Characterization of wastewater streams;
c. Sampling and analysis;
d. Discharge monitoring report preparation;
e. Laboratory analysis and QA;
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f. Development, implementation, and review of spill control and emergency response
procedures;
g. Procedures of management of specific wastewater treatment units;
h. Pollution prevention; and
i. Corrective action to identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
water pollution control procedures relevant to their job function. For example, are they
easily accessible, centrally located, manually (or electronically) available.
a. Verify the accessibility by requesting a sample of water pollution control management
procedures.
5. Determine whether applicable water pollution control management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
6. Determine if water pollution control management procedures such as those listed above
are reviewed and updated on any schedule (e.g., periodically, annually, only when
regulations change) and who is responsible for this review/update.
C. Routine Inspections
1. Interview the environmental and water pollution control managers and water pollution
control inspector to determine if the facility has a program for routine site and equipment
inspections and compliance checks, including appropriate documentation relating to water
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pollution control activities. Specifically, determine if the facility regularly determines
compliance with legal and regulatory requirements such as:
a. Discharge limitations;
b. Wastewater treatment plant operation; and
c. Stormwater collection and monitoring.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Water Pollution Control
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of water pollution control activities.
a. Develop an understanding of all systems that are in place for water pollution control
recordkeeping and document control (e.g., does the facility maintain a log or database
of wastewater generated, inspection logs, discharge monitoring reports, employee
training documentation, etc.). For example, understand the systems for:
1) Tracking of key regulatory schedules (e.g., NPDES permit renewals, discharge
monitoring report submissions, required training, etc.);
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2) Maintenance of compliance records (e.g.. equipment calibration and maintenance
records, stormwater sampling and characterization results); and
3) Preparation and submission of required reports (e.g., discharge monitoring reports,
POTW baseline and periodic reports, spill reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
water pollution control records. Determine whether the files are complete, current, and
readily accessible.
c. Determine how the facility ensures that required water pollution control
reports/notifications are routinely prepared and submitted to the appropriate regulatory
agencies in a timely manner. Through interviews with the environmental manager,
identify the person(s) responsible for regulatory reporting and through interviews with
them determine if they have appropriate experience/training to effectively report on
water pollution control activities. Types of reports/notifications include:
1) Notification to POTW of hazardous waste discharge;
2) Notification to POTW of change in wastewater composition;
3) Upset reports;
4) Discharge monitoring reports; and
5) CERCLA/SARA notification for spills/releases in excess of "reportable quantity".
d. Interview the water pollution control manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
CWA compliance and other related environmental information. (For example, the
facility may choose to maintain POTW and NPDES indefinitely, rather than for the
required three years.)
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with 1..B. Roles and Responsibilities)
c. Verify that the facility maintains POTW and NPDES records for the retention periods
specified by regulation.
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3. Determine how the facility investigates, reports, corrects, tracks, and monitors water
pollution control problems and "incidents" (for example, upsets or bypasses). Interview
water pollution control personnel and review procedures to determine if these are
formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and water pollution control managers, and review internal
memos, newsletters, etc., to understand how environmental information related to water
pollution control is communicated. For example, is water pollution control information
(e.g., wastewater reduction activities, incidents) regularly communicated formally or
informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up.
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover water pollution control issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of water pollution control directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):'
a. Determine how quickly the following types of water pollution control information is
communicated to management:
1) Routine environmental status information;
2) New water pollution control regulations;
3) Incident or major issue information; and
4) Controversial water pollution control issues.
b. Determine how quickly new water pollution control requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to water pollution control.
a. Review files to determine if the concerns and responses are documented.
b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
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1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to water pollution
control. For example:
a. Determine if the facility has any communication programs with the local community
(e.g.. education, visitation of facilities, public reading rooms) to keep them informed
of the water pollution control status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's wastewater have been
received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
water pollution control management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of water pollution control staff to
determine if staffing levels are sufficient to achieve performance goals. Specifically:
. a. Note evidence of insufficient or inexperienced water pollution control management
staff to assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3} Excessive use of contractors.
2. Interview water pollution control management personnel and review their job descriptions
and applicable regulations to determine what qualifications are necessary for staffing and
other positions with responsibilities (e.g.,water pollution control managers, wastewater
treatment plant operator, laboratory technician).
a. Determine if personnel with water pollution control management responsibilities have
the relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in water pollution control management;
2) Relevant water pollution control work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of wastewater issues at the facility) conclude as to the quality and quantity
of water pollution control personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for water pollution control management staff
(including line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for water pollution
control management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if water pollution control management
performance is regularly included in the performance review process.
3. Interview a sample of water pollution control staff (e.g., wastewater treatment plant
operator/staff, stormwater pollution prevention team, laboratory personnel) to confirm that
they are evaluated on how well they perform their water pollution control management
responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing water
pollution control training programs) to determine if the facility has identified specialized
water pollution control training requirements (based on regulatory requirements,
toxicity/volumes of wastewater generated at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate water pollution control training needs
for all relevant personnel who may be involved with wastewater
generation/treatment?
3) How does the facility ensure that water pollution control training courses are •
completed?
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2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. SPCC plan implementation (emergency procedures, equipment, and systems);
b. Treatment plant operation;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm systems;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Sampling and analysis procedures;
h. Personnel health and safety and fire safety; and
i. Shutdown procedures.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and water pollution control managers and reviewing
water pollution control program documentation, determine if the facility conducts water
pollution control self-assessments/appraisals. Note whether the self-assessments/
appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. (Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all water pollution control issues at each self-assessment/appraisal or cover only
one topic at a time (e.g., sampling and monitoring, wastewater treatment);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address water pollution control management
issues relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for water pollution control performance.
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, -programs, or activities that may impact water pollution
control management (for example, projects, programs, or activities that may increase the
volume or toxicity of wastewater generated, require additional personnel or equipment to
handle the wastewater adequately) are carefully reviewed to identify and address
environmental, health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value, -
project type).
2. Based on interviews with facility management, including environmental and water
pollution control managers, and a review of project planning documentation, comment on
how the facility balances environmental concerns against production/operational demands
when reviewing proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of wastewater is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 128S6?
b. Interview a selection of water pollution control management personnel to determine if
they understand the facility goal with regard to pollution prevention.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. .Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 128S6. If so. review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
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a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRJ or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with water pollution control management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
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F. Pollution Prevention Considerations
1. Based on your understanding of the facility operations and types and volumes of
wastewater generated, as well as interviews and a review of files, comment on how well
the facility integrated pollution prevention into its daily activities. Types of pollution
prevention initiatives may include the following (Waste Minimization Plan Linkage with
Phase 1 - Section 3):
a. Has the facility installed (for wastewater treatment):
1) An oil-water interference sensor at the bottom of the oil retention baffle of the
separation tank?
2) Automatic oil skimming equipment?
3) A free water node out tank with sufficient detention time and a pressure relief
valve?
4) An inlet and outlet baffle in the gravity separation tank?
5) A high level alarm, remote dialer and pump shut off in the separation tank?
b. Does the facility store treated water for reuse (perform process reinjection of water)?
c. Does the facility discharge brine after further treatment to a saltwater channel, if
available?
d. Does the facility return oily wastewater and sludge from distribution terminals to the
refinery as permitted by Federal and state recycling regulations?
e. .Has the facility paved process areas to avoid hazardous materials/dirt entry into the
sewer?
f. Has the facility installed sewer drains to avoid hazardous material/dirt entry into the
sewer?
g. Does the facility reuse recycled water for washdown if quality is desirable to minimize
need for discharge?
h. Does the facility selectively cover loading racks and process areas to divert rainwater
and preclude contamination?
i. Does the facility keep tank farms and process areas clean to avoid rainwater
contamination?
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j. Does the facility use closed-loop cooling water systems to avoid water loss?
k. Does the facility prevent the discharge of concentrated laboratory samples to be
discharged into wastewater treatment plant by providing other disposal means?
1. Does the facility make use of jet sprays, water knife sprays, steam cleaners to reduce
the amount of rinse water required?
m. Does the facility treat sludge with heat and chemicals to release more oil and water to
reduce hydrocarbon content in sludge?
n. Does the facility thicken sludge in sludge tanks and decant supernatant to aid in sludge
dewatering?
o. Does the facility use solvent extraction to remove hydrocarbons from sludge?
p. Does the facility use water softeners for cooling water systems to extend the life of the
water?
q. Does the facility utilize high pressure washing equipment to reduce the amount of
waste water generated?
r. Does the facility measure water inflow and outflow rates from each unit process to
control water usage?
s. Does the facility utilize, metal recovery technologies (e.g., ion exchange, reverse
osmosis, electrolysis) or evaporating to facilitate recycling and reuse of rinse waters?
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Phase 2
Section 19
Assessing Effectiveness of Nonhazardous Waste
Program Management
-------
Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
• Organizational Structure
• Environmental Commitment
• Formality of Environmental Program
• Internal and External Communication
• Staff Resources. Training and Development
• Program Evaluation, Reporting and Corrective Action
• Environmental Planning and Risk Management
• Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment. They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities', policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, nonhazardous waste) will allow the auditor
to obtain an understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g..nonhazardous waste storage areas), the auditor often must talk with
other personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review
(e.g.,solid waste landfill). This review serves to further enhance an auditor's understanding of
the management systems and physical controls. Review the following documents:
• Record of current nonhazardous solid waste management practices
• Documentation of locations (maps) and descriptions of all nonhazardous waste storage
and disposal sites
• Records of operational history of all active and inactive disposal sites
• State and Federal inspection reports
• Environmental monitoring procedures or plans
• Records of resource recovery practices, including the sale of materials for the purpose of
recycling
• Solid waste removal contracts and inspection records
• Operating record for onsite landfills
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Disposal sites
• Waste receptacles
• Construction debris areas
• Incinerators'and land disposal sites (active and inactive)
• Solid waste vehicle storage and washing areas
• Compost facilities
• Transfer facilities
• Recycling centers
• Resource recovery facilities
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
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a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central file or are they in individual employees' files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's nonhazardous waste management function is organized.
Determine if the nonhazardous waste management function is characterized by clear lines
of authority and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the nonhazardous waste management function and determine
who:
1) Establishes and enforces facility-wide nonhazardous waste programs, policies, and
procedures/practices;
2) Provides nonhazardous waste oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
b. Determine who the nonhazardous waste manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management.
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the nonhazardous waste manager
and person responsible for overall environmental management are open and
effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequently do they talk, etc.).
c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various nonhazardous waste management activities.
For example, determine through interviews and document review who is responsible
for qualifying and classifying generation of solid waste, determining whether solid
waste is hazardous or nonhazardous, environmental monitoring activities (Linkage with
l.B. Roles and Responsibilities).
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2. Determine if nonhazardous waste managers have sufficient authority to effectively
implement nonhazardous waste programs and to make decisions related to environmental
protection. Interview the nonhazardous waste manager and other nonhazardous waste
personnel (e.g., MSWLF operator) and:
a. Understand the amount of authority given to these personnel at different levels
working with nonhazardous waste and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility).
b. Determine who is responsible for approving specific nonhazardous waste projects or
activities and if those personnel have the appropriate background/authority to approve
these projects.
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
nonhazardous waste management, who is responsible and accountable for waste
'management activities, including, but not limited to training, landfill operation,
nonhazardous waste collection and disposal, transportation, resource recovery,
environmental monitoring, recordkeeping and reporting, coordination of emergency
response measures at the facility, etc.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b.- Interview selected individuals identified above to verify that individual jobs and
responsibilities for nonhazardous waste management match those in program manuals
or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the nonhazardous waste functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall nonhazardous waste management, and determine if this
reporting relationship is clearly and formally defined and understood.
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes nonhazardous waste policy, procedures, and standards;
2) Provides nonhazardous waste oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency nonhazardous waste
policy or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate nonhazardous waste management responsibilities are defined and are
included in their written performance appraisal.
•
a. Interview a selection of nonhazardous waste management personnel to determine if
there is accountability for their environmental performance (e.g., if their nonhazardous
waste management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding
nonhazardous waste management performance or reprimands for failure to carry out
nonhazardous waste management responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
nonhazardous waste management, and the facility manager, if top management has
supported nonhazardous waste programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire nonhazardous waste
handling/treatment/sorting/iecycling equipment, to develop and enhance waste
minimization programs, etc.
1) If financial, technical, and personnel resources are adequate to manage the volume
of nonhazardous waste generated at the facility.
b. Whether top management has a clear set of goals and expectations regarding
nonhazardous waste performance and what they are (e.g., environmental compliance as
a minimum expectation, goals that go beyond compliance, emissions reductions).
2. Review nonhazardous waste management documentation and identify how senior
management communicates its nonhazardous waste goals and expectations to employees;
and, typically, how frequently the goals are communicated. For example, review the
facility's nonhazardous waste mission statements, policies, procedures, orders, directives,
standard operating procedures, etc. and ascertain if they clearly communicate
nonhazardous waste goals.
a. Interview a sample of operating and nonhazardous waste personnel to determine if
they understand the facility nonhazardous waste policies, goals, etc.
3. Interview nonhazardous waste management personnel and understand what types of
nonhazardous waste reports are routinely and periodically provided to top management.
a. Determine if nonhazardous waste reports, environmental monitoring reports,
nonhazardous waste inventory reports, operating record reports, etc., are routinely
prepared for top management and to what extent they address the facility's
nonhazardous waste status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of
nonhazardous waste reports or if reports are prepared for "information only."
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B. Environmental Policy
1. Determine through interviews, what nonhazardous waste policies are widely distributed
and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., nonhazardous
waste manager/inspector, landfill operator, recycling coordinator, environmental manager,
line managers, facility manager, etc.) whose activities may impact nonhazardous waste
performance to determine if they take responsibility and interest in limiting the impact of
their operations. For example:
a. Identify activities in which line managers are involved in nonhazardous waste
management Specifically, do they:
1) Routinely observe field level nonhazardous waste compliance activities.
2) Participate in audits and self-assessments.
3) Write and review nonhazardous waste procedures.
4) Serve on environmental advisory committees.
b. Determine what kind of environmental information, relevant to nonhazardous waste,
line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences involving nonhazardous waste.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support nonhazardous waste activities and how they integrate nonhazardous
waste management into the facility operations. For example, do they observe compliance
activities, conduct self-assessments, train employees, etc.
Phase 2 - Section 1.
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3. Formality of Nonhazardous Waste Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging nonhazardous waste
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of nonhazardous waste regulations, and if there
is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging
nonhazardous waste regulations and trends (e.g., BNA, Federal Register updates,
professional societies, contact with regulator/officials, subscriptions to professional
publications related to nonhazardous waste management).
c. Determine how new nonhazardous waste regulations are interpreted as to their
applicability and by whom (e.g., nonhazardous waste manager, legal department).
d. Note the availability of nonhazardous waste regulatory reference material (for example,
currency of subscription to BNA, automated access via software, CFRs, Federal and
State Registers, state regulations, technical books, and other reference materials
relating to nonhazardous waste management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to nonhazardous
waste program manuals, training courses). Interview selected operating personnel to
obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new nonhazardous waste
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update
nonhazardous waste management programs and procedures to reflect changes in
regulatory requirements, such as landfill operating procedures, environmental
monitoring, closure, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form nonhazardous waste regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B, Procedures
1. Determine the process by which new requirements are incorporated into existing
nonhazardous waste programs, policies, and procedures. Note the frequency that
nonhazardous waste programs, policies, and procedures are updated/new ones developed,
how often they are reviewed, and who approves them. Determine if there is a formal
system in place to update nonhazardous waste management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's nonhazardous waste programs, policies, and procedures. Determine their level
of experience and comment on the appropriateness of these individuals to perform
such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new nonhazardous waste regulatory requirement and determine whether a
new procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
nonhazardous waste management policies, programs, or procedures, whether the
organization has a program (e.g., written procedures) for the management of
nonhazardous waste, including, but not limited to:
a. Identification of waste streams;
b. Characterization of waste streams (hazardous and nonhazardous);
c. Methods used to determine is wastes are hazardous or nonhazardous;
d. Sampling and analysis;
e. Recordkeeping and reporting;
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f. Nonhazardous waste collection and transportation;
g. Labelling of containers;
h. Development, implementation, and review of preparedness and prevention procedures;
i. Recycling;
j. Procedures of management of specific nonhazardous waste management units (e.g.,
landfills, incinerators, containers, etc.);
k. Groundwater monitoring programs;
1. Pollution prevention; and
m. Corrective action to identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
nonhazardous waste procedures relevant to their job function. For example, are they easily
accessible, centrally located, manually (or electronically) available.
a. Verify the accessibility by requesting a sample of nonhazardous waste management
procedures.
5. Determine whether applicable nonhazardous waste management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight.
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6. Determine if nonhazardous waste management procedures such as those listed above are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review.
C. Routine Inspections
1. Interview the environmental and nonhazardous waste managers and nonhazardous waste
inspector to determine if the facility has a program for routine site and equipment
inspections and compliance checks, including appropriate documentation relating to
nonhazardous waste activities. Specifically, determine if the facility regularly determines
compliance with legal and regulatory requirements such as:
a. Nonhazardous waste storage area/container inspections;
b. Vector control;
c. Vehicles used for transport;
d. Nonhazardous waste treatment and disposal facilities;
e. Receipt of prohibited wastes;
f. Proper use of safety/emergency equipment;
g. Use of daily cover; and
h. Proper disposal of wastes.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
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d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Nonhazardous Waste
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of nonhazardous waste activities.
a. Develop an understanding of all systems that are in place for nonhazardous waste
recordkeeping and document control (e.g., does the facility maintain a log or database
of nonhazardous wastes generated, records of resource recovery/recycling, solid waste
removal contracts, inspection logs, off-site transfer reports, employee training
documentation, landfill operating records, incinerator operating records, etc.). For
example, understand the systems for:
1) Tracking of key regulatory schedules (e.g., incinerator and landfill permit renewals,
nonhazardous waste report submissions, required training, etc.);
2) Maintenance of compliance records (e.g., nonhazardous waste storage area
inspection logs, training records, nonhazardous waste inventory and profiles,
closure/post-closure records, financial insurance, etc.); and
3) Preparation and submission of required reports.
b. In general, assess the state of the facility's files and recordkeeping practices regarding
nonhazardous waste records. Determine whether the files are complete, current, and
readily accessible.
c. Determine how the facility ensures that required nonhazardous waste
reports/notifications are routinely prepared and submitted to the appropriate regulatory
agencies in a timely manner. Through interviews with the environmental manager,
identify the person(s) responsible for regulatory reporting and through interviews with
them determine if they have appropriate experience/training to effectively report on
nonhazardous waste activities. Types of reports/notifications include:
1) Reports required by permits;
2) Nonhazardous waste inventories; and
3) Compact ratios/use of cover.
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d. Interview the nonhazardous waste manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
nonhazardous waste compliance and other related environmental information. (For
example, the facility may choose to maintain records indefinitely, rather than for the
regulatory time period.)
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Rotes and Responsibilities).
c. Verify that the facility maintains nonhazardous waste records for the retention periods
specified by regulation).
3. Determine how the facility investigates, reports, corrects, tracks, and monitors
nonhazardous waste problems and "incidents" (for example, landfill liner failure).
Interview nonhazardous waste personnel and review procedures to determine if these are
formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and nonhazardous waste managers, and review internal
memos, newsletters, etc., to understand how environmental information related to
nonhazardous waste is communicated. For example, is nonhazardous waste information
regularly communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there arc consistent line management and environmental staff
meetings that adequately cover nonhazardous waste issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of nonhazardous waste directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of nonhazardous waste information is
communicated to management:
1) Routine environmental status information;
2) New nonhazardous waste regulations;
3) Incident or major issue information; and
4) Controversial nonhazardous waste issues.
b. Determine how quickly new nonhazardous waste requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to nonhazardous waste.
-a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not. determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to nonhazardous
waste. For example:
a. Determine if the facility has any communication programs with the local community
- (e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the nonhazardous waste activities at the facility.
b. Interview a selection of facility management and review facility files to determine'if
any complaints/questions/concerns regarding the facility's nonhazardous waste
activities (e.g., landfill odor, vector problems) have been received from the local
community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
Phase 2 - Section 1!
Management Systems Assessments Nonhazardous Waste
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
nonhazardous waste management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of nonhazardous waste staff to
determine if staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced nonhazardous waste management staff
to assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview nonhazardous waste management personnel and review their job descriptions
and applicable regulations to determine what qualifications are necessary for staffing and
other positions with responsibilities (e.g., landfill operator, incinerator operator).
a. Determine if personnel with nonhazardous waste management responsibilities have the
relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in nonhazardous waste management;
2) Relevant nonhazardous waste work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of nonhazardous waste issues at the facility) conclude as to the quality and
quantity of nonhazardous waste personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for nonhazardous waste management staff
(including line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for nonhazardous waste
management positions.
2., By interviewing the'human resource manager and reviewing documentation relating to the
performance review process, determine if nonhazardous waste management performance
is regularly included in the performance review process.
3. Interview a sample of nonhazardous waste staff (e.g., nonhazardous waste handlers,
incinerator personnel) to confirm that they are evaluated on how well they perform their
nonhazardous waste management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing
nonhazardous waste training programs) to determine if the facility has identified
specialized nonhazardous waste training requirements (based on regulatory requirements,
types/volumes of nonhazardous waste generated at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate nonhazardous waste training needs for
all relevant personnel who may be required to work with nonhazardous waste?
3) How does the facility ensure that nonhazardous waste training courses are
completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Procedures for using, inspecting, and repairing emergency, monitoring, and operating
equipment;
c.. Operation of communications and alarm systems;
d. Response to fire or explosion;
e. Response to leaks or spills;
f. Vector control;
g. Off-base transportation;
h. Container management; and
i. Personnel health and safety and fire safety.
Phase 2 • Section 19
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19-20
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and nonhazardous waste managers and reviewing
nonhazardoos waste program documentation, determine if the facility conducts
nonhazardous waste self-assessments/appraisals. Note whether the self-
assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all nonhazardous waste issues at each self-assessment/appraisal or cover only
one topic at a time (e.g., incinerator operation, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", track/monitor corrective action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address nonhazardous waste management issues
relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Phase 2 • Section 19
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19-21
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for nonhazardous waste management performance.
Phase 2 - Section 19
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19-22
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact nonhazardous waste
management (for example, projects, programs, or activities that may increase the volume
of nonhazardous waste generated, require additional personnel or equipment to handle the
waste adequately, generate nonrecyclable wastes) are carefully reviewed to identify and
address environmental, health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type). . .
2. Based on interviews with facility management, including environmental and nonhazardous
waste managers, and a review of project planning documentation, comment on how the
facility balances environmental concerns against production/operational demands when
reviewing proposed new projects, programs, or activities.
Phase 2 - Section 1
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19-23
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of nonhazardous waste is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of nonhazardous waste management personnel to determine if
they understand the facility goal with regard to pollution prevention/waste
minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
. track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
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a. The person has the authority at the facility to implement/authorize pollution preventic
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
meL
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuam to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with nonhazardous waste management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
Phase 2 - Section 19
Management Systems Assessments • Nonhazardous Waste
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F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (nonhazardous waste), and activities
associated with nonhazardous waste.
1. Based on your understanding of the facility operations and types and volumes of
nonhazardous waste generated, as well as interviews and a review of files, comment on
how well the facility integrated pollution prevention into its daily activities (Waste
Minimization Plan Linkage with Phase 1 - Section 3).
Phase 2 - Section 19
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Phase 2
Section 20
Assessing Effectiveness of Hazardous Waste
Program Management
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Table of Contents
Section 20
Hazardous Waste
Introduction to Management Systems Assessments • 20-1
A. Purpose 20-1
B. Scope 20-1
C. Approach 20-2
D. Understanding Management Systems 20-2
1. Organizational Structure 20-5
A. Management Organization . 20-5
B. Roles and Responsibilities 20-6
2. Environmental Commitment 20-8
A. Top Management Support 20-8
B. Environmental Policy 20-9
C. Line Management Support 20-9
3. Formality of Hazardous Waste Management Program 20-10
A. Regulatory Tracking and Translation . 20-10
B. Procedures . 20-11
C. Routine Inspections 20-1
D. Recordkeeping and Reporting 20-K
4. Internal and External Communication 20-16
A. Internal Communication 20-16
B. External Communication 20-17
5. Staff Resources, Training, and Development 20-18
A. Staffing 20-18
B. Job Descriptions and Performance Evaluations 20-19
C. Training Programs 20-19
6. Program Evaluation, Reporting and Corrective Action 20-21
A. Self-Assessment and Appraisal System 20-21
B. Reporting and Follow-up ' 20-22
7. Environmental Planning and Risk Management 20-23
A. Environmental Planning and Risk Management ' 20-23
8. Pollution Prevention 20-24
A. Pollution Prevention Goals 20-24
B. Pollution Prevention Plan 20-24
C. Pollution Prevention Funding 20-'
D. Pollution Prevention Tracking 20-*.
E. Pollution Prevention Training 20-25
F. Pollution Prevention Considerations 20-26
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
• Organizational Structure
•. Environmental Commitment
• Formality of Environmental Program
• Internal and External Communication
• Staff Resources, Training and Development
• Program Evaluation, Reporting and Corrective Action
• Environmental Planning and Risk Management
•. Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment- required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, hazardous waste) will allow the auditor to
obtain an understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., hazardous waste storage areas), the auditor often must talk with other
personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, hazardous waste contingency plan). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
Generator (including TSDFs if they are also generators):
• Notification of Hazardous Waste Activity (USEPA ID No.)
• Hazardous waste manifests
• Manifest exception reports
• Biennial reports
• Inspection Logs
• Delistings
• Speculative accumulation records
• Land disposal restriction certifications
• Employee training documentation
• Contingency plan
• Notification of hazardous waste oil fuel marketing or blending activity
In addition to the above, TSDFs would require:
• Permits, if issued, otherwise Part A Application
• Unmanifested waste reports
• TSDF audit reports (Inspection log)
• Waste analysis plan(s)
• Operating record
• Groundwater monitoring records and annual reports (where required)
• Biennial reports Closure/Post Closure Plans Closure/Post Closure Notices (where
applicable)
• Other documents as required by the Permit
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or faculties.
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This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
Disposal sites
Accumulation points
Incinerators
Vehicles used for transport
Storage facilities (including drums)
Surface impoundments
OB/OD sites
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central file or are they in 250 individual employees'
files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's hazardous waste management function is organized. Determine
if the hazardous waste management function is characterized by clear lines of authority
and responsibility. For example;
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the hazardous waste management function and determine
who:
1) Establishes and enforces facility-wide hazardous waste programs, policies, and
procedures/practices;
2) Provides hazardous waste oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
b. Determine who the hazardous waste manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management.
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the hazardous waste manager and
person responsible for overall hazardous waste management are open and effective
(e.g., how do these people communicate [verbal, memo, etc.], how frequently do
they talk, etc.).
c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various hazardous waste management activities. For
example, determine through interviews and document review who is responsible for
inventorying hazardous waste streams, maintaining records relevant to hazardous waste
management, training employees; coordinating emergency response measures (Linkage
with n.B. Roles and Responsibilities).
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2. Determine if hazardous waste managers have sufficient authority to effectively implement
hazardous waste programs and to make decisions related to environmental protection.
Interview the hazardous waste manager and other hazardous waste personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with hazardous waste and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific hazardous waste projects or
activities and if those personnel have the appropriate background/authority to approve
these projects, and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with l.B. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
hazardous waste management, who is responsible and accountable for waste management
activities, including, but not limited to training, manifest preparation and tracking,
biennial and exception report recordkeeping and reporting, hazardous waste storage areas,
coordination of emergency response measures at the facility, and hazardous waste
management units.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for hazardous waste management match those in program manuals or
job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the hazardous waste functions specified in their job
descriptions?).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall hazardous waste management, and determine if this reporting
relationship is clearly and formally defined and understood.
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e. Identify, through interviews with facility/site management and review of
organizational/duty allocation charts, who:
1) Establishes hazardous waste policy, procedures, and standards;
2) Provides hazardous waste oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency hazardous waste
policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate hazardous waste management responsibilities are defined and are
included in their written performance appraisal.
a. Interview a selection of hazardous waste management personnel to determine if there
is accountability for their environmental performance (e.g., if their hazardous waste
management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding hazardou:
waste management performance or reprimands for failure to carry out hazardous waste
management responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
hazardous waste management, and the facility manager, if top management has supported
hazardous waste programs. For example, determine:
t
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire hazardous waste
handling/treatment equipment, to develop and enhance waste minimization programs.
1) If financial, technical, and personnel resources are adequate to manage the volume
of hazardous waste generated at the facility.
b. Whether top management has a clear set of goals and expectations regarding
hazardous waste performance and what they are (e.g., environmental compliance as a
minimum expectation, goals that go beyond compliance, emissions reductions).
2. Review hazardous waste management documentation and identify how senior management
communicates its hazardous waste goals and expectations to employees; and, typically,
how frequently the goals are communicated. For example, review the facility's hazardous
waste mission statements, policies, procedures, orders, directives, standard operating
procedures, etc. and ascertain if they clearly communicate hazardous waste goals.
a. Interview a sample of operating and hazardous waste personnel to determine if they
understand the facility hazardous waste policies, goals, etc.
3. Interview hazardous waste management personnel and understand what types of hazardous
waste reports are routinely and periodically provided to top management
a Determine if hazardous waste biennial/annual reports, hazardous waste reduction
progress reports, hazardous waste inventory reports, operating record reports, etc., are
routinely prepared for top management and to what extent they address the facility's
hazardous waste status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of
hazardous waste reports or if reports are prepared for "information only."
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B. Environmental Policy
1. Determine through interviews, what hazardous waste policies are widely distributed and if
they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
•1. Interview a selection of individuals at all levels and in all functions (e.g., hazardous waste
manager/inspector, environmental manager, line managers, facility manager, etc.) whose
activities may impact hazardous waste performance to determine if they take
responsibility and interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in hazardous waste
management Specifically, do they:
1) Routinely observe field level hazardous waste compliance activities?
2) Participate in audits and self-assessments?
3) Write and review hazardous waste procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to hazardous waste, line
managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences involving hazardous waste.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support hazardous waste activities and how they integrate hazardous waste
management into the facility operations. For example, do they observe compliance
activities, conduct self-assessments, train employees, etc.
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3. Formality of Hazardous Waste Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging hazardous waste
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of hazardous waste regulations, and if there is
a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging hazardous
waste regulations and trends (e.g., BNA, Federal Register updates, professional
societies, contact with regulator/officials, subscriptions to professional publications
related to hazardous waste management).
c. Determine how new hazardous waste regulations are interpreted as to their
applicability and by whom (e.g., hazardous waste manager, legal department).
d. Note the availability of hazardous waste regulatory reference material (for example,
currency of subscription to BNA, automated access via software, CFRs, Federal and
State Registers, state regulations, technical books, and other reference materials
relating to hazardous waste management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to hazardous waste
program manuals, training courses). Interview selected operating personnel to obtain
their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new hazardous waste regulatory
requirements is incorporated into facility or site-specific standard operating procedures, as
appropriate.
a. Through interviews, determine if there is a formal system in place to update hazardous
waste management programs and procedures to reflect changes in regulatory
requirements, such as biennial reporting requirements, storage, handling, treatment and
disposal practices for hazardous waste, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form hazardous waste regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing
hazardous waste programs, policies, and procedures. Note the frequency that hazardous
waste programs, policies, and procedures are updated/new ones developed, how often they
are reviewed, and who approves them. Determine if there is a formal system in place to
update hazardous waste management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's hazardous waste programs, policies, and procedures. Determine their level of
experience and comment on the appropriateness of these individuals to perform such
tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new hazardous waste regulatory requirement and determine whether a new
procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
hazardous waste management policies, programs, or procedures, whether the organization
has a program (e.g., written procedures) for the management of hazardous waste,
including, but not limited to:
a. Identification of waste streams;
b. Characterization of waste streams (hazardous and nonhazardous);
c. Methods used to determine is wastes are hazardous or nonhazardous;
d. Sampling and analysis;
e. Manifest preparation;
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f. Hazardous waste transportation;
g. Labelling of containers;
h. Hazardous waste satellite and storage area maintenance and inspection;
i. Facility methods to assess generator status (conditionally exempt small quantity
generator, small quantity generator, or large quantity generator);
j. Development, implementation, and review of preparedness and prevention procedures
and hazardous waste contingency plan;
k. Procedures for managing specific waste streams (e.g., waste oil, PCBs, solvents, etc.);
1. Procedures of management of specific hazardous waste management units (e.g.,
landfills, surface impoundments, tanks, incinerators, etc.);
m. Groundwater monitoring programs;
n. Pollution prevention; and
o. Corrective action to identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction'
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
hazardous waste procedures relevant to their job function. For example, are they easily
accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of hazardous waste management
procedures.
5. Determine whether applicable hazardous waste management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
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e. Training; and
f. Program evaluation and oversight.
6. Determine if hazardous waste management procedures such as those listed a'bove are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review/update.
C. Routine Inspections
1. Interview the environmental and hazardous waste managers and hazardous waste inspector
to determine if the facility has a program for routine site and equipment inspections and
compliance checks, including appropriate documentation relating to hazardous waste
activities. Specifically, determine if the facility regularly determines compliance with legal
and regulatory requirements such as:
a. Hazardous waste storage area/container inspections;
b. Accumulation area inspections;
c. Vehicles used for transport;
d. Surface impoundments; and
e. Disposal sites.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
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b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Hazardous Waste
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of hazardous waste activities.
a. Develop an understanding of all systems that are in place for hazardous waste
recordkeeping and document control (e.g., does the facility maintain a log or database
of hazardous wastes generated, inspection logs, biennial reports, employee training
documentation, hazardous waste manifests, etc.). For example, understand the systems
for:
1) Tracking of key regulatory schedules (e.g., RCRA permit renewals, hazardous
waste report submissions [biennial, exception, etc.], required training, etc.);
2) Maintenance of compliance records (e.g., hazardous waste storage/accumulation
areas inspection logs, manifests, training records, hazardous waste inventory and
profiles, land ban notifications, closure/post-closure records; financial insurance,
etc.); and
3) Preparation and submission of required reports (e.g., biennial reports, exception
reports, spill reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
hazardous waste records. Determine whether the files are complete, current, and
readily accessible.
c. Determine how the facility ensures that required hazardous waste reports/notifications
are routinely prepared and submitted to the appropriate regulatory agencies in a timely
manner. Through interviews with the environmental manager, identify the person(s)
responsible for regulatory reporting and through interviews with them determine if
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they have appropriate experience/training to effectively report on hazardous waste
activities. Types of reports/notifications include:
1) Notification of hazardous waste activity;
2) Change in generator status;
3) Exception reports;
4) Biennial/annual reports;
5) CERCLA/SARA notification for spills/releases in excess of "reportable quantity".
d. Interview the hazardous waste manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized, etc.).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
RCRA compliance and other related environmental information. (For example, the
facility may choose to maintain manifests indefinitely, rather than for the required
three years.) ' '
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities).
c. Verify that the facility maintains hazardous waste records for the retention periods
specified by regulation (e.g., manifests—three years; biennial and exception
reports—three years; land ban notification forms—five years).
3. Determine how the facility investigates, reports, corrects, tracks, and monitors hazardous
waste problems and "incidents" (for example, releases/spills of hazardous waste into the
environment, container/tank failure). Interview hazardous waste personnel and review
procedures to determine if these are formalized procedures.
• a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and hazardous waste managers, and review internal raeraos,
newsletters, etc., to understand how environmental information related to hazardous waste
is communicated. For example, is hazardous waste information (e.g., hazardous waste
management status, incidents) regularly communicated formally or informally throughout
the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover hazardous waste issues (review minutes of meetings,
talk with personnel who regularly attend meetings).
2. Determine if formal communication of hazardous waste directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.a.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of hazardous waste information is
communicated to management:
1) Routine environmental status information;
2) New hazardous waste regulations;
3) Incident or major issue information; and
4) Controversial hazardous waste issues.
b. Determine how quickly new hazardous waste requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and-address employee environmental
concerns related to hazardous waste.
a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to hazardous
waste. For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the hazardous waste status of the facility.
b. Interview a selection of facility management and review facility files .to determine if
any complaints/questions/concerns regarding the facility's hazardous waste have been
received from the local community.
1) Note whether these complaints/questions/concems have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
hazardous waste management activities (this .includes dedicated support staff and others
with collateral duties [e.g., line managers with other support functions}). Interview the
human resource manager as well as a sample of hazardous waste staff to determine if
staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced hazardous waste management staff to
assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview hazardous waste management personnel and review their job descriptions and
applicable regulations to determine what qualifications are necessary for staffing and other
positions with responsibilities (e.g., hazardous waste trainers, hazardous waste managers).
a. Determine if personnel with hazardous waste management responsibilities have the
relevant background and training to cany out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in hazardous waste management;
2) Relevant hazardous waste work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of hazardous waste issues at the facility) conclude as to the quality and
quantity of hazardous waste personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for hazardous waste management staff (including
line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for hazardous waste
management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if hazardous waste management performance is
regularly included in the performance review process.
3. Interview a sample of hazardous waste staff (e.g., hazardous waste handlers, accumulation
point managers) to confirm that they are evaluated on how well they perform their
hazardous waste management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing
hazardous waste training programs) to determine if the facility has identified specialized
hazardous waste training requirements (based on regulatory requirements, types/volumes
of hazardous waste generated at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate hazardous waste training needs for all
relevant personnel who may be required to work with hazardous waste?
3) How does the facility ensure that hazardous waste training courses (e.g., annual
hazardous waste refresher training) are completed?
2. Determine how the training documentation is maintained and updated (e.g. by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Key parameters for automatic waste feed cut-off systems;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm systems;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Waste turn in procedures;
h. Identification of hazardous waste;
i. Container use, marking, labeling, and on-base transportation;
j. Manifesting and off-base transportation;
k. Accumulation point management;
1. Personnel health and safety and fire safety; and
m. Shutdown procedures.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and hazardous waste managers and reviewing
hazardous waste program documentation, determine if the facility conducts hazardous
waste self-assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all hazardous waste issues at each self-assessment/appraisal or cover only one
topic at a time (e.g., manifesting and labelling, storage areas, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", track/monitor corrective action.
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address hazardous waste management issues
relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only'
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for hazardous waste management performance.
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Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact hazardous waste
management (for example, projects, programs, or activities that may increase the volume
or toxicity of hazardous waste generated, require additional personnel or equipment to
handle the waste adequately) are carefully reviewed to identify and address
environmental, health, and safety risks as early as possible.
»
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and hazardous
waste managers, and a review of project planning documentation, comment on how the
facility balances environmental concerns against production/operational demands when
reviewing proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of hazardous waste is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of hazardous waste management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies;
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
i
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with hazardous waste management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention opportunities. Programs could include seminars, pollution prevention
newsletters, annual training courses, inclusion in environmental meeting agendas, etc.
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Phase 2
Section 21
Assessing Effectiveness of CERCLA/SARA Program
Management
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Table of Contents
Section 21
CERCLA/SARA
Introduction to Management Systems Assessments 21-1
A. Purpose 21-1
B. Scope 21-1
C. Approach 21-2
D. Understanding Management Systems . 21-2
1. Organizational Structure 21-4
A. Management Organization 21-4
B. Roles and Responsibilities 21-5
2. Environmental Commitment 21-7
A. Top Management Support 21-7
B. Environmental Policy 21-8
C. Line Management Support 21-8
3. Formality of CERCLA/SARA Management Program 21-8
A. Regulatory Tracking and Translation 21-9
B. Procedures 21-10
C. Routine Inspections 21-11
D. Recordkeeping and Reporting 21-12
4. Internal and External Communication 21-14
A. Internal Communication 21-14
B. External Communication 21-15
5. Staff Resources, Training, and Development 21-16
A. Staffing 21-16
B. Job Descriptions and Performance Evaluations 21-17
C. Training Programs 21-17
6. Program Evaluation, Reporting and Corrective Action 21-19
A. Self-Assessment and Appraisal System 21-19
B. Reporting and Follow-up 21-20
7. Environmental Planning and Risk Management 21-21
A. Environmental Planning and Risk Management 21-21
8. Pollution Prevention 21-22
A. Pollution Prevention Goals 21-22
B. Pollution.Prevention Plan 21-22
' C. Pollution Prevention Funding 21-23
D. Pollution Prevention Tracking 21-23
E. Pollution Prevention Training 21-23
F. Pollution Prevention Considerations 21-22
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and whether they have sufficient structure
and formality to assure that activities are conducted in a manner that is consistent with
environmental regulations and Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of: '
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationship's.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, CERCLA/SARA) will allow the auditor to
obtain an understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., CERCLA/SARA storage areas), the auditor often must talk with other
personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, CERCLA/SARA contingency plan). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
• Spill/release records
• Hazardous substance inventory records
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical feature:
• Cleanup sites
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central file or are they in 250 individual employees'
files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's CERCLA/SARA management function is organized. Determine
if the CERCLA/SARA management function is characterized by clear lines of authority
and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the CERCLA/SARA management function and determine
who:
1) Establishes and enforces facility-wide CERCLA/SARA programs, policies, and
procedures/practices;
2) Provides CERCLA/SARA oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
b. Determine who the CERCLA/SARA manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the CERCLA/SARA manager
and person responsible for overall environmental management are open and
effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequently do they talk, etc.).
c. Determine which departments) and individual(s) have authority and
responsibility/accountability for various CERCLA/SARA management activities. For
example, determine through interviews and document review, who is responsible for
inventorying CERCLA/SARA streams, maintaining records relevant to
CERCLA/SARA management, training employees; who is responsible for coordinating
emergency response measures (Linkage with l.B. Roles and Responsibilities).
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2. Determine if CERCLA/SARA managers have sufficient authority to effectively implement
CERCLA/SARA programs and to make decisions related to environmental protection.
Interview the CERCLA/SARA manager and other CERCLA/SARA personnel (e.g.,
community relations coordinator, environmental planning personnel, emergency response
coordinator, etc.) and:
a. Understand the amount of authority given to these personnel at different levels
working with CERCLA/SARA related issues and determine if it is sufficient to carry
out their responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific CERCLA/SARA projects or
. activities and if those personnel have the appropriate background/authority to approve
these projects, and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
CERCLA/SARA management, who is responsible and accountable for CERCLA/SARA
related management activities, including, but not limited to training, preparing PASIs,
spill and emergency response, hazardous substance inventorying, remedial activities,
community relations coordination, and coordination of emergency response measures at
the facility.
a. Identify where and how these roles and responsibilities are defined, such as in program
manuals or job descriptions.
r
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for CERCLA/SARA management match those in program manuals or
job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the CERCLA/SARA functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall CERCLA/SARA management, and determine if this reporting
relationship is clearly and formally defined and understood.
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes CERCLA/SARA policy, procedures, and standards;
2) Provides CERCLA/SARA oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency CERCLA/SARA
policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate CERCLA/SARA management responsibilities are defined and are
included in their written performance appraisal.
a. Interview a selection of CERCLA/SARA management personnel to determine if there
is accountability'for their environmental performance (e.g., if their CERCLA/SARA
responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding
CERCLA/SARA management performance or reprimands for failure to carry out
CERCLA/SARA responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
CERCLA/SARA management, and the facility manager, if top management has supported
CERCLA/SARA programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire emergency response
equipment, improved spill containment devices, etc.
1) If financial, technical, and personnel resources are adequate to manage the volume
of hazardous materials generated and handled at the facility.
b. Whether top management has a clear set of goals and expectations regarding
CERCLA/SARA performance and what they are (e.g., environmental compliance as a
minimum expectation, goals that go beyond compliance, emissions reductions).
2. Review CERCLA/SARA management documentation and identify how senior
management-communicates its CERCLA/SARA goals and expectations to employees;
and, typically, how frequently the goals are communicated. For example, review the
facility's CERCLA/SARA mission statements, policies, procedures, orders, directives,
standard operating procedures, etc. and ascertain if they clearly communicate
CERCLA/SARA goals.
a. Interview a sample of operating and CERCLA/SARA personnel to determine if they
understand the facility's CERCLA/SARA policies, goals, etc.
3. Interview CERCLA/SARA management personnel and understand what types of
CERCLA/SARA reports are routinely and periodically provided to top management
a. Determine if incident reports, feasibility studies, hazardous waste reduction progress
reports, hazardous waste inventory reports, operating record reports, etc., are routinely
prepared for top management and to what extent they address the facility's
CERCLA/SARA status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of
CERCLA/SARA reports or If reports are prepared for "information only."
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B. Environmental Policy
1. Determine through interviews, what CERCLA/SARA policies are widely distributed and
if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., community
relations coordinator, CERCLA/SARA manager, environmental manager, line managers,
facility manager, etc.) whose activities may impact CERCLA/SARA performance to
determine if they take responsibility and interest in limiting the impact of their operations.
For example:
a. Identify activities in which line managers are involved in CERCLA/SARA
management Specifically, do they:
1) Routinely observe field level CERCLA/SARA compliance activities?
2) Participate in audits and self-assessments?
3) Write and review CERCLA/SARA procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to CERCLA/SARA, line
managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences relevant to CERCLA/SARA.
2. Based on the inforamation gathered in the above step, comment on how line managers
support/do not support CERCLA/SARA activities and how they integrate
CERCLA/SARA management into the facility operations. For example, do they observe
compliance activities, conduct self-assessments, train employees, etc.
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3. Formality of CERCLA/SARA Management Program
A. Regulatory Tracking and Translation
i
1. Determine how the facility stays current with new and emerging CERCLA/SARA
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of CERCLA/SARA regulations, and if there is
a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging
CERCLA/SARA regulations and trends (e.g., BNA, Federal Register updates,
professional societies, contact with regulator/officials, subscriptions to professional
publications related to CERCLA/SARA).
c. Determine how new CERCLA/SARA regulations are interpreted as to their
applicability and by whom (e.g., CERCLA/SARA manager, legal department).
d. Note the availability of CERCLA/SARA regulatory reference material (for example,
currency of subscription to BNA, automated access via software, CFRs, Federal and
State Registers, state regulations, technical books, and other reference materials
relating to CERCLA/SARA).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to CERCLA/SARA
program manuals, training courses). Interview selected operating personnel to obtain
their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new CERCLA/SARA
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update
CERCLA/SARA management programs and procedures to reflect changes in
m regulatory requirements, such as PA/SIs, feasibility studies, reporting requirements,
"remedial actions, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
. .timely manner. •
a. Determine how and in what form CERCLA/SARA regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing
CERCLA/SARA programs, policies, and procedures. Note the frequency with which
CERCLA/SARA programs, policies, and procedures are updated/new ones developed,
how often they are reviewed, and who approves them. Determine if there is a formal
system in place to update CERCLA/SARA management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's CERCLA/SARA programs, policies, and procedures. Determine their level of
experience and comment on'the appropriateness of these individuals to perform such
tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new CERCLA/SARA regulatory requirement and determine whether a new
procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
CERCLA/SARA management policies, programs, or procedures, whether the organization
has a program (e.g., written procedures) for the management of CERCLA/SARA,
including, but not limited to:
a. Notification related to continuous and stable releases;
•
b. Notification of existing hazardous waste sites to EPA;
c. Immediate notification of releases to the NRC;
/
d. Sampling and analysis;
e. Preliminary assessments;
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f. Remedial investigations/feasibility studies/risk assessments; and
g. Conducting community relations activities.
. 3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
CERCLA/SARA procedures relevant to their job function.' For example, are they easily
accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting.a sample of CERCLA/SARA management
procedures.
5. Determine whether applicable CERCLA/SARA management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight.
6. Determine if CERCLA/SARA management procedures such as those listed above are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review.
C. Routine Inspections
1. Interview the environmental and CERCLA/SARA managers to determine if the facility
has a program for routine site and equipment inspections and compliance checks,
including appropriate documentation relating to CERCLA/SARA activities. Specifically,
determine if the facility regularly determines compliance with legal and regulatory
requirements such as:
a. Notification of releases;
Phase 2 - Section 21
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b. Community relations work;
c. PA/SIs; and
d. RI/FSs.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner. . .
0. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of CERCLA/SARA
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of CERCLA/SARA activities.
a. Develop an understanding of all systems that are in place for CERCLA/SARA
recordkeeping and document control (e.g., does the facility maintain a log or database
of CERCLA/SARAs generated, hazardous materials handled, notification issues,
community relations documents, PA/SIs, RI/FSs, employee training documentation,
etc.). For example, understand the systems for:
1) Tracking of key regulatory schedules;
2) Maintenance of compliance records; and
3) Preparation and submission of required reports (e.g., notifications of releases to
NRC, spill reports, notification of hazardous waste sites to EPA).
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b. In general, assess the state of the facility's files and recordkeeping practices regarding
CERCLA/SARA records. Determine whether the files are complete, current, and
readily accessible.
c. Determine how the facility ensures that required CERCLA/SARA reports/notifications
are routinely prepared and submitted to the appropriate regulatory agencies in a timely
manner. Through interviews with the environmental manager, identify the person(s)
responsible for regulatory reporting and through interviews with them determine if
they have appropriate experience/training to effectively report on CERCLA/SARA
activities. Types of reports/notifications include:
1) CERCLA/SARA notification for spills/releases in e'xcess of "reportable quantity";
2) Notification of hazardous waste sites to EPA;
3) Notification of hazardous material handling activity to EPA; and
4) Publish notice of availability of the Administrative Record file.
d. Interview the CERCLA/SARA manager to determine whether the recordkeeping
practices are formal and systematic (e.g.. regularly performed by an assigned
individual, computerized).
i
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
CERCLA/SARA compliance and other related environmental information.
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities)
c. Verify that the facility maintains CERCLA/SARA records.
3. Determine how the facility investigates, reports, corrects, tracks, and monitors
CERCLA/SARA related problems and "incidents" (for example, releases/spills of
CERCLA/SARA into the environment, container/tank failure). Interview CERCLA/SARA
personnel and review procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and CERCLA/SARA managers, and review internal meraos,
newsletters, etc., to understand how environmental information related to CERCLA/SARA
is communicated. For example, is CERCLA/SARA information (e.g., hazardous materials
management status, incidents) regularly communicated formally or informally throughout
the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover CERCLA/SARA issues (review minutes of meetings,
talk with personnel who regularly attend meetings).
2. Determine if formal communication of CERCLA/SARA directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of CERCLA/SARA information is
communicated to management:
1) Routine environmental status information;
2) New CERCLA/SARA regulations;
3) Incident or major issue information; and
4) Controversial CERCLA/SARA issues.
b. Determine how quickly new CERCLA/SARA requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to CERCLA/SARA.
a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to
CERCLA/SARA. For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms, publication of availability
of Administrative Record) to keep them informed of the CERCLA/SARA status of the
facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's CERCLA/SARA have been
received from the local community.
1) Note whether these complaints/questions/concems have been documented.
2) Note whether the facility has responded to the complaints/questions/concems and
documented the response.
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5. Staff Resources, Training, arid Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
CERCLA/SARA management activities (this includes dedicated support staff and others
with collateral duties [e.g., line managers with other support functions]). Interview the
human resource manager as well as a sample of CERCLA/SARA staff to determine if
staffing levels are sufficient to achieve performance goals. Specifically:
•a. Note evidence of insufficient or inexperienced CERCLA/SARA management staff to
assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview CERCLA/SARA management personnel and review their job descriptions and
applicable regulations to determine what qualifications are necessary for staffing and other
positions with responsibilities (e.g., emergency response trainers, hazardous waste/material
managers).
a. Determine if personnel with CERCLA/SARA management responsibilities have the
relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in CERCLA/SARA management;
2) Relevant CERCLA/SARA work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of CERCLA/SARA issues at the facility), conclude as to the quality and
quantity of CERCLA/SARA personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for CERCLA/SARA management staff (including
line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties, and
b. If appropriate job descriptions are established and maintained for CERCLA/SARA
management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if CERCLA/SARA management performance is
regularly included in the performance review process.
3. Interview a sample of CERCLA/SARA staff (e.g., community relations coordinator,
hazardous materials managers, environmental managers) to confirm that they are
evaluated on how well they perform their CERCLA/SARA management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing
CERCLA/SARA training programs) to determine if the facility has identified specialized
CERCLA/SARA training requirements (based on regulatory requirements, types/volumes
of hazardous waste/materials generated at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate CERCLA/SARA training needs for all
relevant personnel who may be required to work with CERCLA/SARA?
3) How does the facility ensure that CERCLA/SARA training courses (e.g.,
emergency response training) are completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated). •
Phase 2 - Section 21
management Systems Assessments CERCLA/SARA
21-17
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Emergency response plan;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
*
d. Operation of communications and alarm systems;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Personnel health and safety and fire safety; and
h. Shutdown procedures.
Phase 2 - Section 21
Management Systems Assessments CERCLA/SARA
21-18
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and CERCLA/SARA managers and reviewing
CERCLA/SARA program documentation, determine if the facility conducts
CERCLA/SARA self-assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all CERCLA/SARA issues at each self-assessment/appraisal or cover only one
topic at a time (e.g., manifesting and labelling, storage areas, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", track/monitor corrective action.
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address CERCLA/SARA management issues
relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Phase 2 - Section 21
Management Systems Assessments CERCLA/SARA
21-19
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility" management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
' notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for CERCLA/SARA management performance.
Phase 2 - Section 21
Management Systems Assessments CERCLA/SARA
21-20
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Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact CERCLA/SARA
management (for example, projects, programs, or activities that may increase the volume
or toxicity of hazardous materials generated/handled, require additional personnel to
manage CERCLA/SARA adequately) are carefully reviewed to identify and address
. environmental, health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and
CERCLA/SARA managers, and a review of project planning documentation, comment on
how the facility balances environmental concerns against production/operational demands
when reviewing proposed new projects, programs, or activities.
Phase 2 - Section 21
Management Systems Assessments . CERCLA/SARA
21-21
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of environmental management personnel to determine if they
understand the facility goal with regard to pollution prevention.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note-the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the faculty's approach to pollution prevention and reflects
current pollution prevention strategies;
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
Phase 2 - Section 21
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or -other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with environmental management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention opportunities. Programs could include seminars, pollution prevention
newsletters, annual training courses, inclusion in environmental meeting agendas, etc.
Phase 2 - Section 21
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21-23
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F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (CERCLA/SARA), and activities
associated with CERCLA/SARA.
1. Based on your understanding of the facility operations and types and volumes of wastes
generated, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities (Waste Minimization Plan Linkage
with Phase 1 - Section 3).
Phase 2 - Section 21
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21-24
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Phase 2
Section 22
Assessing Effectiveness of Spill Control and
Response Program Management
-------
Table of Contents
Section 22
Spill Control and Response
Introduction to Management Systems Assessments 22-1
A. Purpose 22-1
B. Scope 22-1
C. Approach . . 22-2
D. Understanding Management Systems ' 22-2
1. Organizational Structure 22-4
A. Management Organization 22-4
B. Roles and Responsibilities • 22-5
2. Environmental Commitment 22-7
A. Top Management Support 22-7
B. Environmental Policy 22-8
C. Line Management Support 22-8
3. Formality of Spill Control and Response Management Program 22-9
A. Regulatory Tracking and Translation 22-9
B. Procedures 22-10
C. Routine Inspections- 22-11
D. Recordkeeping and Reporting 22-12
4. Internal and External Communication 22-15
A. Internal Communication . 22-15
B. External Communication 22-16
5. Staff Resources, Training, and Development 22-17
A. Staffing 22-17
B. Job Descriptions and Performance Evaluations 22-18
C. Training Programs 22-18
6. Program Evaluation, Reporting and Corrective Action 22-20
A. Self-Assessment and Appraisal System 22-20
B. Reporting and Follow-up 22-21
7. Environmental Planning and Risk Management 22-22
A. Environmental Planning and Risk Management • 22-22
8. Pollution Prevention 22-23
A. Pollution Prevention Goals 22-23
B. Pollution Prevention Plan 22-23
C. Pollution Prevention Funding 22-24
D. Pollution Prevention Tracking 22-24
E. Pollution Prevention Training 22-24
F. Pollution Prevention Considerations 22-25
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Introduction
A. Purpose .
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
• Organizational Structure
• Environmental Commitment
• Formality of Environmental Program
• Internal and External Communication
• Staff Resources, Training and Development
• Program Evaluation, Reporting and Corrective Action
• Environmental Planning and Risk Management
• Pollution Prevention
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
^
22-1
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment. They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, spill control and response) will allow the
auditor to obtain an understanding as to why and how the environmental management systems
work.
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-2
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g.. spill control and response storage areas), the auditor often must talk
with other personnel. This will enable the auditor to develop an increased sense of confidence
in or reliance on the information based on corroboration of multiple sources and to develop
clues as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, volume of oils/chemicals in storage). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
• Spill Control and Response Plan
• Spill training records
• Records of past spills
• Tank inspections/integrity testing
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
* Refueling facilities
• Washrack areas
• Vehicle maintenance areas
• Oil/water separators
• Container storage areas
• Loading/unloading areas
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are spill training records kept in one central file or are they in individual employees'
files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-3
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's spill control and response function is organized. Determine if
the spill control and response management function is characterized by clear lines of
authority and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the spill control and response function and determine who:
1) Establishes and enforces facility-wide spill control and response programs, policies,
and procedures/practices;
2) Provides spill control and response oversight/management to field/operating
personnel; and
3) Provides technical support for field personnel.
b. Determine who the spill control and response manager reports to and how that
reporting function is linked to the facility manager or person responsible for overall
environmental management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the spill control and response
manager and person responsible for overall environmental management are open
and effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequently do .they talk, etc.).
c. Determine which department(s) and indivtdual(s) have authority and
responsibility/accountability for various spill control and response management
activities. For example, determine through interviews and document review, who is
responsible for maintaining records relevant to spill control and response, training
employees, coordinating emergency response measures (Linkage with l.B. Roles and
Responsibilities).
Phase 2 • Section 22
Management Systems Assessments Spill Control and Response
22-4
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2. Determine if spill control and response managers have sufficient authority to effectively
implement spill control and response programs and to make decisions related to
environmental protection. Interview the spill control and response manager and other spill
control and response personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with spill control and response and determine if it is sufficient to carry out
their responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific spill control and response projects
or activities and if those personnel have the appropriate background/authority to
approve these projects, and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
spill control and response, who is responsible and accountable for spill control and
response activities, including, but not limited to training, tracking, recordkeeping and
reporting, storage areas, and coordination of emergency response measures at the facility.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for spill control and response management match those in program
manuals or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the spill control and response functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall spill control and response management, and determine if this
reporting relationship is clearly and formally defined and understood.
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-5
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes spill control and response policy, procedures, and standards;
2) Provides spill control and response oversight/management to field/operating
personnel; and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency spill control and
response policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate spill control and response management responsibilities are defined and
are included in their written performance appraisal.
a. Interview a selection of spill control and response management personnel to determine
if there is accountability for their environmental performance (e.g., if their spill control
and response management/field responsibilities are evaluated during performance
reviews).
b. Determine whether there have been any instances of rewards for outstanding spill
control and response management performance or reprimands for failure to carry out \
spill control and response management responsibilities.
Phase 2 • Section i.
Management Systems Assessments Spill Control and Response
22-6
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
spill control and response management, and the facility manager, if top management has
supported spill control and response programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire spill control and response
equipment, to develop and enhance spill control and response programs, etc.
1) If financial, technical, and personnel resources are adequate to manage spill control
and response activities at the facility.
b. Whether top management has a clear set of goals and expectations regarding spill
control and response performance and what they are (e.g., environmental compliance
as a minimum expectation, goals that go beyond compliance, emissions reductions).
2. Review spill control and response management documentation and identify how senior
management communicates its spill control and response goals and expectations to
employees; and, typically, how frequently the goals are communicated. For example,
review the facility's spill control and response policies, procedures, orders, directives,
standard operating procedures, etc. and ascertain if they clearly communicate spill control
and response goals.
a. Interview a sample of operating and spill control and response personnel to determine
if they understand the facility's spill control and response policies, goals, etc.
3. Interview spill control and response management personnel and understand what types of
spill control and response reports are routinely and periodically provided to top
management.
a Determine if spill control and response reports, and spill control and response
reduction progress reports, training records, etc.. are routinely prepared for top
management and to what extent they address the facility's spill control and response
status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of spill
control and response reports or if reports are prepared for "information only."
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-7
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B. Environmental Policy
1. Determine through interviews, what spill control and response policies are widely
distributed and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., spill control and
response manager/inspector, environmental manager, line managers, facility manager, etc.)
whose activities may impact spill control and response performance to determine if they
take responsibility and interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in spill control and response
management. Specifically, do they:
1} Routinely observe field level spill control and response compliance activities?
2) Participate in audits and self-assessments?
3) Write and review spill control and response procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to spill control and
response, line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to spills.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support spill control and response activities and how they integrate spill
control and response management into the facility operations. For example, do they
observe compliance activities, conduct self-assessments, train employees, etc.?
Phase 2 - Section
Management Systems Assessments Spill Control and Response
22-8
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3. Formality of Spill Control and Response Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging spill control and
response regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of spill control and response regulations, and if
there is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging spill control
- and response regulations and trends (e.g., BNA, Federal Register updates, professional
societies, contact with regulator/officials, subscriptions to professional publications
related to spill control and response management).
c. Determine how new spill control and response regulations are interpreted as to their
applicability and by whom (e.g., spill control and response manager, legal department).
d. Note the availability of spill control and response regulatory reference material (for
example, currency of subscription to BNA, automated access via software, CFRs,
Federal and State Registers, state regulations, technical books, and other reference
materials relating to spill control and response management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to spill control and
response program manuals, training courses). Interview selected operating personnel to
obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new spill control and response
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update spill
control and response management programs and procedures to reflect changes in
regulatory requirements, such as biennial reporting requirements, storage, handling,
treatment and disposal practices for spill control and response, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form spill control and response regulatory information is
transmitted to the facility.
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-9
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing spill
control and response programs, policies, and procedures. Note the frequency that spill
control and response programs, policies, and procedures in updated/new ones developed,
how often they are reviewed, and who approves them. Determine if there is a formal
system in place to update spill control and response management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's spill control and response programs, policies, and procedures. Determine
their level of experience and comment on the appropriateness of these individuals to
perform such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new spill control and response regulatory requirement and determine
whether a new procedure has been developed and approved, or an existing has been
updated and approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
spill control and response management policies, programs, or procedures, whether the
organization has a program (e.g., written procedures) for the management of spill control
and response, including, but not limited to:
a. Developing spill control and response plans;
b. Periodic review and updating of spill plans;
c. Methods used to determine volumes of oils/chemicals on-site;
d. Emergency response;
e. Shipping paper preparation;
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-10
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f. Integrity testing of equipment;
g. Labeling of containers;
h. Storage area maintenance and inspection; and
i. Corrective action for identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
spill control and response procedures relevant to their job function. For example, are they
easily accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of spill control and'response
management procedures.
5. Determine whether applicable spill control and response programs include the following
program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight.
6. Determine if spill control and response procedures such as those listed above are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review/update.
C. Routine Inspections
1. Interview the environmental and spill control and response managers and inspectors to
determine if the facility has a program for routine site and equipment inspections and
compliance checks, including appropriate documentation relating to spill control and
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-11
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response activities. Specifically, determine if the facility regularly determines compliant
with regulatory and internal requirements such as:
a. Storage area/container inspections;
b. Condition/availability of emergency response equipment;
c. Training of personnel;
d. Integrity testing of equipment; and
e. Overfill protection practices.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review. For example:
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Spill Control and Response
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of spill control and response activities.
a. Develop an understanding of all systems that are in place for spill control and
response recordkeeping and document control (e.g., does the facility maintain a log or
Phase 2 - Section 2*
Management Systems Assessments Spill Control and Response
22-12
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database of oil/chemicals in storage, inspection logs, inventory reports, employee
training documentation, shipping papers, etc.). For example, understand the systems
for:
1) Tracking of key regulatory schedules (e.g., updating of spill plans, etc.);
2) Maintenance of compliance records (e.g., inspection logs, shipping papers, training
records, inventory records, etc.); and
3) Preparation and submission of required reports (e.g.. pollution prevention reports,
spill reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
spill control and response records. Determine whether the flies are complete, current,
and readily accessible.
c. Determine how the facility ensures that required spill control and response
reports/notifications are prepared and submitted to the appropriate regulatory agencies
in a timely manner. Through interviews with the environmental manager, identify the
person(s) responsible for regulatory reporting and through interviews with them
determine if they have appropriate experience/training to effectively report on spill
control and response activities. Types of reports/notifications include:
1) Emergency equipment inspection (e.g., California state requirement);
2) Integrity test;
3) Inventory reports; and
4) Notification for spills/releases.
d. Interview the spill control and response manager to determine whether the
recordkeeping practices are formal and systematic (e.g., regularly performed by an
assigned individual, computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
applicable compliance requirements and other related environmental information. (For
example, the facility may choose to maintain integrity testing or training records
indefinitely.)
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities)
«
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
22-13
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c. Verify that the facility maintains spill control and response records for the retention
periods specified by regulation.
3. Determine how the facility investigates, reports, corrects, tracks, and monitors spill
control and response problems and "incidents" (for example, releases/spills of hazardous
waste into the environment, container/tank failure). Interview spill control and response
personnel and review procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
Phase 2 - Section
Management Systems Assessments Spill Control and Respon^
22-14
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and spill control and response managers, and review internal
memos, newsletters, etc., to understand how environmental information related to spill
control and response is communicated. For example, is spill control and response
information regularly communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover spill control and response issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of spill control and response directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of spill control and response information
are communicated to management:
1) Routine environmental status information;
2) New spill control and response regulations;
3) Incident or major issue information; and
4) Controversial spill control and response issues.
b. Determine how quickly new spill control and response requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to spill control and response.
a. Review files to determine if the concerns and responses are documented.'
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason.)
t
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to spill control
and response. For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the spill control and response status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's spill control and response
have been received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
Phase 2 - Section
Management Systems Assessments Spill Control and Respond
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
spill control and response management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of spill control and response staff to
determine if staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced spill control and response staff to assure
compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) 'Excessive overtime; or
3) Excessive use of contractors.
2. Interview spill control and response management personnel and review their job
descriptions and applicable regulations to determine what qualifications are necessary for
staffing and other positions with responsibilities (e.g., spill control and response trainers,
spill control and response managers).
a. Determine if personnel with spill control and response responsibilities have the
relevant background and training to carry out their responsibilities.
b. Review a sample of resumes fromselected staff (e.g., maintenance personnel, storage
facility manager/inspector, emergency response coordinator, etc.) and note the
' following:
1) Specialized training in spill control and response management;
2) Relevant spill control and response work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of spill control and response issues at the facility) conclude as to the
quality and quantity of spill control and response personnel at the facility.
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for spill control and response staff (including line
managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties, and
b. If appropriate job descriptions are established and maintained for spill control and
response positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if spill control and response performance is
regularly included in the performance review process of appropriate personnel.
3. Interview a sample of spill control and response staff (e.g., maintenance, spill response
staff) to confirm that they are evaluated on how well they perform their spill control and
response responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work.
C. Training Programs
1. Review training documentation (training manuals or other documents describing spill
control and response training programs) to determine if the facility has identified
specialized spill control and response training requirements based on regulatory/internal
requirements (spill prevention and control training).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate spill control and response training
needs for all relevant personnel?
3) How does the facility ensure that spill control and response training courses (e.g.,
spill control and response initial/refresher training) are completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
Phase 2 - Section 22
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Key parameters for automatic hazardous materials feed cut-off systems;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm systems;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Integrity testing;
h. Corrosion control;
i. Loading/unloading procedures;
j. Storage facility management; and
k. Personnel health and safety and fire safety.
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and spill control and response managers and reviewing
spill control and response program documentation, determine if the facility conducts spill
control and response self-assessments/appraisals. Note whether the self-
assessments/appraisals :
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all spill control and response issues at each self-assessment/appraisal or cover
only one topic at a time (e.g., manifesting and labeling, storage areas, transportation);
d. Are documented and results retained in organized flies; and
e. Document results, note "findings" or "deficiencies", track/monitor corrective action.
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address spill control and response management
issues relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually).
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for spill control and response management performance.
Phase 2 - Section 22
Management Systems Assessments Spill Control and Response
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact spill control and
response (for example, projects, programs, or activities that may increase the volume or
toxicity of oils/chemicals stored, require additional personnel or equipment to handle the
oils/chemicals adequately) are carefully reviewed to identify and address environmental,
health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention
opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type)..
2. Based on interviews with facility management, including environmental and spill control
and response managers, and a review of project planning documentation, comment on
how the facility balances environmental concerns against production/operational demands
when reviewing proposed new projects, programs, or activities.
Phase 2 - Section 2*
Management Systems Assessments Spill Control and Response
22-22
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of spills is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of spill control management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
• track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
Phase 2 - Section 22
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with spill control and response management personnel and a review
of documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
Phase 2 - Section
Management Systems Assessments Spill Control and Respom..
22-24
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pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
1. Based on your understanding of the facility operations and types and volumes of spills
occurring, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities. Types of pollution prevention
initiatives may include the following (Waste Minimization Plan Linkage with Phase 1 -
Section 3):
a. Has the facility installed proper spill containment (e.g., overflow control devices,
dikes, berms, etc.) so that drainage to the wastewater system and causing systems
upsets can be avoided?
b. Has the facility established spill cleanup procedures to mitigate chances of spills being
discharged to the wastewater treatment plant?
c. Has the facility installed tank overfill prevention systems to prevent spills?
d. Has the facility paved areas under pipe racks to facilitate leak detection?
e. Does the facility contain spills with dikes and absorbent materials to prevent spreading
of spills?
f. Does the facility prevent automatic crossover of storm drains to the wastewater
collection system to prevent spills and firefighting water entering the storm drains
from overwhelming the wastewater treatment plant?
g. Does the facility use sealless pumps?
h. Does the facility use oil-absorbent pads to reclaim both the pads and used oil (instead
of using granulated absorbents)?
i. Has the facility installed splash guards, and drip boards on tanks and faucets?
j. Does the facility ensure that lids and bungs are tight fitting on containers to prevent
loss of chemicals through spillage?
k. Does the facility keep spill records containing information on why, when, where of
spills so that reoccurrences can be avoided?
Phase 2 - Section 22
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Phase 2
Section 23
Assessing Effectiveness of Environmental Impact
Program Management
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Table of Contents
Section 23
Environmental Impact
Introduction to Management Systems Assessments 23-1
A. Purpose 23-1
B. Scope . 23-1
C. Approach . 23-2
D. Understanding Management Systems . 23-2
1. Organizational Structure 23-6
A. Management Organization 23-6
B. Roles and Responsibilities 23-7
2. Environmental Commitment 234
A. Top Management Support 23-9
B. Environmental Policy 23-10
C. Line Management Support 23-10
3. Formality of Environmental Impact Management Program 23-11
A. Regulatory Tracking and Translation 23-11
B. Procedures 23-12
C. Routine Inspections 23-14
D. Recordkeeping and Reporting 23-15
4. Internal and External Communication 23-17
A. Internal Communication 23-17
B. External Communication 23-18
5. Staff Resources, Training, and Development 23-19
A. Staffing • 23-19 -
B. Job Descriptions and Performance Evaluations 23-20
C. Training Programs 23-20
6. Program Evaluation, Reporting and Corrective Action 23-22
A. Self-Assessment and Appraisal System 23-22
B. Reporting and Follow-up 23-23
7. Environmental Planning and Risk Management 23-24
A. Environmental Planning and Risk Management 23-24
8. Pollution Prevention • , 23-25
A. Pollution Prevention Goals 23-25
B. Pollution Prevention Plan 23-25
C. Pollution Prevention Funding 23-26
D. Pollution Prevention Tracking 23-26
E. Pollution Prevention Training 23-26
F. Pollution Prevention Considerations 23-27
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
• Organizational Structure
• Environmental Commitment
• Formality of Environmental Program '
• Internal and External Communication
• Staff Resources, Training and Development
• Program Evaluation, Reporting and Corrective Action
• Environmental Planning and Risk Management
• Pollution Prevention
Phase 2 - Section 23
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C. Approach
In an assessment of specific environmental program-management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment. They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, environmental impact) will allow the auditor
to obtain an understanding as to why and how the environmental management systems work.
Phase 2 - Section 1
Management Systems Assessments Environmental Impact
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., environmental impact storage areas), the auditor often must talk with
other personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, environmental impact contingency plan). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
Administrative Records (CERCLA)
Aerial site photographs
Agricultural and Grazing Lease Contracts
Coastal Zone Management Plans
Dredging permits (Section 10 RHA)
Ecological Risk Assessments (ERA)
Endangered Species Management Plan
Environmental Impact Documentation (e.g., NEPA documents)
Federal/state lists of protected plant and animal species
Fish and Wildlife Cooperative Agreements
Federal Emergency Management Agency (FEMA) flood insurance rate maps (FIRM), to
identify the 100-year floodplain
Forest and Vegetation Management Plans
Grounds Maintenance Contracts
Human Health Risk Assessments (HHRA)
Land and surface water resource management plans
Land use and site development master plans
Memoranda of Agreement (MOA)
National Wetlands Inventory (NWI) maps
Natural Resource Damage Assessments (NRDA)
Natural Resources Management Plan (Facility)
Natural Resources Heritage Programs to get listing of Endangered/Threatened species for
facility area
- CIS maps with above data plotted for facility
NEPA Documents: EA, FONSI, EIS, Supplemental EIS
Notices of Violations (NOVs) for air/water emissions
NPDES permit effluent limitations and effluent monitoring data
Outdoor Recreation Cooperative Agreement
Pollution Prevention Plans
Remedial Investigation/Feasibility Study (RI/FS) reports
Surface water quality monitoring results (compare to federal/state AWQC)
. *
Phase 2 - Section 23
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• U.S. Geological Survey (USGS) topographic maps
• Wetland permits (Section 404 CWA and state permits)
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Agricultural areas: croplands, livestock pens, and grazing pastures/lease areas (condition
and management)
•. Construction, dredging, and excavation sites (landscaping and control of erosion, runoff.
and sedimentation)
• Critical habitats for protected species of flora/fauna
• Devices to prevent wildlife contact with hazardous materials
• Equipment which could damage wildlife, its habitat, or land and water resources (use and
control)
• Exposed soils and steep slopes (condition and erosion)
• Facilities constructed since passage of the CWA (spatial relationship to floodplains and
wetlands)
• Floodplains, associated rivers, dams, and levees
• Forest management areas (condition and management)
• Grounds maintenance areas (beautification and condition)
• Heavy equipment/vehicle lay-down yards/parking lots
• Pipeline, powerline, and sewerage corridors and faculties
• Pesticide application areas (impacts to non-target species)
• Shorelines, coastal storm surge areas, and velocity zones
• Sites undergoing remedial action (impacts of remediation)
• Stormwater drainage areas and management systems (condition)
• Surface water bodies, water intakes, and pumping stations
• Terrestrial wildlife habitats (condition and management)
• Training (e.g. firefighting and spill response) sites
• Vegetated wetland ecosystems
• Vegetation control areas (impacts to non-target species)
• Waste disposal, transfer, and/or storage facilities
• Wastewater biological treatment facilities (incl. wetlands)
• Wildlife containment areas (condition and management)
• Wildlife hunting areas, preserves, and sanctuaries
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
Phase 2 - Section 23
Management Systems Assessments Environmental Impact
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a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central file or are they in individual employees' files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
Phase 2 - Section 23
Management Systems Assessments Environmental Impact
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's environmental impact management function is organized.
Determine if the environmental impact management function is characterized by clear
lines of authority and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the environmental impact management function (programs,
policies, procedures for preparing and submitting of NEPA documents, permitting
procedures, etc.) and determine who:
1) Establishes and enforces facility-wide environmental impact programs, policies, and
procedures/practices;
2) Provides environmental impact oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
b. Determine who the environmental impact manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management.
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the environmental manager and
person responsible for overall environmental impact management are open and
effective (e.g., how do these people communicate [verbal, memo, etc.]; how
frequently do they talk, etc.).
c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various environmental impact management activities.
For example, determine through interviews and document review who is responsible
for preparation of NEPA documents (FONSI, EA, EIS), maintaining administrative
records (CERCLA) Section 10 HRAs/ERAs, remedial investigation/feasibility study
reports (Linkage with l.B. Roles and Responsibilities).
Phase 2 - Section
Management Systems Assessments Environmental Impa*..
23-6
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2. Determine if environmental impact managers have sufficient authority to effectively
implement environmental impact programs and to make decisions related to
environmental protection. Interview the environmental impact manager and other
environmental impact personnel (environmental planning staff, legal counsel, etc.) and:
a. Understand the amount of authority given to these personnel at different levels
working with environmental impact and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific environmental impact projects or
activities and if those personnel have the appropriate background/authority to approve
these projects, and .
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
environmental impact management, who is responsible and accountable for environmental
impact management activities, including, but not limited to preparing NEPA documents,
ecological risk assessments, human health risk assessments (HHRA), wetlands permitting,
managing fish and wildlife cooperative agreements, etc.
. a. Identify where and how these roles and responsibilities are defined, such as in program
manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for environmental impact management match those in program manuals
or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the environmental impact functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall environmental impact management, and determine if this
reporting relationship is clearly and formally defined and understood.
Phase 2 - Section 23
Management Systems Assessments Environmental Impact
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes environmental impact policy, procedures, and standards;
2) Provides environmental impact oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency environmental impact
policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate environmental impact management responsibilities are defined and are
included in their written performance appraisal.
a. Interview a selection of environmental impact management personnel to determine if
there is accountability for their environmental performance (e.g., if their environmental
impact management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding
environmental impact prevention or reprimands for failure to carry out impact
monitoring and mitigation responsibilities.
Phase 2 - Section.
Management Systems Assessments Environmental Impact
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
environmental impact management, and the facility manager, if top management has
supported environmental impact programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds for conducting NEPA reviews,
JJHRAs, etc.
1) If financial, technical, and personnel resources are adequate to determine the
environmental impact related to the activities of the facility.
b. Whether top management has a clear set of goals and expectations regarding
environmental impact performance and what they are (e.g., environmental compliance
as a minimum expectation, goals that go beyond compliance, impact reductions).
2. Review environmental impact management documentation and identify how senior
management communicates its environmental impact goals and expectations to employees;
and, typically, how frequently the goals are communicated. For example, review the
facility's environmental impact mission statements, policies, procedures, orders, directives,
standard operating procedures, etc. and ascertain if they clearly communicate
environmental impact goals.
a. Interview a sample of operating and environmental impact personnel to determine if
they understand the facility's environmental impact policies, goals, etc.
3. Interview environmental impact management personnel and understand what types of
environmental impact reports ate routinely and periodically provided to top management.
a. Determine if EH, natural resource damage reports, HHRA results, etc. are routinely
prepared for top management and to what extent they address the facility's
environmental impact status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of
environmental impact reports or if reports are prepared for "information only."
Phase 2 - Section 23
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B. Environmental Policy
1. Determine through interviews, what environmental impact policies are widely distributed ••
and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g.. legal
department, environmental impact manager, environmental manager, line managers,
facility manager, etc.) whose activities may affect environmental impact performance to
determine if they take responsibility and interest in limiting the impact of their operations.
For example:
a. Identify activities in which line managers are involved in environmental impact
management. Specifically, do they:
1) Routinely observe field level environmental impact compliance activities?
2) Participate in audits and self-assessments?
3) Write and review environmental impact procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to environmental impact,
line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental occurrences with an environmental impact
2. Based on the information gathered in the above step, comment on how line managers
support/do not support environmental impact activities and how they integrate
environmental impact management into die facility operations. For example, do they
observe compliance activities, conduct self-assessments, train employees, etc.
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3. Formality of Environmental Impact Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging environmental impact
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of environmental impact regulations, and if
there is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging
environmental impact regulations and trends (e.g., BNA, Federal Register updates,
professional societies, contact with regulator/officials, subscriptions to professional
publications related to environmental impact management).
c. Determine how new environmental impact regulations are interpreted as to their
applicability and by whom (e.g., environmental impact manager, legal department).
d. Note the availability of environmental impact regulatory reference material (for
example, currency of subscription to BNA, automated access via software, CFRs,
Federal and State Registers, state regulations, technical books, and other reference
materials relating to environmental impact management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to environmental
impact program manuals, training courses). Interview selected operating personnel to
obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new environmental impact
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update
environmental impact management programs and procedures to reflect changes in
regulatory requirements, such as EISs, EAs, FONSIs, supplemental EISs, pollution
prevention plans, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form environmental impact regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing
environmental impact programs, policies, and procedures. Note the frequency with which
environmental impact programs, policies, and procedures are updated/new ones developed,
how often they are reviewed, and who approves them. Determine if there is a formal
system in place to update environmental impact management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's environmental impact programs, policies, and procedures. Determine their
level of experience and comment on the appropriateness of these individuals to
perform such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process (e.g., facility manager, environmental manager, permitting department, etc.).
c. Identify a new environmental impact regulatory requirement and determine whether a
new procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
environmental impact management policies, programs, or procedures, whether the
organization has a program (e.g., written procedures) for the management of
environmental impact, including, but not limited to:
a. Preparing pollution prevention plans;
b. Documentation and management of noise at airport facilities;
c. Management of noise complaints;
d. Use of off-road vehicles on federal lands;
e. Integration of the NEPA process into planning of projects;
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f. Preparation of EAs/EISs/FONSIs;
g. Coordination of preparation of EISs in multiple agency scenarios;
h. Managing public involvement in the EIS process;
i. Soliciting comments from specific individuals (EIS);
j. Preparation of PASIs;
k. Environmental monitoring program; and
I. Wildlife management program (including endangered species and aquatic biota).
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
environmental impact procedures relevant to their job function. For example, are they
easily accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility, by requesting a sample of environmental impact management
procedures.
5. Determine whether applicable environmental impact management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
6. Determine if environmental impact management procedures such as those listed above are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review/update.
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C. Routine Inspections
1. Interview the environmental and environmental impact managers to determine if the
facility has a program for routine site and equipment inspections and compliance checks,
including appropriate documentation relating to environmental impact activities.
Specifically, determine if the facility regularly determines compliance with legal and
regulatory requirements such as:
a. Construction dredging and excavation sites;
b. Forest management areas;
c. Wastewater biological treatment facilities;
d. Stormwater drainage areas and management systems;
e. Devices to prevent wildlife contact with hazardous materials; and
f. Sites undergoing remedial action.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections. .
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
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D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Environmental Impact
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of environmental impact activities.
a. Develop an understanding of all systems that are in place for environmental impact
recordkeeping and document control (e.g., does the facility maintain a log or database
of spill emergency response training, NEPA documents, CERCLA documents, ERAs,
HHRAs, etc.). For example, understand the systems for:
1) Tracking of key regulatory schedules (e.g., NEPA document preparation, required
training, etc.);
2) Maintenance of compliance records (e.g., EAs, ERAs, EISs. Notices of Intent
(NOI). feasibility studies, etc.); and
3) Preparation and submission of required reports (e.g., EISs, FONSIs, etc.).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
environmental impact records. Determine whether the files are complete, current, and
1 readily accessible.
c. Determine how the facility ensures that required environmental impact
reports/notifications are routinely prepared and submitted to the appropriate regulatory
agencies in a timely manner. Through interviews with the environmental manager,
identify the person(s) responsible for regulatory reporting and through interviews with
them determine if they have appropriate experience/training to effectively report on
environmental impact activities. Types of reports/notifications include:
1) Notices of intent;
2) Noise exposure map and noise compatibility program (for airport facilities);
3) FONSIs;
4) EAs; and
5) CERCLA/SARA notification for spills/releases in excess of "reportable quantity".
d. Interview the environmental impact manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized, etc.).
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2. Determine whether the facility has a document control system and record retention polic'
\
a. Determine whether the facility has a formal records retention policy which covers
NEPA/CERCLA/SARA compliance and other related environmental information.
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities)
c. Verify that the facility maintains environmental impact records for the retention
periods specified by regulation.
3. Determine how the facility investigates, reports, corrects, tracks, and monitors
environmental impact problems and "incidents'1 (for example, releases/spills of hazardous
materials into the environment, container/tank failure). Interview environmental impact
personnel and review procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
Phase 2 - Section Su
Management Systems Assessments Environmental Impact
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and environmental impact managers, and review internal
memos. newsletters, etc., to understand how environmental information related to
environmental impact is communicated. For example, is environmental impact information
(e.g., environment impact management status, incidents) regularly communicated formally
or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover environmental impact issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of environmental impact directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of environmental impact information is
communicated to management:
1) Routine environmental status information;
2) New environmental impact regulations;
3) Incident or major issue information; and
4) Controversial environmental impact issues.
b. Determine how quickly new environmental impact requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to environmental impact
a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to environmental'
impact For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms, etc.) to keep them
informed of the environmental impact status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's environmental impact have
been received from the local community.
1) Note whether these complaints/questions/concems have been documented.
2) Note whether the facility has responded to the complaints/questions/concems and
documented the response.
Phase 2 - Section
Management Systems Assessments Environmental Impa*..
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
environmental impact management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of environmental impact staff to
determine if staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced environmental impact management staff
to assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview environmental impact management personnel and review their job descriptions
and applicable regulations to determine what qualifications are necessary for staffing and
other positions with responsibilities (e.g., spill and emergency response trainers, etc.).
a. Determine if personnel with environmental impact management responsibilities have
the relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in EI/NEPA management;
2) Relevant NEPA work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of environmental impact issues at the facility) conclude as to the quality
and quantity of environmental impact personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for environmental impact management staff
(including line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for environmental impact
management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if environmental impact management performance
is regularly included in the performance review process.
.3. Interview a sample of environmental impact staff to confirm that they are evaluated on
how well they perform their environmental impact management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing
environmental impact training programs) to determine if the facility has identified
specialized environmental impact training requirements (based on regulatory requirements,
operations of the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate environmental impact training needs for
all relevant personnel who may be required to work on environmental impact
issues?
3) How does the facility ensure that environmental impact training courses (e.g., spill
and emergency response training) are completed?
2. Determine how the training documentation is maintained and updated (e.g. by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Key parameters for automatic waste feed cut-off systems;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm systems;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Personnel health and safety and fire safety, and
h. Shutdown procedures.
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Management Systems Assessments Environmental Impact
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and environmental impact managers and reviewing
environmental impact program documentation, determine if the facility conducts
environmental impact self-assessments/appraisals. Note whether the self-
assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all environmental impact issues at each self-assessment/appraisal or cover only
one topic at a time;
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address environmental impact management issues
relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Phase 2 - Section
Management Systems Assessments Environmental Impact
23-22
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for environmental impact reduction.
Phase 2 - Section 23
Management Systems Assessments Environmental Impact
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact environmental
impact management (for example, projects, programs, or activities that may increase the
volume or toxicity of hazardous wastes generated, or the use of hazardous materials) are
carefully reviewed to identify and address environmental, health, and safety risks as early
as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and
environmental impact managers, and a review of project planning documentation,
comment on how the facility balances environmental concerns against
production/operational demands when reviewing proposed new projects, programs, or
activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of environmental management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
Phase 2 * Section 23
Management Systems Assessments Environmental Impact
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these'persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with environmental management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
Phase 2 - Section 23
Management Systems Assessments Environmental Impact
23-26
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pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (environmental impact), and activities
associated with environmental impact.
1. Based on your understanding of the facility operations and types and volumes of wastes
generated, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities (Waste Minimization Plan Linkage
with Phase 1 - Section 3).
Phase 2 - Section 23
Management Systems Assessments Environmental Impact
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Phase 2
Section 24
Assessing Effectiveness of Hazardous Materials
Program Management
-------
Table of Contents
Section 24
Hazardous Materials
Introduction to Management Systems Assessments 24-1
A. Purpose 24-1
B. Scope 24-1
C. Approach 24-2
D. Understanding Management Systems 24-2
1. Organizational Structure 24-5
A. Management Organization 24-5
B. Roles and Responsibilities - 24-6
2. Environmental Commitment , 24-8
A. Top Management Support 24-8
B. Environmental Policy 24-9
C. Line Management Support 24-9
3. Formality of Hazardous Materials Management Program 24-10
A. Regulatory Tracking and Translation 24-10
B. Procedures 24-11
C. Routine Inspections 24-13
D. Recordkeeping and Reporting 24-13
4. Internal and External Communication 24-16
A. Internal Communication 24-16
B. External Communication 24-17
5. Staff Resources, Training, and Development 24-18
A. Staffing 24-18
B. Job Descriptions and Performance Evaluations 24-19
C. Training Programs 24-19
6. Program Evaluation, Reporting and Corrective Action 24-21
A. Self- Assessment and Appraisal System 24-21
B. Reporting and Follow-up 24-21
7. Environmental Planning and Risk Management 24-23
A. Environmental Planning and Risk Management 24-23
8. Pollution Prevention 24-24
A. Pollution Prevention Goals 24-24
B. Pollution Prevention Plan 24-24
C. Pollution Prevention Funding 24-25
D. Pollution Prevention Tracking 24-25
E. Pollution Prevention Training 24-25
F. Pollution Prevention Considerations • 24-26
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
* Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
• Organizational Structure
• Environmental Commitment
• Formality of Environmental Program
• Internal and External Communication
• Staff Resources, Training and Development
• Program Evaluation, Reporting and Corrective Action
• Environmental Planning and Risk Management
• Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and whether they have sufficient structure
and formality to assure that activities are conducted in a manner that is consistent with
environmental regulations and Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for .
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
0. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, hazardous materials) will allow the auditor
to obtain an understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., hazardous materials storage areas), the auditor often must talk with
other personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information which cannot
be readily resolved.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, hazardous materials contingency plan). This review serves to further enhance an
auditor's .understanding of the management systems and physical controls. Review the
following documents:
• Hazardous materials inventory
• Hazardous materials organizational charts
• Hazardous materials shipping papers
• Inspection logs
• Hazardous labeling/marking guides
• Personal protective equipment procedures
• Spill/fire incident plans
• Spill incident response equipment
• Material safety data sheets
• Hazard communications program
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Disposal sites
• Shop storage locations
• Vehicles used for transport
• Storage facilities (including drums)
• Safety/response equipment
• Hazard warning signs
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5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with .
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g.. are hazard communication training records kept in one central file or are they in
individual employees' files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment
Phase 2 - Section 24
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel -and a review of organizational charts, mission statements, etc.,
evaluate how the facility's hazardous materials management function is organized.
Determine if the hazardous materials management function is characterized by clear lines
of authority and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the hazardous materials management function and determine
who:
1) Establishes and enforces facility-wide hazardous materials programs, policies, and
procedures/practices.
2) Provides hazardous materials oversight/management to field/operating personnel.
3) Provides technical support for field personnel.
b. Determine who the hazardous materials manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental .management.
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the hazardous materials manager
and person responsible for overall environmental management are open and
effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequently do they talk, etc.).
• c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various hazardous materials management activities.
For example, determine through interviews and document review, who is responsible
for inventorying hazardous materials, maintaining records relevant to hazardous
materials management, training employees; who is responsible for coordinating
emergency response measures (Linkage with l.B. Roles and Responsibilities).
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Determine if hazardous materials managers have sufficient authority to effectively
implement hazardous materials programs and to make decisions related to environmental
protection. Interview the hazardous materials manager and other hazardous materials
personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with hazardous materials and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific hazardous materials purchases
and uses and if those personnel have the appropriate background/authority to approve
these purchases/uses, and
. c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
hazardous materials management, who is responsible and accountable for hazardous
materials management activities, including, but not limited to training, shipping paper
preparation and tracking, inventory, recordkeeping and reporting, hazardous materials
storage areas, and coordination of emergency response measures at the facility.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for hazardous materials management match those in program manuals
or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the hazardous materials functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall hazardous materials management, and determine if this
reporting relationship is clearly and formally defined and understood.
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes hazardous materials policy, procedures, and standards;
2) Provides hazardous materials oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency hazardous materials
policy and/or Federal and state regulations have been assigned.
.-
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate hazardous materials management responsibilities are defined and are
included in their written performance appraisal.
a. Interview a selection of hazardous materials management personnel to determine if
there is accountability for their environmental performance (e.g., if their hazardous
materials management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding hazardous
materials management performance or reprimands for failure to carry out hazardous
materials management responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
hazardous materials management, and the facility manager, if top management has
supported hazardous materials programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire hazardous materials
handling/treatment equipment, to develop and enhance pollution prevention programs.
etc.
1) If financial, technical, and personnel resources are adequate to manage the
hazardous materials used at the facility.
b. Whether top management has a clear set of goals and expectations regarding
hazardous materials performance and what they are (e.g.. environmental compliance as
a minimum expectation, goals that go beyond compliance, emissions reductions).
2. Review hazardous materials management documentation and identify how senior
management communicates its hazardous materials goals and expectations to employees;
and, typically, how frequently the goals are communicated. For example, review the
facility's hazardous materials policies, procedures, orders, directives, standard operating
procedures, etc. and ascertain if they clearly communicate hazardous materials goals.
a. Interview a sample of operating and hazardous materials personnel to determine if they
understand the facility's hazardous materials policies, goals, etc.
3. Interview hazardous materials management personnel and understand what types of
hazardous materials reports are routinely and periodically provided to top management.
a Determine if hazardous materials reports, hazardous materials reduction progress
reports, hazardous materials inventory reports, etc., are routinely prepared for top
management and to what extent they address the facility's hazardous materials status
or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed.
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of
hazardous materials reports or if reports are prepared for "information only."
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B. Environmental Policy
1. Determine through interviews, what hazardous materials policies are widely distributed
and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., hazardous
materials manager/inspector, environmental manager, line managers, facility manager,
etc.) whose activities may impact hazardous materials performance to determine if they
take responsibility and interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in hazardous materials
management. Specifically, do they:
1) Routinely observe field level hazardous materials compliance activities?
2) Participate in audits and self-assessments?
3) Write and review hazardous materials procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to hazardous materials,
line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental occurrences involving hazardous materials.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support hazardous materials activities and how they integrate hazardous
materials management into the facility operations. For example, do they observe
compliance activities, conduct self-assessments, train employees, etc.
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3. Formality of Hazardous Materials Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging hazardous materials
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of hazardous materials regulations, and if there
is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging hazardous
materials regulations and trends (e.g., BNA, Federal Register updates, professional
• societies, contact with regulator/officials, subscriptions to professional publications
related to hazardous materials management).
• c. Determine how new hazardous materials regulations are interpreted as to their
applicability and by whom (e.g.t hazardous materials manager, legal department).
d. Note the availability of hazardous materials regulatory reference material (for example,
currency subscription to BNA, automated access via software, CFRs. Federal and State
Registers, state regulations, technical books, and other reference materials relating to
hazardous materials management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins,'safety/environmental meetings, updates to hazardous
materials program manuals, training courses). Interview selected operating personnel to
obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new hazardous materials
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update hazardous
materials management programs and procedures to reflect changes in regulatory
requirements, such as storage, handling, treatment and disposal practices for hazardous
materials, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form hazardous materials regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing
hazardous materials programs, policies, and procedures. Note the frequency that hazardous
materials programs, policies, and procedures are updated/new ones developed, how often
they are reviewed, and who approves them. Determine if there is a formal system in place
to update hazardous materials management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's hazardous materials programs, policies, and procedures. Determine their level
of experience and comment on the appropriateness of these individuals to perform
such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they,have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new hazardous materials regulatory requirement and determine whether a
new procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
hazardous materials management policies, programs, or procedures, whether the •
organization has a program (e.g., written procedures) for the management of hazardous
materials, including, but not limited to:
a. Identification of hazardous materials;
b. Identification of hazardous characteristics;
c. Methods used to determine hazardous materials characteristics;
d. Shipping paper preparation;
e. Hazardous materials transportation;
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f. Labeling of containers;
g. Hazardous materials storage area maintenance and inspection;
h. Development, implementation, and review of preparedness and prevention procedures
and hazardous materials contingency plan;
i. Procedures for managing specific high hazard materials;
j. Procedures of management of hazardous materials tanks;
' k. Pollution prevention; and
1. Corrective action for identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
hazardous materials procedures relevant to their job function. For example, are they easily
accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of hazardous materials management
procedures.
5. Determine whether applicable hazardous materials management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight.
6. Determine if hazardous materials management procedures such as those listed above are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review/update.
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C. Routine Inspections
1. Interview the environmental and hazardous materials managers and hazardous materials
inspector to determine if the facility has a program for routine site and equipment
inspections and compliance checks, including appropriate documentation relating to
hazardous materials activities. Specifically, determine if the facility regularly determines
compliance with regulatory and internal requirements such as:
a. Hazardous materials storage area/container inspections;
b. Shop area inspections;
c. Vehicles used for transport;
d. Marking/labeling practices; and
e. Safety/emergency equipment use.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a .tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Hazardous Materials
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of hazardous materials activities.
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a. Develop an understanding of all systems that are in place for hazardous materials
recordkeeping and document control (e.g., does the facility maintain a log or database
of hazardous materials used, inspection logs, inventory reports, employee training
documentation, shipping papers, etc.). For example, understand the systems for:
1) Tracking of key regulatory schedules (e.g., hazard communication training, etc.);
2) Maintenance of compliance records (e.g., hazardous materials storage/shop level
inspection logs, shipping papers, training records, hazardous materials inventory);
and
3) Preparation and submission of required reports (e.g., inventory reports, pollution
prevention reports, spill reports).
b. In general, assess the state of the facility's fi! : and recordkeeping practices regarding
hazardous materials records. Determine when - the files are complete, current, and
readily accessible.
c. Determine how the facility ensures that required hazardous materials
reports/notifications are routinely prepared and submitted to the appropriate regulatory
agencies in a timely manner. Through interviews with the environmental manager,
identify the person(s) responsible for regulatory reporting and through interviews with
them determine if they have appropriate experience/training to effectively report on
hazardous materials activities. Types of reports/notifications include:
1) Notification of hazardous materials activity (e.g., California state requirement);
2) Change in user status;
3) Shipping reports;
4) Inventory reports; and
5) CERCLA/SARA notification for spills/releases in excess of "reportable quantity".
d. Interview the hazardous materials manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized, etc.).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
applicable compliance requirements and other related environmental information. (For
example, the facility may choose to maintain shipping papers indefinitely.
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b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities)
c. Verify that the facility maintains hazardous materials records for the retention periods
specified by regulation (e.g., MSDSs - current).
3.' Determine how ihe facility investigates, reports, corrects, tracks, and monitors hazardous
materials problems and "incidents" (for example, releases/spills of hazardous materials
into the environment, container/tank failure). Interview hazardous materials personnel and
review procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and hazardous materials managers, and review internal
memos, newsletters, etc.. to understand how environmental information related to
hazardous materials is communicated. For example, is hazardous materials information
(e.g., hazardous materials inventory status, incidents) regularly communicated formally or
informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover hazardous materials issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of hazardous materials directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of hazardous materials information is
communicated to management:
1) Routine environmental status information;
2) New hazardous materials regulations;
3) Incident or major issue information; and
4) Controversial hazardous materials issues.
b. Determine how quickly new hazardous materials requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to hazardous materials.
a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to hazardous
materials. For example:
a.. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the hazardous materials status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's hazardous materials have
been received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
hazardous materials management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of hazardous materials staff to determine
if staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced hazardous materials management staff
to assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview hazardous materials management personnel and review their job descriptions
and applicable regulations to determine what qualifications are necessary for staffing and
other positions with responsibilities (e.g., hazardous materials trainers, hazardous materials
managers).
a. Determine if personnel with hazardous materials management responsibilities have the
relevant background and training to cany out their responsibilities.
b. Review a sample of resumes from selected staff (e.g., safety manager, storage facility
manager/inspector, emergency response coordinator, etc.) and note the following:
1) Specialized training in hazardous materials management;
2) Relevant hazardous materials work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of hazardous materials issues at the facility) conclude as to the quality and
quantity of hazardous materials personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for hazardous materials management staff
(including line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for hazardous materials
management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if hazardous materials management performance is
regularly included in the performance review process of appropriate personnel.
3. Interview a sample of hazardous materials staff (e.g., hazardous materials handlers, shop
managers) to confirm that they are evaluated on how well they perform their hazardous
materials management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work.
C. Training Programs '
1. Review training documentation (training manuals or other documents describing
hazardous materials training programs) to determine if the facility has identified
specialized hazardous materials training requirements (based on regulatory/internal
requirements, types/volumes of hazardous materials used/stored at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate hazardous materials training needs for
all relevant personnel who may be required to work with hazardous materials?
3) How does the facility ensure that hazardous materials training courses (e.g.,
hazardous materials initial/refresher training) are completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Key parameters for automatic hazardous materials feed cut-off systems;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm sys: .-ms;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Hazardous materials control procedures;
h. Identification of hazardous materials;
i. Container use, marking, labeling, and on-site transportation;
j. Manifesting and off-site transportation;
k. Storage facility management; and
1. Personnel health and safety and fire safety.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and hazardous materials managers and reviewing
hazardous materials program documentation, determine if the facility conducts hazardous
materials self-assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all hazardous materials issues at each self-assessment/appraisal or cover only
one topic at a time (e.g., manifesting and labeling, storage areas, transportation);
d. Are documented and results retained in organized flies; and
e. Document results, note "findings" or "deficiencies", track/monitor corrective action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if: '
a. The guidance documents.adequately address hazardous materials management issues
relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually).
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation).
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
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a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. determine if "lessons learned" programs are implemented to seek out improvement
opportunities for hazardous materials management performance.
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact hazardous materials
management (for example, projects, programs, or activities that may increase the volume
or toxicity of hazardous materials used/stored, require additional personnel or equipment
to handle the hazardous materials adequately) are carefully reviewed to identify and
address environmental, health, and safety risks as early as possible.
' a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention
opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g.. dollar value,
project type).
2. Based on interviews with facility management, including environmental and hazardous
materials managers, and a review of project planning documentation, comment on how
the facility balances environmental concerns against production/operational demands when
reviewing proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of hazardous materials is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of environmental management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
\
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with hazardous materials management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
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pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
1. Based on your understanding of the facility operations and types and volumes of
hazardous materials generated, as well as interviews and a review of files, comment on
how well the facility integrated pollution prevention into its daily activities. Types of
pollution prevention initiatives may include the following (Waste Minimization Plan
Linkage with Phase 1 - Section 3):
a. Does the facility make use of recycling opportunities for the following solvents?
Petroleum Distillates
• Aliphatics
- Hexane
- Heptane
- Stoddard solvent
- Mineral spirits
• Aromatics
- Toluene
- Xylene
Oxygenated Solvents
• Ketones
- Acetone
- Methyl ethyl ketone
- Methyl isobutyl ketone
• Esters
- Ethyl acetate
- Butyl acetate
• Alcohols
- Butyl
- Methyl
- Isopropyl
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Haloeenated Solvents
• Chlorinated solvents
- Methylene chloride
- Perchloroethylene
- Trichloroethylene
- 1.1,1 Trichloroethylene
• Fluorinated solvents
- 1.1,2 Trychlorotrifluoroethane
b. Has the facility evaluated the use of an air knife to blow solutions off the parts and
back into the baths, or increased drain times to reduce dragout?
t
c. Does the facility have an appropriate inventory control system which regulates
inventory amounts, promotes materials use on a first-in-first-out basis to avoid
expiration?
d. Does the facility use peel coatings in place of protective oils to reduce the need for
solvent cleaning?
e. Has the facility considered using less toxic plating solutions (zinc instead of cadmium;
trivalem chromium versus hexavalent chromium; and replacing cyanide and barium
salt baths with sulfate or chloride baths)?
f. Does the facility recover and reuse coolants such as refrigerants or antifreeze?
' g. Does the facility have a hazardous materials purchasing system which prevents random
purchasing of these materials by various operations at the facility which may hamper
hazardous materials control?
h. Does the facility purchase appropriate amounts or hazardous materials? Note:
Materials should be bought in small amounts where appropriate, as bulk purchase
savings can be lost if surplus material must be disposed of.
i. Does the facility dedicate equipment for specific processes, which can reduce die need
for rinsing of tanks between batches?
j. Does the facility routinely perform maintenance and check for leaks in valves and
fittings to reduce hazardous material loss?
k. Does the facility use computer software to track all hazardous materials?
1. Does the facility regenerate clay from jet fuel filtration by washing it with naphtha and
drying by steam heating and feeding to a furnace?
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m. Does the facility reclaim extraction solvents like sulfolane and sulfinol?
n. Has the facility trained paint operators to minimize unacceptable quality and paint
waste?
o. Has the facility optimized (automated?) spray speed, distance, angle, pressure and
other conditions to prevent overspraying of paint?
p. Does the facility use waterbased or high solids paint coatings rather than oil based
paints whenever possible?
q. Does the facility evaluate process performance to help determine efficiency, adjust the
process to make certain waste and off-specification materials/products are kept to a
minimum?
r. Does the facility use three metal 55-gallon drums to triple rinse smaller containers to
accomplish maximum product recovery and the disposal/reuse of small clean
containers for both water and solvent based paints?
s. Has the facility explored alternatives to chemical paint stripping such as sand blasting.
or plastic media blastic for soft metal alloys?
L Has the facility considered using a dry-to-dry unit for drycleaning operations to reduce
solvent loss in the transfer process?
Phase 2 - Section 24
Management Systems Assessments Hazardous Materials
24-38
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Phase 2
Section 25
Assessing Effectiveness of Emergency Planning and
Community Right to Know (EPCRA)
Program Management
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Table of Contents
Section 25
EPCRA
Introduction to Management Systems Assessments 25-1
A. Purpose 25-1
B. Scope 25-1
C. Approach 25-2
D. Understanding Management Systems 25-2
1. Organizational Structure 25-4
A. Management Organization ' 25-4
B. Roles and Responsibilities 25-5
2. Environmental Commitment , 25-7
A. Top Management Support 25-7
B. Environmental Policy ' 25-8
C. Line Management Support 25-8
3. Formality of EPCRA Management Program 25-9
A. Regulatory Tracking and Translation 25-9
B. Procedures 25-10
C. Routine Inspections 25-11
D. Recordkeeping and Reporting 25-12
4. Internal and External Communication 25-14
A. Internal Communication 25-14
B. External Communication 25-15
5. Staff Resources, Training, and Development 25-16
A. Staffing 25-16
B. Job Descriptions and Performance Evaluations ' 25-17
C. Training Programs 25-17
6. Program Evaluation, Reporting and Corrective Action 25-19
A. Self-Assessment and Appraisal System 25*19
B. Reporting and Fotlow-up 25-20
7. Environmental Planning and Risk Management 25-21
A. Environmental Planning and Risk Management 25-21
8. Pollution Prevention 25-22
A. Pollution Prevention Goals 25-22
B. Pollution Prevention Plan 25-22
C. Pollution Prevention Funding 25-23
D. Pollution Prevention Tracking 25-23
E. Pollution Prevention Training 25-23
F. Pollution Prevention Considerations 25-24
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas' for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment. They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key- personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, EPCRA) will allow the auditor to obtain an
understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., EPCRA storage areas), the auditor often must talk with other
personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, EPCRA contingency plan). This review serves to further enhance an auditor's
understanding of the management systems and physical controls. Review the following
documents:
Chemical inventory
Previous Tier I/Tier n reports
Toxic release inventory (TRI) reports (TRI or Form R)
Pollution prevention plan
MSOSs
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Chemical storage areas
• Chemical manufacturing areas
• Recordkeeping system
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g.. are training records kept in one central file or are they in 250 individual employees'
files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc..
evaluate how the facility's EPCRA management function is organized. Determine if the
EPCRA management function is characterized by clear lines of authority and
responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the EPCRA management function and determine who:
1) Establishes and enforces facility-wide EPCRA programs, policies, and
procedures/practices;
2) Provides EPCRA oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
b. Determine who the EPCRA manager reports to and how that reporting function is
linked to the facility manager or person responsible for overall environmental
management.
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the EPCRA manager and person
responsible for overall environmental management are open and effective (e.g.,
how do these people communicate [verbal, memo, etc.], how frequently do they
talk, etc.).
c. Determine which departments) and individual(s) have authority and
responsibility/accountability for various EPCRA management activities. For example,
determine through interviews and document review, who is responsible for creating
Tier I/n reports, toxic release inventories, managing overall EPCRA concerns (Linkage
with 1JJ. Roles and Responsibilities).
Phase 2 - Section 25
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2. Determine if EPCRA managers have sufficient authority to effectively implement EPCRA
programs and to make decisions related to environmental protection. Interview the
EPCRA manager and other EPCRA personnel and:
a. Understand the amount of authority given to these personnel at different levels
. working with EPCRA and determine if it is sufficient to carry out their responsibilities
(e.g., is authority commensurate with responsibility), and
b. Determine who is responsible for approving specific EPCRA projects or activities and
if those personnel have the appropriate background/authority to approve these projects.
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
EPCRA management, who is responsible and accountable for EPCRA management
activities, including, but not limited to training, hazardous materials inventorying, and
coordination of emergency response measures at the facility.
a. Identify where and how these roles and responsibilities are defined, such as in program
manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for EPCRA management match those in program manuals or job
descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the EPCRA functions specified in their job descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall EPCRA management, and determine if this reporting
relationship is clearly and formally defined and understood.
e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes EPCRA policy, procedures, and standards;
'2) Provides EPCRA oversight/management to field/operating personnel; and
4
3) Provides technical support for field personnel.
Phase 2 - Section 25
Management Systems Assessments EPCRA
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f. Determine whether specific roles as required by Federal agency EPCRA policy and/or
Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate EPCRA management responsibilities are defined and are included in
their written performance appraisal.
a. Interview a selection of EPCRA management personnel to determine if there is
accountability for their environmental performance (e.g., if their EPCRA
management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding EPCRA
management performance or reprimands for failure to carry out EPCRA management
responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
EPCRA management, and the facility manager, if top management has supported EPCRA
programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to improve the hazardous materials
storage area, etc.
1) If financial, technical, and personnel resources are adequate to manage the volume
of hazardous waste generated/hazardous materials handled at the facility.
b. Whether top management has a clear set of goals and expectations regarding EPCRA
performance and what they are (e.g., environmental compliance as a minimum
expectation, goals that go beyond compliance, emissions reductions).
2. Review EPCRA management documentation and identify how senior management
communicates its EPCRA goals and expectations to employees; and, typically, how
frequently the goals are communicated. For example, review the facility's EPCRA mission
statements, policies, procedures, orders, directives, standard operating procedures, etc. and
ascertain if they clearly communicate EPCRA goals.
a. Interview a sample of operating and EPCRA personnel to determine if they understand
the facility EPCRA policies, goals, etc.
3. Interview EPCRA management personnel and understand what types of EPCRA reports
are routinely and periodically provided to top management
a. Determine if hazardous materials inventory status reports, toxic chemicals release
reports, emergency planning status, etc., are routinely prepared for top management
and to what extent they address the facility's EPCRA status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
•
'. c. Determine if any actions are taken as a result of top management's review of EPCRA
reports or if reports are prepared for "information only."
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Management Systems Assessments EPCRA
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B. Environmental Policy
1. Determine through interviews, what EPCRA policies are widely distributed and if they are
easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., emergency
response coordinator, environmental manager, line managers, facility manager, etc.) whose
activities may impact EPCRA performance to determine if they take responsibility and
interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in EPCRA management
Specifically, do they:
I) Routinely observe field level EPCRA compliance activities?
2) Participate in audits and self-assessments?
3) Write and review EPCRA procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to EPCRA, line managers
solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental occurrences relevant to EPCRA.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support EPCRA activities and how they integrate EPCRA management
into the facility operations. For example, do they observe compliance activities, conduct
self-assessments, train employees, etc.
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3. Formality of EPCRA Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging EPCRA regulations and
trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of EPCRA regulations, and if there is a formal
system for this function.
b. Determine what documents are regularly reviewed for new and emerging EPCRA
regulations and trends (e.g., BNA, Federal Register updates, professional societies,
contact with regulator/officials, subscriptions to professional publications related to
EPCRA).
c. Determine how new EPCRA regulations are interpreted as to their applicability and by
whom (e.g., EPCRA manager, legal department).
d. Note the availability of EPCRA regulatory reference material (for example, currency
subscription to BNA, automated access via software, CFRs, Federal and State
Registers, state regulations, technical books, and other reference materials relating to
EPCRA management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to EPCRA program
manuals, training courses). Interview selected operating personnel to obtain their
understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new EPCRA regulatory
requirements is incorporated into facility or site-specific standard operating procedures, as
appropriate.
a. Through interviews, determine if there is a formal system in place to update EPCRA
management programs and procedures to reflect changes in regulatory requirements,
such as release reporting, submission of emergency and hazardous chemical
inventories, submission of MSDSs to the emergency commission and fire department
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form EPCRA regulatory information is transmitted to the
facility.
Phase 2 - Section 25
Management Systems Assessments EPCRA
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing EPCRA
programs, policies, and procedures. Note the frequency that EPCRA programs, policies,
and procedures are updated/new ones developed, how often they are reviewed, and who
approves them. Determine if there is a formal system in place to update EPCRA
management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's EPCRA programs, policies, and procedures. Determine their level of
experience and comment on the appropriateness of these individuals to perform such
tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new EPCRA regulatory requirement and determine whether a new procedure
has been developed and approved, or an existing has been updated and approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
EPCRA management policies, programs, or procedures, whether the organization has a
program (e.g., written procedures) for the management of EPCRA, including, but not
limited to:
a. Inventorying/submitting emergency and hazardous chemicals forms;
b. Notification of the emergency response commission;
c. Release reporting;
d. Preparation of Tier I/D reports;
e. Preparation of a pollution prevention plan;
f. MSDS file management; and
Phase 2 - Section 25
Management Systems Assessments EPCRA
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• g. Toxic release inventory report preparation.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
. 4. Interview a selection of operating personnel to determine if they have access to current
EPCRA procedures relevant to their job function. For example, are they easily accessible,
centrally located, manually (or electronically)?
a. Verify the accessibility by requesting a sample of EPCRA management procedures.
5. Determine whether applicable EPCRA management programs include the following
program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
6. Determine if EPCRA management procedures such as those listed above are reviewed and
updated on any schedule (e.g., periodically, annually, only when regulations change) and
who is responsible for this review/update.
C. Routine Inspections
1. Interview the environmental and EPCRA managers to determine if the facility has a
program for routine site and equipment inspections and compliance checks, including
appropriate documentation relating to EPCRA activities. Specifically, determine if the
facility regularly determines compliance with legal and regulatory requirements such as:
a. Hazardous waste/material storage area/container inspections;
- b. Chemical manufacturing areas; and
c. Recordkeeping system.
Phase 2 - Section 25
Management Systems Assessments EPCRA
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2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3.A. Formality of EPCRA Management
Program)'
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of EPCRA activities.
a. Develop an understanding of all systems that are in place for EPCRA recordkeeping
and document control (e.g., does the facility maintain a log or database of toxic
materials stored, employee training documentation. Tier I/II reports, etc.). For example,
understand the systems for:
1) Tracking of key regulatory schedules (e.g., annual chemical inventory submission,
etc.);
2) Maintenance of compliance records (e.g.. hazardous materials storage, inspection
logs, training records, etc.); and
3) Preparation and submission of required reports (e.g., Tier I/II reports, spill reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding „
EPCRA records. Determine whether the files are complete, current, and readily
accessible.
Phase 2 - Section 25
Management Systems Assessments EPCRA
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c. Determine how the facility ensues that required EPCRA reports/notifications are
routinely prepared and submitted to the appropriate regulatory agencies in a timely
manner. Through interviews with the environmental manager, identify the person(s)
responsible for regulatory reporting and through interviews with them determine if
they have appropriate experience/training to effectively report on EPCRA activities.
Types of reports/notifications include:
1) Notification of releases of extremely hazardous substances in amounts exceeding
the reportable quantity;
2) Submission of emergency and hazardous chemicals inventories;
3) Submission of MSDSs to the fire department and emergency response commission;
and
4) CERCLA/SARA notification for spills/releases in excess of "importable quantity".
d. Interview the EPCRA manager to determine whether the recordkeeping practices are
formal and systematic (e.g., regularly performed by an assigned individual,
computerized, etc.).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
EPCRA compliance and other related environmental information. (For example, the
facility may choose to maintain manifests indefinitely, rather than for the required
three years.)
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities).
c. Verify that the facility maintains EPCRA records.
3. Determine how the facility investigates, reports, corrects, tracks, and monitors EPCRA
problems and "incidents" (for example, releases/spills of hazardous materials into the
environment, container/tank failure). Interview EPCRA personnel and review procedures
to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
Phase 2 - Section 25
Management Systems Assessments EPCRA
25-13
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and EPCRA managers, and review internal mernos,
newsletters, etc., to understand how environmental information related to EPCRA is
communicated. For example, is EPCRA information (e.g., toxic release inventory reports,
incidents) regularly communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover EPCRA issues (review minutes of meetings, talk with
personnel who regularly attend meetings).
2. Determine if formal communication of EPCRA directives is timely, and effectively
reaches all responsible elements of the facility. Specifically (Linkage with 3.A. Regulatory
Tracking and Translation):
a. Determine how quickly the following types of EPCRA information is communicated
to management:
1) Routine environmental status information;
2) New EPCRA regulations;
3) Incident or major issue information; and
4) Controversial EPCRA issues.
b. Determine how quickly new EPCRA requirements, programs or other information is
communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and'address employee environmental
concerns related to EPCRA.
a. Review files to determine if the concerns and responses are documented.
Phase 2 - Section 2
Management Systems Assessments EPCRA
25-14
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to EPCRA. For
example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public Heading rooms) to keep them informed
of the EPCRA status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's hazardous chemicals have
been received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
Phase 2 - Section 25
Management Systems Assessments EPCRA
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
EPCRA management activities (this includes dedicated support staff and others with
collateral duties [e.g., line managers with other support functions]). Interview the human
resource manager as well as a sample of EPCRA staff to determine if staffing levels are
sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced EPCRA management staff to assure
compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview EPCRA management personnel and review their job descriptions and applicable
regulations to determine what qualifications are necessary for staffing and other positions
with responsibilities (e.g., EPCRA trainers, EPCRA managers).
a. Determine if personnel with EPCRA management responsibilities have the relevant
background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
*
1) Specialized training in EPCRA management;
2) Relevant EPCRA work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of EPCRA issues at the facility) conclude as to the quality and quantity of
EPCRA personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for EPCRA management staff (including line
managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for EPCRA management
positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if EPCRA management performance is regularly
included in the performance review process.
3. Interview a sample of EPCRA staff (e.g., hazardous material handlers, emergency
response personnel) to confirm that they are evaluated on how well they perform their
EPCRA management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing EPCRA
training programs) to determine if the facility has identified specialized EPCRA training
requirements (based on regulatory requirements, types/volumes of hazardous chemicals
generated/handled at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate EPCRA training needs for all relevant
personnel who may be required to work with EPCRA?
3) How does the facility ensure that EPCRA training courses (e.g., annual EPCRA
refresher training) are completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Emergency response planning;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm systems;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Personnel health and safety and fire safety; and
h. Shutdown orocedures.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and EPCRA managers and reviewing EPCRA program
documentation, determine if the facility conducts EPCRA self-assessments/appraisals.
Note whether the self-assessments/appraisals:
a. Are formally conducted according to some tegular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all EPCRA issues at each self-assessment/appraisal or cover only one topic at a
time (e.g., inventoring of hazardous chemicals, storage areas, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,.
checklist, or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address EPCRA management issues relevant to
the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with l.B. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Phase 2 - Section 25
Management Systems Assessments EPCRA
25-19
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for EPCRA management performance.
Phase 2 - Section 25
Management Systems Assessments EPCRA
25-20
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact EPCRA
management (for example, projects, programs, or activities that may increase -the volume
or toxicity of hazardous materials generated/handled, require additional personnel or
equipment to handle the hazardous materials adequately) are carefully reviewed to
identify and address environmental, health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and EPCRA
managers, and a review of project planning documentation, comment on how the facility
balances environmental concerns against production/operational demands when reviewing
proposed new projects, programs, or activities.
Phase 2 - Section 25
Management Systems Assessments EPCRA
25-21
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established* specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of environmental management personnel determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
Phase 2 - Section 25
Management Systems Assessments EPCRA
25-22
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a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met
C.j Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO I28S6.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with environmental management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
Phase 2 - Section 25
Management Systems Assessments EPCRA
25-23
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F. Pollution Preventidn Considerations
NOTE: Pollution prevention may be applicable to (EPCRA), and activities associated with
EPCRA.
1. Based on your understanding of the facility operations and types and volumes of wastes
as well as interviews and a review of files, comment on how well the facility integrated
pollution prevention into its daily activities. Types of pollution prevention initiatives may
include the following (Linkage with Phase 1 - Section 3 Waste Minimization Plan):
Phase 2 - Section 25
Management Systems Assessments EPCRA
25-24
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Phase 2
Section 26
Assessing Effectiveness of Cultural and Historic
Resources Program Management
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Table of Contents
Section 26
Cultural and Historic Resources Program
Introduction to Management Systems Assessments 26-1
A. Purpose 26-1
B. Scope 26-1
C. Approach 26-2
D. Understanding Management Systems 26-2
1. Organizational Structure 26-4
A. Management Organization 26-4
B. Roles and Responsibilities 26-5
2. Environmental Commitment 26-7
A. Top Management Support ' 26-7
B. Environmental Policy 26-8
C. Line Management Support 26-8
3. Formality of Cultural and Historic Resources Program Management Program 26-10
A. Regulatory Tracking and Translation 26-10
B. Procedures 26-11
C. Routine Inspections 26-13
D. Recordkeeping and Reporting 26-13
4. Internal and External Communication 26-16
A. Internal Communication 26-16
B. External Communication 26-17
5. Staff Resources, Training, and Development 26-18
A. Staffing 26-18
B. Job Descriptions and Performance Evaluations 26-19
C. Training Programs 26-19
6. Program Evaluation, Reporting and Corrective Action 26-21
A. Self-Assessment and Appraisal System 26-21
B. Reporting and Follow-up 26-22
7. Environmental Planning and Risk Management • 26-23
A. Environmental Planning and Risk Management . 26-23
8. Pollution Prevention 26-24
A. Pollution Prevention Goals 26-24
B. Pollution Prevention Plan 26-24
C. Pollution Prevention Funding . 26-25
D. Pollution Prevention Tracking 26-25
E. Pollution Prevention Training 26-26
F. Pollution Prevention Considerations 26-26
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with a benchmark
potential and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizatipnal Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources. Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
Management Systems Assessments
Phase 2 • Section 26
Cultural and Historic Resources
26-1
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment. They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
* Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, Cultural and Historic Resources Program)
will allow the auditor to obtain an understanding as to why and how the environmental
management systems work.
Phase 2 - Section 26
Management Systems Assessments Guttural and Historic Resources
26-2
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., Cultural and Historic Resources Program storage areas), the auditor
often must talk with other personnel. This will enable the auditor to develop an increased
sense of confidence in or reliance on the information based on corroboration of multiple
sources and to develop clues as to potential weaknesses related to inconsistencies or
conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
cultural resources inventory, land use plans, etc.). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
• Cultural and historic resources management plan;
• Agreements with State Historic Preservaton Officer;
• Cultural resources inventory/survey;
• Land use plans;
• Local zoning maps;
• Environmental impact statements; and
• Federal dredge and/or fill permits.
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Site of historic, archeological, or Native American interest, and
• Buildings and structures of potential historical significance.
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are cultural/historic resources management records kept in one central file or are they in
the files of various historical structures?).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
26-3
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's Cultural and Historic Resources Program management function
is organized. Determine if the Cultural and Historic Resources Program management
function is characterized by clear lines of authority and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the Cultural and Historic Resources Program management
function and determine who:
1) Establishes and enforces facility-wide Cultural and Historic Resources Program
programs, policies, and procedures/practices;
2) Conducts Cultural and Historic Resources Program activities (e.g., cultural
services); and
3) Provides support for conducting cultural resource surveys.
b. Determine who the Cultural and Historic Resources Program manager reports to and
how that reporting function is linked to the facility manager or person responsible for
overall environmental management.
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the Cultural and Historic
Resources Program manager and person responsible for overall environmental
management are open and effective (e.g., how do these people communicate
[verbal, memo, etc.], how frequently do they talk, etc.).
c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various Cultural and Historic Resources Program
management activities. For example, determine through interviews and document
review, who is responsible for conducting cultural resources surveys and inventories,
research on historic properties, oversight of EIS documents (Linkage with 1.B Roles
and Responsibilities).
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-4
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2. Determine if Cultural and Historic Resources Program managers have sufficient authority
to effectively implement Cultural and Historic Resources Program programs and to make
decisions related to environmental protection. Interview the Cultural and Historic
Resources Program manager and other Cultural and Historic Resources Program personnel
and:
i
a. Understand the amount of authority given to these personnel at different levels
working with Cultural and Historic Resources Program and determine if it is sufficient
to carry out their responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific Cultural and Historic Resources
Program projects (e.g., removal of historic artifacts) and if those personnel have the
appropriate background/authority to approve these projects,
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
Cultural and Historic Resources Program management, who is responsible and
accountable for historic and cultural resources management activities, including, but not
limited to inventorying historic and cultural resources, repository security for
archeological collections, reporting, and qualifying museum staff.
a. Identify where and how these roles and.responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for Cultural and Historic Resources Program management match those
in program manuals or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the Cultural and Historic Resources Program functions specified
in their job descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall Cultural and Historic Resources Program management, and
determine if this reporting relationship is clearly and formally defined and understood.
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
26-5
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes Cultural and Historic Resources Program policy, procedures, and
standards;
2) Provides Cultural and Historic Resources Program oversight/management to
field/operating personnel; and
f.
3) Provides technical support for field personnel.
Determine whether specific roles as required by Federal agency Cultural and Historic
Resources Program policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate Cultural and Historic Resources Program management responsibilities
are defined and are included in their written performance appraisal.
a. Interview a selection of Cultural and Historic Resources Program management
personnel to determine if there is accountability for their environmental performance
(e.g., if their Cultural and Historic Resources Program management/field
responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding Cultural
and Historic Resources Program management performance or reprimands for failure to
carry out Cultural and Historic Resources Program management responsibilities.
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
264
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
Cultural and Historic Resources Program management, and the facility manager, if top
management has supported Cultural and Historic Resources Program programs. For
example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire facilities for cultural and
historic pieces, to develop and enhance the Cultural and Historic Resources
Management Program.
1) If financial, technical, and personnel resources are adequate to manage the volume
of cultural and historic resources at the facility.
b. Whether top management has a clear set of goals and expectations regarding Cultural
and Historic Resources Program performance and what they are (e.g., environmental
compliance as a minimum expectation, goals that go beyond compliance).
2. Review Cultural and Historic Resources Program management documentation and identify
how senior management communicates its Cultural and Historic Resources Program goals
and expectations to employees; and, typically, how frequently the goals are
communicated. For example, review the facility's Cultural and Historic Resources
Program mission statements, policies, procedures, orders, directives, standard operating
procedures, etc. and' ascertain if they clearly communicate Cultural and Historic Resources
Program goals.
a. • Interview Cultural and Historic Resources Program personnel to determine if they
understand the facility Cultural and Historic Resources Program policies, goals, etc.
3. Interview Cultural and Historic Resources Program management personnel and understand
what types of Cultural and Historic Resources Program reports are routinely and
periodically provided to top management.
a. Determine if Cultural and Historic Resources Program annual reports, Cultural and
Historic Resources Program inventory reports, environmental assessments etc., are
routinely prepared for top management and to what extent they address the facility's
Cultural and Historic Resources Program status or performance.
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
26-7
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b. For these reports, identify to whom they are sent, the type of information conveyed.
and the level of detail provided.
c. Determine if any actions .are taken as a result of top management's review of Cultural
and Historic Resources Program reports or if reports are prepared for "information
only."
B. Environmental Policy
1. Determine through interviews, what Cultural and Historic Resources Program policies are
widely distributed and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., Cultural and
Historic Resources Program manager/inspector, environmental manager, line managers,
facility manager, etc.) whose activities may impact Cultural and Historic Resources
Program performance to determine if they take responsibility and interest in limiting the
impact of their operations. For example:
a. Identify activities in which line managers are involved in Cultural and Historic
Resources Program management Specifically, do they:
1) Routinely observe Cultural and Historic Resources Program compliance activities?
2) Participate in audits and self-assessments?
3) Write and review Cultural and Historic Resources Program procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to Cultural and Historic
Resources Program, line managers solicit and receive and how they obtain this
information.
c. Determine what actions have been taken by line management in response to incidents
involving Cultural and Historic Resources.
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
26-8
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2. Based on the information gathered in the above step, comment on how line managers
support/do not support Cultural and Historic Resources Program activities and how they
integrate Cultural and Historic Resources Program management into the facility
operations. For example, do they observe compliance activities, conduct self-assessments,
train employees, etc.
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-9
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3. Formality of Cultural and Historic Resources Program Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging Cultural and Historic
Resources Program regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of Cultural and Historic Resources Program
regulations, and if there is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging Cultural and
Historic Resources Program regulations and trends (e.g., BNA, Federal Register
updates, professional societies, contact with state historic preservation officers,
subscriptions to professional publications).
c. Determine how new Cultural and Historic Resources Program regulations are
interpreted as to their applicability and by whom (e.g., Cultural and Historic Resources
Program manager, legal department).
d. Note the availability of Cultural and Historic Resources Program regulatory reference
material (for example, currency of subscription to BNA, automated access via
software, CFRs, Federal and State Registers, state regulations, technical books, and
other reference materials relating to Cultural and Historic Resources Program
management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to Cultural and
Historic Resources Program program manuals, training courses). Interview selected
.operating personnel to obtain their understanding of this regulatory communication
process.
2. Determine if there is a process to ensure that guidance on new Cultural and Historic
Resources Program regulatory requirements is incorporated into facility or site-specific
standard operating procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update Cultural
and Historic Resources Program management programs and procedures to reflect
changes in regulatory requirements, such as biennial reporting requirements, storage,
handling, treatment and disposal practices for Cultural and Historic Resources
Program, etc.
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-10
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3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form Cultural and Historic Resources Program regulatory
information is transmitted to the facility.
b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing Cultural
and Historic Resources Program programs, policies, and procedures. Note the frequency
that Cultural and Historic Resources Program programs, policies, and procedures are
updated/new ones developed, how often they are reviewed, and who approves them.
Determine if there is a formal system in place to update Cultural and Historic Resources
Program management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's Cultural and Historic Resources Program programs, policies, and procedures.
Determine their level of experience and comment on the appropriateness of these
individuals to perform such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new Cultural and Historic Resources Program regulatory requirement and
determine whether a new procedure has been developed and approved, or an existing
has been updated and approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-11
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2. Determine, based on interviews with operating and environmental staff and a review of
Cultural and Historic Resources Program management policies, programs, or procedures,
whether the organization has a program (e.g., written procedures) for the management of
Cultural and Historic Resources Program, including, but not limited to:
a. Developing a cultural and historic resources program;
b. Assimilating cultural and historic resources management into the environmental
assessment/impact statement process;
c. Communications with the State Historic Preservation Officer;
d. Nominating properties to the Registrar of Historic Places; and
e. Develop a cultural and historic resources management plan.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection'of operating personnel to determine if they have access to current
Cultural and Historic Resources Program procedures relevant to their job function. For
example, are they easily accessible, centrally located, manually (or electronically)
available. ...
a. Verify the accessibility by requesting a sample of Cultural and Historic Resources
Program management procedures.
5. Determine whether applicable Cultural and Historic Resources Program management
programs include the following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-12
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6. Determine if Cultural and Historic Resources Program management procedures such as
those listed above are reviewed and updated on any schedule (e.g., periodically, annually,
only when regulations change) and who is responsible for this review/update.
C. Routine Inspections
1. Interview the environmental and Cultural and Historic Resources Program managers to
determine if the facility has a program for routine site inspections and compliance checks,
including appropriate documentation relating to Cultural and Historic Resources Program
activities. Specifically, determine if the facility regularly determines compliance with legal
and regulatory requirements such as:
a. Access to religious ceremonial sites;
b. Consulting the SHPO prior to cultural resources planning;
c. Surveying properties prior to demolotion to determine significance; and
d. Maintaining museum facilities/inventory of artifacts.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner. •
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-13
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D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Cultural and Historic
Resources Program Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of Cultural and Historic Resources Program activities.
a. Develop an understanding of all systems that are in place for Cultural and Historic
Resources Program recordkeeping and document control (e.g., does the facility
maintain a log or database of cultural and historic resources, inspection logs.
inventory/survey reports, and employee training documentation, etc.). For example,
understand the systems for:
1) Tracking of key regulatory schedules;
2) Maintenance of compliance records (e.g., inventory and survey reports); and
3) Preparation and submission of required reports (e.g., EIS and EA reports,
correspondence with SHPO).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
Cultural and Historic Resources Program records. Determine whether the files are
complete, current, and readily accessible.
c. Determine how the facility ensures that required Cultural and Historic Resources
Program reports/notifications are routinely prepared and submitted to the appropriate
regulatory agencies in a timely manner. Through interviews with the environmental
manager, identify the person(s) responsible for regulatory reporting and through
interviews with them determine if they have appropriate experience/training to
effectively report on Cultural and Historic Resources Program activities. Types of
reports/notifications include:
1) Environmental Assessment/Impact Statements;
2) Cultural Resources inventory;
3) Cultural and Historic Resources surveys; and
4) National Register of Historic Places.
d. Interview the Cultural and Historic Resources Program manager to determine whether
the recordkeeping practices are formal and systematic (e.g., regularly performed by an
assigned individual, computerized).
Management Systems Assessments
Phase 2 - Section 7
Cultural and Historic Resource*.
26-14
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2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy.
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities)
c. Verify that the facility maintains Cultural and Historic Resources Program records for
the retention periods specified by regulation.
3. Determine how the facility investigates, reports, corrects, tracks, and monitors Cultural
and Historic Resources Program problems and "incidents" (vandalism of
culturally/historically significant properties). Interview Cultural and Historic Resources
Program personnel and review procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
26-15
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and Cultural and Historic Resources Program managers and
review internal memos, newsletters, etc., to understand how environmental information
related to Cultural and Historic Resources Program is communicated. For example, is
Cultural and Historic Resources Program information (e.g., Cultural and Historic
Resources Program management surveys/inventories) regularly communicated formally or
informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover Cultural and Historic Resources Program issues
(review minutes of meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of Cultural and Historic Resources Program
directives is timely, and effectively reaches all responsible elements of the facility.
Specifically (Linkage with 3.A. Regulatory Tracking and Translation):
a. Determine how quickly the following types of Cultural and Historic Resources
Program information is communicated to management:
1) Cultural and historic resources inventory;
2) Recent cultural/historic resources surveys;
3) Nominations to Registrar of Historic Places; and
4) Controversial Cultural and Historic Resources Program issues.
b. Determine how quickly new Cultural and Historic Resources Program requirements,
programs or other information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and' address employee environmental
concerns related to Cultural and Historic Resources Program.
a. Review files to determine if the concerns and responses are documented.
b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-16
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1) Have employee concerns been addressed? (For those that were not, determine the
reason.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with the State Historic
Preservation Officer, environmental groups, and the local community to provide them
, with information and the opportunity to be involved in key decisions related to the
Cultural and Historic Resources Program. For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the Cultural, and Historic Resources Program status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concems regarding the facility's Cultural and Historic
Resources Program have been received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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Cultural and Historic Resources
26-17
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
Cultural and Historic Resources Program management activities (this includes dedicated
support staff and others with collateral duties [e.g., line managers with other support
functions]). Interview the human resource manager as well as a sample of Cultural and
Historic Resources Program staff to determine if staffing levels are sufficient to achieve
performance goals. Specifically:
a. Note evidence of insufficient or inexperienced Cultural and Historic Resources
Program management staff to assure compliance. Evidence of these would include, for
example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3} Excessive use of contractors.
2. Interview Cultural and Historic Resources Program management personnel and review
their job descriptions and applicable regulations to determine what qualifications are •
necessary for staffing and other positions with responsibilities (e.g., Cultural and Historic
Resources Program managers).
a. Determine if personnel with Cultural and Historic Resources Program management
responsibilities have the relevant background and training to carry out their
responsibilities.
b. Review a sample of resumes from selected staff (e.g., Cultural and Historic Resources
Program manager) and note (he following: •
1) Specialized training in Cultural and Historic Resources Program management;
2) Relevant Cultural and Historic Resources Program work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of Cultural and Historic Resources Program issues at the facility) conclude
as to the quality and quantity of Cultural and Historic Resources Program personnel at the
facility.
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Cultural and Historic Resources
26-18
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for Cultural and Historic Resources Program
management staff (including line managers, suppon staff, and others with collateral
duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for Cultural and Historic
Resources Program management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if Cultural and Historic Resources Program
management performance is regularly included in the performance review process for
appropriate personnel.
3. Interview Cultural and Historic Resources Program staff (e.g., Cultural and Historic
Resources Program managers) to confirm that they are evaluated on how well they
perform their Cultural and Historic Resources Program management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work.
C. Training Programs
1. Review training documentation (training manuals or other documents describing Cultural
and Historic Resources Program training programs) to determine if the facility has
identified Cultural and Historic Resources Program training requirements (based on
agency requirements, types of Cultural and Historic Resources Program generated at the
facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate Cultural and Historic Resources
Program training needs for all relevant personnel who may be required to work
with Cultural and Historic Resources Program?
3) How does the facility ensure that Cultural and Historic Resources Program training
courses are completed?
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
26-19
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2. Determine how the training documentation is maintained and updated (e.g. by whom, how
frequently, how is it updated).
3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Applicable regulatory standards (e.g., Historic Sites Act of 1935, National Historic
Preservation Act of 1966);
•
b. Conducting cultural and historic resources management research;
c. Conducting surveys/inventorying cultural and historic resources; and
d. Including cultural and historic resource surveys in EIS/IA processes.
Management Systems Assessments
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Cultural and Historic Resources
26-20
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and Cultural and Historic Resources Program
managers and reviewing Cultural and Historic Resources Program program
documentation, determine if the facility conducts Cultural and Historic Resources Program
self-assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all Cultural and Historic Resources Program issues or cover only one topic at a
time (e.g., manifesting and labeling, storage areas, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklist, or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address Cultural and Historic Resources Program
management issues relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Management Systems Assessments
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Cultural and Historic Resources
26-21
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for Cultural and Historic Resources Program management performance.
Management Systems Assessments
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Cultural and Historic Resources
26-22
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact Cultural and
Historic Resources Program management (for example, projects, programs, or activities
that may impact potentially significant structures, previously undisturbed property) are
carefully reviewed to identify and address cultural and historical risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention
opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and Cultural and
Historic Resources Program managers, and a review of project planning documentation,
comment on how the facility balances environmental concerns against
production/operational demands when reviewing proposed new projects, programs, or
activities.
Phase 2 - Section 26
Management Systems Assessments Cultural and Historic Resources
26-23
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 128S6?
b. Interview a selection of environmental management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. Hie plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
Management Systems Assessments
Phase 2 - Section 26
Cultural and Historic Resources
26-24
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f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
*
2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded'to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 128S6.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
Management Systems Assessments
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Cultural and Historic Resources
26-25
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E. Pollution Prevention Training
1. Through interviews with environmental management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (cultural and historic resources
management), and activities associated with cultural and historic resources
management.
1. Based on your understanding of the facility operations and types and volumes of wastes
generated, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities (Waste Minimization Plan Linkage
with Phase 1 - Section 3).
Management Systems Assessments
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Cultural and Historic Resources
26-26
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Phase 2
Section 27
Assessing Effectiveness of Storage Tank Program
Management
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Table of Contents
Section 27
Storage Tank
Introduction to Management Systems Assessments 27-1
A. Purpose . 27-1
B. Scope 27-1
C. Approach 27-2
D. Understanding Management Systems 27-2
1. Organizational Structure 27-5
A. Management Organization 27-5
B. Roles and Responsibilities 27-6
2. Environmental Commitment 27-8
A. Top Management Support 27-8
B. Environmental Policy 27-9
C. Line Management Support 27-9
3. Formality of Storage Tank Management Program 27-10
A. Regulatory Tracking and Translation 27-10
B. Procedures 27-11
C. Routine Inspections 27-13
D. Recordkeeping and Reporting 27-14
4. Internal and External Communication 27-16
A. Internal Communication 27-16
B. External Communication 27-17
5. Staff Resources, Training, and Development 27-18
A. Staffing 27-18
B. Job Descriptions and Performance Evaluations 27-19
•- C. Training Programs 27-19
6. Program Evaluation, Reporting and Corrective Action 27-21
A. Self-Assessment and Appraisal System 27-21
B. Reporting and Follow-up . 27-22
7. Environmental Planning and Risk Management 27-23
A. Environmental Planning and Risk Management 27-23
8. Pollution Prevention 27-24
A. Pollution Prevention Goals 27-24
B. Pollution Prevention Plan 27-24
C. Pollution Prevention Funding 27-25
D. Pollution Prevention Tracking - 27-25
E. Pollution Prevention Training 27-25
F. Pollution Prevention Considerations 27-26
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives .and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
i
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, storage tanks) will allow the auditor to
obtain an understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., storage tank areas), the auditor often must talk with other personnel.
This will enable the auditor to develop an increased sense of confidence in or reliance on the
information based on corroboration of multiple sources and to develop clues as to potential
weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, storage tank inventory control records, tank tightness testing). This review serves
to further enhance an auditor's understanding of the management systems and physical
controls. Review the following documents:
• Tank management plan
• UST registrations
• Inventory control records
• Tank gauging records
• Tank tightness tests
• Release monitoring data
• Organization charts
• Storage area blueprints
• Piping blueprints
• Release response plans
• Contingency plan
• Inspection logs
• Spill prevention and response plans
• Tank removal/closure plans
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Storage tank areas
• Tank farms
• Aboveground piping
• Fill pipe locations
• Loading/unloading areas
• Cathodic protection devices
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Management Systems Assessments Storage Tanks
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5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are UST registrations kept in a central file or at each tank location?).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment
Phase 2 - Section 27
Management Systems Assessments Storage Tanks
\
27-4
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's storage tank management function is organized. Determine if
the storage tank management function is characterized by clear lines of authority and
responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the storage tank management function and determine who:
1) Establishes and enforces facility-wide storage tank programs, policies, and
procedures/practices;
2) Provides storage tank oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
b. Determine who the storage tank manager reports to and how that reporting function is
linked to the facility manager or person responsible for overall environmental
management • •
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the storage tank manager and
person responsible for overall environmental management are open and effective
(e.g., how do these people communicate [verbal, memo, etc.], how frequently do
they talk, etc.).
c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various storage tank management activities. For
example, determine through interviews and document review, who is responsible for
inventorying storage tanks, maintaining records relevant to storage tank management,
training employees; who is responsible for coordinating emergency response measures
(Linkage with l.B. Roles and Responsibilities).
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Management Systems Assessments Storage Tanks
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2. -Determine if storage tank managers have sufficient authority to effectively implement
storage tank programs and to make decisions related to environmental protection.
Interview the storage tank manager and other storage tank personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with storage tanks and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility), and
b. Determine who is responsible for approving specific storage tank projects and if those
personnel have the appropriate background/authority to approve these projects.
c. Interview management representatives to identify individuals who have slop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
storage tank management, who is responsible and accountable for storage tank
management activities, including, but not limited to training, tank integrity testing,
inventory recordkeeping and reporting, storage areas, and tank registration.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for storage tank management match those in program manuals or job
descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the storage tank functions specified in their job descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall storage tank management, and determine if this reporting
relationship is clearly and formally defined and understood.
e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes storage tank policy, procedures, and standards;
2) Provides storage tank oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
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Management Systems Assessments Storage Tanks
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f. Determine whether specific roles as required by Federal agency storage tank policy
and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate storage tank management responsibilities are defined and are included in
their written performance appraisal.
a. Interview a selection of storage tank management personnel to determine if there is
accountability for their environmental performance (e.g., if their storage tank
management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding storage
tank management performance or reprimands for failure to carry out storage tank
management responsibilities.
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Management Systems Assessments Storage Tanks
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B. Environmental Policy
1. Determine through interviews, what storage tank policies are widely distributed and if
they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., storage tank
manager/inspector, environmental manager, line managers, facility manager, etc.) whose
activities may impact storage tank performance to determine if they take responsibility
and interest in limiting the impact of their operations. For example:-
a. Identify activities in which line managers are involved in storage tank management
Specifically, do they:
\
1) Routinely observe field level storage tank compliance activities?
2) Participate in audits and self-assessments?
3) Write and review storage tank procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to storage tanks, line
managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental occurrences involving storage tanks.
2. Based on the information gathered in the above step, comment on how line managers
'support/do not support storage tank activities and how they integrate storage tank
management into the facility operations. For example, do they observe compliance
activities, conduct self-assessments, train employees, etc.
Phase 2 - Section 27
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2. Environmental Commitment
•A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
storage tank management, and the facility manager, if top management has supported
storage tank programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire storage tank
monitoring/gauging equipment, to develop and enhance spill prevention, etc.
1) If financial, technical, and personnel resources are adequate to manage the volume
of storage tanks at the facility.
i
b. Whether top management has a clear set of goals and expectations regarding storage
tank performance and what they are (e.g., environmental compliance as a minimum
expectation, goals that go beyond compliance, emissions reductions).
2. Review storage tank management documentation and identify how senior management
communicates its storage tank goals and expectations to employees; and, typically, how
frequently the goals are communicated. For example, review the facility's storage tank
policies, procedures, orders, directives, standard operating procedures, etc. and ascertain if
they clearly communicate storage tank goals.
a. Interview a sample of operating and storage tank personnel to determine if they
understand the facility storage tank policies, goals, etc.
3. Interview storage tank management personnel and understand what types of storage tank
reports are routinely and periodically provided to top management
a. Determine if storage tank gauging reports, storage tank integrity reports, storage tank
inventory reports, etc., are routinely prepared for top management and to what extent
they address the facility's storage tank status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of storage
tank reports or if reports are prepared for "information only."
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3. Formality of Storage Tank Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging storage tank regulations
and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of storage tank regulations, and if there is a
formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging storage tank
regulations and trends (e.g., BNA, Federal Register updates, professional societies,
contact with regulator/officials, subscriptions to professional publications related to
storage tank management).
c. Determine how new storage tank regulations are interpreted as to their applicability
and by whom (e.g., storage tank manager, legal department).
d. Note the availability of storage tank regulatory reference material (for example,
currency of subscription to BNA, automated access via software, CFRs, Federal and
State Registers, state regulations, technical books, and other reference materials
relating to storage tank management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to storage tank
program manuals, training courses). Interview selected operating personnel to obtain
their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new storage tank regulatory
requirements is incorporated into facility or site-specific standard operating procedures, as
appropriate.
a. Through interviews, determine if there is a formal system in place to update storage
tank management programs and procedures to reflect changes in regulatory
requirements, such as biennial reporting requirements, storage, handling, treatment and
disposal practices for storage tanks, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form storage tank regulatory information is transmitted to
the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing storage
tank programs, policies, and procedures. Note the frequency that storage tank programs,
policies, and procedures are updated/new ones developed, how often they are reviewed.
and who approves them. Determine if there is a formal system in place to update storage
tank management programs.
•
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's storage tank programs, policies, and procedures. Determine their level of
experience and comment on the appropriateness of these individuals to perform such
tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new storage tank regulatory requirement and determine whether a new
procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
storage tank management policies, programs, or procedures, whether the organization has
a program (e.g., written procedures) for the management of storage tanks, including, but
not limited to:
a. Storage tank management plan;
b. Inventory of tanks in use, inactive and closed;
c. Tank integrity testing programs;
d. Tank gauging practices;
e. Shipping paper preparation;
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f. Corrosion protection methods;
g. Labeling of containers;
h. Tank registration;
i. Development, implementation, and review of preparedness and prevention procedures;
j. Procedures for loading and unloading;
k. Procedures for calibrating and testing safety/alarm systems;
I.' Pollution prevention; and
m. Corrective action for identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
storage tank procedures relevant to their job function. For example, are they easily
accessible, centrally located, manually (or electronically) available.
a. Verify the accessibility by requesting a sample of storage tank management
procedures.
5. Determine whether applicable storage tank management programs include the following
program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
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Management Systems Assessments Storage Tanks
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6. Determine if storage tank management procedures such as those listed above are reviewed
and updated on any schedule (e.g.. periodically, annually, only when regulations change)
and who is responsible for this review.
C. Routine Inspections
1. Interview the environmental and storage tank managers and storage tank inspector to
determine if the facility has a program for routine site and equipment inspections and
compliance checks, including appropriate documentation relating to storage tank activities.
Specifically, determine if the facility regularly determines compliance with regulatory and
internal requirements such as:
a. Tank integrity testing;
b. Overfill protection;
c. Marking of tanks;
d. Cathodic protection; and
e. Availability and condition of emergency equipment
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
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0. Recordkceping and Reporting
(Linkage with 1. Organizational Structure and 3.A. Formality of Storage Tank
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of storage tank activities.
a. Develop an understanding of all systems that are in place for storage tank
recordkeeping and document control (e.g., does the facility maintain a log or database
of storage tanks used, inspection logs, inventory reports, employee training
documentation, etc.). For example, understand the systems for:
1) Tracking of key regulatory schedules (e.g., tank registration, etc.),
2) Maintenance of records (e.g., storage tank registration, spill plans, training records,
storage tank inventory, etc.), and
3) Preparation and submission of required reports (e.g., inventory reports, pollution
prevention reports, spill reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
storage tank records. Determine whether the files are complete, current, and readily
accessible.
c. Determine how the facility ensures that required storage tank reports/notifications are
routinely prepared and submitted to the appropriate regulatory agencies in a timely
manner. Through interviews with the environmental manager, identify the person(s)
responsible for regulatory reporting and through interviews with them determine if
they have appropriate experience/training to effectively report on storage tank
activities. Types of reports/notifications include:
1) Registration of storage tanks;
2) Change in user status;
3) Inventory reports; and
4) CERCLA/SARA notification for spills/releases in excess of "reportable quantity".
d. Interview the storage tank manager to determine whether the recordkeeping practices
are formal and systematic (e.g., regularly performed by an assigned individual,
computerized).
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2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
applicable compliance requirements and other related environmental information. (For
example, the facility may choose to maintain tank registrations indefinitely).
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities)
c. Verify that the facility maintains storage tank records for the retention periods
specified by regulation.
3. Determine how the facility investigates, reports, corrects, tracks, and monitors storage
tank problems and "incidents" (for example, releases/spills of storage tanks into the
environment, container/tank failure). Interview storage tank personnel and review
procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
. A. Internal Communication
1. Interview the environmental and storage tank managers and review internal memos,
newsletters, etc., to understand how environmental information related to storage tanks is
communicated. For example, is storage tank information (e.g., storage tank inventory
status, incidents) regularly communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically'flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover storage tank issues (review minutes of meetings, talk
with personnel who regularly attend meetings).
*
2. Determine if formal communication of storage tank directives is timely, and effectively
reaches all responsible elements of the facility. Specifically (Linkage with 3.A. Regulatory
Tracking and Translation):
a. Determine how quickly the following types of storage tank information is
communicated to management:'
1) Routine environmental status information;
2) New storage tank regulations;
3) Incident or major issue information; and
4) Controversial storage tank issues.
b. Determine how quickly new storage tank requirements, programs or other information
is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to storage tanks.
a. Review files to determine if the concerns and responses are documented.
b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
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I) Have employee concerns been addressed? (For those that were not, determine the
reason.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to storage tanks.
For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the storage tank status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concems regarding the facility's storage tank have been
received from the local community.
1) Note whether these complaints/questions/concems have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
storage tank management activities (this includes dedicated support staff and others with
collateral duties [e.g., line managers with other suppon functions]). Interview the human
resource manager as well as a sample of storage tank staff to determine if staffing levels
are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced storage tank management staff to assure
compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview storage tank management personnel and review their job descriptions and
applicable regulations to determine what qualifications are necessary for staffing and other
positions with responsibilities (e.g., storage tank trainers, storage tank managers).
a. Determine if personnel with storage tank management responsibilities have the
relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff (e.g., corrosion control expert, tank
integrity tester, emergency response coordinator, etc.) and note the following: .
I) Specialized training in storage tank management;
2) Relevant storage tank work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of storage tank issues at the facility) conclude as to the quality and
quantity of storage tank personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for storage tank management staff (including line
managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for storage tank
management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if storage tank management performance is
regularly included in the performance review process of appropriate personnel.
3. Interview a sample of storage tank staff (e.g., storage tank inspectors; maintenance
personnel) to confirm that they are evaluated on how well they perform their storage tank
management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work.
C. Training Programs
1. Review training documentation (training manuals or other documents describing storage
tank training programs) to determine if the facility has identified specialized storage tank
training requirements (based on regulatory/internal requirements, corrosion control
expertise).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate storage tank training needs for all
relevant personnel who may be required to work with storage tank?
3) How does the facility ensure that storage tank training courses (e.g., storage tank
initial/refresher training) are completed?
2. Determine how the training documentation is maintained and updated (e.g. by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Key parameters for automatic feed cut-off systems;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm systems;
e. Response to fire or explosion;
f. Response to leaks or spills;
g. Tank use, marking, and labeling;
h. Tank registration practices;
i. Integrity testing; and
j. Corrosion control.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and storage tank managers and reviewing storage tank
program documentation, determine if the facility conducts storage tank self-
assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all storage tank issues at each self-assessment/appraisal or cover only one topic
at a time (e.g., manifesting and labeling, storage areas, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action.
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols.
checklist, or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address storage tank management issues relevant
to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually).
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for storage tank management performance.
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects,-programs, or activities that may impact storage tank
management (for example, projects, programs, or activities that may increase the number
or size of storage tanks require additional personnel or equipment to manage the storage
tanks adequately) are carefully reviewed to identify and address environmental, health,
and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention
opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and storage tank
managers, and a review of project planning documentation, comment on how the facility
balances environmental concerns against production/operational demands when reviewing
proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of storage tank spill/leak incidents is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b.1 Interview a selection of environmental management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your '
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
i
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 128S6.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with environmental management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
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pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
I. Based on your understanding of the facility operations and types and volumes of wastes
as well as interviews and a review of files, comment on how well the facility integrated
pollution prevention into its daily activities (Linkage with Phase 1 - Section 3 Waste
Minimization Plan).
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Phase 2
Section 28
Assessing Effectiveness of Drinking Water
Program Management
-------
Table off Contents
Section 28
Drinking Water
Introduction to Management Systems Assessments 28-1
A. Purpose 28-1
B. Scope 28-1
C. Approach 28-2
D. Understanding Management Systems 28-2
1. Organizational Structure 28-5
A. Management Organization 28-5
B. Roles and Responsibilities 28-6
2. Environmental Commitment 28-8
A. Top Management Support . 28-8
B. Environmental Policy 28-9
C. Line Management Support 28-9
3. Formality of Drinking Water Management Program 28-10
A. Regulatory Tracking and Translation 28-10
B. Procedures 28-11
C. Routine Inspections 28-12
D. Recordkeeping and Reporting 28-13
4. Internal and External Communication 28-16
A. Internal Communication 28-16
B. External Communication 28-17
5. Staff Resources, Training, and Development 28-18
A. Staffing 28-18
B. Job Descriptions and Performance Evaluations 28-19
C. Training Programs 28-19
6. Program Evaluation, Reporting and Corrective Action 28-21
A. Self-Assessment and Appraisal System 28-21
B. Reporting and Follow-up 28-22'
7. Environmental Planning and Risk Management . 28-23
A. Environmental Planning and Risk Management 28-23
8. Pollution Prevention 28-24
A. Pollution Prevention Goals 28-24
B. Pollution Prevention Plan 28-24
C. Pollution Prevention Funding 28-25
D. Pollution Prevention Tracking 28-25
E. Pollution Prevention Training 28-25
F. Pollution Prevention Considerations 28-26
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment. They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, hazardous waste) will allow the auditor to
obtain an understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., drinking water treatment facility), the auditor often must talk with
other personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, hazardous waste contingency plan). This review serves to further enhance an
auditor's understanding of the management systems and physical controls. Review the
following documents:
• Bacterial and chemical analyses of drinking water, including sampling dates and locations,
dates of analyses, analytical methods used, and results of analyses
• Monthly operating reports (flow, chlorine residual, etc.)
• State and public notification of noncompliance with primary drinking water standards
• Action taken by the facility to correct violations of primary drinking water standards
• Sanitary surveys of the water system conducted by the facility itself, a private consultant,
or any local, state, or Federal agency
Public notification of noncompliance with secondary MCL for fluoride
Variance or exemption granted to the facility for its water supply system
Permit authorizing the operation of an underground injection well
Records of planning and construction of injection wells
Results of injection well monitoring
Records, including any petition for review, of facility projects that may potentially cause
contamination of a sole source aquifer through its recharge zone
• Waivers from the state
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Records of planning and construction of injection wells
• Laboratory analysis facilities
• Underground injection wells
• Drinking water treatment facility
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
' Phase 2 - Section 28
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a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g.. are training records kept in one central file or are they in individual employees' flies).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment
Phase 2 - Section 28
Management Systems Assessments - Drinking Water
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's drinking water management function is organized. Determine if
the drinking water management function is characterized by clear lines of authority and
responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the drinking water management function and determine who:
1} Establishes and enforces facility-wide drinking water programs, policies, and
procedures/practices;
2) Provides drinking water oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
b. Determine who the drinking water manager reports to and how that reporting function
is linked to the facility manager or person responsible for overall environmental
management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the drinking water manager and
person responsible for overall environmental management are open and effective
(e.g., how do these people communicate [verbal, memo, etc.], how frequently do
they talk, etc.).
c. Determine which departments) and individual(s) have authority and
responsibility/accountability for various drinking water management activities. For
example, determine through interviews and document review who is responsible for
operating the drinking water treatment facility, sampling and analysis, conducting
sanitary survey, reporting and recordkeeping (Linkage with l.B. Roles and
Responsibilities).
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2. Determine if drinking water managers have sufficient authority to effectively implement
drinking water programs and to make decisions related to environmental protection.
Interview the drinking water manager and other drinking water personnel and:
a. Understand the amount of authority given to these drinking water personnel at
different levels and determine if it is sufficient to carry out their responsibilities (e.g.,
is authority commensurate with responsibility),
b. Determine who is responsible for approving specific drinking water projects or
activities and if those personnel have the appropriate background/authority to approve
these projects, and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
drinking water management, who is responsible and accountable for drinking water
management activities, including, but not limited to training, recordkeeping and reporting,
sampling and analysis, laboratory management, drinking water treatment facility
management, etc.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for drinking water management match those in program manuals or job
descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the drinking water functions specified in their job descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall drinking water management, and determine if this reporting
relationship is clearly and formally defined and understood.
e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes drinking water policy, procedures, and standards;
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2) Provides drinking water oversight/management to field/operating personnel; and
3) Provides technical support for Held personnel.
f. Determine whether specific roles as required by Federal agency drinking water policy
and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate drinking water management responsibilities are defined and are included
in their written performance appraisal.
a. Interview a selection of drinking water management personnel to determine if there is
accountability for their environmental performance (e.g., if their drinking water
management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding drinking
water management performance or reprimands for failure to carry out drinking water
management responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
drinking water management, and the facility manager, if top management has supported
drinking water programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire drinking water treatment
equipment, to develop and enhance aquifer protection programs, etc.
1) If financial, technical, and personnel resources are adequate to manage the volume
of drinking water treated/supplied at the facility.
b. Whether top management has a clear set of goals and expectations regarding drinking
water performance and what they are (e.g., environmental compliance as a minimum
expectation, goals that go beyond compliance).
2. Review drinking water management documentation and identify how senior management
communicates its drinking water goals and expectations to employees; and, typically, how
frequently the goals are communicated. For example, review the facility's drinking water
mission statements, policies, procedures, orders, directives, standard operating procedures,
etc. and ascertain if they clearly communicate drinking water goals.
a. Interview a sample of operating and drinking water management personnel to
determine if they understand the facility drinking water policies, goals, etc.
3. Interview drinking water management personnel and understand what types of drinking
water reports are routinely and periodically provided to top management
a Determine if drinking water system operating reports, bacterial and chemical analyses
summary reports, water quality reports, injection well activity reports, etc., are
routinely prepared for lop management and to what extent they address the facility's
drinking water status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of drinking
water reports or if reports are prepared for "information only".
Phase 2 - Section 28
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B. Environmental Policy
1. Determine through interviews, what drinking water policies are widely distributed and if
they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., drinking water
manager, environmental manager, drinking water treatment plant manager, facility
manager, etc.) whose activities may impact drinking water performance to determine if
they take responsibility and interest in limiting the impact of their operations. For
example:
a. Identify activities in which line managers are involved in drinking water management
Specifically, do they:
1) Routinely observe field level drinking water compliance activities?
2) Participate in audits and self-assessments?
3) Write and review drinking water procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to drinking water, line
managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences involving the drinking water supply.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support drinking water activities and how they integrate drinking water
management into the facility operations. For example, do they observe compliance
activities, conduct self-assessments, train employees, etc.
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3. Formality of Drinking Water Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging drinking water
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of drinking water regulations, and if there is a
formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging drinking
water regulations and trends (e.g., BNA, Federal Register updates, professional
societies, contact with regulator/officials, subscriptions to professional publications
related to drinking water management).
*
c. Determine how new drinking water regulations are interpreted as to their applicability
and by whom (e.g., drinking water manager, legal department).
d. Note the availability of drinking water regulatory reference material (for example.
currency of subscription to BNA, automated access via software, CFRs, Federal and
State Registers, state regulations, technical books, and other reference materials
relating to drinking water management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to drinking water
program manuals, training courses). Interview selected operating personnel to obtain
their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new drinking water regulatory
.requirements is incorporated into facility or site-specific standard operating procedures, as
appropriate.
a. Through interviews, determine if there is a formal system in place to update drinking
water management programs and procedures to reflect changes in regulatory
requirements, such as reporting requirements, treatment practices, revised MCLs, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form drinking water regulatory information is transmitted;
to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necesssary
department/people learn of the developments with sufficient lead lime to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing drinking
water programs, policies, and procedures. Note the frequency that drinking water
programs, policies, and procedures are updated/new ones developed, how often they are
reviewed, and who approves them. Determine if there is a formal system in place to
update drinking water management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's drinking water programs, policies, and procedures. Determine their level of
experience and comment on the appropriateness of these individuals to perform such
tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new drinking water regulatory requirement and determine whether a new
procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
drinking water management policies, programs, or procedures, whether the organization
has a program (e.g., written procedures) for the management of its drinking water and
drinking water supply, including, but not limited to:
a. Identification of drinking water supply;
b. Identification of possible contamination sources to the drinking water supply:
c. Management of underground injection activities;
d. 'So^pling and analysis;
e. Reco'rdkeeping and reporting;
•
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f. Development, implementation, and review of contingency plans (e.g., alternate
drinking water supply);
g. Groundwater monitoring programs;
h. Pollution prevention; and
i. Corrective action to identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
drinking water procedures relevant to their job function. For example, are they easily
accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of drinking water management
procedures.
5. Determine whether applicable drinking water management programs include the following
program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight.
6. Determine if drinking water management procedures such as those listed above are
reviewed and updated on any schedule (e.g., periodically, annually, only when regulations
change) and who is responsible for this review/update.
C. Routine Inspections
1. Interview the environmental and drinking water managers to determine if the facility has
a program for routine site and equipment inspections and compliance checks, including
appropriate documentation relating to drinking water activities. Specifically, determine if
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the facility regularly determines compliance with legal and regulatory requirements such
as:
a. Backflow prevention device inspections;
b. Cross connection inspections;
c. Equipment calibration checks;
d. Wellhead inspections; and
e. Water quality monitoring.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3..Formality of Drinking Water
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of drinking water activities.
a. Develop an understanding of all systems that are in place for drinking water
recordkeeping and document control (e.g., does the facility maintain a log or database
of bacterial and chemical analyses results, disinfection and filtration records, monthly
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chlorine residual and flow operating reports, etc.). For example, understand the
systems for:
1) Tracking of key regulatory schedules (e.g., permit renewals, sanitary survey
submissions, required training, etc.);
2) Maintenance of compliance records (e.g., analytical records [chemical and
bacterial], monthly operating reports, etc.); and
3) Preparation and submission of required reports/notifications (e.g., public/regulatory
notification for noncompliance, sanitary surveys, waiver applications, etc.).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
drinking water records. Determine whether the files are complete, current, and readily
accessible.
c. Determine how the facility ensures that required drinking water reports/notifications
are routinely prepared and submitted to the appropriate regulatory agencies in a timely
manner. Through interviews with the environmental manager, identify the person(s)
responsible for regulatory reporting and through interviews with them determine if
they have appropriate experience/training to effectively report on drinking water
activities. Types of reports/notifications include:
1) Sanitary surveys;
2) Notification of noncompliance with MCL;
3) Waiver applications;
4) Monthly operating reports; and
5) Inspection of backflow prevention devices.
d. Interview the drinking water manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
SDWA compliance and other related environmental information. (For example, the
facility may choose to maintain records of actions taken to correct or repair any part
of the treatment and distribution system indefinitely, rather than for the required j&ree
years).
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b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities).
c. Verify that the facility maintains drinking water records for the retention periods
specified by regulation (e.g., records of actions taken to correct or repair any part of
the treatment and distribution system—three years; bacteriological analyses—five
years; chemical analyses—ten years; records concerning a variance or exemption—five
years).
3. Determine how the facility investigates, reports, corrects, tracks, and monitors drinking
water problems and "incidents" (for example, noncompliance with MCLs,
treatment/disinfection equipment malfunction). Interview drinking water personnel and
review procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and drinking water managers, and review internal memos,
newsletters, etc., to understand how environmental information related to drinking water is
communicated. For example, is drinking water information (e.g., drinking water quality)
regularly communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover drinking water issues (review minutes of meetings, talk
with personnel who regularly attend meetings).
2. Determine if formal communication of drinking water directives is timely, and effectively
reaches all responsible elements of the facility. Specifically (Linkage with 3.A. Regulatory
Tracking and Translation):
a. Determine how quickly the following types of drinking water information is
communicated to management:
1) Routine environmental status information;
2) New drinking water regulations;
3) Incident or major issue information; and
4) Controversial drinking water issues.
b. Determine how quickly new drinking water requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to drinking water.
a. Review files to determine if the concerns and responses are documented.
b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
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1) Have employee concerns been addressed? (For those that were not, determine the
reason.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to drinking water.
For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the drinking water quality of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's drinking water have been
received from the local community (if the facility also supplies drinking water to the
neighboring community).
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
drinking water management activities (this includes dedicated support staff and others
with collateral dudes [e.g., line managers with other support functions]). Interview the
human resource manager as well as a-sample of drinking water staff to determine if
staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced drinking water management staff to
assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies (MCL exceedance) whose root causes are inadequate
resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview drinking water management personnel and review their job descriptions and
applicable regulations to determine what qualifications are necessary for staffing and other
positions with responsibilities (e.g., laboratory manager, treatment facility operator).
a. Determine if personnel with drinking water management responsibilities have the
relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in drinking water management;
2) Relevant drinking water work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of drinking water issues at the facility) conclude as to the quality and
quantity of drinking water personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for drinking water management staff (including
line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties, and
b. If appropriate job descriptions are established and maintained for drinking water
management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if drinking water management performance is
regularly included in the performance review process.
3. Interview a sample of drinking water staff (e.g., person who performs sampling,
laboratory personnel, treatment facility operator) to confirm that they are evaluated on
how well they perform their drinking water management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing drinking
water training programs) to determine if the facility has identified specialized drinking
water training requirements (based on regulatory requirements, volumes of drinking water
treated/supplied at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate drinking water training needs for all
relevant personnel who may be required to work with drinking water?
3) How does the facility ensure that drinking water training courses (e.g., treatment
plant operator) are completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Contingency plan implementation (emergency procedures, equipment, and systems);
b. Key parameters for automatic disinfection chemicals feed cut-off systems;
c. Procedures for using, inspecting, and repairing emergency and monitoring equipment;
d. Operation of communications and alarm systems;
e. Sampling and analysis techniques.
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6. Program Evaluation, Reporting and Corrective Action
• A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and drinking water managers and reviewing drinking
water program documentation, determine if the facility conducts drinking water self-
assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all drinking water issues at each self-assessment/appraisal or cover only one
topic at a time (e.g., distribution system, backflow prevention devices, disinfection and
filtration);
d. Are documented and results retained in organized files;
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists, or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address drinking water management issues
relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
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B. Reporting and Follow-up
1. Determine if the facility m'aintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for drinking water management performance.
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities thai may impact drinking water
quality/drinking water supply management (for example, projects, programs, or activities
that may be located near the drinking water supply and increase the possibility of
contamination of the drinking water supply raw water) are carefully reviewed to identify
and address environmental, health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and drinking
water managers, and a review of project planning documentation, comment on how the
facility balances environmental concerns against production/operational demands when
reviewing proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the protection of the drinking water supply is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of drinking water management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
c. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with drinking water management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
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pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (drinking water), and activities associated
with drinking water.
1. Based on your understanding of the facility operations and types and volumes of wastes
generated, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities (Waste Minimization Plan Linkage
with Phase 1 - Section 3).
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Phase 2
Section 29
Assessing Effectiveness of PCB
Program Management
-------
Table of Contents
Section 29
PCB
Introduction to Management Systems Assessments 29-1
A. Purpose 29-1
B. Scope 29-1
C. Approach 29-2
D. Understanding Management Systems 29-2
1. Organizational Structure 29-5
A. Management Organization • 29-5
B. Roles and Responsibilities ' 29-6
2. Environmental Commitment 294
A. Top Management Support 29-8
B. Environmental Policy 29-9
C. Line Management Support 29-9
3. Formality of PCB Management Program 29-10
A. Regulatory Tracking and Translation 29-10
B. Procedures 29-11
C. Routine Inspections ' 29-13
D. Recordkeeping and Reporting 29-14
4. Internal and External Communication 29-16
A. Internal Communication 29-16
B. External Communication 29-17
5. Staff Resources, Training, and Development 29-18
A. Staffing 29-18
B. Job Descriptions and Performance Evaluations 29-19
C. Training Programs 29-19
6. Program Evaluation, Reporting and Corrective Action 29-21
A. Self-Assessment and Appraisal System 29-21
B. Reporting and Follow-up . 29-22
7. Environmental Planning and Risk Management 29-23
A. Environmental Planning and Risk'Management 29-23
8. Pollution Prevention 29-24
A. Pollution Prevention Goals 29-24
B. Pollution Prevention Plan 29-24
C. Pollution Prevention Funding • 29-25
D. Pollution Prevention Tracking 29-25
E. Pollution Prevention Training 29-25
F. Pollution Prevention Considerations 29-26
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Introduction
A. Purpose •
The primary purpose of a Management -Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs. ,
• Compliance with Federal agency policies and procedures which address environmental .
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner'consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies.
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, PCB) will allow the auditor to obtain an
understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., PCB storage areas), the auditor often must talk with other personnel.
This wilt enable the auditor to develop an increased sense of confidence in or reliance on the
information based on corroboration of multiple sources and to develop clues as to potential
weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, PCB contingency plan). This review serves to further enhance an auditor's
understanding of the management systems and physical controls. Review the following
documents:
• PCB management plan;
• Notification of PCB Activity (USEPA ID No.);
• PCB manifests;
• Manaifest exception reports;
• PCB annual reports;
• Inspection logs;
• PCB waste analysis records;
• PCB disposal records; and
• PCB incineration records.
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• PCB markings and labels;
• PCB transformers/capacitors;
• PCB circuit breakers;
• Vehicles used for transport;
• PCB storage facilities (including drums): and
• PCB landfill or incinerator.
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are storage records kept in one central file or are they in operations files).
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The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.!
evaluate how the facility's PCB management function is organized. Determine if the PCB
management function is characterized by clear lines of authority and responsibility. For
example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the PCB management function and determine who:
«
1) Establishes and enforces facility-wide PCB programs, policies, and
procedures/practices;
2) Conducts oversight of PCB activities (e.g., storage practices); and
3) Provides analytical support for conducting PCB analyses.
b. Determine who the PCB manager reports to and how that reporting function is linked
to the facility manager or person responsible for overall environmental management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the PCB manager and person
responsible for overall environmental management are open and effective (e.g.,
how do these people communicate [verbal, memo, etc.], how frequently do they
talk, etc.).
c. Determine which depanment(s) and individual(s) have authority and
responsibility/accountability for various PCB management activities. For example.
determine through interviews and document review, who is responsible for conducting
PCB analysis, maintaining facility, PCB inventories, managing PCB storage activities;
coordinating emergency response measures (Linkage with l.B. Roles and
Responsibilities).
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2. Determine if PCB managers have sufficient authority to effectively implement PCB
programs and to make decisions related to environmental protection. Interview the PCB
manager and other PCB personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with PCBs and determine if it is sufficient to carry out their responsibilities
(e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific PCB projects (e.g., removal of
PCB transformers) and if those personnel have the appropriate authority to approve
these projects, and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
PCB management, who is responsible and accountable for PCB management activities,
including, but not limited to, inventorying PCBs. manifest preparation and tracking,
annual reporting, PCB storage areas, and coordination of emergency response measures at
the facility.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for PCB management match those in program manuals or job
descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the PCB functions specified in their job descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall PCB management, and determine if this reporting relationship
is clearly and formally defined and understood.
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
}
1) Establishes PCB policy, procedures, and standards;
2) Provides PCB oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency PCB policy and/or
Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate PCB management responsibilities are defined and are included in their
written performance appraisal.
a. Interview a selection of PCB management personnel to determine if there is
accountability for their performance (e.g., if their PCB management/field
responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding PCB
management performance or reprimands for failure to carry out PCB management
responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the-environmental manager, the person responsible for overall
PCB management, and the facility manager, if top management has supported PCB
programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to replace PCB equipment, to
construct and enhance PCBs storage facilities, etc.
1) If financial, technical, and personnel resources are adequate to manage the volume
of PCB at the facility.
b. Whether top management has a clear set of goals and expectations regarding PCB
performance and what they are (e.g., environmental compliance as a minimum
expectation, goals that go beyond compliance, PCB reductions).
2. Review PCB management documentation and identify how senior management
communicates its PCB goals and expectations to employees; and, typically, how
frequently the goals are communicated. For example, review the facility's PCB mission
statements, policies, procedures, orders, directives, standard operating procedures, etc. and
ascertain if they clearly communicate PCB goals.
a. Interview a sample of operating and PCB personnel to determine if they understand
the facility PCB policies, goals, etc.
3. Interview PCB management personnel and understand what types of PCB reports are
routinely and periodically provided to top management.
a. Determine if PCB annual reports, PCB reduction progress reports, PCB inventory
reports, etc.. are routinely prepared for top management and to what extent they
address the facility's PCB status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of PCB
reports or if reports are prepared for "information only".
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B. Environmental Policy
1. Determine through interviews, what PCB policies are widely distributed and if they are
easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g.. PCB
manager/inspector, environmental manager, line managers, facility manager, etc.) whose
activities may impact PCB performance to determine if they take responsibility and
interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in PCB management
Specifically, do they:
1) Routinely observe field level PCB compliance activities, such as transformer
inspections?
2) Participate in audits and self-assessments?
3) Write and review PCB procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to PCBs, line managers
solicit and receive (PCB inventory) and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accidents involving PCBs.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support PCB activities and how they integrate PCB management into the
facility operations. For example, do they observe compliance activities or conduct self-
assessments, etc.?
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3. Formality of PCB Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging PCB regulations and
trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of PCB regulations, and if there is a formal
system for this function.
b. Determine what documents are regularly reviewed for new and emerging PCB
regulations and trends (e.g., BNA, Federal Register updates, professional societies,
contact with regulator/officials, state PCB regulations).
c. Determine how new PCB regulations are interpreted as to their applicability and by
whom (e.g., environmental manager, legal department).
d. Note the availability of PCB regulatory reference material (for example, currency of
subscription to BNA, automated access via software, CFRs, Federal and State
Registers, state regulations, technical books, and other reference materials relating to '
PCB management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to PCB program
manuals, training courses). Interview selected operating personnel to obtain their
understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new PCB regulatory
requirements is incorporated into facility or site-specific standard operating procedures, as
appropriate.
a. Through interviews, determine if there is a formal system in place to update PCB
management programs and procedures to reflect changes in regulatory requirements,
such as biennial reporting requirements, storage, handling, treatment and disposal
practices for PCBs, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form PCB regulatory information is transmitted to the
facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action. ' '
B. Procedures
1. Determine the process by which new requirements are incorporated into existing PCB
programs, policies, and procedures. Note the frequency that PCB programs, policies, and
procedures are updated/new ones developed, how often they are reviewed, and who
approves them. Determine if there is a formal system in place to update PCB management
programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's PCB programs, policies, and procedures. Determine their level of experience
and comment on the appropriateness of these individuals to perform such tasks.
(Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of PCB procedures to determine if they have
been reviewed, updated, and if the new/revised procedures have gone through an
approval process before becoming finalized. Identify the persons responsible for the
approval process.
c. Identify a new PCB regulatory requirement and determine whether a new procedure
has been developed and approved, or an existing has been updated and approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
PCB management policies, programs, or procedures, whether the organization has a
program (e.g., written procedures) for the management of PCBs, including, but not limited
to:
a. Identification of PCB waste streams;
b. Characterization of PCB waste streams (PCB concentration);
c. Analytical methods used to determine if PCBs are regulated or not;
d. Sampling methods;
e. Manifest preparation;
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f. PCB transportation;
g. Labeling of containers and'tanks;
h. PCB storage area inspection;
i. Facility methods to assess generator status;
j. Development, implementation, and review of preparedness and prevention procedures
and PCB contingency plan;
k. Procedures for managing PCB wastes;
1. Procedures of management of specific PCB management units (e.g., landfills, tanks,
incinerators, etc.);
m. PCB landfill groundwater monitoring programs;
n. Inventory reduction; and
o. Corrective action to identified problems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
PCB procedures relevant to their job function. For example, are they easily accessible,
centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of PCB management procedures.
5. Determine whether applicable PCB management programs include the following program
elements:
«
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
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e. Training; and •
f. Program evaluation and oversight.
6. Determine if PCB management procedures such as those listed above are reviewed and
updated on any schedule (e.g., periodically, annually, only when regulations change) and
who is responsible for this review.
C. Routine Inspections
1. Interview the environmental and PCB managers and PCB inspector to determine if the
facility has a program for routine site and equipment inspections and compliance checks,
including appropriate documentation relating to PCB activities. Specifically, determine if
the facility regularly determines compliance with legal and regulatory requirements such
as:
a. PCB storage area/container inspections;
b. PCB transformers;
c. Vehicles used for transport;
d. Incinerators; and
e. Disposal sites.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
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d. Determine -if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of PCB Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of PCB activities.
a. Develop an understanding of all systems that are in place for PCB recordkeeping and
document control (e.g., does the facility maintain a log or database of PCBs,
inspection logs, annual reports, employee training documentation, PCB manifests, etc.).
For example, understand the systems for:
1) Tracking of key regulatory schedules (e.g., PCB disposal within one year of being
taken out of service, PCB spill reporting, etc.);
2) Maintenance of compliance records (e.g., PCB storage area inspection logs,
manifests, training records, PCB inventory and profiles); and
3) Preparation and submission of required reports (e.g., annual reports, exception
reports, spill reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
PCB records. Determine whether the files are complete, current, and readily accessible.
c. Determine how the facility ensures that required PCB reports/notifications are
routinely prepared and submitted to the appropriate regulatory agencies in a timely
manner. Through interviews with the environmental manager, identify the person(s)
responsible for regulatory reporting and through interviews with them determine if
they have appropriate experience/training to effectively report on PCB activities. Types
of reports/notifications include:
1) Notification of PCB activity;
2) Change in generator status;
3) Exception reports;
4) Annual reports; and
5) Notification for PCB spills/releases.
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d. Interview the PCB manager to determine whether the recordkeeping practices are
formal and systematic (e.g.. regularly performed by an assigned individual,
computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers PCB
compliance and other related environmental information. (For example, the facility
may choose to maintain PCB manifests indefinitely, rather than for the required five
years.)
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with I.B. Roles and Responsibilities)
c. Verify that the facility maintains PCB records for the retention periods specified by
regulation or facility policy, (e.g., manifests — three years; annual reports — five
years).
3. Determine how the facility investigates, reports, corrects, tracks, and monitors PCB
problems and "incidents" (for example, releases/spills of PCB into the environment,
container/tank failure). Interview PCB personnel and review procedures to determine if
these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and PCB managers, and review internal memos. newsletters,
etc., to understand how environmental information related to PCB is communicated. For
example, is PCB information (e.g., PCB management status, incidents) regularly
communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover PCB issues (review minutes of meetings, talk with
personnel who regularly attend meetings).
2. Determine if formal communication of PCB directives is timely, and effectively reaches
all responsible elements of the facility. Specifically (Linkage with 3.A. Regulatory
Tracking and Translation):
a. Determine how quickly the following types of PCB information is communicated to
management:
1) PCB inventory information;
2) New PCB regulations;
3) Incident or major issue information; and
4) Controversial PCB issues.
b. Determine how quickly new PCB requirements, programs or other information is
communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to PCB.
a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
1) Have employee concerns been addressed? (For those that were not, determine the
reason.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to PCBs. For
example:
a. Determine if the facility has any communication programs with the local community
(e.g.,-education, visitation of facilities, public reading rooms) to keep them informed
of the PCB status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's PCB have been received
from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
.A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
PCB management activities (this includes dedicated support staff and others with
collateral duties [e.g.. line managers with other support functions]). Interview the human
resource manager as well as a sample of PCB staff to determine if staffing levels are
sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced PCB management staff to assure
compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview PCB management personnel and review their job descriptions and applicable
regulations to determine what qualifications are necessary for staffing and other positions
with responsibilities (e.g., PCB inspectors, PCB managers).
a. Determine if personnel with PCB management responsibilities have the relevant
background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff (e.g., PCB manager/inspector,
emergency response coordinator, etc.) and note the following:
1) Specialized training in PCB management;
2) Relevant PCB work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of PCB issues at the facility) conclude as to the quality and quantity of
PCB personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for PCB management staff (including line
managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for PCB management
positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if PCB management performance is regularly
included in the performance review process for appropriate personnel.
3. Interview a sample of PCB staff (e.g., PCB inspection personnel, storage facility
managers) to confirm that they are evaluated on how well they perform their PCB '
management responsibilities.
4. Note whether performance emphasis is on task completion/production versus quality of
work, pollution prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing PCB
training programs) to determine if the facility has identified PCB training requirements
(based on agency requirements, types/volumes of PCBs at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate PCB training needs for all relevant
personnel who may be required to work with PCBs?
3) How does the facility ensure that PCB training courses are completed?
2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
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i
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4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Definitions of PCBs. PCB transformers, etc.;
b. Overview of regulatory standards;
c. PCB labeling requirements;
d. Proper inspection techniques;
e. Response to fire or spill;
f. Sampling and analysis techniques;
g. Container use, marking, and labeling;
h. Manifesting and transportation;
i. Storage standards; and
j. Proper disposal methods.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and PCB managers and reviewing PCB program
documentation, determine 'if the facility conducts PCB program self-
assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all PCB issues or cover only one topic at a time (e.g., manifesting and labeling,
storage areas, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action(s).
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address PCB management issues relevant to the
facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Phase 2 - Section 29
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisaJ/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for PCS management performance.
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7. Environmental Planning and Risk Management
.A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact PCB management
(for example, projects, programs, or activities that may increase the inventory or
concentration of PCBs, require additional personnel or equipment to handle the PCBs
adequately) are carefully reviewed to identify and address environmental, health, and
safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention
opportunities for proposed PCB projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and PCB
managers, and a review of project planning documentation, comment on how the facility
balances environmental concerns against production/operational demands when reviewing
proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of PCBs is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of PCB management personnel to determine if they understand
the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is.responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if. top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with environmental management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
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pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (PCBs), and activities associated with
PCBs.
1. Based on your understanding of the facility operations and types and volumes of PCBs
for disposal, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities (Linkage with Phase 1 - Section 3
Waste Minimization Plan).
' Phase 2 - Section 29
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Phase 2
Section 30
Assessing Effectiveness of Pesticide Program
Management
-------
Table of Contents
.Section 30
Pesticide
Introduction to Management Systems Assessments 30-1
A. Purpose 30-1
B. Scope 30-1
C. Approach 30-2
D. Understanding Management Systems 30-2
1. Organizational Structure 30-5
A. Management Organization 30-5
B. Roles and Responsibilities . 30-6
2. Environmental Commitment 30-8
A. Top Management Support 30-8
B. Environmental Policy 30-9
C. Line Management Support 30-9
3. Formality of Pesticide Management Program 30-10
A. Regulatory Tracking and Translation 30-10
B. Procedures ' 30-11
C. Routine Inspections 30-13
D. Recordkeeping and Reporting 30-14
4. Internal and External Communication 30-16
A. Internal Communication 30-16
B. External Communication 30-17
5. Staff Resources, Training, and Development 30-18
A. Staffing 30-18
B. Job Descriptions and Performance Evaluations 30-19
C. Training Programs 30-19
6. Program Evaluation, Reporting and Corrective Action 30-21
A. Self-Assessment and Appraisal System 30-21
B. Reporting and Follow-up 30-22
7. Environmental Planning and Risk Management 30-23
A. Environmental Planning and Risk Management 30-23
8. Pollution Prevention 30-24
A. Pollution Prevention Goals 30-24
B. Pollution Prevention Plan 30-24
C. Pollution Prevention Funding 30-25
D. Pollution Prevention Tracking 30-25
E. Pollution Prevention Training ' 30-25
F. Pollution Prevention Considerations 30-26
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Introduction
•A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment. They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
* Organization. The internal structure that establishes roles, responsibilities, accountabilities.
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that '
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, pesticide) will allow the auditor to obtain an
understanding as to why and how the environmental management systems work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., pesticide storage areas), the auditor often must talk with other
•personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, pesticide contingency plan). This review serves to further enhance an auditor's
understanding of the management systems and physical controls. Review the following
documents:
• Records of pesticides purchased by the facility (purchase orders, inventory)
• Pesticide application records and annual reports
• Description of the management of the facility's pest control program
• Certification status of pesticide applicators
• Pesticide disposal manifests and records
• Contract files
• Respiratory protection program (qualification, medical monitoring and respirator
maintenance/cartridge replacement)
• Any emergency exemption granted to the Federal agency by the USEPA
• Disposal of pesticide containers
• Monitoring of applicator's health status
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
Personnel protection equipment
Pesticide application equipment
Pesticide storage areas, including storage containers
Observation of pesticide applications, procedures and protective equipment
Disposal of used containers and pesticide waste (if any)
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central file or are they in 250 individual employees'
files).
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The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's pesticide management function is organized. Determine if the
pesticide management function is characterized by clear lines of authority and
responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the pesticide management function (programs, policies,
procedures for pesticide application, disposal of pesticides, health monitoring for
applicators, etc.) and determine who:
1) Establishes and enforces facility-wide pesticide management programs, policies.
and procedures/practices;
2) Provides pesticide management oversight/management to field/operating personnel;
and
3) Provides technical support for field personnel.
b. Determine who the pesticide manager reports to and how that reporting function is
linked to the facility manager or person responsible for overall environmental
management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the 'manager and person
responsible for overall management are open and effective (e.g., how do these
people communicate [verbal, memo, etc.], how frequently do they talk, etc.).
c. Determine which department(s) and individual(s) have authority and responsibility/
accountability for various pesticide management activities (e.g., pesticide application,
inspection of storage facilities and application equipment, etc.). For example,
determine, through interviews and document review, who is responsible for pesticide
application, applicator training, disposing of pesticides, storage or pesticides (Linkage
with l.B. Roles and Responsibilities).
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2. Determine if pesticide managers have sufficient authority to effectively implement
pesticide programs and to make decisions related to environmental protection. Interview
the pesticide manager and other pesticide management personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with pesticides and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility), and
b. Determine who is responsible for approving specific pesticide projects or activities and
if those personnel have the appropriate background/authority to approve these projects.
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
pesticide management, who is responsible and accountable for pesticide management
activities, including, but not limited to, training applicators, applicator certifications,
maintaining pesticide application records and annual reports, preparing descriptions of the
facilities' pest control program, maintaining contract files (for contractors performing
pesticide applications), monitoring of applicators' health status, disposing of excess
pesticides and manifests and records, etc.
. a. Identify where and how these roles and responsibilities are defined, such as in program
manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for pesticide management match those in program manuals or job
descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the pesticide managment functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall pesticide management, and determine if this reporting
relationship is clearly and formally defined and understood.
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes pesticide policy, procedures, and standards;
2) Provides pesticide oversight/management to field/operating personnel; and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency pesticide policy and/or
Federal and state regulations have been assigned.
2.' Review job descriptions and performance standards for these individuals to determine if
their appropriate pesticide management responsibilities are defined and are included in
their written performance appraisal.
a. Interview a selection of pesticide management personnel to determine if there is
accountability for their environmental performance (e.g., if their pesticide
management/field responsibilities are evaluated during performance reviews utilizing
integrated pest management techniques, etc.).
b. Determine whether there have been any instances of rewards for outstanding pesticide
management performance or reprimands for failure to carry out pesticide management
responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
pesticide management, and the facility manager, if top management has supported
pesticide programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to optimize pesticide management
through utilization of integrated pest management techniques, or to acquire new
equipment which will optimize pesticide application (e.g., use less chemical), etc.
1) If financial, technical, and personnel resources are adequate to manage the
pesticides used at the facility.
b. Whether top management has a clear set of goals and expectations regarding pesticide
performance and what they are (e.g., environmental compliance as a minimum
expectation, goals that go beyond compliance, pesticide utilization reductions).
2. Review pesticide management documentation and identify how senior management
communicates its pesticide goals and expectations to employees; and. typically, how.
frequently the goals are communicated. For example, review the facility's pesticide
mission statements, policies, procedures, orders, directives, standard operating procedures,
etc. and ascertain if they clearly communicate pesticide management goals (e.g., triple
rinse pesticide containers, do not eat, drink or smoke while handling pesticides, utilize
application techniques which minimize pesticide utilization, etc.).
a. Interview a sample of operating and pesticide management personnel to determine if
they understand the facility pesticide management policies, goals, etc.
3. Interview pesticide management personnel and understand what types of pesticide reports
are routinely and periodically provided to top management
a. Determine if pesticide application records and annual reports, pesticide minimization
reports, applicator health status reports, pesticide incident reports, etc. are routinely
prepared for top management and to what extent they address the facility's pesticide
status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
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c. Determine if any actions are taken as a result of lop management's review of pesticide
related reports or if reports are prepared for "information only".
B. Environmental Policy
1. Determine through interviews, what pesticide policies are widely distributed and if they
are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g., pesticide
manager, environmental manager, line managers, facility manager, etc.) whose activities
may impact pesticide performance to determine if they take responsibility and interest in
limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in pesticide management.
Specifically, do they:
1) Routinely observe field level pesticide compliance activities?
2) Participate in audits and self-assessments?
3) Write and review pesticide procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to pesticide, line
managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences involving pesticide.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support pesticide management activities and how they integrate pesticide
management into the facility operations. For example, do they observe compliance
activities, conduct self-assessments, train employees, etc.
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3. Formality of Pesticide Management Program
•
A. .Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging pesticide regulations and
trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of pesticide regulations, and if there is a
formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging pesticide
regulations and trends (e.g., UNA, Federal Register updates, professional societies,
contact with regulator/officials, subscriptions to professional publications related to
pesticide management).
c. Determine how new pesticide regulations are interpreted as to their applicability and
by whom (e.g., pesticide manager, legal department).
d. Note the availability of pesticide regulatory reference material (for example, currency
of subscription to BNA, automated access via software, CFRs. Federal and State
Registers, state regulations, technical books, and other reference materials relating to
pesticide management).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to pesticide program
manuals, training courses). Interview selected operating personnel to obtain their
understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new pesticide regulatory
requirements is incorporated into facility or site-specific standard operating procedures, as
appropriate.
a. Through interviews, determine if there is a formal system in place to update pesticide
management programs and procedures to reflect changes in regulatory requirements,
such as pesticide application/certification requirements, storage, and handling of
pesticides, reporting on annual usage, structures and procedures to ensure safety of
personnel, etc.
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3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form pesticide regulatory information is transmitted to the
facility.
b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing pesticide
programs, policies, and procedures. Note the frequency that pesticide programs, policies,
and procedures are updated/new ones developed, how often they are reviewed, and who
approves them. Determine if there is a formal system in place to update pesticide
management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's pesticide programs, policies, and procedures. Determine their level of
experience and comment on the appropriateness of these individuals to perform such
tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process (e.g., pesticide program manager, environmental manager, facility manager).
c. Identify a new pesticide regulatory requirement and determine whether a new
procedure has been developed and approved or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
pesticide management policies, programs, or procedures, whether the organization has a
program (e.g., written procedures) for the management of pesticide, including, but not
limited to:
a. Application of pesticides;
b. Pesticide storage, mixing and preparation;
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c. Inspection of storage facilities and containers;
d. Use of .personal protective equipment;
e. Maintaining contract files (for application services);
f. Maintaining purchasing records;
g. Traiing/certifying applicators;
h. Preparing pesticide application and annual reports;
i. Storing and using moderately or highly toxic pesticides; and
j. Spill/emergency response equipment use.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
pesticide procedures relevant to their job function. For example, are they easily accessible.
centrally'located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of pesticide management procedures.
5. Determine whether applicable pesticide management programs include the following
program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
6. Determine if pesticide management procedures such as those listed above are reviewed
and updated on any schedule (e.g., periodically, annually, only when regulations change)
and who is responsible for this review/update.
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C. Routine Inspections
1. Interview the environmental and pesticide managers and pesticide applicators to determine
if the facility has a program for routine site and equipment inspections and compliance
checks, including appropriate documentation relating to pesticide activities. Specifically,
determine if the facility regularly determines compliance with legal and regulatory
requirements such as:
a. Pesticide storage area/container inspections;
b. Personal protective equipment inspections;
c. Vehicles used for transport;
d. Pesticide application equipment inspections; and
e. Disposal of pesticide wastes inspections.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management. (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
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D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Pesticide Management
Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of pesticide program activities.
a. Develop an understanding of all systems that are in place for pesticide recordkeeping
and.document control (e.g., does the facility maintain a log or database of pesticides
used, inspection logs, annual reports, employee training documentation, pesticide
application records, etc.). For example, understand the systems for
•
1) Tracking of key regulatory schedules (e.g., required training, pesticide application
records, etc.);
2) Maintenance of compliance records (e.g., pesticide storage area inspection togs.
training records, pesticide inventory and application records); and
3) Preparation of required reports (e.g., application and annual reports, pesticide
incident reports, etc.).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
pesticide records. Determine whether the files are complete, current, and readily
accessible.
c. Determine how the facility ensures that required pesticide reports/notifications are
routinely prepared and submitted to the appropriate regulatory agencies in a timely
manner. Through interviews with the environmental manager, identify the person(s)
responsible for regulatory reporting and through interviews with them determine if
they, have appropriate experience/training to effectively report on pesticide activities.
Types of reports/notifications include:
1) Applications for exemption (which should include a description of the pesticide; the
proposed use; the target organism; any alternative means of control and why those
means are not feasible);
2) CERCLA/SARA notification for spills/releases in excess of "reportable quantity";
and
3) Reporting requirements (Clean Water Act) triggered by the use of Aldrin/Dieldrin,
DDT, Enadrin, or Toxaphene.
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d. Interview the pesticide manager to determine whether the recordkeeping practices are
formal and systematic (e.g., regularly performed by an assigned individual.
computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
FIFRA compliance and other related environmental information. (For example, the
facility may choose to maintain application records indefinitely, rather than for the .
suggested three years).
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities).
c. Verify that the facility maintains pesticide records for the retention periods
specified/suggested by regulation (e.g., pesticide application records - three years)
3. Determine how the facility investigates, reports, corrects, tracks, and monitors pesticide
problems and "incidents" (for example, releases/spills of pesticide into the environment,
container/tank failure). Interview pesticide management personnel and review procedures
to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and pesticide program managers, and review internal memos,
newsletters, etc.. to understand how environmental information related to pesticides is
communicated. For example, is pesticide information (e.g., pesticide applications,
incidents) regularly communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover pesticide issues (review minutes of meetings, talk with
personnel who regularly attend meetings).
2. Determine if formal communication of pesticide directives is timely, and effectively '
reaches all responsible elements of the facility. Specifically (Linkage with 3.A. Regulatory
Tracking and Translation):
a. Determine how quickly the following types of pesticide information is communicated
to management:
1) Routine environmental status information;
2) New pesticide regulations;
3) Incident or major issue information; and
4) Controversial pesticide issues.
b. Determine how quickly new pesticide requirements, programs or other information is
communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to pesticide.
a. Review flies to determine if the concerns and responses are documented.
b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
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1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1.. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to pesticide. For
example:
a. Determine if the facility has any communication programs with the-local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the pesticide status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's pesticides have been
received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facik'ty has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
pesticide management activities (this includes dedicated support staff and others with
collateral duties [e.g., line managers with other support functions]). Interview the human
resource manager as well as a sample of pesticide management staff to determine if
staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced pesticide management staff to assure
compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview pesticide management personnel and review their job descriptions and
applicable regulations to determine what qualifications are necessary for staffing and other
positions with responsibilities (e.g., pesticide applicator trainers).
a. Determine if personnel with pesticide management responsibilities have the relevant
background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in pesticide application and familiarity with related program
management;
2) Relevant pesticide work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of pesticide issues at the facility) conclude as to the quality and quantity
of pesticide personnel at the facility.
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B. Job Descriptions .and Performance Evaluations
(Linkage with 1. Organizational Structure)
.1. Review forma) written job descriptions for pesticide management staff (including line
managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
. b. If appropriate job descriptions are established and maintained for pesticide
management positions.
j
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if pesticide management performance is regularly
included in the performance review process.
3. Interview a sample of pesticide management staff (e.g., pesticide applicators, hazardous
materials handlers) to confirm that they are evaluated on how well they perform their
pesticide management responsibilities.
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing pesticide
application training programs) to determine if the facility has identified specialized
pesticide training requirements (based on regulatory requirements, types/volumes of
pesticide used at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate pesticide management training needs
for all relevant personnel who may be required to work with pesticides?
3) How does the facility ensure that pesticide training courses (e.g., regular pesticide
application initial/refresher training) are completed?
2. Determine how the training documentation is maintained and updated (e.g. by whom, how
frequently, how is it updated).
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Application of pesticides;
b. Decontamination and disposal of pesticide containers;
c. Mixing, handling and storage of pesticides;
d. Use of personal protective equipment; and
e. Use of spill and emergency response equipment.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and pesticide managers and reviewing the pesticide
program documentation, determine if the facility conducts pesticide self-
assessments/appraisals. Note whether the self-assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all pesticide issues at each self-assessment/appraisal or cover only one topic at a
time (e.g., manifesting and labeling, storage areas, transportation, application);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/monitor corrective
action.
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address pesticide management issues relevant to
the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) 'Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for pesticide management performance.
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact pesticide
management (for example, projects, programs, or activities that may increase the volume
or toxicity of pesticides used, require additional personnel or equipment to handle the
pesticides adequately) are carefully reviewed to identify and address environmental,
health, and safety risks as early as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type). . .
2. Based on interviews with facility management, including environmental and pesticide
managers, and a review of project planning documentation, comment on how the facility
balances environmental concerns against production/operational demands when reviewing
proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of pesticides is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of pesticide management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the faculty's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to •
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 128S6.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with pesticide management personnel and a review of documents,
determine if the facility has programs to educate/train its employees on pollution
prevention/waste minimization opportunities. Programs could include seminars, pollution
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prevention newsletters, annual training courses, inclusion in environmental meeting
agendas, etc.
F. Pollution Prevention Considerations
1. Based on your understanding of the facility operations and types and volumes of
pesticides generated, as well as interviews and a review of files, comment on how well
the facility integrated pollution prevention into its daily activities. Types of pollution
prevention initiatives may include the following (Waste Minimization Plan Linkage with
Phase 1 - Section 3):
a. Has the facility considered non-toxic or less-toxic methods for pest control such as
live trapping opposed to toxic poisons?
b. Does the facility triple rinse empty pesticide containers and recover rinsate before
disposing of the containers?
c. Does the facility limit the access to pesticides containers limited to prevent
untrained/unauthorized people from handling these materials?
d. Does the facility perform regular checks of the pesticide storage area(s) for leaks or
spillage?
e. Does the facility ensure that lids are kept closed and bung holes tightly plugged on
drums or containers of pesticides?
f. Does the facility use an integrated pest control management (IPM) program which
combines chemical, cultural, and biological practices to manage pest populations?
Note: IPM programs are characterized by preventative practices (such as surveying
fields for pest density, timely planting), remedial practices (such as spot spraying only
when required), and economic thresholds, therefore reducing the amount of chemicals
used.
g. Does the facility apply pesticides to minimize excessive spraying by applying dyes to
the chemical (application monitoring), and calibrating pesticide application equipment
to ensure application at the intended rate?
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h. Does the facility apply pesticides to minimize the potential for runoff and leaching of
pesticides by:
• Practicing spot applications (spraying only in areas where needed);
•' Using contact pesticides that do not have to be incorporated into the soil;
• Using row banding application techniques to limit the quantity'of pesticides
applied?
i. Does the facility mix only as much pesticide as required for the application to avoid
surplus generation which may become waste?
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Phase 2
Section 31
Assessing Effectiveness of Groundwater Protection
Program Management
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Table of Contents
Section 31
Groundwater Protection
Introduction to Management Systems Assessments . 31-1
A. Purpose 31-1
B. Scope 31-1
C. Approach 31-2
D. Understanding Management Systems 31-2
1. Organizational Structure 31-4
A. Management Organization . 31-4
B. Roles and Responsibilities 31-5
2. Environmental Commitment 31*7
A. Top Management Support 31-7
B. Environmental Policy 31-8
C. Line Management Support 31-8
3. Formality of Groundwater Protection Management Program 31-9
A. Regulatory Tracking and Translation 31-9
B. Procedures 31-10
C. Routine Inspections 31-11
D. Recordkeeping and Reporting , 31-12
4. Internal and External Communication 31-15
A. Internal Communication 31-15
B. External Communication 31-16
5. Staff Resources, Training, and Development 31-17
A. Staffing 31-17
B. Job Descriptions and Performance Evaluations 31-18
C. Training Programs . 31-18
6. Program Evaluation, Reporting and Corrective Action 31-20
A. Self-Assessment and Appraisal System 31-20
B. Reporting and Follow-up ' 31-21
7. Environmental Planning and Risk Management 31-22
A. Environmental Planning and Risk Management 31-22
8. Pollution Prevention ' 31-23
A. Pollution Prevention Goals 31-23
B. Pollution Prevention Plan 31-23
C. Pollution Prevention Funding 31-24
D. Pollution Prevention Tracking 31-24
E. Pollution Prevention Training 31-24
F. Pollution Prevention Considerations 31-25
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Introduction
A. Purpose
The primary purpose of a Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources, Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment required to effectively manage environmental
activities. Broadly speaking, management systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships. •
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, groundwater protection) will allow the
auditor to obtain an understanding as to why and how the environmental management systems
work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g., groundwater monitoring), the auditor often must talk with other
personnel. This will enable the auditor to develop an increased sense of confidence in or
reliance on the information based on corroboration of multiple sources and to develop clues
as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
sampling and analytical records). This review serves to further enhance an auditor's
understanding of the management systems and physical controls. Review the following
documents:
• Underground injection well permits;
• Sampling records;
• Analytical lab testing results; and
• Injection well plans/as-built drawings.
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Underground injection wells;
• Groundwater monitoring well system;
• Areas surrounding well systems; and
• Sampling/analytical equipment.
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are groundwater monitoring records kept in one central file or are they in environmental
monitoring files).
The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
evaluate how the facility's groundwater protection management function is organized.
Determine if the groundwater protection management function is characterized by clear
lines of authority and responsibility. For example: '
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the groundwater protection management function and
determine who:
1) Establishes and enforces facility-wide ftroundwater protection programs, policies,
and procedures/practices;
2) Conducts oversight of groundwater monitoring activities; and
3) Provides analytical support for conducting groundwater analysis.
b. Determine who the groundwater protection manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship r-. documented in the organizational charts.
3) Determine if the lines of communication between the groundwater protection
manager and person responsible for overall environmental management are open
and effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequent do they talk, etc.).
c. Determine which department(s) and individual(s) have authority and
responsibility/accountability for various groundwater protection activities. For example,
determine through interviews and document review, who is responsible for conducting
groundwater analysis, maintaining facility groundwater monitoring facilities;
conducting groundwater sampling activities and who is responsible for coordinating
emergency response measures (Linkage with l.B. Roles and Responsibilities).
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2. Determine if groundwater protection managers have sufficient authority to effectively
implement groundwater protection programs and to make decisions related to
environmental protection. Interview the groundwater protection manager and other
groundwater protection personnel and:
a. Understand the amount of authority given to these personnel at different levels
working with groundwater protection and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility);
b. Determine who is responsible for approving specific groundwater protection projects
and if those personnel have the appropriate background/authority to approve these
projects; and
c. Interview management representatives to identify who have stop-work authority and
how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
groundwater protection management, who is responsible and accountable for groundwater
protection activities, including, but not limited to training, groundwater sampling and
analysis, annural reporting, monitoring facilities, and coordination of emergency response
measures at the facility.
a. Identify where and how these roles and responsibilities are defined and communicated,
such as through program manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for groundwater protection match those in program manuals or job
descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the groundwater protection functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall groundwater protection, and determine if this reporting
relationship is clearly and formally defined and understood.
e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes groundwater protection policy, procedures, and standards;
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2) Provides groundwater protection oversight/management to Held/operating personnel;
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency'groundwater
protection policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate groundwater protection management responsibilities are defined and are
included in their written performance appraisal.
a. Interview a selection of groundwater protection personnel to determine if there is
accountability for their environmental performance (e.g., if their groundwater
protection management/field responsibilities are evaluated during performance
reviews).
b. Determine whether there have been any instances of rewards for outstanding
performance or reprimands for failure to carry out responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
groundwater protection, and the facility manager, if top management has supported
groundwater protection programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to replace/repair damaged
groundwater protection equipment, to construct and enhance analytical facilities, etc.
1) If financial, technical, and personnel resources are adequate to manage the volume
of groundwater samples at the facility.
b. Whether top management has a clear set of goals and expectations regarding
groundwater protection performance and what they are (e.g., environmental compliance
as a minimum expectation, goals that go beyond compliance).
2. Review groundwater protection management documentation and identify how senior
management communicates its groundwater protection goals and expectations to
employees; and, typically, how frequently the goals are communicated. For example,
review the facility's groundwater protection mission statements, policies, procedures,
orders, directives, standard operating procedures, etc. and ascertain if they clearly
communicate groundwater protection goals.
a. Interview a sample of operating and groundwater protection personnel to determine if
they understand the facility groundwater protection policies, goals, etc.
3. Interview groundwater protection management personnel and understand what types of
groundwater protection reports are routinely and periodically provided to top management.
a. Determine if groundwater protection quarterly/annual reports, groundwater protection
progress reports, groundwater protection trending reports, etc.. are routinely prepared
for top management and to what extent they address the facility's groundwater
protection status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
c. Determine if any actions are taken as a result of top management's review of
groundwater protection reports or if reports are prepared for "information only."
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B. Environmental Policy
1. Determine through interviews, what groundwater protection policies are widely distributed
and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
•
1. Interview a selection of individuals at all levels and in all functions (e.g.. groundwater
protection manager/inspector, environmental manager, line managers, facility manager,
etc.) whose activities may impact groundwater protection performance to determine if
they take responsibility and interest in limiting the impact of their operations. For
example:
a. Identify activities in which line managers are involved in groundwater protection. •
Specifically, do they:
1) Routinely observe field level groundwater protection compliance activities, such as
sampling events.
2) Participate in audits and self-assessments.
3) Write and review groundwater protection procedures.
4) Serve on environmental advisory committees.
b. Determine what kind of environmental information, relevant to groundwater protection,
line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental incidents involving groundwater protection.
2. Based on the.information gathered in the above step, comment on how line managers
support/do not support groundwater protection activities and how they integrate
groundwater protection management into the facility operations. For example, do they
observe compliance activities or conduct self-assessments.
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3. Formality of Groundwater Protection Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging groundwater protection
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of groundwater protection regulations, and if
there is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging groundwater
protection regulations and trends (e.g., BNA, Federal Register updates, professional
societies, contact with regulator/officials, state regulations).
c. Determine how new groundwater protection regulations are interpreted as to their
applicability and by whom (e.g., environmental manager, legal department).
d. Note the availability of groundwater protection regulatory reference material (for
example, currency of subscription to BNA, automated access via software, CFRs,
Federal and State Registers, state regulations, technical books, and other reference
materials relating to groundwater protection).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to groundwater
protection program manuals, training courses). Interview selected operating personnel
to obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new groundwater protection
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update
groundwater protection management programs and procedures to reflect changes in
regulatory requirements, such as biennial reporting requirements, storage, handling,
treatment and disposal practices for groundwater protection, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form groundwater protection regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing
groundwater protection programs, policies, and procedures. Note the frequency that
groundwater protection programs, policies, and procedures are updated/new ones
developed, how often they are reviewed, and who approves them. Determine if there is a
formal system in place to update groundwater protection management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's groundwater protection programs, policies, and procedures. Determine their
level of experience and comment on the appropriateness of these individuals to
perform such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have beert
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process.
c. Identify a new groundwater protection regulatory requirement and determine whether a
new procedure has been developed and approved, or an existing has been updated and
approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
groundwater protection management policies, programs, or procedures, whether the
organization has a program (e.g., written procedures) for the management of groundwater
protection, including, but not limited to:
a. Groundwater monitoring program;
b. Site-specific groundwater monitoring plans;
c. Sampling and analytical techniques;
d. Groundwater monitoring QA/QC program;
e. Training, certification and qualifications programs;
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f. Preservation techniques for samples;
g. Monitoring reports; and
h. Maintaining groundwater monitoring systems.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
4. Interview a selection of operating personnel to determine if they have access to current
groundwater protection procedures relevant to their job function. For example, are they
easily accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of groundwater protection procedures.
5. Determine whether applicable groundwater protection programs include the following
program elements:
•
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
6. Determine if groundwater protection procedures such as those listed above are reviewed
and updated on any schedule (e.g., periodically, annually, only when regulations change)
and who is responsible for this review/update.
C. Routine Inspections
1. Interview the environmental and groundwater protection managers and groundwater
protection inspector to determine if the facility has a program for routine site and
equipment inspections and compliance checks, including appropriate documentation
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relating to groundwater protection activities. Specifically, determine if the facility
regularly determines compliance with legal and regulatory requirements such as:
a. Sampling and analytical techniques;
b. QA/QC programs;
c. Preservation techniques for samples; and
d. Reporting groundwater monitoring results.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up systenvand
responsibilities.
b. Determine if there is a process for reporting exceptions to management (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Groundwater Protection
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of groundwater protection activities.
a. Develop an understanding of all systems that are in place for groundwater protection
recordkeeping and document control (e.g., does the facility maintain a log or database
of groundwater protection logs, annual reports, employee training documentation, chain
of custody forms, etc.). For example, understand the systems for:
1) Tracking of key regulatory schedules (e.g., analyzing samples before preservative
expires, etc.);
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2) Maintenance of compliance records (e.g.. groundwater protection monitoring logs,
training records, groundwater protection inventory and profiles, analytical records);
and '
3) Preparation and submission of required reports (e.g.. quarterly/annual reports,
release reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
groundwater protection records. Determine whether the files are complete, current, and
readily accessible.
• c. Determine how the facility ensures that required groundwater protection
reports/notifications are routinely prepared and submitted to the appropriate regulatory
agencies in a timely manner. Through interviews with the environmental manager,
identify the person(s) responsible for regulatory reporting and through interviews with
them determine if they have appropriate experience/training to effectively report on
groundwater protection activities. Types of reports/notifications include:
1) Underground injection notices;
2) Change in facility UIC;
3) Groundwater monitoring;
4) Laboratory analytical records; and
5) Notification of groundwater releases.
d. Interview the groundwater protection manager to determine whether the recordkeeping
practices are formal and systematic (e.g.. regularly performed by an assigned
individual, computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
groundwater compliance and other related environmental information. (For example,
the facility may choose to maintain monitoring data indefinitely).
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities).
c. Verify that the facility maintains groundwater protection records for the retention
periods specified by regulation (e.g., RCRA disposal facilities - throughout post-
closure care).
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3. Determine how the facility investigates, reports, corrects, tracks, and monitors
groundwater protection problems and "incidents" (for example, releases/spills of
groundwater protection into the aquifer). Interview groundwater protection personnel and
review procedures to determine if these are formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
'Phase 2-Section 31
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4. Internal and External Communication
A. Internal Communication
1. Interview the environmental and groundwater protection managers, and review internal
raemos, newsletters, etc., to understand how environmental information related to
groundwater protection is communicated. For example, is groundwater protection
information (e.g., groundwater protection management status, incidents) regularly
communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up, .
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover groundwater protection issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of groundwater protection directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of groundwater protection information is
communicated to management:
1) Quarterly/annual groundwater monitoring information;
2) New groundwater protection regulations;
3) Incident or major issue information; and
t
4) 'Controversial groundwater protection issues.
b. Determine how quickly new groundwater protection requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to groundwater protection.
a. Review files to determine if the concerns and responses are documented.
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b. Interview selected personnel to de;ermine <•' they believe management listens and
responds to their concerns.
i) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to groundwater
protection. For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the groundwater protection status of the facility.
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's groundwater protection have
been received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
groundwater protection management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of groundwater protection staff to
determine if staffing levels are sufficient to achieve performance goals. Specifically:
a. Note evidence of insufficient or inexperienced groundwater protection staff to assure
compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
•
3) Excessive use of contractors.
2. Interview groundwater protection personnel and review their job descriptions and
applicable regulations to determine what qualifications are necessary for staffing and other
positions with responsibilities (e.g., groundwater sampling technicians, groundwater
protection managers).
a. Determine if personnel with groundwater protection management responsibilities have
the relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff (e.g., groundwater protection
manager/sampler, emergency response coordinator, etc.) and note the following:
1) Specialized training in groundwater protection;
2) Relevant groundwater protection work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of groundwater protection issues at the facility) conclude as to the quality
and quantity of groundwater protection personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review formal written job descriptions for ground water protection staff (including line
managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for groundwater
protection positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if groundwater protection management
performance is regularly included in the performance review process for appropriate
personnel.
3. Interview a sample of groundwater protection staff (e.g., groundwater protection sampling
personnel, analytical technicians) to confirm that they are evaluated on how well they'
perform their groundwater protection responsibilities.
4. Note whether performance emphasis is on task completion/production versus quality of
work.
C. Training Programs
1. Review training documentation (training manuals or other documents describing
groundwater protection training programs) to determine if the facility has identified
groundwater protection training requirements (based on agency requirements,
types/volumes of groundwater samples generated at the facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs.
2) How does the facility identify and evaluate groundwater protection training needs
for all relevant personnel who may be required to work with groundwater
protection.
3) How does the facility ensure that groundwater protection training courses are
completed.
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2. Determine how the training documentation is maintained and updated (e.g, by whom, how
frequently, how is it updated).
3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. Groundwater sampling techniques;
b. Proper analytical and sample preservation;
c. Recordkeeping and reporting standards;
d. Applicable regulatory standards; and
e. Response to releases.
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6. Program Evaluation, Reporting and Corrective Action
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and groundwater protection and reviewing groundwater
protection program documentation, determine if the facility conducts groundwater
protection program self-assessments/appraisals. Note whether the self-
assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all groundwater protection issues or cover only one topic at a time (e.g.,
manifesting and labeling, storage areas, transportation);
•
d. Are documented and results retained in organized files; and
e. Documented results noted, "findings" or "deficiencies" monitored/corrective action
tracked.
2. Review guidance documents for the self-assessments/appraisals (e.g., audit protocols.
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address groundwater protection issues relevant to
the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1) Determine whether they are reviewed on a regular basis (e.g., annually) or only
when regulations or operations change.
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
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B. Reporting and Follow-up
1. Determine if the facility maintains records of the self-appraisal/appraisals and has a
program to track and correct "findings" or "deficiencies".
a. Identify and interview'the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for groundwater protection management performance.
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects; programs, or activities that may impact groundwater
protection (for example, projects, programs, or activities that may increase the
concentration of groundwater contaminants, require additional personnel or equipment) are
carefully reviewed to identify and address environmental, health, and safety risks as early
as possible.
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention
opportunities for proposed groundwater projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type).
2. Based on interviews with facility management, including environmental and groundwater
protection managers, and a review of project planning documentation, comment on how
the facility balances environmental concerns against production/operational demands when
reviewing proposed new projects, programs, or activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of groundwater pollution is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of groundwater management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
*
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A-106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 12856.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with groundwater management personnel and a review of documents,
determine if the facility has programs to educate/train its employees on pollution
prevention/waste minimization opportunities. Programs could include seminars, pollution
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prevention newsletters, annual training courses, inclusion in environmental meeting
agendas, etc.
F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (groundwater protection) and acvities
associated with groundwater protection.
1. Based on your understanding of the facility operations and types and volumes of wastes
generated, as well as interviews and a review of files, comment on how well the facility
integrated pollution prevention into its daily activities (Waste Minimization Plan Linkage
with Phase 1 - Section 3).
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Phase 2
Section 32
Assessing Effectiveness of Environmental Radiation
Program Management
-------
Table of Contents
Section 32 .
Environmental Radiation
Introduction to Management Systems Assessments 32-1
A. Purpose 32-1
B. Scope 32-1
C. Approach 32-2
D. Understanding Management Systems 32-2
1. Organizational Structure 32-5
A. Management Organization 32-5
B. Roles and Responsibilities , 32-6
2. Environmental Commitment , 32-8
A. Top Management Support • ' 32-8
B. Environmental Policy 32-9
C. Line Management Support 32-9
3. Formality of Environmental Radiation Management Program 32-10
A. Regulatory Tracking and Translation 32-10
B. Procedures . . . 32-11
C. Routine Inspections 32-13
D. Recordkeeping and Reporting 32-13
4. Internal and External Communication 32-16
A. Internal Communication 32-16
B. External Communication 32-17
5. Staff Resources, Training, and Development 32-18
A. Staffing 32-18
B. Job Descriptions and Performance Evaluations ' 32-19
C. Training Programs 32-19
6. Program Evaluation, Reporting and Corrective Action 32-21
A. Self-Assessment and Appraisal System 32-21
B. Reporting and Follow-up 32-22
7. Environmental Planning and Risk Management 32-23
A. Environmental Planning and Risk Management 32-23
8. Pollution Prevention 32-24
A. Pollution Prevention Goals 32-24
B. Pollution Prevention Plan . 32-24
C. Pollution Prevention Funding 32-25
D. Pollution Prevention Tracking 32-25
E. Pollution Prevention Training 32-25
F. Pollution Prevention Considerations 32-26
-------
Introduction
A. Purpose
The primary purpose of a' Management Assessment is to provide the Federal facility with
concise information pertaining to:
• Strengths and weaknesses of management systems which support environmental
compliance programs at the Federal facility.
• Adherence with Best Management Practices pertaining to environmental management
systems and programs.
• Compliance with Federal agency policies and procedures which address environmental
management systems and programs.
• Identification of underlying causal factors contributing to the occurrence of observed
management deficiencies.
• Noteworthy environmental management practices.
Also, these assessments are intended to provide the Federal facility and its contractors with
feedback on the effectiveness of specific environmental program management systems
identifying areas for improvement through recognition of programs with benchmark potential
and/or status.
B. Scope
The scope of a discipline-specific Environmental Management Assessment includes eight
major areas with key characteristics and elements of effective environmental management
systems. These eight areas are the following:
Organizational Structure
Environmental Commitment
Formality of Environmental Program
Internal and External Communication
Staff Resources. Training and Development
Program Evaluation, Reporting and Corrective Action
Environmental Planning and Risk Management
Pollution Prevention
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C. Approach
In an assessment of specific environmental program management systems, the responsibility
of the environmental management specialist Is to assess these systems to determine whether
they effectively meet the performance objectives and have sufficient structure and formality to
assure that activities are conducted in a manner consistent with environmental regulations and
Federal agency policy.
The assessment is based on a combination of staff interviews, document reviews and limited
inspections. Interviews are exceptionally important in conducting an environmental program
specific assessment They provide the primary means of gathering information for
.understanding the organizational relationships, roles and responsibilities, policies, and systems
that form the framework for the management of environmental issues. More importantly, they
often reveal differences in the actual implementation of programs versus their intended
design. Document reviews verify the formality of the system and confirm interview
information. Limited inspections validate document reviews and staff interviews.
D. Understanding Management Systems
Management systems are the framework for guiding, measuring, and evaluating environmental
performance. They are the collection of programs, operations, people, documents, policies,
guidelines, procedures, facilities, and equipment .required to effectively manage environmental
activities. Broadly speaking; mariagement systems consist of:
• Organization. The internal structure that establishes roles, responsibilities, accountabilities,
and reporting relationships.
• Guidance. Plans, policies, procedures, directives, and standards that provide instructions
as to how activities and functions are to be carried out.
• Controls. Inspections, reviews, etc., built into facility operations to ensure that
performance is consistent with objectives and requirements.
• Communications. Mechanisms for collecting, handling, and reporting information.
The basic steps the auditor should take in evaluating tasks and functions are summarized
below.
1. Interview Key Facility Personnel
Interviewing key personnel involved in the execution of compliance activities associated with
an assigned functional area (e.g., drinking water, environmental radiation) will allow the
auditor to obtain an understanding as to why and how the environmental management systems
work.
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2. Talk with Other Personnel
In order to obtain a complete and accurate understanding of how the facility manages a
particular activity (e.g.,- environmental radiation storage areas), the auditor often must talk
with other personnel. This will enable the auditor to develop an increased sense of confidence
in or reliance on the information based on corroboration of multiple sources and to develop
clues as to potential weaknesses related to inconsistencies or conflicting information.
3. Review Relevant Documentation
The auditor should review documentation relevant to a particular topic under review (e.g.,
spill plan, environmental radiation contingency plan). This review serves to further enhance
an auditor's understanding of the management systems and physical controls. Review the
following documents: ,
NRC License
License application
Radioactive material inventory
Records of radioactive material quantities discharged via the sanitary sewer
Radioactive material receiving procedures
NESHAP compliance documentation
Radioactive waste shipping manifests
Decommissioning funding plan
Previous audits and inspections
4. Review Physical Controls
In order to fully understand how a particular environmental issue is managed, the auditor
should, where appropriate, obtain a firsthand understanding of the equipment or facilities.
This is often accomplished in conjunction with the first activity described above (interview
key facility personnel). Inspect the following physical features:
• Laboratories
• Radioactive waste storage areas
• Radioactive material storage areas
5. Conduct Limited Verification Testing
Each auditor should also conduct limited testing to confirm his/her understanding. This might
involve looking at examples of records or practices to develop a fuller understanding as to
how the system actually works. The objective of this testing is not to verify compliance with
a regulatory requirement, but rather to confirm your understanding of what you are being told
(e.g., are training records kept in one central file or are they in 250 individual employees'
fdes).
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The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment
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1. Organizational Structure
A. Management Organization
1. Through interviews with the facility manager, environmental manager, and other
appropriate personnel and a review of organizational charts, mission statements, etc.,
• evaluate how the facility's environmental radiation management function (programs,
policies, procedures for compiling radioactive material inventories, radioactive material
receiving, preparing radioactive wate manifests, etc.) is organized. Determine if the
environmental radiation management function is characterized by clear lines of authority
and responsibility. For example:
a. Review organizational charts, mission statements, and any other documentation of
organizational design for the environmental radiation management function and
determine who:
1) Establishes and enforces facility-wide environmental radiation programs, policies,
and procedures/practices;
2) Provides environmental radiation oversight/management to field/operating
personnel; and
3) Provides technical support for field personnel.
b. Determine who the environmental radiation manager reports to and how that reporting
function is linked to the facility manager or person responsible for overall
environmental management.
1) Interview these individuals to determine if the reporting relationships are clearly
defined.
2) Determine if the reporting relationship is documented in the organizational charts.
3) Determine if the lines of communication between the environmental radiation
manager and person responsible for overall environmental management are open
and effective (e.g., how do these people communicate [verbal, memo, etc.], how
frequently do they talk, etc.).
c. Determine which department(s) and individual(s) have authority and responsibility/
accountability for various environmental radiation management activities (e.g.,
licensing; radioactive material inventorying; funding plan; etc.). For example,
determine, through interviews and document review, who is responsible for radioactive
' Phase 2 - Section 32
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waste management; licensing application; preparing radioactive material inventories
(Linkage with l.B. Roles and Responsibilities).
2. Determine if environmental radiation managers have sufficient authority to effectively
implement environmental radiation programs and to make decisions related to
environmental protection. Interview the environmental radiation manager and other
environmental radiation personnel and:.
a. Understand the amount of authority given to these personnel at different levels
working with environmental radiation and determine if it is sufficient to carry out their
responsibilities (e.g., is authority commensurate with responsibility),
b. Determine who is responsible for approving specific environmental radiation projects
or activities and if those personnel have the appropriate background/authority to
approve these projects, and
c. Interview management representatives to identify individuals who have stop-work
authority and how quickly they can effect a necessary response.
B. Roles and Responsibilities
(Linkage with 5. Staff Resources, Training, and Development)
1. Determine, by interviewing the environmental manager or person responsible for overall
environmental radiation management, who is responsible and accountable for waste
management activities, including, but not limited to identification of radioactive waste
streams, training, radioactive waste manifest preparation and tracking, recordkeeping and
reporting, radioactive waste storage areas, coordination of emergency response measures
at the facility, and radioactive hazardous waste management units.
a. Identify where and how these roles and responsibilities are defined, such as in program
manuals or job descriptions.
b. Interview selected individuals identified above to verify that individual jobs and
responsibilities for environmental radiation management match those in program
manuals or job descriptions.
c. Determine whether these roles and responsibilities are formally implemented (e.g., do
they actually perform the environmental radiation functions specified in their job
descriptions).
d. Understand the reporting arrangements between these individuals and the person
responsible for overall environmental radiation management, and determine if this
reporting relationship is clearly and formally defined and understood.
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e. Identify, through interviews with facility management and review of organizational/
duty allocation charts, who:
1) Establishes environmental radiation policy, procedures, and standards;
2) Provides environmental radiation oversight/management to field/operating
personnel; and
3) Provides technical support for field personnel.
f. Determine whether specific roles as required by Federal agency environmental
radiation policy and/or Federal and state regulations have been assigned.
2. Review job descriptions and performance standards for these individuals to determine if
their appropriate environmental radiation management responsibilities-are defined and are
included in their written performance appraisal.
a. Interview a selection of environmental radiation management personnel to determine if
there is accountability for their environmental performance (e.g., if their environmental
radiation management/field responsibilities are evaluated during performance reviews).
b. Determine whether there have been any instances of rewards for outstanding
environmental radiation management performance or reprimands for failure to carry
out environmental radiation management responsibilities.
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2. Environmental Commitment
A. Top Management Support
1. Determine, by interviewing the environmental manager, the person responsible for overall
environmental radiation management, and the facility manager, if top management has
supported environmental radiation programs. For example, determine:
a. If sufficient allocation of resources (financial, technical, personnel) are provided.
Determine if top management has allocated funds to acquire additional environmental
radiation safety devices for radioactive waste storage areas, etc.
1) If financial, technical, and personnel resources are adequate to manage the
radioactive materials handled at the facility.
b. Whether top management has a clear set of goals and expectations regarding
environmental radiation performance and what they are (e.g., environmental
compliance as a minimum expectation, goals that go beyond compliance, emissions
reductions).
2. Review environmental radiation management documentation and identify how senior
management communicates its environmental radiation goals and expectations to
employees; and, typically, how frequently the goals are communicated. For example, .
review the facility's environmental radiation mission statements, policies, procedures,
orders, directives, standard operating procedures, etc. and ascertain if they clearly
communicate environmental radiation goals.
a. Interview a sample of operating and environmental radiation personnel to determine if
they understand the facility environmental radiation policies, goals (e.g., reduction of
radioactive materials use), etc.
3. Interview environmental radiation management personnel and understand what types of
environmental radiation reports are routinely and periodically provided to top
management
a. Determine if decomissioning funding plans, status reports on radioactive stored at the
facility, audit reports, etc., are routinely prepared for top management and to what
extent they address the facility's environmental radiation status or performance.
b. For these reports, identify to whom they are sent, the type of information conveyed,
and the level of detail provided.
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c. Determine if any actions are taken as a result of top management's review of
environmental radiation reports or if reports are prepared for "information only."
B. Environmental Policy
1. Determine through interviews, what environmental radiation policies are widely
distributed and if they are easily accessible and understood throughout the facility.
2. Interview selected environmental staff and operations staff to determine what the current
goals are and what their status is.
C. Line Management Support
1. Interview a selection of individuals at all levels and in all functions (e.g.. environmental
radiation manager/inspector, environmental manager, line managers, facility manager, etc.)
whose activities may impact environmental radiation performance to determine if they
take responsibility and interest in limiting the impact of their operations. For example:
a. Identify activities in which line managers are involved in environmental radiation
management. Specifically, do they:
1) Routinely observe field level environmental radiation compliance activities?
2) Participate in audits and self-assessments?
3) Write and review environmental radiation procedures?
4) Serve on environmental advisory committees?
b. Determine what kind of environmental information, relevant to environmental
radiation, line managers solicit and receive and how they obtain this information.
c. Determine what actions have been taken by line management in response to
environmental accident occurrences involving environmental radiation.
2. Based on the information gathered in the above step, comment on how line managers
support/do not support environmental radiation activities and how they integrate
environmental radiation management into the facility operations. For example, do they
observe compliance activities, conduct self-assessments, train employees, etc.
Phase 2 - Section 32
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*
32-9
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3. Formality of Environmental Radiation Management Program
A. Regulatory Tracking and Translation
1. Determine how the facility stays current with new and emerging environmental radiation
regulations and trends.
a. Through interviews with the facility and environmental managers, identify who in the
organization is responsible for tracking of environmental radiation regulations, and if
there is a formal system for this function.
b. Determine what documents are regularly reviewed for new and emerging .
environmental radiation regulations and trends (e.g., UNA, Federal Register updates,
professional societies, contact with regulator/officials, subscriptions to professional
publications related to environmental radiation management).
c. Determine how new environmental radiation regulations are interpreted as to their
applicability and by whom (e.g., environmental radiation manager, legal department).'
d. Note the availability of environmental radiation regulatory reference material (for
example, currency of subscription to UNA, automated access via software, CFRs,
Federal and State Registers, state regulations, technical books, and other reference
materials relating to environmental radiation).
e. Determine how new requirements are communicated to appropriate operating
personnel (e.g., bulletins, safety/environmental meetings, updates to environmental
radiation program manuals, training courses). Interview selected operating personnel to
obtain their understanding of this regulatory communication process.
2. Determine if there is a process to ensure that guidance on new environmental radiation
regulatory requirements is incorporated into facility or site-specific standard operating
procedures, as appropriate.
a. Through interviews, determine if there is a formal system in place to update
environmental radiation management programs and procedures to reflect changes in
regulatory requirements, such as NRG licensing requirements, storage, handling,
treatment and disposal practices for radioactive waste, NESHAP, manifesting, etc.
3. Determine if relevant regulatory information is routinely distributed to installations in a
timely manner.
a. Determine how and in what form environmental radiation regulatory information is
transmitted to the facility.
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b. Interview staff responsible for regulatory updates to determine whether the necessary
department/people learn of the developments with sufficient lead time to take
appropriate action.
B. Procedures
1. Determine the process by which new requirements are incorporated into existing
environmental radiation programs, policies, and procedures. Note the frequency that
environmental radiation programs, policies, and procedures are updated/new ones
developed, how often they are reviewed, and who approves them. Determine if there is a
formal system in place to update environmental radiation management programs.
a. Identify the individual(s) responsible for incorporating new requirements into the
facility's environmental radiation programs, policies, and procedures. Determine their
level of experience and comment on the appropriateness of these individuals to
perform such tasks. (Linkage with 1. Organizational Structure)
b. Test the system by selecting a sample of procedures to determine if they have been
reviewed, updated, and if the new/revised procedures have gone through an approval
process before becoming finalized. Identify the persons responsible for the approval
process (e.g., environmental radiation manager, environmental manager,'facility
manager).
c. Identify a new environmental radiation regulatory requirement and determine whether
a new procedure has been developed and approved, or an existing has been updated
and approved.
d. By interviewing operating personnel, understand the process by which relevant
regulatory information is transmitted to facility personnel.
2. Determine, based on interviews with operating and environmental staff and a review of
environmental radiation management policies, programs, or procedures, whether the
organization has a program (e.g., written procedures) for the management of
environmental radiation, including, but not limited to:
a. Identification of radioactive waste streams;
b. Discharge of radionuclides into the storm sewer/sanitary sewer,
c. Releases of radio nuclides in airborne and gaseous effluents;
d. Radioactive waste management (e.g., decay-in-storage, transfer to another licensee,
land disposal, etc.);
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e. Manifest preparation;
f. Radioactive waste transportation;
g. Labeling of containers;
h. Preparation of decoraissioning cost estimate;
i. Monitoring and control of operations to assure that the annual total effective dose
equivalent to a member of the public does not exceed 100 mill ?? «- ; and
j. Preparation of the NRC license application.
3. Review a sample of specific procedures to assess the quality and adequacy of instruction
(too technical, too vague, etc.).
•
4. Interview a selection of operating personnel to determine if they have access to current
environmental radiation procedures relevant to their job function. For example, are they *
easily accessible, centrally located, manually (or electronically) available?
a. Verify the accessibility by requesting a sample of environmental radiation management
procedures.
5. Determine whether applicable environmental radiation management programs include the
following program elements:
a. Formal policy and plan;
b. Understanding of applicable regulatory requirements;
c. Responsibilities;
d. Recordkeeping and reporting systems;
e. Training; and
f. Program evaluation and oversight
6. Determine if environmental radiation management procedures such as those listed above
are reviewed and updated on any schedule (e.g., periodically, annually, only when
regulations change) and who is responsible for this review/update.
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C. Routine Inspections
1. Interview the environmental and environmental radiation managers to determine if the
facility has a program for routine site and equipment inspections and compliance checks.
including-appropriate documentation relating to environmental radiation activities.
Specifically, determine if the facility regularly determines compliance with legal and
regulatory requirements such as:
a. Radioactive waste storage area/container inspections;
b. Discharge limitations;
c. Emission limitations; and
d. Disposable/transfer of radioactive wastes.
2. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
3. Confirm that the facility has a formal system for follow-up of exceptions noted during
inspections, and if it is supported by management review.
a. Interview environmental staff to develop an understanding of the follow-up system and
responsibilities.
b. Determine if there is a process for reporting exceptions to management (Linkage with
2. Environmental Commitment)
c. Determine whether management reviews inspection documentation and corrective
actions.
d. Determine if there is a tracking process to ensure the corrective actions are followed in
a timely manner.
D. Recordkeeping and Reporting
(Linkage with 1. Organizational Structure and 3. Formality of Environmental Radiation
Management Program)
1. Through interviews with the environmental and facility managers, determine what systems
are in place for maintaining records of environmental radiation activities.
a. Develop an understanding of all systems that are in place for environmental radiation
recordkeeping and document control (e.g., does the facility maintain a log or database
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of environmental radiations generated, inspection logs, discharge records/permits.
NESHAP compliance documentation, radioactive waste manifests, etc.). For example,
understand the systems for;
1) Tracking of key regulatory schedules (e.g., NRC permit renewals, etc.);
2) Maintenance of compliance records (e.g., radioactive waste storage area inspection
logs, manifests, training records, radioactive inventory and profiles); and
3) Preparation and submission of required reports (e.g., incident reports, AIRDOS-PC
reports).
b. In general, assess the state of the facility's files and recordkeeping practices regarding
environmental radiation records. Determine whether the files are complete, current, and
readily accessible.
c. Determine how the facility ensures that required environmental radiation
reports/notifications are routinely prepared and submitted to the appropriate regulatory
agencies in a timely manner. Through interviews with the environmental manager,
identify the person(s) responsible for regulatory reporting and through interviews with
them determine if they have appropriate experience/training to effectively report on
environmental radiation activities. Types of reports/notifications include:
1) AIRDOS-PC reports. "
d. Interview the environmental radiation manager to determine whether the recordkeeping
practices are formal and systematic (e.g., regularly performed by an assigned
individual, computerized).
2. Determine whether the facility has a document control system and record retention policy.
a. Determine whether the facility has a formal records retention policy which covers
environmental radiation regulation compliance and other related environmental
information. (For example, the facility may choose to maintain manifests indefinitely,
rather than for the required three years.)
b. Assess whether individuals responsible for recordkeeping are knowledgeable of the
record retention policy. (Linkage with l.B. Roles and Responsibilities).
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3. Determine how the facility investigates, reports, corrects, tracks, and monitors
environmental radiation problems and "incidents" (for example, releases/spills of
radioactive waste/materials into the environment, container/tank failure). Interview
environmental radiation personnel and review procedures to determine if these are
formalized procedures.
a. Select a sample of "incidents" and determine whether corrective actions have been
planned and implemented for these incidents.
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4. Internal and External Communication
A. Internal Communication
. 1. Interview the environmental and environmental radiation managers, and review internal
memos, newsletters, etc., to understand how environmental information related to
environmental radiation is communicated. For example, is environmental radiation
information (e.g., environmental radiation management status, incidents) regularly
communicated formally or informally throughout the facility.
a. Understand whether the internal communication typically flows top-down, bottom-up,
or laterally.
b. Determine whether there are consistent line management and environmental staff
meetings that adequately cover environmental radiation issues (review minutes of
meetings, talk with personnel who regularly attend meetings).
2. Determine if formal communication of environmental radiation directives is timely, and
effectively reaches all responsible elements of the facility. Specifically (Linkage with 3.A.
Regulatory Tracking and Translation):
a. Determine how quickly the following types of environmental radiation information is
communicated to management:
1) Routine environmental status information;
2) New environmental radiation regulations;
3) Incident or major issue information; and
4) Controversial environmental radiation issues.
b. Determine how quickly new environmental radiation requirements, programs or other
information is communicated to the field/operating personnel.
3. Determine if the facility has a means to solicit and address employee environmental
concerns related to environmental radiation.
a. Review files to determine if the concerns and responses are documented.
b. Interview selected personnel to determine if they believe management listens and
responds to their concerns.
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1) Have employee concerns been addressed? (For those that were not, determine the
reason why.)
c. Note whether well-founded concerns expressed in one facility or group are shared with
other facilities or groups that might have similar problems.
B. External Communication
1. Determine whether the facility has frequent, proactive interaction with regulatory
agencies, environmental groups, and the local community to provide them with
information and the opportunity to be involved in key decisions related to environmental
radiation. For example:
a. Determine if the facility has any communication programs with the local community
(e.g., education, visitation of facilities, public reading rooms) to keep them informed
of the environmental radiation status of the facility.
•
b. Interview a selection of facility management and review facility files to determine if
any complaints/questions/concerns regarding the facility's environmental radiation have
been received from the local community.
1) Note whether these complaints/questions/concerns have been documented.
2) Note whether the facility has responded to the complaints/questions/concerns and
documented the response.
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5. Staff Resources, Training, and Development
A. Staffing
1. Review organizational charts/duty rosters to understand how many staff are dedicated to
environmental radiation management activities (this includes dedicated support staff and
others with collateral duties [e.g., line managers with other support functions]). Interview
the human resource manager as well as a sample of environmental radiation staff to
determine if staffing levels are sufficient to achieve performance goals. Specifically:
.a. Note evidence of insufficient or inexperienced environmental radiation management
staff to assure compliance. Evidence of these would include, for example:
1) Compliance deficiencies whose root causes are inadequate resources;
2) Excessive overtime; or
3) Excessive use of contractors.
2. Interview environmental radiation management personnel and review their job
descriptions and applicable regulations to determine what qualifications are necessary for
staffing and other positions with responsibilities (e.g., environmental radiation trainers,
environmental radiation managers).
a. Determine if personnel with environmental radiation management responsibilities have
the relevant background and training to carry out their responsibilities.
b. Review a sample of resumes from selected staff and note the following:
1) Specialized training in environmental radiation management;
2) Relevant environmental radiation work; and
3) Continuing education programs.
3. Based on the information gathered (interviews, document review, your understanding of
the complexity of environmental radiation issues at the facility) conclude as to the quality
and quantity of environmental radiation personnel at the facility.
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B. Job Descriptions and Performance Evaluations
(Linkage with 1. Organizational Structure)
1. Review focmal written job descriptions for environmental radiation management staff
(including line managers, support staff, and others with collateral duties). Determine:
a. Whether they are current, complete, and reflective of existing duties; and
b. If appropriate job descriptions are established and maintained for environmental
radiation management positions.
2. By interviewing the human resource manager and reviewing documentation relating to the
performance review process, determine if environmental radiation management
performance is regularly included in the performance review process.
3. Interview a sample of environmental radiation staff (e.g., radioactive waste handlers,
storage area managers) to confirm that they are evaluated on how well they perform their
environmental radiation management responsibilities.
•
4. Note whether emphasis is on task completion/production versus quality of work, pollution
prevention, etc.
C. Training Programs
1. Review training documentation (training manuals or other documents describing
environmental radiation training programs) to determine if the facility has identified
specialized environmental radiation training requirements (based on regulatory
requirements, types/volumes of radioactive waste/materials generated and used at the
facility).
a. Determine how the facility tracks its training program requirements. For example:
1) Is there a computerized database listing all employees and matrixed to training
needs?
2) How does the facility identify and evaluate environmental radiation training needs
for all relevant personnel who may be required to work with radioactive materials?
3) How does the facility ensure that environmental radiation training courses are
completed?
2. Determine how the training documentation is maintained and updated (e.g. by whom, how
frequently, how is it updated).
• Phase 2-Section 32
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3. Determine whether training is included in job descriptions and/or individual professional
development plans. (Linkage with l.B. Roles and Responsibilities)
4. Determine who conducts training and verify that the training program is directed by a
qualified individual.
5. Review the training materials/records to determine if the training program includes the
following:
a. NESHAP monitoring;
b. Radioactive waste, storage and handling;
c. Preparing NRC license;
d. Radioactive materials receiving procedures;
e. Tracking of radioactive wastes:
f. Preparation of radioactive waste manifests;
g. Preparing decomisstoning and funding plans;
h. Preparation of AIRDOS-PC reports;
i. container use, marking, labeling, and on-site transportation; and
j. Personnel health and safety and fire safety.
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6. Program Evaluation, Reporting and Corrective Action
/
A. Self-Assessment and Appraisal Programs
1. By interviewing the environmental and environmental radiation managers and reviewing
environmental radiation program documentation, determine if the facility conducts
environmental radiation self-assessments/appraisals. Note whether the self-
assessments/appraisals:
a. Are formally conducted according to some regular schedule (e.g., monthly, annually);
b. Cover compliance with internal policies and procedures, applicable laws and
regulations, and best management practices;
c. Cover all environmental radiation issues at each self-assessment/appraisal or cover
only one topic at a time (e.g.. manifesting and labeling, storage areas, transportation);
d. Are documented and results retained in organized files; and
e. Document results, note "findings" or "deficiencies", and track/corrective action.
2. Review guidance documents for the self-assessments/appraisals (e.g.. a'udit protocols,
checklists or other tools) and interview the person responsible for coordinating/overseeing
the self-assessments/appraisals to determine if:
a. The guidance documents adequately address environmental, radiation management
issues relevant to the facility.
b. The guidance documents are regularly updated and reviewed. Specifically:
1') They are reviewed on a regular basis (e.g., annually) or only when regulations or
operations change. ' ~
2) Test the currency of the guidance documents by noting if a recent regulatory
change or facility operational procedure has been incorporated into the materials.
(Linkage with 3.A. Regulatory Tracking and Translation)
3) Interview the person responsible for reviewing and updating them and determine if
this person has an adequate background for such responsibility.
Phase 2 • Section 32
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B. Reporting and Follow-up
1. Determine if'the facility maintains records of the self-appraisal/appraisals and has a •
program to track and correct "findings" or "deficiencies".
a. Identify and interview the person responsible for tracking and correcting "findings" or
"deficiencies".
b. Determine how corrective actions are prioritized.
c. Determine if facility management or the environmental manager is regularly and
formally informed of the results of the self-assessments/appraisals or if such
notification only occurs when a major issue is identified.
2. Determine if "lessons learned" programs are implemented to seek out improvement
opportunities for environmental radiation management performance.
Phase 2 - Section 32
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7. Environmental Planning and Risk Management
A. Environmental Planning and Risk Management
1. Determine if all new projects, programs, or activities that may impact environmental
radiation management (for example, projects, programs, or activities that may increase the
volume or toxicity of radioactive waste generated, reactive material handled, require
additional personnel or equipment to handle the radioactive wastes/materials adequately)
are carefully reviewed to identify and address environmental, health, and safety risks as
early as possible.
i
a. Identify who is responsible for conducting this review and understand how decisions
are made whether to proceed, modify, or cancel a proposed project, program, or
activity.
b. Determine if there is a formal review process to identify pollution prevention/waste
minimization opportunities for proposed projects during the planning phase.
c. Determine whether project reviews typically follow a standard approach and whether
there is any formal guidance on the approach.
d. Identify the criteria used for assessing the impacts of a project (e.g., dollar value,
project type). . .
2. Based on interviews with facility management, including environmental and
environmental radiation managers, and a review of project planning documentation,
comment on how the facility balances environmental concerns against
production/operational demands when reviewing proposed new projects, programs, or
activities.
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8. Pollution Prevention
A. Pollution Prevention Goals
1. Determine if the facility has established specific, measurable pollution prevention goals
and milestones by reviewing mission statements, environmental policy, etc. Determine if
the prevention/reduction of radioactive wastes is specifically detailed.
a. Does the facility goal contribute to the agency 50% reduction goal established in
EO 12856?
b. Interview a selection of radioactive waste management personnel to determine if they
understand the facility goal with regard to pollution prevention/waste minimization.
c. From interviews, a review of pollution prevention documentation, and your
understanding of operations, comment on whether the goals are comprehensive and
realistic and whether the facility is actively pursuing its goals.
B. Pollution Prevention Plan
1. Determine if the facility has established a comprehensive pollution prevention plan
pursuant to EO 12856. If so, review the plan and note the following:
a. It is consistent with federal/agency policy and reduction goals;
b. It addresses all agency/regulatory requirements for pollution prevention;
c. It addresses the facility contribution to the agency 50% reduction goals;
d. The plan clearly outlines the facility's approach to pollution prevention and reflects
current pollution prevention strategies (e.g., are process redesign, recovery/reuse
systems, product substitution, etc. being considered);
e. The plan includes formal milestones and reduction schedules and there is a system to
track progress; and
f. The extent to which the plan addresses any state or local pollution prevention planning
requirements.
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2. Determine who is responsible for developing the plan and coordinating/tracking pollution
prevention initiatives. Interview the person and determine if:
r
a. The person has the authority at the facility to implement/authorize pollution prevention
activities; and
b. The plan is regularly reviewed and updated as operations change and as milestones are
met.
C. Pollution Prevention Funding
1. Identify the persons responsible for budgeting pollution prevention projects. Through
interviews with these persons and with other environmental personnel and document
review, determine if:
a. Pollution prevention projects are adequately considered and appropriately funded to
meet requirements; and
b. Pollution prevention projects are included in facility A* 106 plan submissions with
appropriate categorizations.
D. Pollution Prevention Tracking
1. Understand how the facility tracks its progress against the pollution prevention plan and
identify who is responsible for tracking progress.
a. Is progress being measured against TRI or other toxic pollutant baseline established in
CY 1994 persuant to EO 128S6.
b. Determine if top management receives updates on the facility's pollution prevention
progress.
b. Determine if operating personnel are regularly made aware of the facility's pollution
prevention progress.
E. Pollution Prevention Training
1. Through interviews with radioactive waste management personnel and a review of
documents, determine if the facility has programs to educate/train its employees on
pollution prevention/waste minimization opportunities. Programs could include seminars,
Phase 2 - Section 32
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pollution prevention newsletters, annual training courses, inclusion in environmental
meeting agendas, etc.
F. Pollution Prevention Considerations
NOTE: Pollution prevention may be applicable to (environmental radiation and activities
associated with environmental radiation.
1. Based on your understanding of the facility operations and types and volumes of waste
generated, as well as interviews and a review of files, comment on how well the facility
' integrated pollution prevention into its daily activities (Waste Minimization Plan Linkage
with Phase 1 - Section 3).
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Phase 2
Appendix
Pollution Prevention
Assessment Guidance
-------
Pollution Prevention Assessment Guidance
I. Program Infrastructure
»
A. Program Structure
1. Pollution prevention plan
a. Does the organization have a comprehensive pollution prevention plan? (See other
sections of this assessment guidance to evaluate the adequacy and quality of the
planning addressing each item, e.g., program objectives and strategy, goals/milestones.)
b. Does the plan address the following two goals identified in the Waste
Minimization/Pollution Prevention Crosscut Plan?
"To reduce total releases of toxic chemicals to the environment, and off-site
transfers of such chemicals for treatment and disposal across the DOE complex, by
50 percent by 12/31/99."
•
"To establish site-specific goals achievable by 12/31/99 to reduce the generation of
all types of waste and pollutants, including hazardous, radioactive, radioactive
mixed, and sanitary from site operations."
c. Does the plan address all applicable regulatory and legal requirements? (See
Appendix A for a list of pollution prevention-related regulations and documents.)
d. Does the plan address how the site will comply with Executive Order 12856, Federal
Compliance with Right-To-Know Laws and Pollution Prevention Requirements?
e. How does the site's P2 plan relate to Headquarters? CSO? Operations Office?
f. Does the plan address site contractors' responsibilities for developing pollution
prevention programs?
g. Who was involved in the development of the plan? Was input from various divisions
and staff functions included (e.g., engineering, maintenance, R&D)?
h. To whom was the plan distributed (i.e., what divisions, departments, level of
individuals)?
i. When was the plan developed/issued? When was it last updated? How often will the
plan be reviewed and updated?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-1
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j. Does the site have a requirement for division-specific plans? If so, have these been
developed? Review the plans for a sample of divisions and evaluate according to site
plan objectives and all the questions noted above.
2. Policy and Definitions
a. Is there a written policy that specifically addresses pollution prevention?
b. Is this policy consistent with policy from the Cognizant Secretarial Office (CSO)?
From Headquarters?
c. Based on your knowledge of pollution prevention policies in other organizations, how
does the policy compare?
d. Is pollution prevention also an integral part of the site's environmental compliance
policy?
e. What department/position issued the policy? Does this department/position have
sufficient stature/authority within the organization for the policy to be taken seriously?
f. Has P2 policy been issued by more than one department? Why? If so. are the
policies conflicting?
g. Does the policy describe and adopt the hierarchy of waste reduction practices (source
reduction, reuse, etc.) either explicitly or implicitly?
h. Does the policy address all types of waste (hazardous, radioactive, radioactive mixed,
sanitary)?
i. Does the policy address releases to all media (air. water, soil)?
j. Is "pollution prevention" defined? Where? Who (what group) was responsible for the
definition?
k. Is the definition of "pollution prevention" consistent with the way pollution prevention
is defined by other parts of the CSO? By Headquarters?
1. Does the definition of P2 differ from waste minimization? If so, how?
m. Is energy conservation considered part of pollution prevention?
n. Is treatment considered part of pollution prevention?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-2
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o. Is there a common understanding of this definition among the individuals involved in
P2 activities?
3. Program-Objectives and Strategy
a. Are pollution prevention program, objectives clearly stated in the pollution prevention
plan?
b. Are the objectives specific enough to be capable of accomplishment?
c. Is a strategy for achieving the pollution prevention objectives described?
d. Has a statement of pollution prevention objectives and plans for achieving the
objectives been distributed to employees and contractors?
e. How is P2 integrated with other planning activities (short-term, long-term, strategic)?
f. Who represents P2 issues in key strategic and operations planning meetings and
committees?
g. How does the organization balance short-term needs with longer term activities, such
as pollution prevention?
4. Goals/Milestones
a. What pollution prevention goals have been established? How were the goals
developed (e.g., based on historical results, demonstrated technology)? Were process
waste assessments (PWAs) used to establish goals?
b. Was DOE goal-setting guidance used to establish goals? If so, from HQ, CSO,
Operations Office?
c. Have goals been prescribed by higher levels of management within DOE? If so, from
HQ, CSO, Operations Office?
d. Do goals address all emissions and effluents or only hazardous waste? What media
are assessed? Why were some media, if any excluded?
e. Are the goals specific? Quantitative? Measurable? Assignable? Realistic? Time-
oriented?
f. Do the goals address volume, toxicity. or both?
g. How are the goals expressed (e.g., percentage, volume, mass)?
• Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-3
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h. Are the goals consistent with DOE requirements? Executive Order 12856?
Applicable state requirements?
i. Are there short-term and long-term goals which address the intent of the facility
mission statement and pollution prevention policy?
j. Have success demonstration criteria been established?
k. Does the pollution prevention plan include programmatic goals for the evaluation of
new technologies to reduce waste generation?
1. Do the goals have completion dates?
m. Does the plan contain a comprehensive, detailed schedule for implementation of the
P2 program and attainment of milestones?
S. Top Management Support
a. How has senior management demonstrated its commitment to pollution prevention
(e.g., formal statements, issuance of pollution prevention policy, incentive and award
programs, budget and resource allocation, etc.)?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-5
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B. Resource Implementation, Strategy, and Schedule
1. Financial Budgeting.
a. Review Activity Data Sheets (ADS), Five Year Plans, A-106 reports.
b. Obtain an overview of the* capital and operating budgeting processes, including roles,
responsibilities, and annual timing.
c. Are P2 projects considered in annual budgeting processes and given an appropriate
level of attention?
d. For the budget categories which focus on P2, identify the lead person responsible, and
• determine how the budget estimate was made.
e. Are budgets established a priori, or in light of known project development work?
f. Are there established ranking systems for project approval throughout the capital 'and
operating budget processes? What priority is assigned to environmental projects vs.
production or other activities? What priority does P2 have vs. environmental
compliance projects?
g. Do P2 project compete with other projects for capital funding strictly on a return on
investment basis?
h. Do P2 projects only compete with environmental projects or against all other site
projects?
i. Using past and current budget (and initial budget iterations), determine whether P2
projects were identified/considered as candidates for funding.
j. Determine whether projects considered were approved and implemented. Why?
k. Have P2 projects been denied funding in the past? Why?
1. Are there special funds or sources dedicated to pollution prevention? What is the
relative contribution of P2 funding from all sources (CSOs, contractors, etc.)?
m. Interview site personnel to determine if current funding for P2 activities is
sufficient to meet P2 program goals.
n. Does the site/facility's plan contain a line-item budget for its pollution prevention
program? Does the line-item budget have specific allocations for PWAs. tracking
systems, process modifications, staff, QA, R&D, and program implementation?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-S
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o. Are line items expressed in dollar amounts? Are line items expressed as a percentage
of the total facility budget for that activity (e.g., waste minimization training as a
percentage of total training budget)?
2. Staffing
a. Do the budget or other planning documents indicate how many full-time equivalents
are assigned to pollution prevention? If yes, how many and for what roles?
b. What are the backgrounds and experience of the personnel with P2 responsibilities?
How well does it relate to their P2 responsibilities?
c. Are their P2 responsibilities appropriate given their other responsibilities?
d. What other staff are related to P2 activities (secondarily or peripherally)?
e. Are the staffing levels adequate to meet the organization's goals and objectives? If
not, what level would be required?
3. Implementation Strategy, Schedule, and Guidance
a. Does the site pollution prevention plan contain a narrative description of the strategy
for implementing the pollution prevention program?
b. Does the plan contain a schedule for implementation of the pollution prevention
program?
c. Are there sites directives or guidance which provide additional instruction for plan
implementation?
d. Has pollution prevention guidance been included in all relevant standard operating
procedures?
. Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-6
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C. Employee Motivation
1. Awareness
a. Does the organization have a P2 awareness program? What does it consist of? 'Who
is included (e.g., managers, all employees, contractors, etc.)?
b. Is it consistent with HQ policy and requirements?
c. Is the site Pollution Prevention Awareness Plan included as pan of the Waste
Minimization Plan? Is it a separate plan?
d. Has the pollution prevention plan been distributed to affected personnel?
e. How are pollution prevention concepts and awareness incorporated into facility culture
and job ethic?
f. How often is a site-wide pollution prevention awareness campaign conducted?
g. From interviews conducted by the Pollution Prevention Assessment Team, how can '
overall P2 awareness at the facility be characterized?
2. Training
a. Has a pollution prevention awareness orientation/training program been established for
all personnel?
b. Are p2 training needs identified and addressed by an existing training program (e.g.,
needs assessment, recordkeeping, tracking, etc.)?
c. Has'a pollution prevention training program been established for personnel involved in
waste generation and management? Middle managers? Senior managers?
d. Have staff with specific P2 responsibilities had formal P2-related training (e.g., what is
pollution prevention, how to conduct PWAs)? On-the-job training? What did this
consist of and how does it relate to their responsibilities? Have they used the
knowledge or skills teamed in this training?
e. If P2 training is' done in-house, is it supported by appropriate training materials and
qualified trainers?
f. Besides formal or on-the-job training, what type of P2 technical assistance is
provided? Where does this assistance come from? Is it sufficient?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-7
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g. Is there a program and schedule for evaluating whether employees have proper
training and equipment to achieve pollution prevention goals?
h. Are .pollution prevention concepts and assignments incorporated as pan of executive*
management training?
i. How is the effectiveness of pollution prevention training assessed?
3. Incentives/Awards
a. How does the organization encourage individual and collective pollution prevention
initiatives?
b. What programs exist to recognize and reward individual and collective contributions to
achieving P2 goals?
c. Have innovative incentives such as the use of monetary savings to effect further
reductions been implemented to encourage policies and procedures that promote cost-
effective pollution prevention practices?
d. Is there a system for soliciting and following-up on employee pollution prevention
suggestions?
e. Are P2 aspects of individual job responsibilities included in job descriptions and
performance standards used in the performance appraisal process?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-e
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D. Communications
1. Internal
a. Has the-pollution prevention plan been distributed to affected personnel? To whom?
b. Does the organization communicate its pollution prevention hierarchy to staff? How?
Identify specific examples.
c. What mechanisms are used to share pollution prevention information across the site
(e.g., signs, newsletters, dedicated bulletin boards, seminars, meetings)?
d. How is pollution prevention information communicated between the site and
Headquarters? CSO? Operations Office?
e. How does the site stay abreast of DOE P2 requirements and approaches (e.g., formal
training and guidance, technical assistance, memoranda, reports, etc.)?
f. From interviews conducted by the Pollution Prevention Assessment Team, characterize
the effectiveness of internal communication systems to disseminate P2 information.
2. External
a. Is there a program or a process for exchange of information with other government
agencies? Industry? Educational institutions?
b. Does the site exchange information through newsletters? Workshops or seminars?
Field trips? HAZWRAP, EPA. or other databases?
c. How does the organization keep apprised of new requirements and new P2 ideas and
approaches in government and industry?
d. Are personnel with P2 responsibilities involved in industry associations? Do they
receive relevant journals or literature?
e. What systems are used to disseminate lessons learned to other DOE facilities?
f. How does the organization gather and communicate publicly P2 success stories?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
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E. Information Management and Tracking
1. Information Management
a. Have guidelines or requirement been established with regard to methods to be used in
developing or assembling pollution prevention or environmental data? If so, what are
they? How are they developed? Who (or what group) developed them? How are
they disseminated? How are they updated/changed?
b. How does the organization manager pollution prevention data? Is there a centralized
system? Who is responsible for it?
c. How does the organization ensure the quality of its pollution prevention data?
2. Material Inventory
a. Has the site developed a hazardous materials procurement control system? What type
of materials are controlled? How are they controlled?
b. Is there a tracking system for identification and reporting on procurement of recycled
or recyclable products?
c. Are reports generated from this system? Who receives them?
3. Waste Generation
a. Is there a method for (racking waste throughout the production process to point of
discharge or treatment, storage, or disposal? Is it computerized?
b. What type of wastes are tracked (solid wastes, air, liquid, all types)?
c. Do waste generators have access to information on their waste generation?
d. Does the site generate classified wastes? How are these wastes tracked for
information purposes?
e. Has the organization developed baseline data for the generation of waste?
f. Is the tracking system designed to facilitate meeting reporting requirements of DOE,
EPA, and the states? Who else receives the reports? Site management?
g. Are Federal and state reporting requirements included in a master schedule?
h. Is the tracking compatible with DOE-wide waste generation tracking to facilitate
compatibility of reports?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-10
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4. Waste Management Costs
a. Are waste management costs identified? What is included in these costs
(characterization, handling, packaging, treatment, disposal, other)?
b. Are the costs of compliance activities, regulatory oversight, and future liabilities
estimated and considered?
c. Is there a tracking system for waste management costs? Is it computerized?
d. Are reports generated from this system? Who receives them?
e. Do waste generators have access to information on their waste management costs?
5. Waste Reduction Savings
a. Have cost savings due to pollution prevention been identified? How are cost savings
calculated and what factors are considered?
b. Is there a tracking system to monitor performance and savings under the pollution
prevention plan?
c. Are reports generated from this system? Who receives them?
d. Do waste generators have access to information on their waste reduction savings?
Phase 2 - Appendix
nagement Systems Assessments Pollution Prevention Assessment Guidance
A-11
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F. Cost Accounting
.a. Does the pollution prevention plan describe the type of pollution prevention or waste
management costs that are considered?
b. Are certain costs not considered? Why?
c. How are costs accounted for? Is there a standard system? What costs are included?
d. Are costs beyond startup tracked?
e. How is accounting handled for integrated projects (i.e., where P2 is incorporated
within other projects)? How are costs and savings assigned?
f. How are savings accounted for? For how long?
g. How are these projects and savings utilized? Are they considered in cost estimation of
future projects?
h. Is there a system to account for short and long term costs associated with the
underutilization of raw materials found in waste streams?
i. Are associated costs considered (e.g., personnel, recordkeeping. transportation,
pollution control equipment, treatment, storage, disposal, liability, compliance, and
oversight)?
j. Are waste management costs included in proposals, budget planning, and cost
accounting?
k. Are departments and managers charged for the waste management costs they generate?
1. Are pollution prevention projects subjected to life cycle analyses? How are waste
minimization, pollution prevention, and energy efficiency considered in such analyses?
Phase 2 - Appendix
Management Systems Assessments Pollution Prevention Assessment Guidance
A-12
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G. Sitewide vs. Generator Specific Programs
1. Procurement/Inventory
a. Does the site have a policy regarding the procurement of hazardous materials?
b. Does procurement-have an inventory control system for toxic materials? How are
materials which have .exceeded their shelf life kept to a minimum? How are samples
from salespeople accounted for?
c. Does the procurement process include consideration of toxicity of materials, quantities
purchased for identified need, etc.? What factors are considered (e.g., price, toxicity,
compatibility with existing materials, disposal costs, shelf life)?
d. What authority does procurement have to substitute less toxic materials?
e. Is there an inventory reduction program or effort in place?
f. Does procurement try to find environmentally-committed vendors? Do they work with
vendors to minimize pollution (e.g., reusable packaging, pallets, etc.)?
g. Is there a schedule for routine and periodic review and revision of design requirements
and specifications in order to implement cost-effective affirmative procurement?
2. Materials Exchange and Substitution
a. Does the facility have a materials exchange and substitution program?
b. Who/what department administers this program?
c. What types of materials are included (scrap metal, chemicals, etc.)?
d. What are some of the successes of the program? Failures? Why?
e. Are records kept of the materials exchanged and the cost savings?
f. What have been the costs to implement this program?
g. Are reports generated from these records? Who receives them?
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3. Nonhazardous Waste Recycling
a. Does the facility have a recycling program which includes administrative and sanitary
waste (paper, aluminum cans, toner cartridges, pallets, etc.)?
*
b. Who/what department administers this program?
c. What recycling options have been implemented? Onsite? Offsite?
d. How much waste has been avoided?
e. What are the cost savings?
f. What have been the costs to implement this program?
g. Are reports generated from this information? Who receives them?
4. 33/50
a. Does the facility participate in the EPA's 33/50 Program?
b. Who/what department administers this program?
c. Have reduction goals been set for the use and release of the 17 chemicals identified in
the 33/50 Program?
d. What have been the results of this program?
e. What have been the costs to implement this program?
f. Are reports generau ? Who receives them?
5. CFCs
a. Does the facility have a program to phase out use of ozone-depleting substances?
b. Who/what department administers this program?
c. Are the goals for phasing out the purchase and use of ozone-depleting substances
consistent with requirements of the Montreal Protocol and the Clean Air Act
Amendments of 1990?
d. What have been the results of this program?
e. What have been the costs to implement this program?
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f. Are reports generated? Who receives them?
6. Energy Conservation
a. Does the site have an energy conservation program?
b. Who/what department administers this program?
c. Is the program integrated with the pollution prevention program? If so, how?
d. What areas of conservation are included (lighting, HVAC, computers, equipment)?
e. What are some of the major energy conservation projects?
f. What have been the results of this program?
g. What have been the costs to implement this program?
h. Are reports generated? Who receives them?
7. ALARA
a. Does the site have a program to ensure that radioactive doses to workers and the
public are releases to the environment are as low as reasonable achievable?
b. Are all pathways (air, liquid, solid) considered?
c. How is pollution prevention integrated into the site's ALARA program?
d. What have been the results of this program?
e. What have been the costs to implement this program?
f. Are reports generated? Who receives them?
8. NEPA
a. How is P2 integrated into NEPA activities? What is considered and at what point in
the process?
b. Is there a system to ensure that P2 is considered?
c. Are P2 decisions related to NEPA activities documented?
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d. Are new processes and projects evaluated for pollution prevention opportunities before
being implemented?
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H. Contractor Performance
a. Have site contractors been directed to establish P2 programs? P2 plans? If so, have
P2 programs and plans been developed? If not, are the preparation of contractor
programs and plans scheduled?
b. Are site contractors required to follow the guidance and format found in the
Operations Office/Operating Contractor pollution prevention plan?
c. Is the accomplishment of pollution prevention goals and milestones included in the
evaluation of contractors' performance and award fees?
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I. Program Evaluation and Reporting
1. Program Evaluation
a. Is there a system to measure P2 progress against program goals?
b. How frequently is progress measured? Is there a schedule?
c. Have success demonstration criteria been established?
d. Have any self-assessments of the P2 program or specific P2 projects been conducted?
What were the results? How were these results used?
e. Have obstacles or lessons learned form evaluations been identified? How were these
issues addressed or followed-up? Is there an approach to overcome barriers?
f. Are the reports used to establish future pollution prevention goals and program
objectives?
g. What are the successful aspects of the program? What factors make it so?
h. What are the unsuccessful aspects of the program? What factors make it so?
2. Reporting
a. How does the organization report P2 results (both progress and setbacks) to
management? Who develops the reports and who receives them? What is the content
of the reports (exception-based, results-based, lessons learned)? How frequently are
the reports generated?
b. What reporting to regulatory agencies is required (e.g., RCRA waste minimization,
TRI)? Is there a system to ensure this reporting occurs as required, or in a timely
manner?
c. Is there a schedule for preparation annually of Form R reports to EPA and the state,
including data on source reduction and recycling as well as-toxic chemical inventories
and releases?
d. Is there a schedule for reporting to DOE field offices on the progress in meeting goals
of the 33/50 Program?
e. Is there a schedule for preparation of annual reports to DOE on collection, tracking,
and compilation or data on the progress of TRI reporting?
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f. Is there a schedule for preparation of annual reports on the effectiveness of and
compliance with affirmative procurement programs?
g. Is there a schedule for reporting annually to DOE operations offices on efforts and
success in phasing out the use of ozone-depleting substances?
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II. Facility Implementation Process
A. Existing Facility Operations
/. Waste Assessments/Inventories
a. Scope
1) What types of wastes have been included? Hazardous, radioactive, mixed wastes?
What definitions delineate hazardous waste? If nonhazardous wastes are included,
are both regulated and unregulated wastes addressed? Is there a list of all wastes
covered?
2)' Have all media releases been considered? Air (point source and area)? Water
(wastewater point source, stormwater, spills/leaks)? Solid wastes (regulated,
special and unregulated)?
3) What is the range of onsite waste generating activities covered?
Operations/manufacturing? Maintenance? Construction? Administration?
Remediation?
4) Are potential sources of waste production included that are (may be) nonroutine,
such as tank spills or spills from chemical/materials handling, annual tank cleaning,
changing filters, bleeding lines, etc.? Or are these addressed in other efforts?
5) Does the waste analysis extend beyond onsite activities? Is offsite disposition of
waste covered (including transportation)? Is waste associated with product use and
disposition included?
6) Are material supplies (procurement, store, etc.) considered as part of the waste
assessment for each process or as a separate process?
b. Methodology
1) What methods were used to develop the waste analysis data? Are they based on
DOE guidelines? To what aspects of the waste analysis do they apply (processes,
sources, waste types, specific chemicals)?
2) How is the inventory organized/compiled in characterizing facility operations and
activities? Are categorizations by waste type or specific constituents developed --
radioactive (e.g., high level, low level, TRU, mixed); degree of toxicity or hazard;
regulatory categories; etc.)?
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3) How are methodologies selected for obtaining data? Have established techniques
for measuring releases of wastes or "in-process" production been developed? If so,
what are they and to what waste types or processes to they apply?
4) Are pre-existing data sources used? If so, which ones - waste manifests, permits,
SARA III reports, other?
5) How much of the data derives from on-line monitoring systems? Routine grab
sampling/analysis? Which sources or waste types are covered?
6) Are routine plant operating and production records used? Which ones? How?
7) Are accepted estimating procedures used? ASTM? Regulatory-based? Others?
8) Have specific, focused sampling/analysis programs been undertaken to verify data,
or fill gaps? What types of programs? When/where has this been necessary? ,
9) Are material and energy balances performed? What is involved in these balances?
How are they defined?
10) Has guidance for conducting waste assessments been provided? How?
11) Does the-plan reference DOE PWA Guidance? EPA Waste Minimization
Opportunity Assessment Manual? Model PWA Plan?
c. Approach
1) In terms of identification of sources of waste generation, how far up the
"production chain" does the waste analysis go? Is waste generation upstream of
onsite treatment addressed or just releases and discharges? Are individual process
operations or units identified and characterized?
2) How are all of the facilities' sources, activities, and process operations identified
that are to be included within the waste analysis? Who (or what group) does this?
What information sources are used (e.g., existing waste management tracking
systems, waste manifests, SARA III reports, permits, process flow diagrams, piping
and instrumentation diagrams)?
3) Are waste characterizations developed for specific facility processes, activities or
areas? If so, in what ways?
4) How have variability and changes in facility operation or activities been factored
into the waste analysis? How are ongoing changes accounted for? Planned
changes? Anticipated construction or remediation work?
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S) How are waste assessment teams selected? Is participation voluntary or
mandatory? Fixed members or as-needed? Who selects the team members?
6) What are the technical qualifications of team members? Are both line and
management organizations represented?
7) Are teams made up of direct line personnel from the relevant process areas to be
assessed? From other process areas?
8) How are the waste assessment data compiled? In a database? Custom or off-the-
shelf?
d. Quality Assurance
1) How is the waste analysis maintained? Is it updated routinely? How often? Do
updates trigger complete reviews of the waste analysis or just significant changes?
2) How are data validated or cross-checked for consistency and accuracy?
3) Are there any efforts underway or implemented to improve accuracy or
completeness of data?
4) Is an "audit trail" maintained that documents the connection between
metrics/methodology and the waste analysis?
e. Responsibility
1) Who (what group) is responsible for maintaining and coordinating the waste
analysis?
/
2) How is organizational responsibility for waste assessment assigned (e.g., by
divisions, business organizations, etc.)?
f. Status
1) Have waste assessments been conducted? How many?
2) Is there a schedule for completing waste assessments?
3) Are waste assessments to be conducted on a recurring basis?
4) What is the cost experience to date (e.g., cost per waste assessment - maximum,
minimum, average)?
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2. Waste Streams Prioritization
a. What are the current priorities and how are these defined? Have specific chemicals or
waste types been identified? Emission sources? Process operations?
b. Is cost/economics an explicit priority? Implicit priority? •
c. Has a hierarchy within the priorities been established?
d. What were the criteria used to establish the priorities? Do these criteria relate to
specific waste types? Waste constituents? Quality of waste? Water/constituent
impacts? Cost of treatment? Public awareness? Environmental liability?
e. Who (what group) developed the criteria? How were the criteria selected?
f. How were the criteria applied in developing priorities? Was a ranking system used?
Were "gates" used (e.g., certain hazard levels and above)? "Weights" (e.g., scoring
system)?
g. Are priorities reviewed and re-evaluated? How often? What triggers this review?
Who (what group) is responsible?
h. How are waste streams selected to be assessed (e.g., quantity of waste generated,
toxicity, divisional minimization goals, overall site minimization goals, compliance
issues, etc.)?
3. Evaluations of Options/Waste Minimization Techniques
a. Identification
1) How are options identified and developed? Who (what group) is responsible for
identifying potential options? Who (what group(s)) are responsible for developing
the options?
2) How is technology transfer integrated into the process? What internal DOE
resources/experiences are accessed in identifying options? Are external
resources/experiences used? If so, what?
3) Is a hierarchy of P2 considered in identifying options - such as sources reduction
(administrative-operations adjustment-material substation-process modification-
technology upgrade-etc.); followed by internal recycle-reuse; then byproduct
conversion; and finally waste treatment/disposal?
4) Are options prescreened in any way? If so, how? What criteria are used?
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' S) To what level of detail are options developed? Design? O&M requirements?
Costs? Residual environmental impacts? Are these project/option specific or
consistent across all project?
6) How does the organization estimate costs of a specific project? Is there a standard
procedure? Is it documented?
7) What sources of information and resources are use din developing options? Site
only? Other Internal DOE? External to DOE?
8) Are developed options subjected to independent review? If so, by whom (or what
group)?
9) If certain options require R&D or demonstration, how are these handled?
10) Is research (surveys) carried out on a continuing basis regarding particular areas
for which acceptable options have yet to be identified or developed?
11) What technology transfer systems are in place and how well do they work?
12) Is the organization involved in any P2 partnerships with external organizations
(e.g., EPA, industry, academia, other government agencies)?
13) Has a technology transfer team been established to collect lessons learned about
technologies used and to pass information on to other DOE facilities and
programs?
14) Does the plan describe the establishment of partnerships and cooperative
agreements with other agencies or with industry to develop and exchange
technology and experience in pollution prevention?
IS) Is the organization working to commercialize new technologies?
16) Does the organization have cooperative agreements with potential manufacturers
or engineering service organizations which serve commercial markets?
b. Evaluations
1) What are the principle technical considerations (e.g., practicality and compatibility;
performance; commercial demonstration; reliability/operational flexibility)?
2) What are the principle economic considerations (e.g., payback; capital investment;
incremental return on waste reduction; life cycle analysis)?
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3) What are the principle ESH considerations (e.g., P2, hierarchy; "permStability";
extent of waste reduction; safety/occupational health; secondary environmental
impacts)?
4) What are the principle implementation considerations (e.g., schedule;
facility/process downtime; space; system retirement/D&D)?
5) Are there other considerations (e.g., public relations; institutional acceptance
barriers; regulatory incentives/disincentives; future uncertainties; fulfillment of
regulatory commitment)?
6) Obtain an overview of the evaluation process (a "flow diagram" would be helpful).
What are the steps? Who (what groups) are involved?
7) How are all of the evaluation factors balanced in the evaluation process? Are
weights assigned? What criteria are used in ranking or recommending options?
8) Are the process and criteria the same for different types of waste producing
activities (e.g., operations vs. remediation)?
9) What resources are used in developing/preparing options? Sit-bysite? Coordinated
among sites and CSOs?
10) Is prior DOE experience factored into the evaluation? Industry experience?
11) How are uncertainties and R&D or demonstration requirements factored into the
evaluation?
c. Selection
1) How are final selections made? Who (what group) makes the selection decisions?
2) Do P2 projects compete against conventional capital projects? Do P2 projects
compete against environmental compliance projects? Are P2 and compliance
projects covered by the same budget?
3) What are the selection criteria? Are they the same as conventional projects?
Compliance projects? Is there "value" assigned to P2 projects beyond directly
quantifiable costs and impacts? If so, what are they?
4) Do selection and decision processes differ for integral P2 projects and stand-alone
P2 projects, and if so, how?
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5) How are funding decisions related to the selection process (e.g.. Are selections
made based on. available funds? Are selections pre-established? Are selections
made independently of subsequent funding decisions?)?
6) How are R&D projects selected (e.g., Is there a separate budget for the site? Are
these coordinated with Headquarters, laboratories, or other sites? How is continued
funding of specific R&D projects determined?)?
4. Project Implementation
a. Who is responsible for implementing capital intensive P2 projects?
b. Are the internal staffing and contracted resources available for, or devoted to,
implementation of stand-alone P2 the same as other environmental projects? Non-
environmental projects?
c. Is there continuity of DOE staff involvement from project inception (option
identification) through project startup?
d. Are there opportunities to fast-track low/no capital cost projects? Is this done?
e. How many P2 projects have been implemented to date? What types of projects?
Which have been most successful? Why?
f. How are obstacles during implementation dealt with? Examples of obstacles and
implementation strategies?
g. Have a schedule and budget been prepared for implementing waste minimization
options?
h. How is implementation tracked?
5. Project Evaluation
a. If waste minimization options have been implemented, are follow-up evaluations
planned to see how effective they are in minimizing waste?
b. Is there a description of waste minimization technologies that have been implemented
•and the results of those technologies?
c. How is project status reported to management?
d. Which efforts have failed?
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e. Which efforts have succeeded?
f. What systems are used to track the success/failure of P2 projects?
g. Determine whether benefits defined during the project's approval process have
been/are being achieved.
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B. Integration with Support Activities
1. Maintenance
a. Have maintenance personnel had P2 awareness training?
b. Is P2 considered a pan of daily activities? Is there a mechanism for maintenance to
request substitute products? How are evaluations made?
c. Is preventive maintenance an integral pan of P2 programs? How?
d. Are maintenance activities reviewed to incorporate P2 opportunities?
e. Does maintenance participate in review of P2 projects?
f. Has maintenance been a prime mover in any P2 projects? Examples?
2. R&D
a. What P2 R&D projects have been conducted or are underway?
b. How is P2 considered in the R&D process?
c. Does the R&D organization proactively coordinate with operating facilities to identify
P2 needs and establish appropriate R&D programs?
d. Are R&D activities conducted at the site and/or coordinated with other sites at a
central facility?
e. What are examples of P2 projects of R&D? How are they identified? Funded?
f. Have R&D personnel had P2 training?
g. How are wastes from R&D managed?
h. Does the plan identify R&D projects related to pollution prevention?
i. Does the budget include funding for pollution prevention R&D project?
j. Does the plan identify R&D projects related to pollution prevention R&D projects?
k. Is there a process for monitoring the R&D program to ensure that it is achieving its
plan?
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1. Is there a system for tracking pollution prevention R&D activities?
m. Have completed R&D activities been incorporated into operations? Which ones
and when?
n. Has cost/benefit analysis been done for completed R&D activities?
3. Engineering/Design
a. Have lead engineering and design staff had P2 training? Construction personnel?
What does this training consist of?
b. Have engineering personnel been trained in Design for the Environment (DfE) and
life-cycle assessment?
c. Is pollution prevention considered a design criteria? Examples? Is it a pan of design
reviews? Is it included in value engineering? What are the guidelines?
d. To what extent does engineering and process design consider P2 in their normal
activities?
e. Is P2 an element of every engineering and design project? How? Examples?
4. Construction
a. How are construction wastes managed? What consideration is given to minimizing
construction wastes?
b. Is P2 a consideration in planning construction? In day-to-day activities? Do
constructability reviews incorporate minimization of wastes during construction?
c. Does the plan explain how design principles that minimize waste generation are
incorporated into new construction and into options that involve new or modified
processes as required by DOE Order 6430.1 A?
5. DAD
a. How does the organization approach P2 in planning D&D projects? Is it incorporated
at the beginning of planning activities?
b. Are P2 opportunities identified and assessment throughout the entire D&D process
from initial facility/area shutdown through final disposition? If so, is this coordinated
between the generator organization and EM? Is this included in the transition plan?
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c. How are P2 options identified? Evaluated? Selected?
d. Is there a hierarchy of P2 techniques established? If so, what are the techniques and
hierarchy?
e. How are costs for wastes and savings from byproducts/recycling established for P2
evaluations?
f. What guidance has been provided by HQ regarding requirements/considerations for
P2?
g. Have any D&D projects been initiated? Completed? How has P2 been a part of these
projects?
h. What barriers exist to implementing P2 opportunities?
6. Remediation and Restoration
a. How does the organization approach P2 in planning remediation projects? Is it
incorporated at the outset when establishing the baseline plan?
b. Is P2 a part of overall project development and integrated throughout? Is it considered '
separately for each remediation phase?
c. Is consideration given to such techniques as minimizing the amount of soil removed
(number and size of bore holes, etc.)? What types of P2 techniques are used in
remediation for treating contaminated materials? How are these assessed?
d. Is consideration given to the ability to minimize cost and water production through
combined P2 opportunities coordinated with several separate projects?
e. What pollution prevention activities associated with remedial actions have been
implemented?
f. How much waste has been generated? How much waste has been avoided? How is
this measured?
g. What are the cost savings associated with pollution prevention during remedial
actions?
h. What guidance has been provided from HQ regarding the importance of and/or
techniques for implementing P2?
i. How are P2 options identified? Evaluated? Selected?
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j. Has a hierarchy of techniques been established? If so, what are the techniques and
• hierarchy?
k. Are specific P2 R&D efforts identified in remediation evaluations? How are they
determined? Funded? Who conducts the R&D?
1. Is technology transfer a significant component in P2 options identification? Is this
within the DOE complex? With industry in general?
m. How are costs for wastes and savings from byproducts/recycling established for P2
evaluations?
n. Is P2 affected by regulatory factors (constraints) in developing remediation plans? Are
these determined at the outset in EPA reviews?
o. What other barriers exist to implementing P2 opportunities?
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Pollution Prevention-Related Requirements and Documents
Federal
Clean Air Act, 40 CFR Pan 82, Protection of Stratospheric Ozone; Refrigerant Recycling;
Proposed Rule; Federal Register (FR) 12/10/92
Clean Air Act, 40 CFR Part 63, National Emission Standards for Hazardous Air
Pollutants for Source Categories; FR 12/29/92
Clean Air Act, Final NPDES General Permits for Storm Water Discharges Associated
from Construction Sites; Notice; FR 9/9/92
Clean Air Act, Final NPDES General Permits for Storm Water Discharges Associated
with Industrial Activity; Notice; FR 9/9/92
Federal Facility Compliance Act, 1/3/92
Pollution Prevention Act of 1990, 11/5/90
Procurement of Environmentally-Sound and Energy-Efficient Products and Services,
Policy Letter No. 92-4; FR 11/9/92
Resource Conservation and Recovery Act of 1976. Section 6002 [42 U.S.C. 6962] Federal
Procurement
Resource Conservation and Recovery Act of 1976, Section 3002 Standards Applicable to
Generators of Hazardous Waste
Emergency Planning and Community Right-To-Know Act (EPCRA), Superfund
Amendments and Reauthorization Act of 1986, Section 313, EPCRA, 40 CFR Part 372,
Toxic Chemical Release Inventory Reporting Form/Form R; FR 2/16/88
Council on Environmental Quality; National Environmental Policy Act (NEPA); Pollution
Prevention; FR 1/29/93
Executive Orders
12088 Federal Compliance with Pollution Control Standards, 10/13/78
12780 Federal Agency Recycling and the Council on Federal Recycling and
Procurement Policy, FR 11/4/91
12844 Procurement Requirements and Policies for Federal Agencies for Ozone-
Depleting Substances, 4/23/93
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12844 Federal Use of Alternate Fueled Vehicles, 4/23/93
12845 Requiring Agencies to Purchase Energy Efficient Computer Equipment, 4723/93
12856 Federal Compliance with Right-To-Know Laws and Pollution Prevention
Requirements, 8/3/93
12873 Federal Acquisition, Recycling, and Waste Prevention, 10/20/93
State Requirements
As applicable
DOE Orders
Environmental Protection Agency's Pollution Prevention Strategy (1/91) - Analysis of the
EPA's Pollution Prevention Strategy; (EH-231), 3/27/91
Memorandum for Principle Secretarial Offices: Actions on the Elimination of
Procurement and Technical Requirements that Mandate the Use of Ozone-Depleting
Substances at DOE Facilities and Steps to Accelerate the Phaseout of the Substances,
7/29/92
Memorandum on Fiscal Year 1992 Report on Effectiveness of Affirmative Procurement
Program, 11/17/92
Memorandum on the Appointment of the Department of Energy Recycling Coordinator
(EH-352), 11/13/92
Waste Minimization, DOE Radiological Control Manual, Chapter 4-11, 6/92
Waste Minimization/Pollution Prevention Crosscut Plan Update, 11/93
Waste Minimization Crosscut Plan Implementation, SEN 37-92, 5/13/92
DOE Model Process Waste Assessment Plan
DOE Policy on Waste Minimization and Pollution Prevention, 8/20/92
DOE Order 5400.1, Environmental Program Plans, Ch. 3, Sec. 4(b), 4(c)
DOE Order 5400.3, Hazardous & Radioactive Mixed Waste Program, Sec. 7(d)(5)
DOE Order 5700.6C, Quality Assurance
DOE Order 5820.2A, Radioactive Waste Management
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Phase 3
Protocol for Conducting Environmental Management
Assessments of Federal Facilities/Organizations
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Table of Contents
Phase III
Introduction
A. Purpose
B. Scope and Format
C. Approach
Protocol Disciplines for Facility Wide Environmental Management Systems
Section 33 Organizational Structure
Section 34 Environmental Commitment
Section 35 Environmental Protection Programs
Section 36 Formality of Environmental Program
Section 37 Internal and External Communication
Section 38 Staff Resources, Training, and Development
Section 39 Program Evaluation, Reporting and Corrective Action
Section 40 Environmental Planning and Risk Management
Appendix - Selecting Individuals to Interview and Documents to Review for
Environmental Management Assessments
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Introduction
A. Purpose
The primary purpose of Environmental Management Systems Assessment is to provide the
Federal facility concise information pertaining to:
• Strengths and weaknesses of environmental management systems and programs at Federal
facilities;
• Adherence with Best Management Practices pertaining to environmental management
systems and programs;
• Compliance with Federal agency's policies which address environmental management
systems and programs;
• Identification of underlying causal factors contributing to the occurrence of observed
compliance deficiencies; and
• Noteworthy environmental management practices.
These assessments are also intended to provide Federal facilities and contractors feedback on '
the effectiveness and benchmark performance of their environmental management systems and
to identify opportunities for improvement.
Phase 3 reviews take a look at the "big picture" by assessing the overall ftinctoining of
established environmental management systems at a facility. This document divides Phase 3
protocols into the eight organizational disciplines listed below and attempts to provide
assistance to the management of a facility when it seeks to understand and evaluate the
systems which have been developed to manage and control environmental performance at a
facility. In this review, the task of the assessor shifts from compliance auditor (Phase 1) and
systems specific environmental discipline evaluator (Phase 2), to systems function evaluator
of environmental performance at the facility.
B. Scope and Format
The scope of an Environmental Management Systems Assessment includes eight disciplines
which are based on "key characteristics and elements of effective environmental management
systems. These eight disciplines are the following:
• Organizational Structure
• Environmental Commitment
• Environmental Protection Programs
Management Systems Assessments Phase 3 - Introduction
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Formality of Environmental Programs
Internal and External Communication
Staff Resources, Training, and Development
Program Evaluation, Reporting, and Corrective Action
Environmental Planning and Risk Management
(NOTE: Pollution prevention is dealt with comprehensively in each of-the sections of
Phase 2 as it pertains to those disciplines. Additionally, an overview has been provided
as an Appendix to Phase 2.)
Each discipline is organized as follows:
• Performance Objective: This is a general statement of the overall objective to be met in
each discipline.
• Key Evaluative Concerns: This section provides information on the major elements that
will be evaluated in each discipline.
• Criteria: These are specific criteria that should be satisfied in order to meet the overall
performance objective for each discipline. Each criteria is identified by a capital letter.
The criteria within a discipline have been grouped and organized along the lines of the
major elements identified in Key Evaluative Concerns.
The bullets under each criterion are intended to provide guidance to the assessor in evaluating
that criterion; they are not intended to be subcriteria. Additional bullets or lines of inquiry
may be appropriate depending on the specific organization being reviewed.
Many Federal facilities have tenant organizations, usually other Federal agencies, but also
state and local agencies and private parties. Even though these tenant organizations may be
responsible for environmental compliance of their activity, the facility owner may be
ultimately held accountable by regulators should compliance problems persist or should future
liabilities be discovered. These protocols can be used to address environmental compliance
and management issues associated with tenant organizations. The agreements between the
facility owner and the tenant organization need to clearly establish environmental
responsibilities of both the facility owner and tenant organization and the mechanisms that the
facility owner will utilize to monitor compliance, including application of these protocols to
the tenant organizations.
Federal facilities must observe A-106 requirements. The A-106 planning process is a
systematic methodology for identifying and prioritizing environmental requirements, and
targeting resources necessary to address them. The process assists in establishing funding
. priorities for projects to meet statutory and regulatory requirements. Using a standardized
format, Federal agencies must update their plans semi-annually and submit them to the EPA
for review. EPA uses a computerized system (FEDPLAN-PC) to track these requirements
from the time they are first identified until they are executed. The authority for the
Management Systems Assessments Phase 3 - Introduction
2
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development of these plans and review by EPA is contained in E.O. 12088 and Office of
Management and Budget (OMB) Circular A-106. The procedures for developing Federal
agency environmental plans are discussed in detail in EPA's Federal Agency Environmental
Management Program Planning Guidance document, dated October 1994.
C. Approach
In an assessment of facility wide environmental programs, the responsibility of the
environmental management specialist is to assess these programs to determine whether they
effectively meet the performance objectives and whether they have sufficient structure and
formality to assure that activities are conducted in a manner that is consistent with
environmental regulations and Federal agency policy.
The assessment is based on a combination of staff interviews and document reviews.
Interviews are exceptionally important in conducting an Environmental Program Assessment.
They provide the primary means of understanding the organizational relationships, roles and
responsibilities, policies, and systems that form the framework for the management of
environmental matters. More importantly, they often reveal differences in the actual versus the
documented practices. Document review is important to verify the formality of the system and
confirm interview information. Suggestions for the type of staff to interview and documents
to review are provided in the appendix.
Management Systems Assessments Phase 3 • Introduction
3
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Phase 3
Section 33
Assessing Environmental Programs
Organizational Structure
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fable of Contents
1. Performance Objective ' 33-1
2. Key Evaluative Concerns 33-1
3. Criteria 33-1
A. Management Organization 33-1
B. Roles and Responsibilities 33-3
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1. Performance Objective
The structure of the organization being assessed should be such that environmental
management functions are congruent and effectively integrated with other functions and
processes. Roles, responsibilities, and accountabilities should be well defined and clearly
communicated to effectively manage environmental issues. Authorities should be' delegated to
organizational levels that can ensure the effective implementation of environmental programs.
2. Key Evaluative Concerns
In this assessment discipline, the organization of the environmental management organization
will be reviewed and evaluated. Important characteristics of an effective organizational
structure include well defined roles and responsibilities, sufficient authorities, appropriate
layers of management, effective reporting relationships, and congruence of the environmental
management organization with the larger Federal agency organization.
3. Criteria
A. Management Organization
1) The organizational structure of the environmental management function is
characterized by clear lines of authority and responsibility.
a. Review organizational charts, mission statements, and any other documentation
of organizational design for the environmental management function.
b. Determine whether departmental missions and responsibilities related to
environmental management are clearly defined and understood. Note any
overlaps or conflicts of interest.
c. Determine which offices and individual(s) have authority and
responsibility/accountability for various environmental management functions.
2) The environmental management function is organized in such a way that managers
can be leveraged effectively, without being spread too thinly.
a. Determine the breadth and depth of responsibility of key environmental
managers.
b. Determine whether environmental managers have too much responsibility to
effectively carry out their jobs.
c. Determine whether environmental managers have too little responsibility to be
cost effective to the organization.
Phase 3 - Section 33
Assessing Overall Environmental Programs Organizational Structure
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3) Reporting relationships within the environmental management function are well
defined, clearly communicated, and effectively integrated into the overall
organizational structure.
a. Interview mangers and environmental staff to understand these reporting
relationships.
b. Determine where those relationships are defined and how they are
communicated.
c. Evaluate whether actual reporting arrangements for environmental management
(as determined through interviews) match those shown on existing
organizational charts or on distribution lists. Note any differences.
d. Evaluate how well these reporting relationships and the environmental
management organization fits in with the overall organization, e.g.,
• centralization versus decentralization,
• line versus matrix organizational structure.
4) Environmental managers are positioned high enough in the organization and have
sufficient organizational stature, independence, and authority to effectively
implement environmental programs and to make decisions related to environmental
protection.
a. Understand the amount of authority given to environmental managers at
different levels and determine if it is sufficient to carry out their responsibilities.
b. Understand the approval process and the level of approval necessary for specific
actions or projects.
c. .Identify who has stop-work authority and how quickly they can affect a
necessary response.
d. Note how many reporting levels separate the organization's most senior
manager and the person in charge of environmental matters.
e. Determine whether there are too many layers of management between these
two positions (the organization's most senior management and the
environmental professional).
f. Determine the effectiveness of communication between these two positions (the
organizations most senior management and the environmental professional).
(Linkage with Section 37).
Phase 3 - Section 33
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5) The integrity and effectiveness of the organizational structure is periodically
reviewed and revisions are made when warranted.
a. Note how often it is reviewed and by whom.
b. Understand the criteria used to evaluate organizational structure.
c. Determine whether the organizational structure of the environmental
management function has changed as a result of past reviews.
B. Roles and Responsibilities
(Linkage with Section 38)
1) Environmental roles and responsibilities are well defined, clearly communicated,
and understood by all personnel whose activities may impact environmental
performance.
a. Identify where and how these roles and responsibilities are defined, such asiin
program manuals or job descriptions.
b. Verify through interviews that individual jobs and responsibilities for
environmental management match those in program plans and job descriptions.
c. Determine whether specific roles as required by Federal agency policy or
Federal and state regulations have been assigned (e.g., NEPA Compliance
Officer, Radiation Safety Officer).
d. Determine whether these roles and responsibilities are formally implemented.
e. Determine whether functional relationships between the environmental support
group and the line units are formally defined and understood.
f. Review tenant/host agreeraent(s) to ensure environmental responsibilities are
. clearly defined between the tenant and the agreement holder (pg. 33-3).
2) Roles, responsibilities, and accountabilities are supported by management systems and
documentation such as job descriptions, performance standards and performance
appraisals.
a. Review job descriptions and performance standards for a sample of line
management and operations staff to determine if appropriate environmental
responsibilities are included.
Phase 3 - Section 33
Assessing Overall Environmental Programs Organizational Structure
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b. Review performance standards for select personnel (line managers and
operations staff) to verify that environmental performance is a written criterion.
c. Determine, through interviews, whether performance appraisals appropriately
measure environmental performance for both environmental staff and non-
environmental staff.
3) Personnel responsible for environmental management are held accountable for their
performance and the performance of those they manage.
a. Determine if awards are available for environmental activities or actions.
4) A group independent of line management with responsibility for policy and
standards development and oversight and technical support has been established.
This group has the authority and management support to implement their
responsibilities.
a. Determine whether responsibilities of these support groups are clearly defined.
b. Identify who:
• Establishes organization-wide environmental policy and standards;
• provides environmental oversight of line organizations;
• provides technical support for line organizations.
c. Determine how these environmental support groups fit into the overall
organizational structure. Note the organizational placement of environmental
support groups and whether they are independent of line management.
d. Determine whether these groups have appropriate levels of authority.
e. Determine if environmental managers have been successful in implementing
past initiatives.
Phase 3 - Section 33
Assessing Overall Environmental Programs Organizational Structure
33-4
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Phase 3
Section 34
Assessing Environmental Programs
Environmental Commitment
-------
Table of Contents
1. Performance Objective ' 34.1
2. Key Evaluative Concerns 34-1
3. Criteria 34.-)
A. Top Management Support 34. \
B. Environmental Policy 34.3
C. Line Management Support 34.4
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1. Performance Objective
The organization should exhibit a commitment to environmental excellence demonstrated by
top management support, line management accountability for environmental performance, and
formal environmental policy.
2. Key Evaluative Concerns
The focus of this audit discipline is the commitment to environmental excellence exhibited
throughout the organization -- from top management through line management and staff. Top
management support is critical to ensure environmental excellence and is necessary to
emphasize the importance of and commitment to the organization's environmental goals. Top
management support is evaluated based on demonstration of commitment to environmental
programs and performance.
The existence of overall and issue-specific environmental policies is essential to establish both
a framework for and a direction to the organization's environmental expectations. The
organization's environmental policy will be evaluated in terms of comprehensiveness,
compliance with environmental requirements, and provisions for environmental excellence
that go beyond regulatory requirements.
Finally, to achieve environmental excellence, all personnel must take personal responsibility
for environmental performance. Line management's commitment is evaluated based on the
sense of responsibility for environmental protection shown by managers and operating
personnel at all levels and in all functions.
3. Criteria
A. Top Management Support
I) Top management clearly communicates its commitment to environmental protection
through the issuance of formal statements and policies that explicitly state
environmental goals and expectations, with full compliance as a minimum goal.
a. Determine whether top management's commitment to environmental protection
has been stated in mission statements, annual reports, general environmental
policy or other broadly disseminated materials.
b. Determine whether top management includes environmental protection in
internal or external speeches.
2) Top management demonstrates its commitment to environmental excellence through
personal and managerial actions.
a. Determine whether routine senior management meetings include discussion of
environmental issues/programs.
Phase 3 - Section 34
Assessing Overall Environmental Programs Environmental Commitment
. 34-1
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b. Determine if top management has supported environmental programs through
sufficient allocation of resources (financial, technical) (Linkage with Section 38
& Section 40).
c. Identify personal actions that provide evidence of top management support, for
example:
• Initiation of environmental programs/projects;
• participation in professional associations;
• work with local community organizations; and
• participation in self-assessment reviews.
d. Determine whether senior management has a clear set of goals and expectations
regarding environmental performance and what they are (e.g., environmental
compliance as a minimum expectation, goals that go beyond compliance,
emissions reductions, etc.).
e. Compare explicit goals to apparent implicit goals and identify any conflicting
messages.
f. Identify how senior management communicates its environmental goals and
expectations to employees and, typically, how frequently the goals-are
communicated.
3) Top management's commitment is demonstrated through required routine reporting
regarding environmental performance and the status of environmental initiatives.
(Linkage with Section 37)
a. Determine what formal reports are routinely prepared for top management and
to what extent they address the organization's environmental status or
performance.
b. For these reports, identify to whom they are sent, the type of information
conveyed, and the level of detail provided.
c. If environmental information is not included in routine management reports,
investigate whether top management utilizes or relies upon any informal means
for determining the organization's environmental status or performance. If yes,
identify the means and how it works.
•
d. Check for any formal written requests from top management for information on
environmental status or performance.
4) Senior managers have a basic understanding of and appreciation for environmental
requirements relevant to the scope of the operations for which they are responsible.
Phase 3 - Section 34
Assessing Overall Environmental Programs Environmental Commitment
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a. Through interviews, determine if senior managers understand general regulatory
requirements, and have knowledge of internal environmental programs and
responsibilities.
b. Determine what training or background these managers have related to
environmental management.
5) Top management encourages openness and is receptive to input on environmental
issues from all employees, as well as from the public at large. (Linkage with
Section 37)
a. Identify mechanisms by which employee input has been encouraged and identify
examples.
b. Seek evidence that employee input is considered in environmental
decisionmaking.
c. Identify mechanisms by which public input has been encouraged and identify
examples.
d. Determine whether public input is considered in environmental decisionmaking.
6) Top management has created a culture of compliance, awareness, teamwork, and
line responsibility for environmental management.
a. Based on input from other members of the Assessment Team, determine if such
a culture exists in the organization and how this culture was established.
b. Determine top management's role in encouraging or discouraging such a culture.
B. Environmental Policy
1) A formal environmental policy statement that has been issued from a high enough
level of authority within the organization to communicate its importance.
a. Determine the existence of and review the organization's formal written
statement of environmental policy.
b. Identify the individual and level within the organization from which the policy
statement was issued.
2) Environmental compliance is formally established as the minimum acceptable
standard.
Phase 3 - Section 34
Assessing Overall Environmental Programs Environmental Commitment
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a. Review the environmental policy statement, and identify its principal
environmental goals and objectives.
b. Determine whether the policy statement satisfies the Federal agency's goal of
achieving environmental excellence.
c. Note whether implementation guidance or other supplemental, subsidiary
statements clarify how the organization intends to meet its policy objectives.
3) The organization has established issue-specific policies for the major environmental
issues consistent with the scope of its operations.
a. Determine whether the organization has issued any additional, issue-specific
policies addressing more focused environmental concerns, 'e.g., underground
storage tanks, PCBs, groundwater protection, hazardous waste, air emissions,
NEPA, etc. •
b. Assess whether issue-specific policies are consistent with the overall
environmental policy.
4) Environmental policies are widely distributed, easily accessible, and understood
throughout the organization.
a. Identify how environmental policies are communicated.
b. Based on interviews, determine the level of awareness and understanding of
environmental policies.
C. Une Management Support
1) Individuals throughout the organization recognize the environmental aspects of their
job responsibilities, and take personal responsibility for and demonstrate a sense of
"ownership" of environmental protection.
a. Determine line management's sense of personal responsibility for environmental
performance.
b. Determine whether line operating personnel and functional personnel understand
how their individual jobs affect the organization's environmental performance
and whether they make any specific connections between the two.
c. Note specific instances which reveal management or staff attitudes or beliefs
regarding the importance of their contribution to good environmental
performance.
Phase 3 - Section 34
Assessing Overall Environmental Programs Environmental Commitment
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d. Determine whether attitudes and behavior of management reinforce the message
that line operating personnel are primarily responsible for ensuring good
environmental performance.
e. Determine the organization's sense of the relative importance of the roles of
operating personnel and environmental staff in determining environmental
performance.
2) Managers at all levels have formally stated and demonstrated their commitment to
environmental excellence.
a. Identify and review managers' statements of this commitment, for example:
• Memoranda;
• records of formal meetings; or
• bulletin board postings.
b. Identify actions that provide evidence of environmental commitment.
3) Managers at all levels and in all functions whose activities may impact
environmental performance take responsibility and interest in limiting the
environmental impacts of their operations.
a. Identify'activities in which line managers are involved, for example:
• They routinely observe field level compliance activities;
• participate in audits and self-assessments;
• write and review procedures; or
• serve on environmental advisory committees.
b. Determine what kind of environmental information line managers solicit and
receive and how they obtain this information.
c. Review internal memos relevant to environmental management activities and
manager meeting minutes to assess their level of involvement.
d. Determine what actions have been taken by line management in response to
environmental accidents and occurrences.
4) Management and staff cooperate fully and openly with internal and external
oversight groups. (Linkage with Section 33 and Section 37)
a. Based on interviews with internal environmental staff and external oversight
organizations, determine whether the relationship between the two is cooperative
or adversarial.
Phase 3 - Section 34
Assessing Overall Environmental Programs Environmental Commitment
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Phase 3
Section 35
Assessing Environmental Programs
Environmental Protection Programs
-------
Table of Contents
1. Performance Objective • 35-1
2. Key Evaluative Concerns 35.1
3. Criteria 35-1
A. Specific Environmental Protection Programs 35-1
B. Specific Program Plans 35.3
C. Other Programs Related to Environmental Protection 35-4
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1. Performance Objective
Programs should be in place to ensure compliance with applicable Federal, state, and local
environmental protection laws and regulations, and internal Federal agency policies that are
designed to protect the environment and public health and welfare.
2. Key Evaluative Concerns
The purpose of this assessment discipline is to evaluate the extent to which the organization
has developed and implemented specific environmental protection programs and plans which,
if properly managed, should help maintain compliance and ensure movement towards
environmental excellence. This category will be evaluated based on the existence, quality, and
effectiveness of specific programs, including all necessary program elements.
Whereas the other protocol areas evaluate specific characteristics and elements of
environmental management systems, this discipline will evaluate the implementation of these
systems for issue specific environmental programs.
3. Criteria
A. Specific Environmental Protection Programs
1) For each of the EPP programs (as a minimum, these tested in Phase 2)
determine whether a program is necessary and whether existing programs are
sufficient to identify, quantify, and control risks.
a. Determine whether applicable environmental programs include the
following program elements:
• formal policies and plans;
• identification and characterization of sources;
• understanding of applicable regulatory requirements;
• responsibilities;
• implementation procedures;
• recordkeeping and reporting systems;
• training; and
• program evaluation and oversight.
b. Evaluate the effectiveness of the organization's environmental programs
2) Effective environmental protection programs are in place to identify, control,
and monitor air emissions.
3) The organization has a program for the protection of surface waters, including:
a. Identification of discharge points and sources;
Phase 3 - Section 35
Assessing Overall Environmental Programs Environmental Protection Programs
35-1
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b. applicable discharge permits, monitoring program, an effective Spilt
Prevention, Control, and Countermeasures Plan; and
c. reporting and recordkeeping systems.
4) The organization has a program for the protection of potable water supplies
(including backflow prevention systems).
5) The organization has determined and documented the need for site specific
groundwater protection programs. When necessary, a groundwater monitoring
program has been established to address the needs of specific sites.
6) Programs are in place for the proper management and control of toxic and
chemical materials to prevent or minimize their release into the environment,
including programs for:
a. Procurement, handling, and storage of toxic and chemical materials;
b. management and control of polychlorinated biphenyls;
c. management and control of pesticides;
d. management and control of petroleum, petroleum products, and chemicals
in aboveground or underground storage tanks; and
e. containment or removal of asbestos.
7) The organization has a program for the management of solid, hazardous, and
radioactive waste, including:
a. Waste source identification;
b. waste characterization;
c. waste acceptance criteria, where appropriate;
d. treatment, storage and disposal practices;
e. contingency plans;
f. recordkeeping systems;
g. training;
h. waste minimization, and
Phase 3 - Section 35
Assessing Overall Environmental Programs Environmental Protection Programs
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i. a formalized pollution prevention program as outlined in relevant executive
orders.
8) Programs are in effect that provide for environmental radiation protection
through adherence to ALARA principals. Additional programs are in place that
require:
a. Radiological environmental surveillance;
b. evaluation of unplanned releases of radioactive materials; and
c. evaluation of radiation exposure to the public.
9) The organization has a program to identify, remove, and/or routinely monitor
underground storage tanks.
10) The organization has a program for compliance with Federal agency
requirements for implementing NEPA, including screening/review and
determination of the appropriate level of NEPA documentation for each
proposed action.
a. Identify the system to assess the acceptability of contractors preparing
NEPA documentation.
b. Determine whether environmental evaluations or checklists are used to
initially screen every proposed action.
c. Identify the criteria and process used to recommend the level of NEPA
documentation to the appropriate Federal agency authority for
determination.
B. Specific Program Plans
1) The responsible field organization has prepared and routinely updated formal
program plans for the following:
a. Groundwater protection management;
b. waste minimization; and
c. pollution prevention awareness.
Phase 3 - Section 35
Assessing Overall Environmental Programs Environmental Protection Programs
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2) The organization has developed an environmental monitoring and surveillance
plan.
a. Determine whether the organization has a monitoring plan and whether it
addresses all environmental monitoring needs and requirements relevant to
the organization.
C. Other Programs Related to Environmental Protection
1). A program is in place to plan and effectively implement all actions required to
manage responses to releases of hazardous substances to the environment from
inactive waste sites or to releases of reportable quantities of hazardous
materials.
a. Determine whether the organization has formal written emergency response
plans, such as SPCC Plan, etc. as required.
b. Assess whether these plans are clear, complete, and current'as to who has
the Emergency Coordinator responsibility, what emergency response
equipment is available and where, and whether the emergency response
procedures are site-specific.
c. Determine whether staff have received appropriate training in planned
emergency response procedures. Does the organization hold periodic drills
or other readiness exercises.
d. Review emergency response plan documents, internal records of emergency
response drills, other readiness exercises conducted.
2) The organization has developed and implemented preventive maintenance
programs to ensure proper operation of pollution control equipment. (Linkage
with Section 40)
a. Determine what has been the operating experience of this organization over
the past year with respect to pollution control equipment outage, needed
repairs.
b. Assess whether the organization has preventive maintenance programs in
place and functioning for any critical operating and pollution control
equipment.
c. Determine whether preventive maintenance schedules are automated or how
responsible personnel know when a particular planned maintenance activity
is to be performed.
Phase 3 - Section 35
Assessing Overall Environmental Programs Environmental Protection Programs
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c. Determine whether preventive maintenance schedules are automated or how
responsible personnel know when a particular planned maintenance activity
is to be performed.
3) The organization has emergency preparedness plans such as contingency plans,
Spill Prevention, Control, and Countermeasures plans, and a general emergency
plan that addresses any potential hazard including natural disasters, fire,
explosions, etc.
a. Verify that emergency response plans and programs include all applicable
elements, including roles and responsibilities, procedures, training, and
equipment.
b. Determine whether crisis management responsibilities are defined at all
organizational levels.
c. Review responsibilities in the emergency response plan against
organizational charts and general responsibilities.
4) A Quality Assurance Program and organization is in place to assure that
environmental programs provide adequate protection to the environment and to
public health, and that environmental data are representative and defensible.
a. Determine whether environmental measurement activities are conducted
following EPA-approved methods and procedures.
5) A P2 plan outlines a facility's environmental future with respect to all
environmental impacts and compliance programs.
A. Pollution Prevention Plan Development Steps
Develop P2 goals;
Obtain Management commitment;
Establish a P2 team;
Develop a baseline;
Identify P2 activities and opportunities;
Develop criteria and rank the activities and opportunties; and
Conduct management review.
B. P2 Plan - a P2 program is a road map describing:
P2 activities;
The status of activities in progress;
P2 goals; and
Reductions achieved thorugh P2 activities.
Phase 3 - Section 35
Assessing Overall Environmental Programs Environmental Protection Programs
35-5
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Phase 3
Section 36
Assessing Environmental Programs
Environmental Commitment
-------
Table of Contents
1. Performance-Objective 36.1
2. Key Evaluative Concerns 35-1
3. Criteria 36-1
A. Regulatory Tracking and Translation 36-1
B. Procedures 35.3
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1. Performance Objective
Formal systems and procedures should be in place to manage day-to-day environmental
compliance. This includes systems to track and understand regulatory requirements,
procedures for implementation of policies and programs, routine inspections, and systems for
recordkeeping and reporting.
2. Key Evaluative Concerns
In this audit discipline, the formality of environmental programs and supporting management
systems for ensuring compliance will be evaluated. This discipline complements the
Environmental Protection Programs discipline by focusing on the formal systems and controls
that are in place to assure compliance of day-to-day operations. The assessment team will
assess the existence and effectiveness of a formal system for tracking, interpreting, and
distributing relevant regulatory requirements. The organization will also be evaluated on its
implementation of environmental programs through specific guidance procedures and
standards. The organization's system for the conduct of routine inspections to identify and
prevent problems will be evaluated. Finally, systems for the maintenance and retention of
records as well as assurance of necessary reporting will be assessed.
3. Criteria
A. Regulatory Tracking and Translation
1) A formal system is in place to routinely track and interpret new and/or changes to
Federal, state, and local regulations and Federal agency policies for the
organization.
a. Determine how the organization stays current with new and emerging
environmental regulations and trends.
b. Identify who within the organization is responsible for regulatory tracking.
c. Determine how new regulations are interpreted as to their applicability to the
organization and by whom. Determine the role of the legal department in this
task.
d. Determine whether the organization has a formal system for ensuring that new
requirements are incorporated into existing programs, policies, and procedures.
e. Note the availability of regulatory reference material (compilations such as
BNA, automated access via software, etc.), technical books, and other reference
materials.
Phase 3 - Section 36
Assessing Overall Environmental Programs Formality of Environmental Program
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2) There is a process to ensure that guidance on new regulatory requirements is
incorporated into organization or site-specific standard operating procedures, as
appropriate.
a. Determine if there is, a formal system in place to update environmental
programs and procedures to reflect changes in regulatory requirements.
3) Relevant regulatory information is routinely distributed to field organizations in a
timely manner.
a. Determine how and in what form regulatory information is transmitted to the
field.
b. Determine whether the right people learn of the developments with sufficient
lead time to take appropriate action.
4) Field organizations are provided sufficient guidance for compliance with new
regulations or policies in the form of guidance documents, sample plans and
procedures.
a. Determine how this guidance is provided and by whom, such as through
guidance manuals, training, memorandum, etc.
b. Determine the level of guidance provided to the field along with regulatory
distribution, and assess the adequacy of this guidance.
•
c. Interview field personnel and obtain their opinion of the adequacy of guidance.
B. Procedures
1) The organization has a formal, controlled process for reviewing, creating, updating,
and approving new procedures.
a. Develop an understanding of this process, including types of approval,
responsibilities, etc.
b. Test the system by identifying a sample of procedures to determine if they have
been reviewed and updated. Test also by identifying a new regulatory
requirement and determining whether a procedure has been created and
approved.
2) Procedures and standards are issued from an organizational level with the authority
to mandate implementation. (Linkage with Section 33)
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a. Identify who issues environmental standards and their level of authority within
the organization.
b. Assess whether the level of procedure issuance is sufficient to ensure
implementation.
3) Formal standards and procedures have been developed for the implementation of
specific environmental protection programs.
a. Determine whether the organization has written procedures for environmental
. activities associated with specific environmental programs, for example,
inspections, reporting, emergency response, NEPA.
b. Review a sample of program specific procedures to assess the quality and
adequacy of instruction.
c. Evaluate the process to review the technical content and adequacy of NEPA
documentation.
4) There are procedures to ensure that any activities that might impact the
environment are reviewed for environmental protection considerations.
a. Determine whether standard operating procedures include environmental
protection standards.
b. Determine whether the organization has a system to ensure that all procedures
are reviewed and revised to include environmental protection considerations
(Linkage with Section 40).
5) Procedures are part of a formal, audttable document control system designed to
ensure that personnel have ready access to current versions of procedures
containing environmental requirements.
a. Develop an understanding of how procedures are organized and controlled, for
example, whether procedures are centrally located or at each individual
operating site, and whether they are controlled using a manual or computerized
system.
b. Determine which environmental procedures are routinely accessible at the
facility level.
c. Verify accessibility by requesting a sample of specific procedures.
6) The organization has implemented a system to periodically review and update
environmental procedures.
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a. Determine how often procedures are reviewed and updated and by whom.
b. Determine how revised or updated procedures are communicated/distributed to
the rest of the organization.
c. Determine whether there is a requirement for periodic review of procedures by
users.
C. Routine Facility Inspections
(Linkage with Section 35 and Section 39)
1) The organization has a program for routine site and equipment inspections and
compliance checks, including appropriate documentation.
a. Determine whether environmental or other staff conduct occasional or routine
inspections to determine compliance with specific environmental legal and
regulatory requirements, and check the frequency of these inspections.
b. Determine whether regular tests and inspections are performed on critical
operating and pollution control equipment, (e.g., electrostatic precipitators,
scrubbers, air monitors, or environmental measurement devices).
c. Determine whether these inspections follow a formal written protocol or
checklist.
d. Determine whether results of inspections are documented and retained. Review
documentation of a sample of routine inspections.
2) The organization has a formal system for follow-up of exceptions noted in
inspections, which is supported by management review.
a. Develop an understanding of the follow-up system and responsibilities.
b. Determine if there is a process for reporting exceptions to management.
c. Determine whether management reviews inspection documentation and
corrective actions.
d. Determine if there is a tracking process to ensure the corrective actions or
repairs are taken in a timely manner.
e. Determine whether the organization has a system in place to minimize repeated
exceptions as noted in inspections (e.g., through root cause analysis).
Phase 3 - Section 36
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D. Recordkeeping and Reporting
(Linkage with Section 33 and Section 35)
1) Systems are in place for the appropriate documentation and.recordkeeping of
environmental performance.
a. Develop an understanding of all systems that are in place for recordkeeping and
document control.
• Tracking of key regulatory schedules (e.g., permit renewals, report
submissions, required training.).
• Maintenance of compliance records (e.g., inspection logs, source and/or
ambient measurement data.).
• Preparation and submission of required regulatory reports (e.g., RCRA
generator report, hazardous material inventory and release reports, PCB
inventory and disposal report.).
b. Determine whether the organization maintains appropriate documentation and
records of environmental inventories, permits, and environmental performance
for the following programs:
• Water pollution control;
• air pollution control;
• hazardous waste management;
• importable spill incidents;
• PCB inventory and disposal;
• Toxic Substance Control Act Section 8(c) and 8(e) files;
• training; and
• EPA.
c. In general, assess the state of the organization's files and recordkeeping practice
regarding these environmental records. Determine whether the files are
complete, current, and readily accessible.
d. Determine the extent to which environmental information management is
automated or manual.
e. Determine whether recordkeeping practices are formal and systematic.
2) The organization has a document control system and record retention policy.
a. Determine whether the organization has a formal records retention policy which
covers environmental compliance and other related environmental information.
In lieu of a formal policy, are guidelines provided to staff regarding
environmental records retention.
b. Assess whether individuals are knowledgeable of the record retention policy.
Phase 3 - Section 36
Assessing Overall Environmental Programs Formality of Environmental Program
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c. Where applicable, verify that the organization retains environmental records for
the retention period specified by regulation.
d. Determine whether the system has the capability to track the status of NEPA
compliance for planning, funding, approval, design, and construction phases of
all proposed actions.
e. Determine whether the system accounts for classified documentation, if
necessary.
3) There are systems in place to ensure that environmental reports required by Federal
and state regulations and Federal agency policy are routinely prepared and
submitted on a timely basis.
a. Determine how the organization ensures that environmental'reports required by
Federal or state regulation are routinely prepared and submitted to the
appropriate regulatory agencies in a timely manner.
b. Assess the effectiveness of the system by checking some reporting requirements
such as the following:
• Annual hazardous waste generator reports have been-submitted to
appropriate state or Federal EPA.
4) Environmental status reports with the appropriate level of detail are routinely
prepared for internal management purposes and for reporting environmental
concerns to higher levels of management in a timely manner. (Linkage with
Section 33 and Section 34)
a. Identify what kind of reports are prepared, and determine the content and
frequency of these reports.
b. Determine whether these reports include the full range of environmental
issues/activities.
c. Determine whether other systems for conveying environmental information are
in place (regular meetings, reports, self assessments, etc.).
d. Note whether environmental status information includes an appropriate level of
detail to sufficiently inform senior management.
e. Note whether environmental status reports compare accomplishments to goals.
Phase 3 - Section 36
Assessing Overall Environmental Programs Formality of Environmental Program
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S) There are formal mechanisms to investigate, report, correct, track, and monitor
trends in environmental problems and "incidents." The types and magnitudes of
the problems that should be reported are well defined. (Linkage with Section 39)
a. Determine whether the organization has a formal written procedure for
environmental incident investigation and reporting.
b. Review files of investigation reports to determine whether root causes of
problems and incidents are identified and trended and whether there have been
recurring problems.
c. Determine whether corrective actions have been planned and implemented for
these incidents.
Phase 3 - Section 36
Assessing Overall Environmental Programs Formality of Environmental Program
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Phase 3
Section 37
Assessing Environmental Programs
Internal and External Communication
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Table of Contents
1. Performance Objective •> 37.1
2. Key Evaluative Concerns 37.1
3. Criteria 37.1
A. Internal Communication 37.1
B. External Communication 37.3
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1. Performance Objective
Formal and informal channels of communication should be utilized to facilitate
implementation of all environmental management systems and programs; to emphasize
management commitment to environmental protection; to generate a sense of environmental
awareness throughout the organization; and to manage relationships with external oversight
organizations and others who are likely to be concerned with the success of the organization's
environmental protection efforts.
2. Key Evaluative Concerns
The focus of this audit discipline is an evaluation of internal and external communication
systems. The effectiveness of internal communication systems will be determined through an
evaluation of the understanding of roles and responsibilities and the awareness of
environmental policies, procedures, and programs throughout the organization. The extent and
effectiveness of external communications will be assessed based on consistency of the
external dialogue, monitoring of external concerns, and external recognition of the
organization's environmental commitment.
3. Criteria
A. Internal Communications
1) Environmental information is effectively communicated through formal or informal
means throughout the organization (top-down, bottom-up, and lateral).
a. Determine whether these formal channels exist and in what form (reports,
meetings, memoranda, etc.).
b. Determine whether there are regular line management and environmental staff
meetings that adequately cover environmental issues.
c. Evaluate the flow of communication between line management and operating
staff, as well as between various functional areas.
2) There is a formal system in place to allow personnel to anonymously communicate
(without retribution) environmental concerns to upper levels of management for
resolution.
i
a. Determine whether such a system exists, how it works, to whom concerns are
reported, and what type of action is taken.
b. Determine whether personnel at various levels in the organization are aware of
its existence.
Phase 3 - Section 37
Assessing Overall Environmental Programs Internal and External Communications
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c. Note any evidence that the system is used, and whether it is considered useful.
d. Evaluate demonstrated management support for the system.
3) Informal channels of internal communication are encouraged as a means of
developing cooperation and commitment to environmental protection.
a. Identify the informal modes of communication used in the organization and
assess their effectiveness.
b. Determine whether environmental staff across programs, facilities, and units
share information and assist each other on environmental problems.
4) Environmental awareness is continually reinforced throughout the organization via
the use of newsletters, bulletin boards, videotapes, office-wide programs, or other
means. (Linkage with Section 37)
a. Identify communication modes used to promote environmental awareness.
b. Note observations of environmental awareness promotion throughout the
facility.
c. Compare environmental awareness to health and safety awareness for
perspective.
5) Formal communication of environmental protection directives is timely, and
effectively reaches all responsible elements of the organization. (Linkage with
Section 33 and Section 36)
a. Determine how quickly the following types of environmental information is
communicated to management:
•• Routine environmental status information;
• incident or major issue information; and
• controversial issues requiring NEPA.
b. Determine how quickly new environmental requirements, programs or other
information is communicated to the field.
6) Employee environmental concerns are solicited and addressed, and both the.
concerns and responses are documented.
a. Identify employee environmental concerns that have and have not been
addressed.
Phase 3 - Section 37
Assessing Overall Environmental Programs Internal and External Communications
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b. For those that were addressed, note the organization's response, and whether the
concerns were documented.
•
c. For those that were not addressed, identify reasons why..
d. Note whether well-founded concerns expressed in one facility or group are
shared with other facilities or groups that might have similar problems.
7) The effectiveness of communication is demonstrated by a widespread awareness
and acceptance of the organizational commitment to environmental protection.
(Linkage with Section 34)
a. Through interviews, assess the general understanding and appreciation for
environmental issues exhibited by organization employees.
8) Effective working relationships exist between headquarters and field environmental
staff as well as between staff and line personnel whose functional responsibilities
impact environmental performance.
a. Check for close working relationships between environmental staff, line
management and other key functional specialists within the organization, (e.g.,
engineering, legal, purchasing).
b. Note any examples where networking by environmental staff with these other
professionals has resulted in decisions or actions which have increased the
effectiveness of the environmental management function.
c. Note any evidence of lack of cooperation between line and oversight groups.
B. External Communication
1) The organization has a good working relationship and cooperates fully and openly
with external oversight organizations.
a. Determine whether the organization has frequent, proactive interaction with
regulatory agencies and keeps them informed of the environmental status of the
organization.
b. Determine whether the relationship between environmental staff and external
oversight organizations appears cooperative or adversarial, based on interviews
with representatives of both.
c. If appropriate, interview regulatory representatives to obtain their perspective of
the working relationship.
Phase 3 - Section 37
Assessing Overall Environmental Programs Internal and External Communications
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2) The organization has defined who will be the internal points of contact with
external parties, and has identified the points of contact within appropriate external
. parties.
a. Identify the key internal points of contact for interaction with external
organizations.
b. Determine whether the organization has identified points of contact in external
organizations.
3) A program exists for communicating with external parties such as regulatory
agencies, environmental groups, and the local community to provide them with
information the opportunity to be involved in key decisions related to
environmental protection.
T
a. Determine what kinds of communication programs the organization has with the
local community, (e.g., community relations plan, education, visitation of
facilities, public reading rooms, etc.)
b. Based on interviews with facility staff, assess how the organization interacts
with environmental groups.
c. Identify any complaints from neighbors and determine how the organization
handles them.
d. Identify recent key decisions by the organization that have related to
environmental protection. Determine whether external agencies, organizations,
or individuals were provided the opportunity to be involved.
. e. Based on interviews with regulatory agencies, environmental groups, and
representatives of the local community, determine whether external
organizations perceive that they have had such opportunities.
4) Formal communication of environmental risks and protection efforts occurs
frequently, is timely, and effectively reaches external organizations, including
regulatory agencies, environmental groups, and representatives of the local
community.
a. Evaluate whether environmental risks and protection efforts are communicated
to such contacts routinely or only on an infrequent basis. Note whether the
information is timely.
Phase 3 - Section 37
Assessing Overall Environmental Programs Internal and External Communications
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b. Based on outside interviews, determine whether the information is received and
is perceived to be comprehensible. Determine whether recipients believe they
are being kept up to date on the organization's activities that may impact
environmental performance.
5) The environmental concerns of external parties are addressed, and both the
concerns and responses are documented.
a. Review files to determine whether external concerns have been documented and
addressed.
b. For those that were addressed, note the organization's response, and whether the
concerns were documented and trended.
6) The effectiveness of communication is demonstrated by a widespread external
recognition of the organization's commitment to environmental protection.
a. To the extent possible, determine the recognition of this commitment among
regulatory agencies, environmental groups, and representatives of the local
community.
7) The organization periodically assesses the effectiveness of external
communications, makes changes as necessary, and documents the results of the
evaluations and changes made.
a. Determine how the organization assesses effectiveness and what changes have
resulted from such an evaluation.
Phase 3 - Section 37
Assessing Overall Environmental Programs Internal and External Communications
37-5
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Phase 3
Section 38
Assessing Environmental Programs
Staff Resources, Training, and Development
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Table of Contents
1. Performance Objective 38-1
2. Key Evaluative Concerns 38-1
3. Criteria 38-1
A. Environmental Staffing 38-1
B. Job Descriptions and Performance Evaluations 38-2
C. Environmental Training Program 38-3
D. Staff Development Opportunities ' 38-6
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1. Performance Objective
Programs should be in place, to ensure that staff resources are sufficient to effectively develop
and implement the organization's environmental protection programs. The organization should
have a formal program in place to ensure that all personnel have received environmental
protection training appropriate for their job responsibilities. The organization should also
provide staff development and career advancement opportunities for environmental staff.
2. Key Evaluative Concerns
In this assessment discipline, the Assessment Team will determine whether environmental
staffing resources are sufficient from a quantitative and qualitative perspective to properly
address the organization's environmental risks. Job responsibilities and performance appraisal
processes will be reviewed for evidence of the importance of individual environmental
performance. The degree of formality, completeness, and appropriateness of the organization's
systems for identifying and satisfying environmental skills training needs and for providing
opportunities for career development will also be assessed.
3. Criteria
A. Environmental Staffing
1) Environmental staffing levels are sufficient to achieve environmental performance
goals. This includes dedicated environmental support staff and others with
collateral duties' (e.g., line managers with other support functions).
a. Determine how the organization assesses environmental staffing needs.
b. Determine whether staffing is in line with identified needs.
c. Determine whether requests for additional environmental staff have been
approved or denied and why.
d. Identify environmental programs or projects that have not been undertaken or
completed because of insufficient environmental staff.
e. Note any other evidence of insufficient environmental staff to assure
compliance, e.g.,
• . compliance deficiencies whose root causes are inadequate resources;
• excessive overtime; or
• excessive use of contractors.
Phase 3 - Section 38
Staff Resources,
Assessing Overall Environmental Programs Training, and Development
38-1
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2) Personnel with environmental responsibilities have the relevant background and
training to carry out their responsibilities.
a. Determine what qualifications are necessary for environmental staffing and other
positions with environmental responsibilities.
b. Review a sample of resumes for selected environmental staff and note the
following:
• Educational training in environmental management;
• diplomas and certifications of environmental training (internal and external);
and
• relevant work experience in environmental management.
c. Environmental suppon staff demonstrate sufficient knowledge and familiarity
with the organization's operations, environmental issues, and programs and
procedures to effectively carry out their respective environmental protection
responsibilities.
3) Staffing for environmental protection activities is provided in a timely manner.
a. Determine whether additional staff with environmental responsibilities are added
as the need arises or whether there is a significant delay.
b. Determine whether environmental activities requiring immediate attention (e.g.,
a spill or a determination of environmental non-compliance) are responded to in
a timely manner.
4) A system is in place to identify both short-term and long-term environmental
staffing requirements, both within the environmental support group and within
line units with environmental responsibilities.
a. Determine how short- and long-term environmental staffing requirements are
determined.
b. Determine whether this staffing assessment includes both the environmental
suppon staff and line management needs.
B. Job Descriptions and Performance Evaluations
(Linkage with Section 33 B.)
1) Appropriate job descriptions are established and maintained for environmental
positions.
a. Review formal written job descriptions for environmental staff to determine
Phase 3 - Section 38
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Assessing Overall Environmental Programs Training, and Development
384
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whether they are current, complete, and reflective of existing duties.
b. Identify other positions in each department that include environmental
responsibilities. Review the formal written job descriptions for these other key
tine management and operating personnel and assess whether these job
descriptions incorporate any statements regarding their environmental-related
duties and responsibilities.
2) Performance standards used in the performance appraisal process include the
environmental aspects of individual job responsibilities, including line management
responsibilities for environmental performance. Environmental factors ate given
comparable emphasis to safety and productivity factors.
a. Determine whether explicit measures of performance have been identified for
specific jobs, including both environmental staff and line management
personnel.
b. Determine whether environmental criteria receive substantially less emphasis
than other criteria such as productivity and safety.
c. Determine whether periodic staff performance reviews include explicit measures
of environment-related job performance. Note example's of environmental
performance criteria used.
3) Good environmental performance is rewarded in practice, and poor performance is
penalized.
a. Identify reward, incentive or bonus systems (financial or nonfinancial) for
environmental staff and other personnel with environmental responsibilities.
b. Determine what actions are taken for poor environmental performance.
c. Identify other methods used for praise or corrective action such as verbal
feedback, memorandums, internal announcements, etc.
C. Environmental Training Programs
1) Environmental training programs are defined in controlled documents such as a
training program manual.
a. Understand how environmental training requirements are determined and where
they are explicitly identified, e.g., training plans.
b. Determine if a training manual or other documents describe environmental
training programs.
Phase 3 - Section 38
Staff Resources,
Assessing Overall Environmental Programs . Training, and Development
38-3
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2) There is a process in place to identify and evaluate environmental training needs
for all personnel. These needs are incorporated into individual professional
development plans.
a. Determine whether the organization has assessed its environmental training
needs including type of training and staff requiring it.
b. Determine whether environmental skill training requirements (e.g., regulatory
hazardous materials handling, emergency and spill response) have been
identified for all job classifications where employees' work activities can affect
environmental performance. '
c. Determine whether environmental training is included in job descriptions and/or
individual professional development plans.
d. Determine how the organization ensures that employees receive the necessary
training at appropriate intervals.
3) The environmental training program is supported by appropriate training materials
and qualified trainers.
a. Review training materials and determine whether the materials (e.g., written,
audiovisual) are appropriate and adequate to the purpose.
b. Review resumes of trainers and determine whether the trainers have the
appropriate educational background and experience for the particular training
they deliver.
4) There is a formal process to ensure that training courses are developed at an
appropriate depth and provide adequate coverage of Federal and state regulations,
and internal policies and procedures.
a. Develop an understanding of the process for ensuring that all relevant regulatory
requirements are covered in training courses.
5) All levels of personnel -- from operators to lower, middle, and upper
management - undergo some level of environmental awareness training.
(Linkage with Section 34)
a. Determine who receives environmental awareness training.
b. Determine whether environmental awareness training is given to all line
personnel whose activities may impact environmental management and
compliance, as well as to their supervisors.
Phase 3 - Section 38
Staff Resources,
Assessing Overall Environmental Programs Training, and Development
38-4
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c. Determine what environmental training and awareness activities, if any. the
organization specifically directs toward middle and upper level management.
d. Determine whether contractors are included in awareness training.
6) Environmental protection training is included in new employee and contractor
orientation training, and environmental protection training requirements have been
established for temporary employees and visitors.
a. Determine whether the organization routinely conducts a formal orientation
program for all new employees and contractors, and assess the adequacy of the
training content.
b. Review training records to determine if all new employees and contractors have
attended orientation training.
7) Training activities are documented and the training recordkeeping system is
auditable, complete, and current.
a. Determine how the organization maintains employee environmental training
records and who is responsible for this activity.
b. Identify certain training required by regulations (e.g., hazardous waste training,
etc.) and determine whether all individuals performing these tasks have had the
necessary training.
c. Select a sample of environmental and non-environmental employees and review
training records to determine if they are accurate, complete, and current.
d. For these same individuals, compare actual training completed with training
needs identified for their position or in their individual staff development plan.
e. Assess whether the training recordkeeping system is easily accessible, complete
and current.
8) There is a formal documented process for the periodic evaluation of the
effectiveness of training programs.
a. Determine whether and how evaluations of the training program are conducted.
b. Review the results of the latest evaluation and check changes made in response
to the evaluation.
Phase 3 - Section 38
Staff Resources,
Assessing Overall Environmental Programs Training, and Development
38-5
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c. Interview selected personnel regarding their training and determine whether
training was absorbed.
d. Determine whether training feedback mechanisms (e.g., tests, course feedback
forms) are provided to evaluate effectiveness of training.
D. Staff Development Opportunities
1) The organization provides career opportunities and advancement for environmental
staff within the program, where possible, or in other programs/facilities.
a. Determine whether well-established career paths exist within the environmental
management function. Identify these paths, and determine whether they can lead
to top management positions or whether they eventually reach "dead-ends."
b. Identify line positions that are of the same government grade (or that are shown
in the organization's hierarchy to be at the same organizational level) as the
various environmental support positions.
c. Determine whether environmental support personnel and these "line peers" are
considered equally eligible for lateral job changes that provide breadth of
experience, and for advancement up the organization's management ladder. To
gather evidence, ask senior management, line management, supervisors of
environmental support personnel, line personnel, and environmental support
personnel.
d. Identify any middle or senior management staff that have environmental support
experience.
2) In staff development efforts, environmental support staff are encouraged to acquire
management and professional skills in order to build their supervisory and '
management potential.
a. Through interviews with environmental support staff, determine whether they
are encouraged and given opportunities to acquire management skills.
b. Compare training records of environmental support personnel and "line peers" to
see whether training in skills necessary for promotion up the management ladder
are offered equally to both groups. Examples of such training include
managerial skills, supervisory competencies, presentation techniques, media
relations, policy/program development, and negotiation skills.
Phase 3 - Section 38
Staff Resources,
Assessing Overell Environmental Programs Training, and Development
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3) Cross-functional training is available and encouraged to maintain and expand staff
capabilities.
a. Determine what kinds of programs exist to perform cross-functional tasks or to
move from one department to another in an effort to expand staff skill base.
Phase 3 - Section 38
Staff Resources,
Assessing Overall Environmental Programs Training, and Development
3S-7
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Phase 3
Section 39
Assessing Environmental Programs
Program Evaluation, Reporting and Corrective Action
-------
Table of Contents
1. Performance Objective 39-1
2. Key Evaluative Concerns 39-1
3. Criteria 39-1
A. Self-Assessment and Appraisal Programs 39-1
B. Reporting and Follow-up 39-3
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1. Performance Objective
The organization should have self-assessment and oversight programs in place to effectively
evaluate environmental protection activities, anticipate and report environmental concerns, and
implement corrective actions. The major objective of self-assessment programs is to establish
accountability and excellence at the "grassroots" level, thereby involving people who are the
most familiar with the operations and their management. Self-assessment is a continual line
management activity that acquires, assimilates, documents, and reports through all levels of an
organization on the effectiveness, adequacy, efficiency, and economy of its activities. Self-
assessment should establish a culture of accountability and continuous improvement as well as
foster excellence in all program activities.
2. Key Evaluative Concerns
The purpose of this audit discipline is to evaluate programs that assess the design adequacy
and implementation effectiveness of environmental protection systems as well as the reporting
and follow up activities associated with these appraisals. Program evaluation includes a
review of all major audits; appraisals; and self-assessments. It does not include routine
inspections, which are addressed in the Formality of Programs section of this protocol.
Programs will be evaluated on the basis of its design and implementation to ensure adequate
breadth and depth of coverage. Reporting and follow-up will be assessed for adequacy of
formal systems to clearly communicate in a timely fashion the results of the reviews to
appropriate levels of management. Finally, the system for periodic trends analysis of all
findings to identify underlying programmatic and' management deficiencies will be evaluated.
3. Criteria
A. Self-Assessment and Appraisal Programs
• The depth of detail required and the magnitude of resources expended for self-
assessment should be commensurate with the element's relative importance to
environmental compliance and/or other facility-specific requirements. Self-assessment
should incorporate both internal self-assessments and independent technical and
management appraisals.
1) Facilities and departments have implemented on-going formal, written programs
which include both internal assessments and independent oversight appraisals.
a. Determine whether these programs include appropriate elements/components,
such as:
• Formal program charter;
• comprehensive scope;
• defined schedules;
• standard .operating procedures for self-assessment;
• formal reporting system;
Phase 3 - Section 39
Program Evaluation, Reporting
Assessing Overall Environmental Programs and Corrective Action
39-1
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• root cause analysis;
• formal corrective action system;
• formal process to identify trends;
• formal mechanisms to communicate root causes, trends, and lessons learned
throughout the organization;
• formal self-assessment training, program;
• full cooperation with external oversight or assessment organizations; and
• line management-fostered atmosphere of continual self-evaluation and
quality improvement.
b. Determine whether the organization has a formal, documented environmental
self-assessment program.
c. Determine whether the program covers compliance with internal policies and
procedures, applicable governmental laws and regulations, and best management
practices.
d. Determine whether subordinate offices and facilities have a self-assessment
program.
e. Identify the environmental programs (e.g., air, surface water, drinking water,
groundwater, hazardous and solid waste, etc.) that are evaluated in self-
assessments.
f. Determine responsibilities, frequency, and process for conducting self-
assessments.
g. Determine whether self-assessment activities are integrated both within the line
organization and across staff functions to ensure a comprehensive self- •
assessment process.
2) Responsibilities and authorities for self-assessment activities are clearly defined.
(Linkage with Section 35)
a. Determine who is responsible for implementing the self assessment and
appraisal programs.
b. Determine if these individuals are sufficiently independent and have enough
authority to effectively perform this responsibility.
c. Determine whether organizational staff are specifically dedicated to
environmental appraisals or if not, how the organization staffs appraisals.
Assessing Overall Environmental Programs
Phase 3 - Section 39
Program Evaluation, Reporting
and Corrective Action
39-2
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3) Frequency of self-assessments and appraisals is congruent with the program's goals.
a. Determine how frequently self-assessments and appraisals are conducted and
how the organization determines .frequency schedule.
b. Assess whether this frequency is sufficient to meet program goals.
4) Focused functional appraisals are conducted on specific issues to reduce the
organization's long-term environmental liabilities. (Linkage with Section 40).
a. Determine whether the organization has a system to identify problem areas that
require focused assessments.
5) Audits/appraisals are conducted by professionals who are trained and qualified.
a. Determine how assessors are selected and what qualifications or criteria are
used in the selection process.
6) Audits/appraisals are conducted using formal, written guidance documents and are
documented.
a. Determine whether guidance documents, audit protocols, checklists, and other
tools are used in the preparation and conduct of the self-assessments and
appraisals.
b. Determine whether notes are taken during the audits, and retained for future
reference.
7) Self-assessment program implementation is addressed in budget planning and
budget requests (Linkage with Section 40).
a. Determine whether environmental self-assessments have been factored into
strategic planning in terms of resource and budgetary requirements.
8) The systems used for environmental program evaluations are periodically critiqued
and modifications are made as necessary.
a Determine what system is in place to review environmental program
evaluations.
b. Determine how often these programs are evaluated.
c. Identify changes made to the assessment program as a result of program review.
Phase 3 - Section 39
Program Evaluation, Reporting
Assessing Overall Environmental Programs and Corrective Action
39-3
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B. Reporting and Follow-up
1) Assessment results are documented in formal reports distributed in a timely manner
to appropriate levels of management.
a. Identify all self-assessments and appraisals that have been conducted over the
last few years and determine if reports were prepared.
b. Review past self-assessment and appraisal reports. Identify level of reporting
detail and individuals on distribution list. Assess whether reports reach high
enough levels of management and wide distribution to related functions (e.g.,
legal, engineering, etc.). Assess whether reports provide adequate detail.
2) Corrective actions to address root cause of findings are developed and implemented
by line management.
a. Determine how corrective actions are prioritized.
b. Corrective action plans are approved by both the oversight group and senior
management prior to implementation.
c. For each self-assessment/appraisal that has been conducted, determine if a
corrective action- plan was developed by the appropriate department, approved
by management, and implemented.
3) Corrective actions are independently tracked to ensure their completion, objectively
verified at completion, and formally closed out.
a. Determine whether the organization and field offices have a system to track
progress of corrective actions.
b. Assess the adequacy of progress on existing corrective action plans.
4) "Lessons learned" programs are implemented to seek out improvement
opportunities for environmental performance.
a. Determine whether the organization has developed a program or system for
learning from past problems, and sharing this information across the
organization.
Phase 3 - Section 39
Program Evaluation, Reporting
Assessing Overall Environmental Programs and Corrective Action
3*4
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5) Trending analysis of findings is conducted on a periodic basis to identify
underlying programmatic or management root causes.
*
a. Determine if any trending analysis is conducted and how frequently.
b. Review the results of these analyses and inquire about actions taken to correct
root causes.
6) Performance indicators for environmental protection have been defined and are
tracked and analyzed for trends.
•
a. Determine what performance indicators have been established.
b. Determine how performance indicators are tracked and analyzed for trends.
Phase 3 - Section 39
Program Evaluation, Reporting
Assessing Overall Environmental Programs and Corrective Action
39-5
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Phase 3
Section 40
Assessing Environmental Programs
Environmental Planning and Risk Management
-------
Table of Contents
1. Performance Objective 40_1
2. Key Evaluative Concerns 40-1
3. Criteria 40.1
A. Environmental Planning and Budgeting 40. i
B. Risk Management 40.3
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1. Performance Objective
The organization should plan for environmental management activities to ensure that
environmental resources needs are adequately addressed and the organization's environmental
goals can be met. Planning for environmental protection should be integrated with planning
for other organizational functions.
The organization should have a formal system to identify environmental hazards, assess the .
resulting environmental risks of those hazards, and mitigate risks.
2. Key Evaluative Concerns
This assessment discipline focuses on the environmental planning and risk management
process. It evaluates the extent to which technical and financial planning related to
environmental management is conducted and integrated with overall organizational planning.
In addition, this discipline addresses the organization's system for identifying, assessing, and
addressing potential environmental risks, including risk management program design and
approach, issues identification, and management involvement
3. Criteria
A. Environmental Planning and Budgeting
1) Environmental planning is conducted with comparable formality to planning for
other organizational functions and includes both short- and long-term planning.
a. Determine the extent to which environmental planning decisions result from a
formal, organized planning process.
b. Determine the frequency of formal environmental planning and the planning
horizon (e.g., 1 year, 5 years, 10 years).
c. Compare how staffing and budgetary requirements for the environmental
management function and for other organizational functions are determined.
d. Determine whether environmental planning is viewed as a strategic element in
the organization's long-term success.
e. Determine whether the facility has a system to identify projects planned in the
next year or two that will need NEPA review.
f. Determine if the facility utilizes the A-106 planning process and semi-annually
updates its prioritized environmental requirements and submits them to EPA for
review.
Phase 3 - Section 40
Environmental Planning and
Assessing Overall Environmental Programs Risk Management
40-1
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g. Agency Environmental Plan is developed in accordance with EPA guidance
contained in Federal Agency Environmental Management Program Planning and
forwarded to EPA for formal review prior to being forwarded to OMB, in
accordance with E.O. 12088 and OMB Circular A-106.
2) Environmental protection considerations are adequately included in planning for
other organizational functions.
a. Review strategic and/or organizational plans, annual budget documents,
proposed major capital projects, and property acquisitions and determine
whether they include environmental considerations.
b. Identify any recent instances where environmental concerns raised through a
program/project planning process have influenced proposed operating plans.
financial plans, or other factors.
3) Environmental issues are represented by qualified personnel in key strategic and
operations planning meetings/committees.
a. Review minutes of planning meetings to determine if environmental personnel
were involved.
b. Determine whether environmental issues were considered in planning meetings
or activities.
4) In the planning process, the organization has a system for establishing priorities
and weighing competing factors, with environmental protection receiving equal
weight to production.
a. Assess whether priority setting (i.e.. selecting projects for budget) reflects
environmental excellence goals.
b. Investigate environmental projects that have been delayed or canceled.
Determine if these projects received equal consideration to other projects.
c. Determine whether plans for environmental management take into account and
adequately reflect the implications of proposed operating and financial plans and
initiatives.
d. Assure that all environmental projects are reviewed to ensure that assigned
priorities reflect guidance issued by EPA in Federal Agency Environmental
Management Program Planning and are reported to OMB in the Agency annual
plan.
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Assessing Overall Environmental Programs Risk Management
40-2
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5) Commitment of funds for environmental-related activities is satisfactory to serve
the organization's environmental performance goals, through both capital and
maintenance projects.
a. Compare capital budget requests and annual budget allocations for
environmental programs/projects to determine whether adequate funds have been
committed to environmental protection.
b. Determine whether all environmental items, including staff and technical
resources, have been identified in budget requests.
6) Environmental protection is an integral part of the budget and planning process.
a. Review budget requests and allocations for line operations and other functional
areas to determine if they include environmental costs.
b. Determine whether environmental concerns are taken into consideration in
budget decisions.
c. Ensure that all project funding necessary to comply with environmental
standards is included in Agency budget plans and reported in the annual agency
OMB environmental plan to EPA in accordance with Federal Agency
Environmental Management Program Planning guidance.
7) The organization has assessed its needs for pollution control technologies and other
technical equipment to achieve its performance goals.
a. Determine how the organization assesses its technical equipment needs to
maintain compliance and reduce risks.
b. -Identify programs or systems to keep updated on the latest pollution control
technology and ensure that best available technology is used for maintaining
compliance and reducing risks.
c. Determine whether environmental excursions and noncompliances are analyzed
to identify whether technology can be improved to eliminate or reduce similar
episodes in the future.
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Assessing Overall Environmental Programs Risk Management'
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8) The organization has a system in place for the control and oversight of purchased
materials, equipment, and services supporting environmental protection activities to
ensure that they meet environmental specifications .
a. Determine how the organization ensures that new chemicals, equipment or
contractors meet regulatory requirements and comply with organizational
policies on environmental protection.
B. Risk Management
1) A formal environmental risk management program has been established and is
operational. This program includes objectives, approach, procedures and risk
evaluation criteria.
a. Identify the elements of the organization's risk management program and
determine if the program is complete.
b. Review internal guidelines or criteria, quantitative or qualitative, used to
determine whether a particular environmental risk arising out of operations
would be deemed "acceptable" or "unacceptable".
2) A formal, systematic review of the organization's operations/activities is
periodically conducted to identify and manage environmental risks.
a. Develop an understanding of and assess the process used to evaluate risks.
b. Determine how often these reviews are conducted, and by whom.
c. Determine what actions have been taken to mitigate or manage identified risks.
3) The organization has developed programs or standards to manage environmental
risks not covered by regulatory requirements. (Linkage to Section 35)
a. Identify examples of how risk assessment has led to the development or
enhancement of environmental protection programs.
4) All new projects, programs, or activities that may impact the environment are
carefully reviewed to identify and address environmental risks as early as
possible. A formal project/program review and approval process, which includes
environmental considerations, has been established. (Linkage with Section 40.
I.B.)
Phase 3 - Section 40
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Assessing Overall Environmental Programs Risk Management
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a. Besides NEPA. identify what types of projects have environmental reviews
performed, e.g.. capital projects. R&D projects, facility-level maintenance
modifications.
b. Determine whether these reviews are performed only under certain
circumstances or routinely for all projects.
c. Determine the focus of the reviews and whether the project may raise any
significant environmental compliance issues, or lead to any potentially
significant environmental risks.
d. Determine whether project environmental reviews typically follow a standard
approach and whether there is any formal guidance on the approach.
e. Identify the criteria used for assessing the impacts of a project (e.g., dollar
value, project type, etc.).
f. Review records or files of environmental reviews that have been performed.
Phase 3 - Section 40
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Assessing Overall Environmental Programs Risk Management
40-5
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Phase 3
Appendix
Selecting Documents to Review and Individuals to
Interview for Environmental Management
Assessments
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The following discussion provides suggestions, by protocol discipline, for the most useful
types of documents to review and general types of individuals to interview in the process of
performing an Environmental Management Assessment.
Organizational Structure
The following types of individuals should be interviewed for this protocol area:
• Representatives from the Federal agency's site office as well as subcontractors to
determine roles, responsibilities, reporting relationships, authorities, and level of
coordination;
• Environmental, health and safety (EHS) staff and top management at the facility to
determine the reporting "distance" between the person with primary responsibility for
environmental support and the overall management of the organization; and to assess the
appropriateness of layers of management and span of control; and
• EHS and line staff to understand the functional relationship of EHS to other parts of the
organization; and to determine the organizational stature of the EHS office within the
organization.
The following types of documents should be reviewed:
• Documents that define organizational responsibility, authority, or accountability for
environmental programs;
• Organizational charts;
• Position or job descriptions for line and staff personnel;
• Environmental planning documents; and
• Formal measures used in assessing job performance.
Phase 3 - Appendix
Selecting Documents to Review
and Individuals to Interview for
Assessing Overall Environmental Programs EnvironmentalManagement Assessments
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Environmental Commitment
The following types of individuals should be interviewed for this protocol area:
• Top management to determine level of knowledge, personal involvement in environmental
affairs, and inclusion of environmental issues in routine senior management meetings.
• Management and line staff at all levels and across all functional areas to determine level
of environmental commitment, sense of "ownership" of environmental protection, degree
to which environmental policies are distributed and understood, and allocation of human,
financial, and technical resources.
• Staff in non-environmental specialty areas to determine the level of general environmental
awareness.
The following types of documents should be reviewed:
• Environmental planning documents;
• general environmental policy statements;
• issue-specific policies addressing focused environmental concerns;
• environmental program descriptions and implementation plans;
• senior management statement of support for environmental programs, including reports.
speeches, and newsletters;
• accounts of employee or organization involvement in or work with environmental task
forces, environmental professional associations, or local community organizations;
• samples of routine environmental reports to upper management; and
• minutes of senior management meetings.
Phase 3 - Appendix
Selecting Documents to Review
and Individuals to Interview for
Assessing Overall Environmental Programs EnvlronmentalManagement Assessments
A-3
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Environmental Protection Programs
The following types of individuals should be interviewed for this protocol area:
• EHS staff and line management as well as subcontractors to determine level of
development or implementation of environmental programs or plans.
The following types of documents should be reviewed:
• Environmental monitoring and surveillance plans;
• source and emission inventories for air and water pollution control;
• NESHAPs agreement;
• toxic and chemical materials management plan;
• emergency response and remedial action plan;
• environmental incident reporting procedures;
• preventative maintenance and inspection procedures;
• reports to management or regulatory agencies; and
• opportunity assessments.
Assessing Overall Environmental Programs
Phase 3 - Appendix
Selecting Documents to Review
and Individuals to Interview for
EnvironmentalManagement Assessments
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Formality of Environmental Programs
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible far tracking relevant environmental regulations to determine if the
organization is up-to-date on new. proposed, and emerging regulatory issues.
• Personnel responsible far the development and implementation of procedures and
standards to determine the level of congruence with Federal agency's policies.
• Personnel responsible for conducting routine site walk-through inspections andfollowing-
up on inspection findings to determine adequacy of the system.
• Personnel responsible for record-keeping and document control to assess the document
control system.
The following types of documents should be reviewed:
• Policies and procedures relating to project and field office implementation of
environmental requirements;
• environmental protection plans;
• standard operating procedures for the site;
• regulatory tracking protocols and procedures;
• inspection checklists and logs; and
• examples of a variety of environmental records and reports, including incident and
environmental performance reports.
Phase 3 - Appendix
Selecting Documents to Review
and Individuals to Interview for
Assessing Overall Environmental Programs EnvlronmentalManagement Assessments
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Internal and External Communication
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible for communication of environmental information (e.g., goals,
performance, policies, and procedures) to understand how formal and informal
communication channels are used.
• Management and line staff to determine extent to which environmental information is
distributed within the organization.
V Important external stakeholders, such as environmental groups, state and Federal
environmental regulators, and Federal agency management to determine extent of
communication with and knowledge of the facility.
The following types of documents should be reviewed:
• Samples of the scope of environmental management reports;
• staff meeting minutes;
• internal newsletters which contain environmental information;
• forms and guidelines for internal anonymous reporting of environmental issues;
• documentation of information provided to and awareness programs for external
stakeholders; and
• press releases relating to environmental issues.
Phase 3 - Appendix
Selecting Documents to Review
and Individuals to Interview for
Assessing Overall Environmental Programs EnvironmentalManagement Assessments
A-6
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Staff Resources, Training, and Development
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible for securing an adequate level of environmental staffing to
understand to assess the system to identify short- and long-term environmental staffing
and resource requirements.
• A sample of management and line staff at all levels of the organization to determine if
there is an adequate level of staffing for environmental functions and to determine the
level of environmental training throughout the organization.
• Training office personnel to assess the training program and the process to evaluate and
establish the organization's training needs.
• Career development office personnel to identify career opportunities for environmental
staff.
The following types of documents should be reviewed:
• Documented requests and justifications for additional staff with environmental
responsibilities;
• hiring plans;
• a sample of resumes for environmental and non-environmental staff who have
environmental responsibilities;
• training program manuals;
• training records for a range of individuals within the organization, including
environmental support personnel and their "line peers";
• job descriptions and performance criteria for line management and operating personnel;
and
• individual professional development plans.
Phase 3 - Appendix
Selecting Documents to Review
and Individuals to Interview for
Assessing Overall Environmental Programs EnvironmentalManagement Assessments
A-7
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Program Evaluation, Reporting, and Corrective Action
The following types of individuals should be interviewed for this protocol area:
• Personnel responsible for conducting and/or managing the self-appraisal process to
assess the design of the process.
• Top management to determine how self-appraisal information is used within the
organization.
• A sample of managers and line staff responsible for implementing corrective actions.
The following types of documents should be reviewed:
• Formal descriptions of the oversight program or process, including responsibilities of key
staff;
• self-appraisal program budget allocation;
• audit and appraisal reports;
• corrective action plans;
• documentation of follow-up activities for corrective actions; and
• trend analysis and performance indicator reports.
Phase 3 - Appendix
Selecting Documents to Review
and Individuals to Interview for
Assessing Overall Environmental Programs EnvironmentalManagement Assessments
A-8
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Environmental Planning and Risk Management
The following types of individuals should be interviewed for this protocol area:
• Environmental planning personnel to evaluate budgeting, priority-setting and allocation of
resources activities.
• Staff with the budgeting office to determine if environmental planning is integrated with
other organizational planning functions (e.g., development of operating and capital
budgets).
• Risk management personnel to evaluate the adequacy of systems to identify and minimize
environmental hazards.
The following types of documents should be reviewed:
• Short- and long-term business plans and strategic plans;
• formal risk management documents, such as readiness review plans or risk assessments;
and
• environmental risk tracking and trending reports.
Phase 3 - Appendix
Selecting Documents to Revie*
and Individuals to Interview fc
Assessing Overall Environmental Programs EnvironmentalManagement Assessments
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