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United Stales
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Healthcare Environmental Assistance Resources
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U.S. Army Environmental
Management System
Implementers Guide
Version 1.0
May 2003
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ACKNOWLEDGMENTS
This document was developed for the U.S. Army by the Logistics Man-
agement Institute (LMI). In preparing this guide, the authors relied on nu-
merous public documents and information sources for background
information, implementation ideas, examples, and other critical references.
The following sources were invaluable in developing this guide:
International Organization for Standardization, Environmental man-
agement systemsSpecification with guidance for use, ISO
14001:1996.
International Organization for Standardization, Environmental man-
agement systemsGeneral guidelines on principles, systems and
supporting techniques, first edition, ISO 14004:1996(E).
Concurrent Technologies Corporation, Environmental Management
System Guidance Manual: Implementing ISO 14001.
Concurrent Technologies Corporation, Environmental Management
ToolkitAn Environmental Management System Implementation
Tool, October 2002.
National Science Foundation International Strategic Registrations
(NSF-ISR), Ltd., Environmental Management SystemsAn Imple-
mentation Guide for Small and Medium-Sized Organizations, sec-
ond edition, January 2001.
The Public Entity Environmental Management System Resource
(PEER) Center, How to Implement an EMS [on-line document], un-
dated [cited February 2003]. Available from http://www.peercen-
ter.net/howtoimplement/.
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Contents
Chapter 1 Introduction 1-1
PURPOSE OF THIS GUIDE 1-1
WHAT Is AN EMS? 1-1
Mission Focus 1-1
ISO 14001 1-1
IMPLEMENTATION REQUIREMENTS 1-2
ARMY POLICY 1-3
General 1-3
Metrics and Reporting Requirements 1-4
RESOURCING IMPLEMENTATION 1-5
IMPLEMENTATION ROADMAP 1-6
ROLES AND RESPONSIBILITIES 1-8
CONTINUAL IMPROVEMENT 1-8
FREQUENTLY ASKED QUESTIONS 1-8
Chapter 2 Step-by-Step Guidance 2-1
INTRODUCTION 2-1
Step 1. Designate the EMSMR 2-2
Step 2. Coordinate with senior leaders and select the CFT 2-2
Step 3. Orient and train the CFT in EMS implementation 2-4
Step 4. Conduct a self-assessment (by 30 March 2004) 2-6
StepS. Meet with the EQCC 2-7
Step 6. Prepare an EMS implementation plan 2-8
Step 7. Obtain CDR approval of the EMS implementation plan
(by 30 September 2004) 2-9
Step 8. Hold an EMS implementation kickoff meeting 2-9
Step 9. Identify mission focus 2-11
Step 10. Revise and sign installation environmental policy
statement (by 30 September 2003) 2-15
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Step 11. Plan and conduct EMS awareness training (by 30
March 2005) 2-18
Step 12. Initiate EMS documentation 2-22
Step 13. Develop EMS document control procedures 2-25
Step 14. Establish communications procedures 2-28
Step 15. Compile legal and other requirements 2-31
Step 16. Identify all mission and installation activities, products,
and services 2-36
Step 17. Identify the environmental aspects of your installation's
activities, products, and services that can be controlled or
influenced 2-40
Step 18. Identify the environmental impacts of each aspect 2-44
Step 19. Identify significant environmental aspects 2-47
Step 20. Develop or revise installation environmental
management programs 2-57
Step 21. Establish environmental objectives and targets 2-59
Step 22. Describe structure and responsibilities 2-67
Step 23. Develop SOPs and work practices for activities
associated with significant aspects 2-68
Step 24. Identify and fulfill environmental competency-based
training requirements for all installation personnel
(garrison and tenants) 2-69
Step 25. Establish monitoring and measurement procedures 2-73
Step 26. Establish procedures for maintaining EMS records 2-76
Step 27. Develop and review emergency preparedness and
response documents and procedures 2-79
Step 28. Establish procedures for nonconformance and
preventive and corrective actions 2-83
Step 29. Conduct periodic EMS audits 2-87
Step 30. Conduct periodic EMS management reviews 2-90
References
Appendix A. Acronyms
VI
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Contents
FIGURES
Figure 1-1. ISO 14001 Model with Mission Focus 1-2
Figure 1-2. Suggested EMS Implementation Sequence for Army Installations 1-7
Figure 2-1. EMSMR and Cross Functional Team Implement the EMS 2-11
Figure 2-2. EMS Document Hierarchy 2-22
Figure 2-3. Fuel Storage and Dispensing Operations 2-43
Figure 2-4. EMS Document Hierarchy 2-77
Figure 2-5. Linkages Among EMS Audits, Corrective Action, and
Management Reviews 2-89
TABLES
Table 2-1. Federal Laws and Regulations 2-34
Table 2-2. Mission or Functional Areas and Their Processes 2-37
Table 2-3. Environmental Aspects of Vehicle Maintenance Activities 2-42
Table 2-4. Environmental Aspects and Impacts of Vehicle Maintenance
Activities 2-45
Table 2-5. Sample Rating Factors for Frequency or Likelihood of
Environmental Impact 2-49
Table 2-6. Sample Rating Factors for Severity of Environmental Impacts or
Consequences 2-50
Table 2-7. Sample Rating Factors for Severity of Mission Impacts 2-50
Table 2-8. Sample Rating Factors for Regulatory Status 2-51
Table 2-9. Sample Rating Factors for Community Concern 2-51
Table 2-10. Information Sources 2-62
Table 2-11. Preliminary Environmental Objectives 2-62
Table 2-12. Regulatory Requirements and Objectives 2-63
Table 2-13. Installation Communications 2-64
Table 2-14. Target Objectives 2-64
Table 2-15. Performance Measures for Final Objectives 2-66
VII
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Chapter 1
Introduction
PURPOSE OF THIS GUIDE
This guide provides Army personnel an easy-to-use, step-by-step tool for
implementing the Army's environmental management system (EMS). It
provides the information needed to establish and implement an installation
EMS, while allowing the flexibility to address differing installation missions
and operational readiness requirements.
WHAT Is AN EMS?
An EMS is the part of an organization's overall management system that
integrates environmental concerns and issues in the organization's man-
agement processes. An EMS addresses organizational structure, plan-
ning activities, responsibilities, practices, procedures, processes, and re-
sources for developing, implementing, achieving, reviewing, and maintain-
ing environmental policy. An EMS enables an organization of any size or
type to control the impact of its activities, products, or services on the
natural environment, allowing it to not only achieve and maintain compli-
ance with current environmental requirements, but to recognize and
proactively manage future issues that might impact mission sustainability.
Implementing an EMS generally will not require installations to create an
entirely new system. Many of the required elements of an EMS are
already in place as part of existing programs.
Mission Focus
Each installation's EMS must focus on supporting and sustaining the in-
stallation's mission. This guide shows how to identify and incorporate
mission priorities in EMS implementation. The resulting management sys-
tem will help organizations identify, manage, and mitigate the environ-
mental impacts associated with mission-related activities.
ISO 14001
The Army leadership has decided to use the ISO 14001 standard devel-
oped by the International Organization for Standardization as a model for
developing and implementing an EMS at each installation. The ISO
14001 standard provides EMS specifications that apply to a wide variety of
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organizations. Click here to view the ISO 14001 standard. This imple-
mentation guide is specifically designed to enable Army installations to
develop a mission-focused EMS that conforms with the ISO 14001 stan-
dard.
Figure 1-1 shows the ISO 14001 model, which employs a continual cycle
of policy, planning, implementation and operation, checking and corrective
actions, and management review. The ultimate goal is to continually im-
prove environmental performance as the cycle is repeated.
Figure 1-1. ISO 14001 Model with Mission Focus
Mission
Focus
Environmental
Policy
Management
Review
Checking &
rrective Action
Implementation
& Operation
IMPLEMENTATION REQUIREMENTS
Executive Order (EO) 13148, "Greening the Government Through Leader-
ship in Environmental Management," directs all federal agencies as fol-
lows:
By 31 December 2005, each agency shall implement an [EMS] at
all appropriate agency facilities based on facility size, complexity,
and the environmental aspects of facility operations.
The facility [EMS] shall include measurable environmental goals,
objectives, and targets that are reviewed and updated annually.
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Introduction
Once established, [EMS] performance measures shall be incorpo-
rated in agency facility audit protocols.1
ARMY POLICY
General
The Deputy Assistant Secretary of the Army (Environment, Safety and
Occupational Health) signed an action memorandum on EMS, which di-
rects installations to meet the following requirements:
Implementation shall be initiated NLT [no later than] FY04, with an
environmental management system in place NLT 31 December
2005.
Adopt the internationally recognized management system standard,
ISO 14001, as a goal.
Full conformance with the ISO 14001 standard shall be completed
NLT FY09.2
The action memorandum also states the following:
Third party registration to the standard is not required. However,
installation commanders may pursue registration when it provides
clear and documented mission benefits.
Implementation of the standard will be incremental. It will be con-
sistent with available funds and the requirements of Executive Or-
der 13148, "Greening the Government Through Leadership in Envi-
ronmental Management."
The Army's EMS policy directs a phased approach to satisfying EO 13148
and EMS implementation:
First, comply with EO 13148 by meeting the Army/Department of
Defense (DoD) implementation metrics by 31 December 2005 (see
below).
1 Executive Order 13148, "Greening the Government Through Leadership in Envi-
ronmental Management," April 21, 2000.
2 Memorandum for Assistant Chief of Staff for Installation Management, from Ray-
mond J. Fatz, Deputy Assistant Secretary of the Army (Environment, Safety and Occupa-
tional Health), OASA(I&E), Subject, Army Environmental Management System, July 13,
2001. Available from http://aec.army.mil/usaec/support/ems-requirements080601.pdf.
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Then, use continual improvement to build the remaining parts of a
mission-focused, ISO 14001-conformant EMS by December 2009.
Developing and implementing an EMS is required at all appropriate Army
installations, including those located in the Continental United States
(CONUS) and Outside Continental United States (OCONUS), as well as
all Army Reserve and National Guard installations. Click here for a defini-
tion and listing of appropriate organizations and installations. Installations
OCONUS will integrate EMS elements into existing management practices
and procedures, in consonance with Final Governing Standards and ap-
plicable host nation requirements. As indicated previously, no boilerplate
EMS applies to all Army installations. Although the ISO 14001 standard
can be applied to many different types of organizations, differences in or-
ganization and mission dictate that EMSs must be tailored to individual
installations. Installation staffs must individually determine the best way to
design or adapt their own management procedures to conform with the
ISO 14001 standard.
Click here for the latest EMS guidance specific to Army National Guard
(ARNG), OCONUS, and government-owned, contractor-operated (GOCO)
installations and other special categories of organizations.
Metrics and Reporting Requirements
Beginning first quarter FY04, installations must submit data semiannually
to the Environmental Quality Report (EQR) on EMS implementation
status. The Army will track EMS implementation in the Strategic Readi-
ness System (SRS). Click here for the latest guidance on reporting re-
quirements. The following Army EMS implementation metrics3 meet the
requirements of EO 13148 and should be completed by the listed dates:
Develop an ISO 14001-conformant environmental policy state-
ment, consistent with the Army EMS action memorandum, signed
by the commander, NLT 30 September 2003.
Complete an installation-wide EMS self-assessment with appropri-
ate documentation, signed by the commander, NLT 30 March 2004.
3 Memorandum for Deputy Assistant Secretary of the Army (Environment, Safety and
Occupational Health) from John Paul Woodley, Jr., Assistant Deputy Undersecretary of
Defense (Environment), Subject, Environmental Management System (EMS) Implemen-
tation Criteria and Metrics, 30 Jan 2003.
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Introduction
Complete a written EMS implementation plan with defined dates,
identified resources, and organizational responsibilities for imple-
menting a mission-advancing, ISO 14001-conformant EMS, signed
by the commander, NLT 30 September 2004.
The meaning of the term commander, as used in this guide, varies by organization:
For active-Army and Army Reserve organizations, it means the garrison com-
mander.
For ARNG organizations, it refers to the adjutant general or garrison com-
manders at major training sites.
For civil works organizations, it refers to the district chief of operations.
Environmental aspect is an element of an organization's activities, products, or ser-
vices that can interact with the environment. Chapter 2 discusses environmental as-
pects in detail.
Compile a prioritized list of environmental aspects NLT 30 March
2005.
Provide awareness-level briefings on the Army's EMS to all appro-
priate installation personnel NLT 30 March 2005.
Complete at least one management review in accordance with the
installation's documented policy for recurring internal EMS man-
agement reviews NLT 31 December 2005.
These metrics are minimum requirements. Installations should complete
them before the scheduled dates if resources allow. Some organizations
have reported that moving faster maintains interest and makes implemen-
tation easier.
Scheduling management reviews. Instructions regarding the EMS management review
do not appear until Step 30 of this guide. However, we recommend periodic (annual or
semiannual) management reviews during the implementation process as well. These
reviews will help you meet the Army EMS implementation metrics above and maintain
senior leader oversight of EMS implementation.
RESOURCING IMPLEMENTATION
Army leadership has programmed funds for installation-wide EMS imple-
mentation, including ranges and training areas. Implementation funding
will be available starting in FY04 and will continue through FY06. Click
here for the latest EMS funding guidance. Typical installation resource
requirements for implementing an EMS include the cost of people, time,
and contractors. As the Army gains experience in implementing EMSs,
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implementation costs will likely decrease. Although initial costs of devel-
oping and implementing an EMS can be significant, the program will lead
to efficiencies in the long term. Click here to view case studies of EMS
costs and cost savings.
Updated tools, training materials, example documentation, and guidance
are available to help Army installations implement an EMS. For informa-
tion related to EMS tools and guidance, see the Defense Environmental
Network Information Exchange (DENIX) Army EMS website
https://www.denix.osd.mil/denix/DOD/Library/EMS/ems.html.
IMPLEMENTATION ROADMAP
This guide identifies 30 EMS implementation steps that lead to a mission-
focused, ISO 14001-conformant EMS. Chapter 2 provides step-by step
instructions. Figure 1-2 is a suggested implementation sequence chart,
which provides installations a visual overview of the 30 steps. The steps
are arranged in a logical order that progressively builds the essential parts
of an ISO-conformant EMS.
The sequence in Figure 1-2 differs slightly from ones you may see in other
EMS guidance documents:
It contains additional requirements specifically designed for Army
installations.
Certain requirements or elements have been moved forward in the
implementation sequence to help installations get an early start in
meeting dates associated with Army implementation metrics.
Requirements associated with communications and documentation
procedures have been moved forward in the sequence to help in-
stallations manage the implementation process.
The implementation sequence is not rigid and can be adapted to
accommodate an installation's specific situation. In Figure 1-2, yel-
low boxes highlight the requirements associated with Army and
DoD implementation metrics, which must be completed by 31 De-
cember 2005.
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Figure 1-2. Suggested EMS Implementation Sequence for Army Installations
LMI
The elements shown in the blocks below provide a logical sequence for planning and
implementing an EMS, starting at the left side of the page and following the arrows. You
may also choose to revise this sequence to accommodate specific situations at
your installation. We recommend you carefully read the entire guide before
choosing an alternative sequence.
31 December 2005 Milestone:
At a minimum, the Army metric elements (in yellow)
must be completed and an annual management review
performed before 31 December 2005 in order to satisfy
Army Policy and EO 13148 requirements.
Start Here
Commander (CDR) and
EMS Management Representative(EMSMR)
Initiate EMS Planning (Steps 1-8):
EMSMR and Cross Functional
Team (CFT) Implement the EMS:
CDR Selects EMSMR
CDR/EMSMR Coordinate with EQCC and
Select Cross Functional Team (CFT)
CFT Receives EMS Training
CFT Conducts Self-Assessment
CDR/EMSMR Brief the EQCC
CFT Prepares EMS Implementation Plan
CDR Approves EMS Implementation Plan
CDR/EMSMR Hold EMS Kickoff Meeting
Step9
Mission
Step 10
Environmental
Policy, ISO 14001
Sec 4.2
Step 11
Awareness
Training ISO 14001
Sec 4.4.2
H
Step 12
Documentation
ISO 14001
Sec 4.4.4
>n ^^ D
Step 13
ocument Contr
ISO 14001
Sec 4.4.5
t
NOTE: The EMSMR leads the CFT.
After all EMS elements are
implemented, the system shifts to a
"continual improvement" mode,
where all EMS elements are
periodically reviewed and revised to
improve mission focus and
environmental performance.
Step 20: Environmental Management
Programs, ISO 14001, Sec 4.3.4
Step 21: Objectives & Targets
ISO 14001. Sec 4.3.3
Step 22: Structure & Responsibility
ISO 14001, Sec 4.4.1
Step 23: Operational Control
ISO 14001, Sec 4.4.6
Step 24: Competence Training,
ISO 14001, Sec 4.4.2
Step 25: Monitoring and Measurement
ISO 14001, Sec 4.5.1
Step 26: Records, ISO 14001, Sec 4.5.3
Step 15
Legal and Other
Requirements
ISO 14001
Sec 4.3.2
Step 14
Communicatio
ISO 14001
Sec 4.4.3
I
I
Step 27
Emergency
Preparedness and
Response
ISO 14001
Step 28
on-Conformance and
Corrective and Preventive
Actions, ISO 14001
Sec 4.5.2
;
ive
Step 30
Management Review
ISO 14001, Sec 4.6
Step 29
EMS Audits
ISO 14001, Sec 4.5.
30 September 2009 Milestone:
Installations must complete all the elements
above and have a fully functioning EMS
(ISO 14001 compliant).
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ROLES AND RESPONSIBILITIES
Chapter 2 recommends specific roles and responsibilities for overseeing
and completing the elements shown in Figure 1-2. Senior leaders have a
particularly important role in supporting EMS implementation. The com-
mander has overall responsibility for the implementation but delegates au-
thority for executing the process to a designated EMS management repre-
sentative. The installation environmental quality control committee
(EQCC), or similar senior leader advisory group, provides installation-wide
oversight and support to the EMS implementation effort.4 Establishing an
active EQCC facilitates the senior leader oversight and buy-in vital to EMS
implementation. All on-site contractors are required to operate in confor-
mance with and support the EMS. Click here for detailed guidance
regarding contractors and non-DoD entities located on the installation.
CONTINUAL IMPROVEMENT
An EMS must be continually updated to address changes in missions, en-
vironmental aspects and impacts, legal requirements, roles and responsi-
bilities, and training requirements. Audits and periodic reviews of the EMS
procedures and documentation identify areas for improvement. Once im-
plementation is completed, EMS responsibilities continue, but mostly at
the operational or functional process level. If the EMS has been properly
designed and implemented, most day-to-day EMS activities become part
of how the installation conducts its business, as opposed to a special,
separate program. Chapter 2 describes key EMS and continuous im-
provement activities.
FREQUENTLY ASKED QUESTIONS
Click here to view frequently asked questions and responses regarding
EMS implementation.
4 We use the abbreviation EQCC throughout this report to refer to an actual EQCC or
any similar senior leader advisory group.
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Chapter 2
Step-by-Step Guidance
INTRODUCTION
The remainder of this guide leads the user through required actions for
EMS implementation by defining terminology, describing recommended
actions, identifying those involved, and giving detailed instructions, exam-
ple documentation, and links to tools and other materials that will help im-
plement the EMS. The sequence of steps shown in this guide is not
unalterable. You can rearrange the sequence to fit your situation.
COMMANDER AND EMS
MANAGEMENT REPRE
SENTATIVE INITIATE EMS
PLANNING (STEPS 1-8)
CDR selects EMSMR
CDR/EMSMR coordinate with EQCC and selects CFT
CFT receives EMS training
CFT conducts self-assessment
CDR and EMSMR meet with EQCC
CFT prepares EMS implementation plan
CDR approves EMS implementation plan
CDR/EMSMR hold EMS kickoff meeting
EMS implementation at the installation begins with the commander (CDR).
The CDR must ensure that several key actions are completed before EMS
implementation can actually start:
Designate the EMS management representative (EMSMR).
Coordinate with senior leaders and select the cross-functional team
(CFT).
Conduct a self-assessment.
Meet with the EQCC.
Prepare an implementation plan.
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Step 1. Designate the EMSMR.
The CDR designates the EMSMR, who is responsible for managing and
overseeing the EMS implementation effort. In some cases, the CDR may
designate him or herself as the EMSMR to ensure the appropriate level of
visibility and support for EMS. If so, the CDR should also designate an ac-
tion officer or assistant to attend to the day-to-day details of implementing
the EMS. In other cases, the CDR might designate a key staff member as
the EMSMR. The EMSMR (or designated action officer) should possess
the necessary authority,
a good understanding of installation organizations, and
the project management and facilitation skills needed to succeed in
this role.
The EMSMR coordinates the implementation, manages day-to-day opera-
tions, and leads and manages the CFT. Specific responsibilities include
planning and managing EMS implementation,
delegating tasks and establishing deadlines,
collecting and evaluating work, and
arranging training, guidance, and assistance.1
The CDR should consider background, experience, availability, and other
appropriate factors when designating the EMSMR. Consider individuals
outside the environmental office when choosing the EMSMR. The EMS
needs installation-wide support to be effective, and designating a non-
environmental person to implement the system conveys the message that
EMS involves much more than environment. In many cases, members of
the CDR's special staff are prime choices for the EMSMR position.
Step 2. Coordinate with senior leaders and select the CFT.
EMS implementation requires support from across the installation. The
CFT coordinates this support and is responsible for implementing the EMS
installation wide. This step has two objectives: coordinating with senior
leaders on the installation to get their buy-in and (in some cases) obtaining
a CFT member from their organizations. Under the leadership of the
1 The Public Entity Environmental Management System Resource (PEER) Center,
How to Implement an EMS [on-line document], undated [cited February 2003]. Available
from http://www.peercenter.net/howtoimplement/.
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Step-by-Step Guidance
EMSMR, CFT members become the EMS experts and proponents in each
functional area. Typical responsibilities of the CFT include
gathering, organizing, and disseminating information;
delegating EMS tasks and general responsibilities;
collecting and evaluating work;
developing EMS procedures;
advising, coordinating, and facilitating EMS implementation;
representing all functional areas of the installation regardless of ac-
tual CFT representation; and
managing the reactions to the changes resulting from EMS imple-
mentation.2
Each CFT member should have clear responsibilities for representing and
coordinating with specific organizations on the installation. For example, a
CFT member from a military unit might serve as the CFT representative
for all the military units on the installation.
Do the following to make the CFT succeed:
Look to the leaders. You need motivated, organized individuals: let supervi-
sors identify the appropriate candidates.
Provide training.
Clearly communicate member roles and responsibilities.
Secure time commitments from management.
(The PEER Center, How to Implement an EMS)
CFT members should include a representative from the environmental of-
fice as well as representatives concerned with key installation activities
such as operations and training, logistics, acquisition, and ranges. The
CDR and EMSMR should seek volunteers or ask other senior leaders on
the installation to recommend employees to serve on the CFT.
2 PEER Center, How to Implement an EMS [on-line document], undated [cited Feb-
ruary 2003]. Available from http://www.peercenter.net/howtoimplement/.
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The CFT should consist of no more than eight people. The CDR and
EMSMR should ask the following questions when selecting the team
members:
Are they motivated, interested, and able?
Are they experts in their own functional areas?
Are they good communicators?
Can they give credence to the EMS program?3
Do coworkers trust and respect them?
Are they responsible for environmental issues?4
Do they represent functional areas that are directly concerned with
or potentially affected by environmental issues?5
Are they aware of the installation's most critical environmental is-
sues?
Are key functions represented?6
The CDR and EMSMR should ask the commanders or supervisors of
various tenants, activities, and units to approve potential team members,
after which the CDR announces the team.
Step 3. Orient and train the CFT in EMS implementation.
After the EMSMR and CFT members are selected, the EMSMR should
hold a CFT orientation meeting before CFT training begins. At this meet-
ing, the EMSMR should do the following:
Provide members with copies of the EMS implementation guidance
and other pertinent information.
Establish an initial CFT EMS training schedule and set additional
research assignments, if needed.
3 PEER Center, How to Implement an EMS [on-line document], undated [cited Feb-
ruary 2003]. Available from http://www.peercenter.net/howtoimplement/.
4 PEER Center, How to Implement an EMS [on-line document], undated [cited Feb-
ruary 2003]. Available from http://www.peercenter.net/howtoimplement/.
5 PEER Center, How to Implement an EMS [on-line document], undated [cited Feb-
ruary 2003]. Available from http://www.peercenter.net/howtoimplement/.
6 PEER Center, How to Implement an EMS [on-line document], undated [cited Feb-
ruary 2003]. Available from http://www.peercenter.net/howtoimplement/.
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Step-by-Step Guidance
Establish a schedule for periodic CFT meetings (weekly breakfast,
monthly, etc.). The periodic CFT meetings need not be formal, just
a venue for reviewing the current implementation status, discussing
new initiatives, checking status of research assignments, etc.
Appoint a member of the CFT as the EMS document coordinator.
This person will be responsible for ensuring the proper documents
are created, stored, and maintained in accordance with procedures
established later in the implementation process. This can be a big
job, and it will continue to require effort beyond initial EMS imple-
mentation. The document coordinator should have a strong infor-
mation technology (IT) background because the EMS documenta-
tion is best managed electronically. This person should have
access to the necessary files (with appropriate security clearances)
and the capability to store and modify documents, as well as dis-
tribute information as needed. Choose someone well organized:
this job is key to initial EMS implementation and continuous opera-
tion.
Choose a member of the CFT as meeting recorder (possibly the
same person as the EMS document coordinator). This person is
responsible for properly documenting each meeting (including the
initial one) through written minutes. The recorder also files and
maintains the meeting records in accordance with the procedures
the EMS document coordinator establishes.
Is EMS management software necessary?
Numerous commercial off-the-shelf (COTS) software packages are available to help
you implement and manage your EMS. In May 2003, the Army completed an evalua-
tion of 19 of these systems, using a variety of evaluation criteria. These systems can
be very useful, providing you choose a system appropriate for your needs. Don't buy
the first one you see. Click here to view the EMS software evaluation, and do your
homework!
All team members need in-depth EMS training and a clear understanding
of their roles and responsibilities to plan and lead the implementation ef-
fort. Specific training objectives should include the following:
EO requirements
Army policy
ISO 14001 requirements
EMS fundamentals (what it is, how it works, who is responsible
etc.).
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Training is available from many sources. The CFT can be trained by con-
tractors on- or off-site, at private institutions or training centers, or through
Army training sites. The training can be done in-house via distance learn-
ing or train-the-trainer sources. Click here to find information on training
resources.
Step 4. Conduct a self-assessment (by 30 March 2004).
Army EMS Implementation Metric
Self Assessment: An installation-wide EMS self-assessment consistent with Army
EMS policy has been conducted, documented, and briefed to the CDR.
The CFT is responsible for performing a self-assessment to analyze the
installation's current conformance with the ISO 14001 standard. This sys-
temic-level self-assessment should examine installation policies, proc-
esses, and procedures relevant to EMS requirements. The self-
assessment itself is not a required ISO 14001 element, but it is one of the
Army's EMS implementation metrics. It should require only a few days to
complete, and the assessment team (headed by the EMSMR) should be
no more than six people.
CFT members should have a basic understanding of ISO 14001 before
conducting the self-assessment. Completing initial EMS training, plus
some additional self-study, should suffice. Use the following links to ac-
cess tools to assist with the assessment. These assessment tools help
you determine what your installation has and what it needs to have for an
Army-approved EMS. (Click here to view a self-assessment worksheet.
Click here to view a gap analysis checklist. Click here to view a gap
analysis scoring worksheet.) Since the self-assessment is one of the
Army's EMS implementation metrics you should maintain internal records
of the results. However, ISO 14001 does not require self-assessment re-
cords for conformance.
The self-assessment team should report the results to the CDR. These
results ultimately help the EMSMR and CFT develop an implementation
plan and identify the resources needed to implement the EMS.
Because most Army installations have well-established environmental programs,
some basic components of the EMS are likely already in place.
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Step-by-Step Guidance
Step 5. Meet with the EQCC.7
After the self-assessment is completed, the CDR should meet with the
EQCC and discuss the following:
EMS implementation efforts
> Provide a brief EMS introduction and overview.
> Explain that the garrison is implementing an EMS per Army pol-
icy and EO 13148.
> Explain that the garrison will involve them in future tasks, such
as implementation planning and management reviews.
> Obtain buy-in and set the stage for future meetings.
Results from the self-assessment
> Explain the purpose of the self-assessment.
> Provide the installation's EMS statusthe requirements already
met and those pending.
> Ask for assistance in highlighting areas that may require signifi-
cant resources (including non-environmental ones) and identify-
ing funding sources.
Reviewing and revising the environmental policy statement
> Explain that the environmental policy is an Army metric for im-
plementing the EMS and must be completed by 30 September
2003.
> Explain that your staff will revise the installation's environmental
policy to reflect EMS implementation efforts and that they will be
included in the staffing process.
> Obtain input.
If your installation does not have the required EQCC or it has not been
meeting regularly, you must form one (as required by Army Regulation
(AR) 200-1) and set a regular meeting schedule. The EQCC is the ideal
senior leader group to participate in EMS implementation because it in-
cludes mission commanders and other senior representatives from all the
major organizations and tenants on the installation.
7 We use the abbreviation EQCC throughout this report to refer to an actual EQCC or
any similar senior leader advisory group.
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Step 6. Prepare an EMS implementation plan.
Using the results of the self-assessment and guidance from the meeting
with the EQCC, the EMSMR should begin working with the CFT to de-
velop an EMS implementation plan and associated budget:
The implementation plan is critical because it is the roadmap for
EMS implementation across the installation. Completing the plan
and obtaining command approval is also an Army EMS implemen-
tation metric.
Use the self-assessment results and this guidance to determine
what parts of the EMS your installation needs and how to complete
them.
The EMS implementation plan should detail the key actions needed
to complete the elements required in an ISO 14001-conforming
system, who completes those elements, the resources needed,
who provides the resources, and when the work is completed.8
The plan must clearly cite the desired goals for EMS implementa-
tion (for example, whether certification is desired) and clearly define
roles and responsibilities for plan execution. Make sure it includes
key milestones.
Use automated project planning tools as needed to help plan and
manage the EMS implementation process over time.
Some organizations may elect to establish timekeeping codes to track
hours spent implementing the EMS. These data can be useful in tracking
total EMS implementation costs and in continuing project management
efforts.
Click here to view an example implementation plan.
NSF International Strategic Registrations (NSF-ISR), Ltd., Environmental Manage-
ment SystemsAn Implementation Guide for Small and Medium-Sized Organizations,
2001, p. 13.
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Step 7. Obtain CDR approval of the EMS implementation plan (by 30
September 2004).
Step-by-Step Guidance
Army EMS Implementation Metric
Implementation Plan. A written plan with defined dates, identified resources,
timelines, and organizational responsibilities for implementing an installation-wide
EMS consistent with Army EMS policy has been signed by the CDR.
When completed, the implementation plan and budget must be staffed
through all senior leaders in the garrison and non-garrison organizations,
and then reviewed and signed by the CDR. By concurring with the imple-
mentation plan, mission commanders and directors commit to providing
the necessary resources (funding and manpower) for EMS implementa-
tion. Be certain to identify specific funding sources in the plan budget.
Resources include human resources and specialized skills, technology, and funding.
After the plan is approved, file it in an accessible location (see documenta-
tion requirements) and give it and the budget to the installation manage-
ment regional office (IMRO). Use the approved plan as the primary
project management tool to identify potential roadblocks and to ensure
task accomplishment. Periodically review implementation progress with
regard to milestones and analyze the budget. ISO 14001 does not require
documentation or records regarding the implementation plan. However,
since the plan is required by the Army implementation metrics, we rec-
ommend controlling the implementation plan under the document control
system (Step 13) and tracking implementation progress with appropriate
records (Step 26).
Step 8. Hold an EMS implementation kickoff meeting.
An installation-wide EMS implementation kickoff meeting is a good way to
formally announce the EMS effort. Explain why the installation is imple-
menting an EMS and the benefits that will result from EMS implementa-
tion. Present the self-assessment results as the foundation for EMS
implementation efforts across the installation and discuss the installation
and Army goals for EMS implementation. A wide variety of people should
attend this kickoff meeting, including the following:
CDR
EMSMR
CFT
EQCC
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Installation master planning representative
Installation environmental staff
Representatives from all installation functional areas
IMRO representative, if available
Unions
Contracting officer or contracting officer's representative
Community advisory boards
Interested parties from the community.
The CDR should sponsor and announce the kickoff meeting. The EMSMR
prepares the agenda and supports the CDR as required. At the kickoff
meeting, the CDR should introduce the installation's EMS efforts, explain
why the initiative is important, and briefly overview how the implementa-
tion is going to occur.
Click here to view draft talking points for the CDR's briefing.
Ensure that members of the environmental management office attend the
kickoff meeting since they provide environmental technical support regard-
ing specific environmental issues. Include representatives from all func-
tional areas on the installation to inform them how they are expected to
contribute to the implementation effort. Good representation from tenants,
activities, and units at the installation is essential. Emphasize that EMS
implementation requires support from across the installation. Tenants, ac-
tivities, and units are all involved in implementation efforts. Finally, invite
an IMRO representative. The IMRO is the next higher headquarters
above the garrison in the Installation Management Agency (IMA) organiza-
tional structure. An IMRO representative may be willing to attend the
kickoff and make some remarks regarding the IMA and the regional per-
spective on the EMS implementation initiative.
EMSMR AND CFT IMPLEMENT THE EMS
At this point, most of the preparatory work is complete and you are ready
to begin the critical phase of EMS implementation. Except for "Mission
Focus," all elements in Figure 2-1 directly relate to the requirements of
ISO 14001. Those highlighted in yellow include requirements contained in
the Army and DoD implementation metrics.
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Step-by-Step Guidance
Figure 2-1. EMS MR and Cross Functional Team Implement the EMS
Step 10
Environmental
Policy. ISO 14001
Sec 4.2
Step 11
Awareness Training
ISO 14001
Sec 4.4.2
Documentation
ISO 14001
Sec 4.4.4
Document Control
ISO 14001
Sec 4.4.5
Step 20: Environmental Management
Programs, ISO 14001. Sec 4.3.4
Step 21: Objectives & Targets
ISO 14001. Sec 4.3.3
Step 22: Structure & Responsibilitv
ISO 14001. Sec 4.4.1
Step 23: Operational Control
ISO 14001. Sec 4.4.6
Step 24: Competence Training,
ISO 14001. Sec 4.4.2
Step 25: Monitoring and Measurement
ISO 14001, Sec 4.5.1
Step 26: Records. ISO 14001. Sec 4.5.3
S
^ En'
I
^
^^"
Steps 16-19
Environmental
Aspects
ISO 14001
Sec 4.3.1
Step 15
Legal and Other
Reguirements
ISO 14001
Sec 4.3.2
Step 14
Communication
ISO 14001
Sec 4.4.3
Emergency
Preparedness and
Step 28
Nonconformance and
Corrective and Preventive
Actions. ISO 14001
Sec 4.5.2
Response
ISO 14001
Sec 4.4.7
Step 30
Management Review
ISO 14001. Sec 4.6
Step 29
EMS Audits
ISO 14001. Sec 4.5.4
Remember, you can rearrange the sequence of these steps as ap-
propriate for your situation. To accelerate implementation and frontload
the implementation metric requirements, you can postpone Steps 12, 13,
and 14 until after the aspects and impacts analysis is completed. You can
also perform many of these steps concurrently, if resources permit.
The concept of continual improvement is critical to the EMS. The entire
EMS is periodically reviewed and revised to improve performance and ad-
dress changes in mission or installation operations.
Step 9. Identify mission focus.
Objective
Identify and document installation-level mission priorities.
In order to create a mission-enhancing EMS, the CFT members must in-
terview senior leaders from the major organizations on the installation to
help determine installation-level mission priorities. The interview process
should accomplish the following objectives:
Identify and prioritize actions that installation units and organiza-
tions must currently perform to maintain readiness or to accomplish
the organization's day-to-day missions.
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Identify and prioritize anticipated (future) mission requirements (3 to
5 years in the future).
Identify future large-scale issues that might affect the installation
mission (10 or more years in the future).
Identify environmental roadblocks or impediments that affect mis-
sion capabilities.
Why Is Mission Focus Important?
An essential step in designing an EMS is understanding the mission priori-
ties of the units and organizations on the installation. The warfighting,
training, and sustaining missions are the top priorities of any installation:
these missions are why the installation exists. The challenge is to identify,
manage, and mitigate the environmental impacts of mission-related activi-
ties. By proactively managing these impacts, you can continue to train
and perform critical activities now and in the future. Clearly identifying fu-
ture missions and large-scale issues early allows greater time and flexibil-
ity for identifying impacts and finding solutions. A well-designed EMS
supports realistic, effective, and sustainable training and operations, and
helps the installation prepare for new mission requirements.
Every installation has a unique set of mission priorities based on the dif-
ferent organizations residing, operating, and training on the installation.
The following paragraphs provide recommendations for planning and
completing mission focus interviews.
1. Develop an inventory of all units and organizations to be inter-
viewed. This will help you make sure that no organization is left
out, set completion milestones, and schedule interviews.
> Get copies of organizational charts and learn the chain of com-
mand, so you understand the hierarchy of the military organiza-
tions.
> As you develop the inventory, you must consider all units, or-
ganizations, and tenants on the installation, including Table of
Organization and Equipment (TOE), Table of Distribution and
Allowances (TDA), active, Reserve, and ARNG.
> If your installation has multiple units with the same organization
and mission (three infantry battalions, for example), limit the in-
terview to one of those units.
> Identify unit environmental compliance officers (ECOs) in mili-
tary units and their respective level of training per AR 200-1.
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Step-by-Step Guidance
> In preparation for selecting the leaders to be interviewed, review
recent notices of violation (NOVs), environmental enforcement
actions, and Environmental Program Assessment System
(ERAS) or Environmental Compliance Assessment System
(EGAS) findings. Be certain to interview the leaders of organi-
zations where environmental problems or issues have been
identified.
2. Notify leaders and ECOs to be interviewed.
> Explain the purpose of the interview.
> Provide read-ahead materials and request completion and re-
turn of the unit information sheet along with a copy of the unit
mission-essential task list (METL), if available.
> When scheduling interviews, begin with the garrison com-
mander, senior mission commanders, and directors of non-TOE
activities on the installation. Include senior leaders of any non-
Army organizations that are tenants on the post.
> The read-ahead materials should include an EMS information
brochure, unit information sheet and instructions, and the inter-
view format and instructions. Click here to view an example unit
information sheet.
3. Select the interviewers and prepare for the interviews. Be cer-
tain to match the interviewer's experience and knowledge with the
organization being interviewed. Persons interviewing commanders
of military units should have a good understanding of Army units
and operations and should spend time reviewing the unit informa-
tion sheet before conducting the interviews.
4. Conduct the Interviews.
> Begin each interview by explaining the purpose of the interview
and how the results will be used to develop a mission-
enhancing EMS. Use a written format sheet to guide the dis-
cussion and record information. Click here to view a recom-
mended interview format. Click here to view the instructions for
using the interview template.
> Major interview objectives
Identify current missions and mission priorities. What are
the unit's most important missions and mission-related
activities? One technique for determining priorities is to
perform a hypothetical resource allocation. If the leader had
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100 "resource units" to fund mission priorities, how would
they be distributed?
Identify and prioritize anticipated future missions (3 to 5
years out). What new missions or weapons systems will be
assigned to the unit in the near future? Where do these fall
in the priority scheme?
Identify future large-scale issues that might affect the
installation and its missions (10 or more years out). Ask the
leader to discuss any situations that might significantly limit
future mission capabilities. Examples include regional
issues, such as water shortages and power grid or
infrastructure limitations, and military issues, such as
increased training space requirements for new longer-range
weapons systems.
Discuss environmental "roadblocks" or issues that negatively
affect the mission. These should be issues that are difficult
to work around or that cause significant impairments to the
mission or training. Examples include endangered species
habitats, noise restrictions, and air emission restrictions
(dust, smoke, etc.).
5. Determine the installation's top mission priorities. After com-
pleting all the interviews, combine the results and total the resource
units for each mission listed on the interview sheets. The activities
with the highest (composite) resource allocations are the installa-
tion's top mission activities. When the roll-up (installation-level)
mission priorities are determined, the CFT (with assistance from the
environmental office) reviews and verifies the results, which will be
used in the aspects and impacts analysis, described in Steps 16
through 19. As you determine the significance of environmental
aspects and impacts, be certain to consider the aspects and im-
pacts associated with the top priority missions identified in this step.
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Step 10. Revise and sign installation environmental policy
statement (by 30 September 2003).
Step-by-Step Guidance
Environmental Policy,
ISO 14001, Section 4.2
Army EMS Implementation Metric
Policy. An installation-wide environmental policy has been signed by the CDR and
made available to installation personnel and the public.
Objective
Complete an installation environmental policy statement that conforms to
ISO 14001 requirements.
Importance of the Environmental Policy
The environmental policy is the installation's statement of the overall direc-
tion and principles of action regarding its environmental responsibility. "It
sets the goal as to the level of environmental responsibility and perform-
ance required of the organization, against which all subsequent actions
will be judged."9
ISO 14001 defines an environmental policy as a statement by the organization of its
intentions and principles in relation to its overall environmental performance, which is
a framework for action and for setting its environmental objectives and targets.
Your installation probably already has an installation environmental policy.
Use this opportunity to review the policy and make sure it fulfills the re-
quirements described below. The EMSMR will need to work with the CDR
and CFT to review and revise, or create, a suitable environmental policy
statement.
Policy Content
In order to conform with ISO 14001 and be relevant to an Army installa-
tion, the policy must include the following key features:
It must be appropriate for the nature, scale, and environmental im-
pacts of the installation's activities, products, or services. This is
one of the reasons why we examined mission focus in Step 9. The
policy must have some reference to the installation's mission.
9 International Organization for Standardization, Environmental management sys-
temsGeneral guidelines on principles, systems and supporting techniques, ISO 14004,
1996, Section 4.1.4, p.6.
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It must include a commitment to continual improvement and pre-
vention of pollution. Nothing elaborate is requiredjust a brief
statement that commits the installation to these two concepts.
ISO 14001 defines continual improvement as the process of enhancing the EMS to
achieve improvements in overall environmental performance in line with the organiza-
tion's environmental policy.
ISO 14001 defines prevention of pollution as the use of processes, practices, materi-
als, or products that avoid, reduce, or control pollution, which may include recycling,
treatment, process changes, control mechanisms, efficient use of resources, and ma-
terial substitution.
The policy must make a commitment to comply with relevant envi-
ronmental legislation and regulations and with other requirements
to which the installation subscribes. If the installation has already
made this commitment, it can be stated in one sentence in the pol-
icy.
It must provide the framework for setting and reviewing environ-
mental objectives and targets. Again, no elaborate explanation is
required. You might state that you will be setting objectives and
targets in the same sentence as continual improvement.
The policy must be documented, implemented, maintained, and
communicated to all employees. The policy must be managed and
controlled in accordance with your document control procedures
(Step 13). It must be signed by the CDR and reissued following
changes of command (some installations make the initial signing
ceremony a media event or press release). It must also be com-
municated to and understood by everyone in the organization.
Some installations have used wallet cards to assist in this effort.
And finally, the policy must be available to the public, at least as re-
quested. Your installation may choose to publish the policy in a
newspaper or on your website.10
10 International Organization for Standardization, Environmental management sys-
temsSpecification with guidance for use, ISO 14001, 1996, Section 4.2, p. 2.
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Step-by-Step Guidance
Optional Content
Your environmental policy may include other goals for which your installa-
tion strives, for example,
minimize any significant adverse environmental impacts of new
missions or processes through the use of the integrated environ-
mental management procedures and planning;
incorporate sustainability and life-cycle thinking in planning deci-
sions;
select products that minimize environmental impacts in production,
use, and disposal;
reduce waste and the consumption of resources (materials, fuel,
and energy) and commit to recovery and recycling, as opposed to
disposal, where feasible;
improve environmental education and training of the workforce;
share environmental experience;
promote involvement of and communication with interested parties;
work with local communities toward sustainable development; and
encourage the use of EMS by suppliers and contractors.11
Anything you include in the policy is subject to audit. If you commit to
something, you must follow through and be able to prove it.
Staffing and Finalizing
In most cases, the EMSMR is responsible for drafting a new or revised
environmental policy. After completing the draft, staff the policy according
to your installation's staffing guidance. Staffing is essential for obtaining
constructive input and commitment from those who will implement the pol-
icy. The garrison commander will want to ensure that key subordinates
and the installation's major tenant commanders understand and support
the environmental policy.
Click here to view an example of an ISO 14001-conformant, installation-
level environmental policy from Fort Lewis. Click here to view Toby-
hanna's policy statement.
11 ISO 14004, Section 4.1.4, p. 7.
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Step 11. Plan and conduct EMS awareness training
(by 30 March 2005).
Training, Awareness and
Competence, ISO 14001,
Section 4.4.2
Objective
Army EMS Implementation Metric
Training. Installation personnel defined as appropriate by the CDR have received
awareness-level EMS training that is consistent with Army EMS policy and docu-
mented.
Plan and complete EMS awareness training to meet ISO 14001 require-
ments.
Importance
This is not the same as the competency-based environmental training, covered in
Step 24, which ISO 14001, Section 4.4.2, also requires.
ISO 14001 addresses awareness and competency training in the same
section, but does not clearly distinguish between the two. The Army has
decided to address awareness training early in the implementation proc-
ess to prepare and educate all installation personnel on the basic con-
cept of the EMS and how it might generally affect them. Competency-
based training addresses job-specific issues and occurs later in the im-
plementation process, after key elements of the EMS are already in place.
One of the great benefits of implementing an EMS is that it educates and
empowers employees so everyone (not just the environmental office) can
find ways to improve environmental performance. The purpose of EMS
awareness training is to create a basic awareness and understanding of
EMS principles. Installations must complete all EMS awareness training
requirements by 31 December 2005.
The purpose of this general environmental awareness training is to
gain commitment to the environmental policy;
gain commitment to achieving organization objectives and targets;
and
instill a sense of individual responsibility.
12
12
ISO 14004, Section 4.3.2.4, p. 16.
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Step-by-Step Guidance
The EMSMR should work with the CFT to plan and conduct EMS aware-
ness training annually for all installation personnel. The CFT is re-
sponsible for identifying training needs; establishing and maintaining
procedures for conducting training; and keeping records of the training
that has been completed.
The first time you conduct awareness training, your EMS will probably not
be complete and all the elements and requirements of your EMS will not
be in place. Therefore, you may not be able to address all the require-
ments of Section 4.4.2 in the initial training sessions. Simply tell the at-
tendees that some parts of the EMS are still being developed and they will
receive additional guidance during refresher awareness training. As new
EMS elements are implemented, they must be incorporated into subse-
quent presentations of the awareness training to fully comply with the ISO
14001 requirement (by 2009).
For EMS awareness training content, consider using some of the same
training sources that you used in previous steps (see Step 3 for the CFT
training).
Required Elements
Awareness training is intended to be general in nature. Remember that
individuals whose work has a direct impact on the environment will later
receive specialized competency-based training. The required elements of
EMS awareness training include
discussion of the installation's environmental policy and the impor-
tance of conformance with the policy and its associated proce-
dures;
what an EMS is, why the installation needs one, and how the EMS
procedures and requirements help protect the environment;
examples of relationships between typical work or mission activities
and significant environmental impacts;
what individuals can (and are expected to) do to protect the envi-
ronment;
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roles and responsibilities in achieving conformance with the envi-
ronmental policy and procedures and the EMS requirements, in-
cluding emergency preparedness and response; and
the potential consequences of departure from operating proce-
dures.13
Optional Elements
Optional elements of the EMS awareness training include
the Army's environmental policy;
possible actions to minimize or eliminate environmental impacts
and how each employee can contribute;
the importance of compliance with standard operating procedures
(SOPs) and regulatory requirements;
the overall improvement of the installation's environmental per-
formance; and
involvement of the local community and other interested parties.14
Key Actions
Take the following steps to implement EMS awareness training:
1. Meet with the training managers at your installation. Discuss
the requirements for EMS awareness training, the resources avail-
able, and what needs to be done. In most cases, they will assist
you in scheduling and arranging the training sessions and notifying
attendees. You may choose to incorporate EMS awareness train-
ing into regularly scheduled training events, such as unit training
days. You may also have access to computer-based training re-
sources or closed circuit television systems. Always remember that
EMS must be fully integrated into the installation's business proc-
esses and should therefore be a standard part of the installation's
training requirements.
13 ISO 14001, Section 4.4.2, p. 3.
14 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 33.
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Step-by-Step Guidance
2. Schedule and initiate awareness training.
> Start EMS awareness training as soon as the environmental
policy has been updated and signed. You may have to sched-
ule multiple training sessions to accommodate all the employ-
ees who require the training.
Examples
At one large facility, all EMS awareness training is provided via CBT. The training ma-
terials have been placed on the facility's main computer server. Employees log on and
go through the training materials, which typically requires about 1 hour. The comput-
erized training program tracks who has taken the training and each person's test
scores, thus providing the necessary training records.
Environmental awareness classes provided by one global company use multiple-
choice tests to give the instructor an idea of the staff's level of understanding and help
the employees become more knowledgeable. This company also observed that as
employees learn more about the organization and what it does to protect the envi-
ronment, their sense of ownership grows.
> The awareness training does not have to be conducted in a
classroom. Consider alternatives, such as computer-based
training (CBT), resources listed on the Defense Environmental
Network and Information Exchange (DENIX), training work-
shops, and videos.
> Maintain records of EMS training. These records can be cen-
trally managed at the installation's training office or elsewhere.
They must be kept current and readily available for review or
audit, and their location must be specified in the EMS Records
procedures (see Step 26).
3. Ensure the continuing adequacy of EMS training. Offer training
frequently to reach new employees, transfers between depart-
ments, new contractors, and military units using the training areas.
Most installations provide a monthly or quarterly "newcomers orien-
tation" for new employees and military transfers. This is one venue
for providing EMS awareness training to the target audience. At
range areas, some installations add an EMS briefing to the required
safety brief.
4. Update and maintain training materials. Establishing standard-
ized training materials, and periodically reviewing and updating
them, will help keep the training relevant as situations, missions,
and organizations change. It will also help keep the training consis-
tent, even if different instructors or presentation media are used. It
also provides a good overview of training content for auditors or
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other interested parties. Procedures for maintaining, reviewing,
and updating the training materials should be included in your EMS
document control procedures (see Step 13).
Click here to access awareness training materials and training sources.
Step 12. Initiate EMS documentation.
Objective
IS Documentation,
ISO 14001. Section 4.4.4
u
Design a standardized framework your installation will use to develop and
organize the various types of documentation required by ISO 14001.
Importance
Complete, well-organized documentation is essential for describing, man-
aging, evaluating, and improving the EMS. EMS documentation provides a
written description of your installation's EMS and directions for how things
should be done. Developing EMS documentation is an ongoing process.
Some of the required documentation already exists on your installation
you just need find it, review it, and ensure that it is kept current. Other
parts of the documentation required by ISO 14001 will take time to de-
velop. The following subsections describe the types of EMS documenta-
tion required. You can now start to develop and organize it.
Documentation Hierarchy
Think of EMS documentation as a tiered system, as shown in Figure 2-2.
Figure 2-2. EMS Document Hierarchy
A
V
More Detail
Procedures
Operational Controls
EMS Records
EMS Documentation
provides policy and
direction
EMS Records describe results
Four types of EMS documentation typically constitute the hierarchy. (Re-
cords are not considered part of documentation.) As you move down the
pyramid, the amount of information, degree of specificity, and number of
pages generally increase.
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Step-by-Step Guidance
Environmental Policy
EMS Manual
The first level of documentation is the environmental policya statement
of the installation's mission, intentions, and principles related to its envi-
ronmental performance. (You completed the environmental policy in
Step 10.)
The EMS manual is the central document that describes core elements of
the EMS and how they fit together. The ISO 14001 specification does not
specifically require a manual, but a manual provides a simple and effective
solution for achieving conformance with ISO 14001 EMS documentation
requirements. The manual provides a roadmap of the installation's EMS,
briefly addresses each of the elements within the EMS, and clearly out-
lines the processes the installation uses to run the EMS (think of it as an
EMS concept of operations). You should now develop an outline for your
EMS manual, which lists its basic content:
Environmental policy
An outline of the installation environmental management programs
The location of EMS roles, responsibilities, and authorities
The location of current EMS objectives and targets
The location of other documentation, such as emergency response
plans, training plans, and sops (consider using a flowchart)
The location of document control and records procedures
The location of monitoring, measuring, and corrective action proce-
dures
The location of information on regulatory and other requirements.
As you continue implementation of your EMS, you will develop the infor-
mation and procedures described above. Think about organizing the
manual along the lines of the EMS elements shown in Figure 2-1, which
address the requirements in ISO 14001. This will help you check your
conformance with the ISO 14001 standard.
15
15 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 40; and ISO 14004, Section
4.3.3.2, p. 19.
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The EMS manual is not a comprehensive physical collection of all the de-
tailed procedures developed throughout the EMS implementation. Try to
keep the EMS manual short, no more than one page per EMS element,
and as simple as possible.16 You do not need to describe every detail of
your EMS in the manual: refer to other documents or procedures so that
you can revise individual procedures without revising the entire EMS
manual. The EMS manual can be a useful tool for explaining the installa-
tion's EMS to new employees, auditors, or other interested parties, if de-
sired. Review and update the manual according to your document control
procedure (Step 13) to account for any changes to your EMS. Click here
for examples of EMS manuals developed by other Army installations.
In addition to the EMS manual, the installation needs more detailed docu-
mentation of its EMS.17 As you continue with the implementation process,
you will create procedures for certain elements of the EMS. These proce-
dures are part of the EMS, and your manual should include directions to
locate the EMS procedures. As you create area- or activity-specific in-
structions (SOPs) on certain operations or activities, you may also choose
to include their locations in the EMS manual.
You will not be able to complete the manual until you finish EMS imple-
mentation, but starting it now helps you organize and document ongoing
efforts.
EMS Procedures
The third level of documentation is EMS procedures, which describe how
to operate and maintain the EMS and define the authority, responsibility,
and accountability for implementation and follow-through. Developing and
maintaining EMS procedures is mainly the responsibility of the CFT. This
guide will prompt you to develop the required EMS procedures as you
continue implementation. When you reach the end of this implementation
guide, most of your EMS procedures should be completed. As you oper-
ate and refine your EMS, you will probably see a need to revise some of
the procedures or add new ones to address emerging issues.
Operational Controls (SOPs)
The fourth level is the collection of EMS operational controls or SOPs.
Your installation already has SOPs for most major processes or activities.
Supervisors and leaders are responsible for the SOPs in their functional
areas. As you implement the EMS, the goal is to ensure the SOPs direct
16 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 47.
17 NSF-ISR, Environmental Management S
Small and Medium-Sized Organizations, p. 47.
17 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
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Step-by-Step Guidance
employees to perform their jobs in ways consistent with the installation's
environmental policy and the goals and objectives of the EMS. The SOPs
should incorporate significant environmental aspects (Step 19), objectives
and targets (Step 21) and monitoring and measurement procedures (Step
25) into the daily activities or job practices of installation personnel.
CFT members and environmental personnel should work with unit leaders
and civilian supervisors to produce SOPs that support the EMS. These
SOPs give specific, detailed instructions that describe the methods for at-
taining environmental goals and hence complying with environmental pol-
icy.
Although most SOPs are already in place, reviewing and revising them
can be a lengthy process. We recommend you develop a prioritized
schedule that starts with environmentally significant processes or activities
on your installation and maintain steady progress toward revising the
SOPs. Step 23 provides detailed guidance for developing and revising
SOPs.
EMS Records
EMS records are not considered part of EMS documentation. Documen-
tation describes policies, procedures, and other directive information,
while records provide a written history of EMS performance and actions
completed (such as training). We detail the EMS records and related ISO
14001 requirements in Step 26. Click here to view a summary of ISO
14001 and Army requirements for EMS documentation and records.
Step 13. Develop EMS document control procedures. Document control,
ISO 14001, Sec 4.4
Objective
Importance
Develop written procedures to ensure proper management of EMS docu-
mentation and conform to the IS014001 standard.
In order to effectively implement and operate the EMS, installation per-
sonnel must have access to the information they need to do their jobs
properly. They need correct and current procedures, instructions, and
other reference documents. "Without a mechanism to manage these EMS
documents, the organization cannot be sure that people are working with
the right tools."18 To ensure everyone works with the proper documents,
you need a procedure to describe how the documents are controlled.
18 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 50.
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Requirements
ISO 14001 requires only that organizations "establish and maintain"
document control procedures. We recommend these procedures be writ-
ten and maintained as part of the EMS documentation. Your document
control procedure should ensure that documents
can be easily located and accessed (employees must know where
to find them);
are kept current (the latest version or revision);
are kept as paper or electronic copies (but paper copies must be
kept up to date, controlled, and effectively managed in a central lo-
cation);
Because keeping documentation up to date and maintaining it at a central location is
difficult, you may (and are encouraged to) use electronic systems to manage your
EMS documentation. The feasibility of using an electronic format depends on your
installation's computer network and the degree of employee access to the system. If
your installation is already using an electronic document management system, you
should try to use it, if possible. If you plan to purchase a new document control sys-
tem for the EMS, be sure that it meets your needs and is compatible with other sys-
tems already in use.
are periodically reviewed, revised as needed, and approved by ap-
propriate personnel (check to make sure documents are still valid);
are available at all locations where operations essential to the
effective functioning of the EMS are performed (make sure the peo-
ple who need the documents have access);
that are obsolete are promptly removed from all points of issue and
points of use, or otherwise kept from unintended use (prevent peo-
ple from using the wrong document); and
are suitably identified if obsolete and retained for legal reasons or
knowledge preservation.
Try to keep your system as simple as possible, including only documents
that need to be controlled. You can quickly overwhelm the system by in-
cluding unnecessary documents. Ensure that everyone knows how to use
the system and understands their individual responsibilities for maintaining
the system.
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Step-by-Step Guidance
Click here to view a document control worksheet that summarizes key
questions regarding the document control process. By answering the
questions on the worksheet, you can build a framework for your EMS
document control procedures.
Among others, the following EMS documents should be managed under
the document control system:
Environmental policy
Aspects and impacts analysis data and results
Environmental management program documents
Objectives and targets
Roles, responsibilities, and authorities
EMS manual
EMS procedures
Process- or activity-level procedures
Related plans (such as emergency response plans).19
Click here to view a document index spreadsheet for listing and tracking
the status of controlled EMS documents.
Click here to view examples of systems used successfully at other Army
installations.
19 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 51.
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Document Control System Hints
Keep the document control procedure simple. Consider other document con-
trol procedures on the installation when developing yours.
Limit document distributionmake only the copies you need.
Consider using the LAN or Intranet as a paperless system. Consider com-
mercial document control software packages, but make sure the system
meets your needs.
Prepare a document control index that shows all your EMS documents, their
location, their revision history, and the date of the next review. Include a ref-
erence to the index in the EMS manual, but do not include the index in the
manual, because the index will require frequent revisions. If you use a paper-
based system, prepare a distribution list that shows who has copies of the
documents and their location.
When revising documents, highlight the changes (using highlight, bold, under-
line, different colors, etc.) or use a change sheet to show the changes.
(NSF-ISR, Ltd., Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, 2001)
Step 14. Establish communications procedures.
Objective
Communication ISO
14001, Section 4.4.3
Importance
Develop procedures for internal and external communication of EMS in-
formation, as required by the IS014001 standard.
ISO 14001 requires only that the organization establish and maintain pro-
cedures for communication and does not require documentation. How-
ever, we recommend that you document (write down) communication
procedures if you want personnel to universally understand and consis-
tently follow the procedures.
Good communication, within the installation and to external interested par-
ties, is essential for developing and implementing the EMS. "Effective en-
vironmental management requires effective communications, both
internally and externally."20 The installation must establish and maintain
two different types of communications procedures:
Internal communications between the various levels and functions
on the installation, and
20
NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 43.
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Step-by-Step Guidance
External communications.
Most installations already have basic communications procedures in
place. If that is the case at your installation, you need only revise the pro-
cedures to address EMS information.
Internal Communications
Internal communications include verbal communication (staff meetings,
brown bag lunches, training, etc.), e-mail, intranet, memoranda, newslet-
ters, posters, and bulletin boards. When developing the procedures, take
advantage of existing communications channels and consider how differ-
ent target audiences on the installation access or distribute information.
Some employees may not have consistent access to a computer for e-
mail and intranet-based information, so multiple types of communication
may have to be used. The following information needs to be communi-
cated internally:
Information on day-to-day EMS operations, including the environ-
mental policy and how it will be publicly available
General EMS education and awareness information, including the
process for receiving and responding to the concerns of employees
and other interested parties
Environmental regulatory reporting requirements
How to achieve objectives and targets
Environmental incidents
Environmental aspects
Personnel responsible for various parts of the EMS
How the EMS will be monitored
EMS audit results and results, including the process for making all
personnel aware of those results (communicated through the
EQCC)
The management review cycle.
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External Communications
You need an effective procedure for dealing with external communica-
tions. The installation must establish procedures describing how it distrib-
utes information to the public and how it receives, documents, and
responds to relevant communication from different types of external inter-
ested parties. The procedure should clearly identify the information to be
made available to the public. ISO 14001 requires only that the environ-
mental policy be made available, but some installations also include the
following:
Environmental aspects and impacts
Installation environmental objectives and targets
Meeting minutes
Permits
Compliance information, such as fines and NOVs.
Consult the public affairs office (PAO), legal office, security, operations,
and other involved staff elements before deciding what information to re-
lease.
In addition to listing the publicly available information, document how you
make it available and how frequently your installation updates it.
The PAO likely coordinates external communications and is probably the
best external point of contact (POC). If no external POC exists, establish
one and require the POC to coordinate and maintain records of external
communications. ISO 14001 requires documenting or keeping records of
communications with external parties. The procedure for recording exter-
nal communications can be as simple as stapling an inquiry to the re-
sponse and then filing them together.21
The installation leadership determines whether the installation initiates and
establishes external communication of the installation's significant aspects
(see Step 19). Army installations are not required to publicly communicate
this information. We recommend you decide in advance what information
will be shared with the public and record your decision. If you choose, you
can share EMS information by various means:
Reports and newsletters
Press releases in newspapers, in magazines, or on television
21 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 44.
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Step-by-Step Guidance
Websites
Public meetings.
Although it is not an ISO 14001 requirement, we recommend you docu-
ment the internal and external communications procedures, including
who manages inquiries and the flow of information,
who is responsible for preparing and approving responses, and
types of information to be communicated.
Written communications procedures should be maintained in accordance
with the installation's document control procedures.
Effective internal and external environmental communication and reporting
has the following characteristics:
It is two-way.
Information is understandable and adequately explained.
Information is verifiable.
It presents an accurate picture of the organization's performance.
Information is presented in a consistent form (for example, similar
units of measure to allow comparison of two periods).22
Click here to view an example of an internal communications procedure
document. Click here to view an example of an external communications
procedure document.
Step 15. Compile legal and other requirements. Le9a| and other Requirements,
r ISO 14001, Section 4.3.2
Objective
Develop a written procedure to compile and keep current all legal and
other requirements pertaining to installation environmental issues.
ISO 14001 requires only that the organization establish and maintain pro-
cedures pertaining to legal and other requirements and does not require
documentation. However, we recommend that you document the proce-
dure to ensure it is periodically reviewed and revised as needed.
22 ISO 14004, Section 4.3.3.1, p. 18.
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Importance
Legal and other requirements are part of the baseline for your EMS. As
your installation performs its mission activities, everyone must be aware of
the environmental regulations and other requirements that they must
meet.
In addition, the revised environmental policy (developed in Step 10) re-
quires a commitment to legal and other requirements. To fulfill this com-
mitment, your organization needs to know the legal requirements that
apply to your operations, activities, or services and how they affect what
you do.
23
Your installation probably already has a process for identifying legal and
other requirements that pertain to environmental issues. In this step, you
review the process to ensure that it captures all the applicable laws and
regulations.
Your installation does not have to commit to additional voluntary require-
ments not mandated by law or Army policies. However, if your installation
has previously volunteered or subscribed to other requirements, you must
follow through on that commitment. This commitment also holds if you
plan to participate in such activities in the future.24
Legal requirements include all federal, state, and local legislative and regulatory envi-
ronmental requirements that apply to your operations, including all Army policies and
regulations. They also include administrative requirements, such as permits, authori-
zations, licenses, records, reporting, and environmental plans.
Other requirements include voluntary obligations to which the organization commits,
including the following:
Industry standards of practice, such as American National Standards Institute
(ANSI) and ASTM standards
Agreements with public authorities, such as consent decrees and U.S. Envi-
ronmental Protection Agency (EPA) programs
Internal installation requirements, such as ISO 9000
Environmental management principles.
(U.S. Army Guidance Manual, p. 16.)
23
PEER Center, How to Implement an EMS [on-line document], undated [cited Feb-
ruary 2003]. Available from http://www.peercenter.net/howtoimplement/.
24 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 16.
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Step-by-Step Guidance
As you review your current process for identifying legal and regulatory re-
quirements, make sure it meets the following criteria:
Identifies relevant requirements, including state and local.
Identifies proposed requirements and changes to existing ones.
Describes a process for reviewing and analyzing requirements to
determine potential impacts on installation activities, including who
reviews and how results are recorded and communicated.
Is properly documented and sufficiently detailed.
Is stored and maintained in accordance with your EMS document
control procedure.25
Table 2-1 lists laws and regulations that govern common activities at Army
installations. The environmental management office should be able to
provide a list of applicable environmental regulations. The following
sources can also help identify legal requirements:
AR 200-1, 200-2
DENIX
IMRO
U.S. Army Environmental Center (USAEC) regional environmental
offices (REOs)
Federal, state, and local governmental agencies
Industrial trade associations, societies, and other related groups
Commercial databases
Professional services, including environmental consultants and law
firms
ECAS/EPAS
Publications that pertain to self-compliance audits or environmental
checklists.26
25ISO14004, Section 4.2.3, p. 9.
26 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 17.
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Table 2-1. Federal Laws and Regulations
Federal laws and regulations
Clean Air Act (CAA), 40 CFR Parts 50-99
Clean Water Act (CWA), 40 CFR parts 100-
145,220-232,410-471
Resource Conservation and Recovery Act
(RCRA), 40 CFR Parts 240-299
Spill Prevention, Control, and Countermea-
sures (SPCC), 40 CFR Parts 112-114
Toxic Substances Control Act (TSCA),
40 CFR Parts 700-799
Comprehensive Environmental Response,
Compensation and Liability Act (CERCLA,
also known as Superfund),
40 CFR Parts 300-31 1
Emergency Planning and Community Right-
To-Know Act (EPCRA, also known as SARA
Title III), 40 CFR Parts 350-374
Hazardous Materials Transportation Act
(HMTA), 49 CFR Parts 100-180
Safe Drinking Water Act (SDWA), 40 CFR
Parts 141 -149
AR200-4
Federal Insecticide, Fungicide, and Rodenti-
cide Act (FIFRA), 40 CFR parts 150-171
Endangered Species Act (ESA), 16 USC
1531 etseq.
Sikes Act, 16 USC 670a-670f
AR200-3
Noise Control Act (NCA)
EO 13148 "Greening the Government
Through Environmental Management" and
Pollution Prevention Act
Common activities
Air emissions, including ozone depleting chemicals
(ODCs) from operations, stack or fugitive emissions,
equipment, and stored chemicals or fuel
Water discharges, including storm water, wastewater,
and sewage
Chemical or hazardous material or waste, or energy
resources (such as coal and petroleum fuels) storage
Hazardous waste generation, storage, handling, trans-
port, or disposal
Solid waste related activities, including sanitary land-
fills and recycling and waste minimization programs
Underground storage tanks
Storage, handling, or transport of oil of any kind, in-
cluding petroleum, fuel oil, sludge, oil refuse, and oil
mixed with wastes, other than dredge spoils
Manufacture, process, distribution, use, or disposal of
TSCA-regulated chemicals
Releases of hazardous substances needing to be re-
ported under CERCLA
Contaminated site cleanup
Toxic chemical or extremely hazardous substance use
(according to EPA's list)
Toxic chemical or extremely hazardous substance (ac-
cording to EPA's list) transport, processes, use, or
storage.
Drinking water systems, underground injection, well-
head protection or cross-connection control, and back-
flow prevention
Cultural resources management
Pest management
Threatened and endangered species, critical habitat,
or associated initiatives
Natural resources management
Natural resources management
Noise mitigation, monitoring, and management
Pollution prevention activities versus compliance-
based solutions, priority chemical use reduction, pollu-
tion prevention plans
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COMPLETE ASPECTS AND IMPACTS
ANALYSIS AND DEVELOP PRIORITIZED
ASPECT LIST (STEPS 16-19)
(BY 30 MARCH 2005)
Step-by-Step Guidance
Environmental Aspects
ISO 14001, Section 4.3.1
Army EMS Implementation Metric
Prioritized List of Aspects. A list of environmental aspects consistent with ISO
14001 and Army EMS policy has been developed, documented, and briefed to the
CDR.
Steps 16 through 19 collectively identify the significant environmental as-
pects resulting from your installation's activities, products, and services:
Step 16. Identify all mission and installation activities, products, and
services.
Step 17. Identify the environmental aspects of your installation's ac-
tivities, products, and services.
Step 18. Identify the environmental impacts of each aspect.
Step 19. Identify significant environmental aspects.
The identification of significant environmental aspects is critical in develop-
ing your EMS because they provide the basis for establishing environ-
mental management programs, developing objectives and targets,
identifying training requirements, determining requirements for operational
controls and work procedures (such as SOPs), performing general risk
assessments, and completing periodic management reviews.
These steps have proven the most difficult for organizations to implement
because the methods used can vary widely in detail and complexity and
can quickly snowball if you don't tailor your approach to capture the most
significant aspects before you exhaust available time and resources. The
recommended procedures that follow will help you achieve maximum ef-
fectiveness with minimum complexity. ISO 14001 requires only that or-
ganizations establish and maintain procedures to identify environmental
aspects, but we recommend that you develop written documentation for
these procedures to help ensure consistency and understanding.
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Step 16. Identify all mission and installation activities, products, and
services.
Objective
Identify all major installation activities (tactical and nontactical), products,
and services for consideration in the aspects and impacts analysis.
Importance
Activities, products, and services provide the basis for identifying environ-
mental aspects and impacts.
This step will particularly challenge the CFT because of the sheer num-
bers of organizations on an installation and the variety of missions and
functions they undertake. Executing assigned missions and functions
usually involves undertaking a number of different activities; procuring, us-
ing, and developing specific products; and providing services daily in sup-
port of the operational readiness mission and routine base operations
functions.
Mission or Functional Areas and Associated Processes
To identify your installation activities, products, and services, follow the
simple hierarchy depicted below.
Mission or
functional area
Associated
processes
Activities, products,
and services
Before defining activities, products, and services, you need to understand
the various mission and functional areas and associated processes that
both tactical and nontactical organizations undertake across the installa-
tion. Table 2-2 shows typical mission and functional areas and associated
processes at the installation level.
Activities, Products, and Services
Within each mission or functional area, a number of major processes are
likely. For example, within the transportation equipment functional area, a
typical installation process is to conduct vehicle maintenance operations.
At the next level, conducting vehicle maintenance operations might involve
a number of specific activities, products, and services.
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Step-by-Step Guidance
Table 2-2. Mission or Functional Areas and Their Processes
Mission or
functional area
Description of associated processes
Weapons system
acquisition
Major systems acquisition phases of concept and technology development,
system development and demonstration, production and deployment, opera-
tions and support, and demilitarization and disposal
Example: Demilitarization and disposal of excess or waste munitions
Logistics support
Acquisition, storage, distribution, and recovery of all classes of supply; main-
tenance of materials and equipment; transportation of personnel and mate-
riel; provision of support services such as food, commissaries, laundries, and
property disposal; and facilities (real property) operation and maintenance,
including utilities, minor construction, and general engineering support
Example: Ammunition supply operations
Training
Click here for specific
guidance on identifying
processes, activities,
aspects, and impacts
associated with tactical
training.
Providing and conducting individual, functional, and organizational (tactical
and nontactical) training
Example: Conducting basic training
Infrastructure
development and
maintenance
Processes required to operate the total system of facilities; buildings; struc-
tures; horizontal transportation facilities (roads, railroads, bridges, dams, and
airfields); utility, transport, and communication systems; ranges and other
training areas; ports; airfields; and associated lands and equipment
Example: Road maintenance
Industrial operations
Manufacture of commodities, equipment, and weapons systems
Example: Manufacturing small arms ammunition
Base operations
Processes required to support the missions and functions of assigned and
tenant units and activities at the installation level
Example: Providing and maintaining troop housing
Health and medical
support
Providing general health care and medical and dental support to personnel
and operating and maintaining Army hospitals, medical centers, dental and
veterinary clinics, medical treatment facilities, and supporting laboratories
Example: Providing outpatient medical services
Transportation
equipment
Operation of tactical and nontactical vehicles, fixed and rotary wing aircraft,
rail systems, watercraft, and supporting maintenance operations
Example: Perform vehicle maintenance
Mobilization and
deployment
Assembly and organization of material and personnel resources in response
to war or other emergencies, and the physical movement of those resources
to the theater of operations
Example: Railhead operations
Research,
development, testing,
and evaluation
(RDT&E)
Testing and evaluation of materiel, equipment, and weapons systems at
Army proving grounds, laboratories, and related facilities
Example: Development of new flameless ration heater
Note: The list is not all inclusive and varies from one installation to another.
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Scoping
Activities related to vehicle maintenance include changing oil, lubricating
chassis, replacing brake linings, and rebuilding engines. Products that
might be used or provided include oil, solvents, grease, and repair parts.27
Provided services could include vehicle washing and operator mainte-
nance training.
Another example is the base operations functional area. Typical installa-
tion processes include operating a water or wastewater treatment plant,
power generation facility, or sanitary landfill. Activities include primary and
secondary treatment of wastewater, operating boilers to power generators,
or covering solid waste with earth fill. Products include potable water,
while products used include water, fossil fuels, and various chemicals.
Provided services include electric power, potable water distribution, solid
waste disposal, and recycling.
As illustrated by these examples, "activity" generally refers to a major ele-
ment of a process undertaken to achieve the mission, a desired objective,
or end state. "Product" refers to any commodity or item used, consumed,
or created (for example, ammunition manufactured at an industrial facility)
during a process. "Service" refers to useful labor or efforts that do not
necessarily produce a tangible commodity, but otherwise provide value to
a customer.
A fine line distinguishes an activity, product, or service. What one views
as an activity, another may see as a product or service. Do not allow this
to become problematic. Identifying all key elements of the major installa-
tion processes for subsequent use in aspects and impacts analysis is the
key.
Clearly, the total number of processes, activities, products, and services
on the typical installation can be very large. At least one Army installation
reports having identified over 600 activities across all mission and func-
tional areas. The number may have been exaggerated because the com-
pilers went into too much detail or listed elements of work as activities.
(The steps involved in changing vehicle fluids aren't activities.) Also, keep
in mind that you should identify mayor processes and related activities,
products, and services only.
More realistic is 100 to 200 activities, but even that relatively small number
engenders much work completing the aspects and impacts analysis and
subsequent EMS implementation steps. For this reason, installations may
27 Products can also be defined as tangible results of a process that turns inputs
(such as raw materials) into outputs (such as a weapons system).
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Step-by-Step Guidance
decide to limit the scope of initial EMS implementation to one or two mis-
sion or functional areas, and then gradually expand the EMS to the other
areas. Fort Lewis, WA, took this approach by starting EMS implementa-
tion in the directorate of public works (DPW). Now that the complete sys-
tem is in place at the DPW, Fort Lewis is working to bring in other
organizations and functions across the installation.
Regardless of your approach, you must ensure that all installation organizations, ac-
tivities, and tenants are covered under the broad umbrella of the installation EMS by
31 December 2005.
Getting Started
To do a thorough job of identifying all installation activities, products, and
services, you should start by compiling as much information as possible,
beginning at the process level and working down. Identify every organiza-
tion (tactical and nontactical) that resides within the installation fence line,
including sub-installations. (You accomplished this in Step 9 when you
identified mission focus.)
Once you have identified every organization, you should learn as much as
possible about their assigned missions, functions, and inherent processes.
(Again, you should have already done a much of this in Step 9.) For tacti-
cal units, for example, you should already have copies of the unit mission
statements and appropriate METLs or Army Readiness Training Evalua-
tion Programs (ARTEPs). The METLs and ARTEPs in particular provide a
wealth of information about the primary processes and activities involved
in mission execution and maintaining operational readiness. You should
be able to obtain similar mission and function information from nontactical
support organizations, in hard copy or by interviewing key personnel. On
industrial installations, contractual documents for GOCO facilities can pro-
vide valuable information for this effort. National Environmental Policy Act
(NEPA) documents and other historical assessment records can also as-
sist in defining processes and associated impacts and aspects.
Identify all missions, functions, processes, and activities subject to environmental
regulations or permits. Members of the environmental staff can assist.
If your installation has implemented activity-based costing (ABC), docu-
mentation developed during ABC implementation can provide most of the
information you need for the entire installation in a single package. In ad-
dition, this guide includes a matrix of typical DoD installation major proc-
esses and activities. To view the matrix, click here. Reviewing the major
processes and activities that Fort Lewis identified in its analysis can also
help. To view a PowerPoint presentation of Fort Lewis's results, click
here.
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You can assign responsibility for specific mission or functional areas to
CFT members. When feasible, CFT experts in functions (such as logis-
tics, operations, and training) should be assigned responsibility for compil-
ing information on those functional areas. Unfortunately, since the
number of functional areas usually exceeds the number of CFT members,
some members must compile information on areas with which they are
less familiar. They have to do the best they can by gathering as much in-
formation as possible with the time and resources available. Regardless
of the approach and sources used, the goal is to compile a comprehensive
listing of all major activities, products, and services by mission or func-
tional area and process.
Compiling Information and Keeping Records
The CFT members should compile activities, products, and services for
their assigned mission or functional areas using a simple Excel spread-
sheet to capture information. This will enable the CFT to readily compile,
revise, and manipulate information to perform various analyses or future
revisions. To view a sample Excel form (with a few entries) for collecting
this information, click here.
Step 17. Identify the environmental aspects of your installation's activities,
products, and services that can be controlled or influenced.
Objective
Examine your list of major activities, products, and services and identify
the associated environmental aspects that can reasonably be controlled or
managed.
Definitions and Examples
Once you have listed the installation's major activities, products, and ser-
vices, you must identify the environmental aspects associated with them.
ISO 14001 defines environmental aspects as "elements of an organiza-
tion's activities, products, and services which can interact with the envi-
ronment." An environmental aspect signifies the potential for an
environmental impact, whether good or bad.
Environmental aspects are the cause component of a cause-and-effect
relationship (with the resulting environmental impact being the effect,
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Step-by-Step Guidance
which is discussed in the next step). Generally, the environmental as-
pects of Army installation activities, products, and services fall into one or
more of the following categories:
Air emissions (fugitive or stationary), such as particulate matter,
open burn/open detonation (OB/OD), smokes and obscurants, ve-
hicle exhaust, dust, combustion gases, smoke from prescribed
burning, dust, and noise.
Hazardous waste generation, such as various types of industrial
and hazardous wastes, contaminated containers, and solvents.
Nonhazardous waste generation, such as solid waste.
Uncontrolled releases to air, water, or ground, such as lead and
migrating munition constituents from ranges.
Spills to water or ground, such as fuel or petroleum, oil, or lubricant
(POL) spills, hydraulic fluid leaks, storage tank leaks.
Discharges (point and nonpoint) to ground or surface waters, in-
cluding sewage, sediment, and other wastes.
Energy consumption or conservation, including electricity, petro-
leum-based, and alternative fuels.
Natural resource and raw material consumption or conservation, in-
cluding water, timber, minerals, and soil.
Ecological resource degradation or conservation, such as wetland
protection or destruction and endangered species.
Natural resource degradation or conservation, including ground dis-
turbance, hydrological alteration, and vegetation alteration.
Cultural resource degradation or conservation, including historic
properties, archeological sites, and more traditional cultural re-
sources.
Generation of heat or radiation.
You are only required to identify the aspects (and related impacts) that
you can control or influence.
For example, consider the environmental aspects of vehicle maintenance
activities, products, and services presented and discussed in Step 16.
Table 2-3 summarizes them.
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Table 2-3. Environmental Aspects of Vehicle Maintenance Activities
Activity, product,
or service
Environmental aspects
Change fluids
Spills (oil or antifreeze)
Discharge to ground or surface water (storm water discharge)
Nonhazardous waste generation (used oil, oily rags, etc.)
Resource use (petroleum, antifreeze)
Resource conservation (if oil or antifreeze is recycled)
Lubricate chassis
Nonhazardous waste generation (greasy rags)
Spills (grease)
Discharge to ground or surface water (storm water discharge)
Replace brake linings
Air emissions (brake dust)
Solid waste generation (old linings)
Resource conservation (if linings are recycled)
Clean and degrease
parts
Air emissions (volatile organic compounds [VOCs] from solvent)
Spills (solvent)
Hazardous waste generation (spent solvent)
Resource conservation (if spent solvent is recycled)
Wash vehicles
Discharge to ground or surface water (storm water discharge)
Resource use (water, electricity)
Resource conservation (if wastewater is recycled and reused on
site)
Strategies for Identifying Environmental Aspects
Now that you understand environmental aspects in general terms, what is
the best way to go about identifying them? Once again, you primarily rely
on the CFT members who are identifying the activities, products, and ser-
vices information. In instances where they are in fact mission or functional
area experts, they should be able to readily identify the environmental as-
pects for the various activities, products, and services. If they are not ex-
perts themselves, then they will have to consult other installation experts
and have them describe how their activities, products, and services may
interact with the environment. In addition, other information sources are
available to gain insight into environmental aspects. These include the
following:
Previous aspects and impacts evaluations
Process flow charts and hazard analyses
Air emissions inventories
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Step-by-Step Guidance
National Environmental Policy Act (NEPA) studies (environmental
assessments or environmental impact statements)
Product economic analyses
Design for the environment (DFE) documentation
Facility pollution prevention and waste minimization audits
EGAS reports and corrective action plans
Environmental site assessments
Risk assessments
Environmental cost accounting records
Project safety and hazard reviews.
Process Flow Charts
It may be helpful to prepare simple process flow charts that capture inputs
and outputs for the various activities, products, and services. For exam-
ple, Figure 2-3 shows another logistics function, fuel storage and dispens-
ing operations, which includes fuel receipt, storage, and shipping and
dispensing activities.
Figure 2-3. Fuel Storage and Dispensing Operations
GASOLINE DIESEL
FUEL
ENERGY
(pumps, lights)
RECEIVING
1
UNLOADING
SPILLS (storm)
1
STORAGE
I
TANK
LEAKS
' 1
SHIPPING/
DISPENSING
' i 1
voc
EMISSION SPILLS VOC
(breathing) (storm) EMISSION
(displacement
r
VOC
EMISSIONS
(displacement)
PIPING
LEAKS
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By laying the process out in this way, you can easily conceptualize the re-
source inputs to each activity and the manner in which each activity inter-
acts with the environment. Whether or not you use this approach is purely
a matter of preference.
Tips and Tools
Regardless of your approach, as you identify specific aspects, you should
try to capture as much related quantitative information as possible. For
example, if an activity generates waste solvent, estimate the total amount
(for example, 100 gallons per month). Other information that should be
captured includes specific legal and other requirements that may apply,
permits in force, special record-keeping requirements, pollution controls or
equipment in use, best management practices that are currently em-
ployed, regulatory monitoring requirements, etc. This information will help
you identify environmental impacts and determine their significance.
As you identify environmental aspects, you must include all mission and
functional areas. A key mission area you must evaluate is the training that
supports METL and ARTEP skills. Click here to view a tool specifically
designed to identify the activities and associated aspects for training and
range operations. Click here to view a matrix that outline typical canton-
ment area activities and associated aspects.
To view an example of an environmental aspects worksheet completed for
one of the previously presented vehicle maintenance activities, click here.
Step 18. Identify the environmental impacts of each aspect.
Objective
For each activity, product, or service identified in Step 16, determine what
environmental impacts might reasonably be produced by the associated
aspects.
Definitions and examples
Once you have identified the environmental aspects of the installation's
major activities, products, and services, you must next identify the envi-
ronmental impacts associated with them. ISO 14001 defines an environ-
mental impact as "any change to the environment, whether adverse or
beneficial, wholly or partially resulting from an organization's activities,
products, or services."
For example, Table 2-4 summarizes some of the environmental aspects
and impacts of the vehicle maintenance activities, products, and services
discussed in Steps 16 and 17.
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Step-by-Step Guidance
Table 2-4. Environmental Aspects and Impacts of Vehicle Maintenance Activities
Activity, product,
or service
Environmental aspect
Environmental impact
1. Change fluids
Oil or antifreeze spills
Storm water discharge
Nonhazardous waste generation (used
oil, oily rags, etc.)
Resource use (petroleum, antifreeze)
Resource conservation (if oil or anti-
freeze is recycled)
Contaminated water or soil
Contaminated surface water
Solid waste disposal
Depleted petroleum reserves and
virgin antifreeze supplies
Petroleum reserves last longer; less
virgin antifreeze needed
2. Lubricate chassis
Nonhazardous waste generation
(greasy rags)
Grease spills
Storm water discharge
Solid waste disposal
Contaminated water or ground
Contaminated storm water
3. Replace brake lin-
ings
Air emissions (brake dust)
Solid waste generation (old linings)
Resource conservation (if linings are
recycled)
Reduced air quality
Solid waste disposal
Reduced resource use (virgin metals
and other components)
4. Clean/degrease
parts
Air emissions (VOCs from solvent)
Solvent spills
Hazardous waste generation (spent
solvent)
Resource conservation (if spent sol-
vent is recycled)
Reduced air quality
Contaminated water or ground
Hazardous waste disposal
Reduced disposal requirements
5. Wash vehicles
Wastewater discharge
Resource use (water, electricity)
Resource conservation (if wastewater
is recycled and reused on site)
Wastewater treatment
Depleted water, electricity
Increased potable water availability
As illustrated by this example, environmental impacts are the effect com-
ponent of a cause-and-effect relationship. Generally, the environmental
impacts of Army installation activities, products, and services fall into one
or more of the following categories:
Air, water, and ground pollution and associated reductions in envi-
ronmental quality (such as ozone depletion)
Energy consumption (or conservation as a positive impact)
Natural resource depletion or conservation
Cultural resource damage or destruction
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Damage to the natural environment (such as ground disturbance,
erosion, and tree and vegetation loss)
Hazardous, biohazardous, and medical waste disposal
Solid waste disposal (or recycling and reuse as a positive impact)
Sewage disposal
Nuisances to local communities.
Strategies for Identifying Environmental Impacts
Now that you have a general picture of environmental impacts, what is the
best way to identify them? As with previous steps, the expertise you need
primarily resides with the CFT members. Representatives from the envi-
ronmental functional area probably know the most about environmental
issues, applicable regulatory requirements, resource (air, water, soil) sen-
sitivities to harmful emissions or discharges, local community concerns,
etc.
One approach is to have the environmental staff members facilitate a
structured CFT brainstorming session to analyze each aspect for potential
impacts, including a team review of the activities involved and process in-
puts and outputs. Although some team members are not environmental
professionals, with a little probative questioning and group discussion,
those who know the activity itself should be able to lend insight into how it
affects the environment. Have a staff member take detailed minutes of
the discussion, review decisions, and action items.
The CFT should work through the process by mission and functional area,
capturing the results as they are developed. For example, begin by look-
ing at the logistics support mission and functional area, evaluating each
activity, product, and service and its identified environmental aspects. Af-
ter you identify and document all associated environmental impacts, move
on to the next mission and functional area (for example, training).
As in previous steps, compile your results on a spreadsheet. To view an
example environmental aspects and impacts worksheet with a few data
entries for the vehicle maintenance process, click here. This form in-
cludes columns on the far right used to evaluate the significance of envi-
ronmental impacts and related aspects. You should ignore those columns
until you get to the next step.
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Step-by-Step Guidance
Step 19. Identify significant environmental aspects
Objective
Establish, use, and maintain a procedure to examine and prioritize the en-
vironmental impacts and aspects identified earlier and determine which
are significant.
Although the ISO 14001 standard does not require documentation of the
procedure, we recommend that you maintain written documentation to en-
sure consistency in execution.
Definition
A significant environmental aspect is an aspect that has or can have sig-
nificant environmental impact. As stated earlier, your significant environ-
mental aspects form the basis for establishing your environmental
management programs (EMPs) (Step 20) and objectives and targets (Step
21).
Determining Significance
Once you have identified all environmental aspects and associated im-
pacts for your activities, products, and services, you must then determine
which environmental aspects are significant. ISO 14001 does not specify
how an organization should determine which impacts are significant be-
cause the relative significance of an impact can vary widely from one or-
ganization to another, depending on environmental and business
concerns and other site-specific considerations. However, the ISO 14004
companion document to ISO 14001 does list several environmental and
business related factors that an organization can consider in evaluating
the significance of an environmental impact, including the following:
Environmental considerations
> Scale of the impact
> Severity of the impact or potential impact
> Probability of occurrence
> Duration of the impact
> Frequency of the impact or potential impact
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> Location of the facility (for example, in an environmentally sensi-
tive area)
> Scope of the impact (local, regional, or global).
Business considerations
> Potential regulatory and legal exposure
> Difficulty of changing the impact
> Cost of mitigating the impact
> Effect of change on other activities and processes
> Concerns of interested parties
> Effect on the organization's public image
> Return on investment of the cost to mitigate the impact.
Army installations must also consider the affect on mission accomplish-
ment of any restrictions imposed because of the impact (for example, op-
erational noise levels may restrict your ability to fire weapons, conduct
demolition training, or employ aircraft).
Identifying Rating Factors and Numerical Ratings
A commonly used approach to determining the significance of environ-
mental impacts employs a simple numerical rating system. You identify a
number of rating factors (considerations), define numerical ratings, and
use an algorithm incorporating those factors and ratings to calculate a sig-
nificance score for each impact. You then can sort and rank impacts by a
relative significance score and make a combination of objective and sub-
jective judgments to determine the significant impacts.
The greater the number of rating factors used, the more difficult it is to de-
velop an easy-to-use, structured process for impact evaluation. As a start-
ing point, try limiting the number to five. Good choices are the following:
Environmental impact frequency or likelihood
Environmental impact severity
Mission impact severity (if the impact results in mission constraints,
or if the organization cannot perform, produce, or provide the activ-
ity, product, or service at all)
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Step-by-Step Guidance
Regulatory status
Community concerns.
After selecting the rating factors you will use, define the numerical ratings
that will apply. For the five rating factors shown above, Tables 2-5
through 2-9 provide some suggested numerical ratings. You may modify
these as you see fit on the basis of your own unique situation or experi-
ence.
Frequency or Likelihood
The probability that an impact might occur, or how often it actually occurs
will affect the significance of the impact.
Table 2-5. Sample Rating Factors for Frequency or Likelihood of
Environmental Impact
Frequency or likelihood (F) scale
5 = Continuousongoing or daily.
4 = Frequentmore than once per month.
3 = Infrequentmore than once per year, less than once per month.
2 = Rareimpact may occur once every year or two.
1 = Nevernever occurred or highly unlikely.
Environmental Impact Severity
Table 2-6 provides a suggested format for scoring the potential severity of
environmental impacts, assuming they occur. When evaluating environ-
mental impact severity, it may help to consider the following:
Proximity of the impact to people or environmentally sensitive areas
Toxicity of substances involved
Quantities of substances involved
Effects from startup and shutdown conditions
Duration of exposure or effects
Size of the area affected
Potential for migration of the hazard.
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Table 2-6. Sample Rating Factors for Severity of Environmental Impacts
or Consequences
Environmental impact severity (E) scale
5 = Severeimmediate threat likely to result in widespread damage to human health or
the environment; requires great effort to remediate or correct.
4 = Seriousno immediate health threat, but significantly damages the environment; dif-
ficult but possible to remediate.
3 = Moderatesomewhat harmful, but correctable.
2 = Mildsmall potential for harm to environment, correctable.
1 = Insignificanttrivial consequences, easily correctable or not impact.
Mission Impact Severity
In Table 2-7, the severity of mission impacts can be influenced by the fol-
lowing:
Priority or importance of the impacted missions (see Step 9)
Restriction of specific activities (digging, using smoke, etc.)
Duration restrictions (such as limiting boiler operations to 12 hours
per day)
Permanent versus temporary closure or restrictions of training ar-
eas or industrial processes
Availability of alternative training sites or training techniques.
Table 2-7. Sample Rating Factors for Severity of Mission Impacts
Mission impact severity (M) scale
5 = Loss of ability to accomplish critical mission or near mission failure.
4 = Severely degraded mission capability or serious mission restrictions.
3 = Moderate mission restrictions.
2 = Minor mission impacts or restrictions.
1 = Insignificant mission impacts or restrictions; alternative courses of action are avail-
able.
0 = No mission impacts or restrictions.
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Step-by-Step Guidance
Regulatory Impact
Impacts subject to federal or state regulations are automatically signifi-
cant. Situations involving a high risk of noncompliance demand increased
priority.
Table 2-8. Sample Rating Factors for Regulatory Status
Regulatory impact (R) scale
5 = Regulatednoncompliance condition; actual or possible enforcement action or NOV.
4 = Regulatedgenerally in compliance, but not completely controlled or managed;
some risk of noncompliance in future, or under scrutiny by regulators.
3 = Regulatedin compliance, well controlled or managed; little regulator interest.
2 = Likely to be regulated in future by federal, state, or host nation agency.
1 = Best management practice (BMP) applies.
0 = No requirements apply.
Community Concerns
When determining community concern ratings in Table 2-9, consider the
following actions or situations:
Lawsuits
Obstruction efforts
Negative or positive press coverage
Number and scope of citizen complaints
Community-generated political or regulator interest
Level of positive interaction with the local community.
Table 2-9. Sample Rating Factors for Community Concern
Community concern (C) scale
4 = Public outcry or lawsuits.
3 = Serious community concern, political or activist inquiries, intense negative media.
2 = Moderate community concern, some media coverage.
1 = Community is not currently concerned, but could become so.
0 = Community is ambivalent or unconcerned.
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Calculating Impact Significance Score
Calculate the impact significance score (SS), in the following example, as
SS = frequency x (environmental impact severity + mission impact sever-
ity) + regulatory status + community concern.
With the rating factors shown, the maximum possible SS for any given im-
pact is [5 x (5 + 5) + 5 + 4], or 59.
Examples
1. Assume you have five large boilers in operation on the installation that
heat water for subsequent distribution and use across all facilities. They
are oil-fired and regulated under a single Title V operating permit. The
boilers are designed for continuous operation and release air emissions in
amounts within the operating parameters prescribed in the permit. How-
ever, because you are located in a non-attainment area for sulfur and ni-
trogen oxides, these sources are under considerable regulator scrutiny,
and operation of the boilers has been restricted to 12 hours per day. This
in turn has required the installation to cut back on the operation of indoor
ranges and other indoor training facilities, resulting in some degradation of
operational readiness. No major issues about boiler operation exist within
the surrounding community.
Given this scenario, you might arrive at the following results:
Activity, product, or service: boiler operation
Environmental aspect: air emissions
Environmental impact: degraded air quality
Impact SS determination
> frequency of impact: 5 (happens daily for 12 hours per day)
> environmental impact severity: 2 (small potential for harm to the
environment, correctable)
> mission impact severity: 2 (moderate mission restrictions)
> regulatory status: 4 (in compliance, but strong regulator interest)
> community concern: 0 (public is not concerned).
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Step-by-Step Guidance
Applying these ratings to the equation yields the following:
SS = frequency x (environmental impact severity + mission impact sever-
ity) + regulatory status + community concern.
SS = 5 x (2 + 2) + 4 + 0 = 24.
2. Assume you are generating substantial quantities of spent solvents
across the installation during daily vehicle maintenance parts cleaning ac-
tivities and that the related environmental aspect you are evaluating is
spills. The spent solvents are not being recycled; consequently, they must
be temporarily stored on site until your supporting contractor picks them
up and transports them off-site for local disposal in accordance with
RCRA. You have been storing and disposing of spent solvents in this
manner for many years, having had only two minor spills (less than 10 gal-
lons) within the past year. In those instances, the spills were quickly con-
tained and cleaned up with only minor soil contamination, and no
disruption of maintenance operations occurred. However, a larger spill
could cause significant contamination of a nearby stream, seriously affect-
ing the local trout fishing industry. For this reason, local regulators are
closely watching this activity and have increased the frequency of unan-
nounced inspections. The local community has had minor concerns over
the past few years regarding the storage and transport of hazardous mate-
rials and wastes and the potential for spills, but restricting parts cleaning
activities or general solvent use has not been necessary.
Given this scenario, you might arrive at the following results:
Activity, product, or service: parts cleaning or degreasing
Environmental aspect: virgin or waste solvent spills
Environmental impact: contaminated soil or water
Impact SS determination
> Frequency of Impact: 3 (more than once a year, less than once
a month)
> Severity of Environmental Impact: 3 (harmful but not immedi-
ately fatal to humans or the environment, difficult but possible to
remediate)
> Severity of Mission Impact: 0 (no restrictions)
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> Regulatory Status: 4 (in compliance, but under scrutiny by regu-
lators)
> Community Concern: 2 (moderate community concern)
Applying these ratings to the equation yields the following:
SS = frequency x (environmental impact severity + mission impact sever-
ity) + regulatory status + community concern.
SS = 3x(3 + 0) + 4 + 2 = 15.
3. In this final scenario, consider the routine daily vehicle washing activi-
ties at the various vehicle maintenance facilities. All facilities use modern
wash racks that collect wastewater and process it through an oil/water
separator before discharge to the local municipal wastewater treatment
plant. Dirt, oil, grease, and other harmful wastes are collected from the
oil/water separators and disposed of in accordance with applicable regula-
tions. The total quantity of these wastes is generally very small from
month to month. No incidents involving harmful discharges from these fa-
cilities to the publicly owned treatment works (POTW) have occurred in
the past 5 years. Regulators do not have a special interest in vehicle
washing facilities at this time, and no major issues or concerns about ve-
hicle washing exist in the surrounding community. No restrictions exist on
vehicle washing. Restrictions would have little to no mission impact any-
way because vehicle washing is not a mission-critical activity.
Given this scenario, you might arrive at the following results:
Activity, product, or service: vehicle washing
Environmental aspect: water use, wastewater generation
Environmental impact: water resource depletion, degraded water
quality
Impact significance score determination
> Frequency of impact: 5 (occurs daily)
> Severity of environmental impact: 1 (insignificant)
> Severity of mission impact: 0 (no restrictions)
> Regulatory status: 3 (in compliance, well controlled)
> Community concern: 0 (community is not concerned)
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Step-by-Step Guidance
Applying these ratings to the equation yields the following result:
SS = frequency x (environmental impact severity + mission impact sever-
ity) + regulatory status + community concern.
SS = 5x(1 +0) + 3 + 0 = 8.
As in all previous steps, you should record the results of significance scor-
ing. To view the example aspects and impacts worksheet presented ear-
lier with a few sample entries, click here (the spreadsheet calculates the
significance score automatically on the basis of the values you input). Ig-
nore the far right column on the worksheet until you get to the end of this
step.
Determining Significant Impacts
Once you determine the significance score for each impact, you must then
decide which impacts are in fact significant.
The only required criterion for determining significance is regulatory
impact. If an impact is regulated by state or federal laws, the impact
(and the associated aspect) is considered significant.
In addition to determining significance by regulatory status, you should
rank all impacts by significance score and sort them from high to low. This
ranking helps identify impacts and aspects that are not regulated but still
significant, and helps establish priority among the significant regulated im-
pacts and aspects. Outside of the regulatory status requirement, you
have considerable flexibility in determining what impacts and as-
pects are significant. You could draw a numerical cut line (such as SS =
12) where all impacts having a significance score at or above the cut line
would be significant. Using this approach, both the first and second sce-
narios (boiler operation and solvent spills) would result in significant im-
pact designations (degraded air quality and soil or water contamination).
Tracking this back to the associated environmental aspects would then
result in air emissions and spills becoming significant aspects.
Another possible approach would be to look at the individual ratings that
you applied to each rating factor. For example, you might decide that any
actual or potential impact receiving one or more ratings as follows would
be considered significant regardless of its overall significance score:
Environmental impact severity rating of 3 or higher
Mission impact rating of 3 or higher
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Regulatory status rating of 3 or higher (anything regulated is signifi-
cant)
Community concern impact rating of 3 or 4.
Applying this approach would make the scenario 1 and 2 impacts signifi-
cant. The scoring system is a useful tool in this process, but you are
not obligated to use the numerical scores as your sole criteria for de-
termining significance. Use good judgment, and tailor the system to
your needs.
Cumulative Impacts and Significance
Also try to identify and address any impacts that may have a cumulative
effect. This is especially important when a large number of different activi-
ties, products, or services produce a common impact. Individually, the
significance scores for these impacts may be low, but in some cases, the
cumulative impact may be significant.
Determining Significant Aspects
As stated earlier, significant aspects are simply those that you determine
to have significant impacts. All you have to do at this point is to apply your
chosen approach to each impact and then document the results in the far
right column of the aspects and impacts worksheet by indicating yes or no
(click here).
Looking across the entire installation at all mission and functional areas,
activities, products, and services, you undoubtedly can identify a large
number of environmental aspects and impacts. However, many environ-
mental aspects and impacts repeat themselves. Once you compile a list-
ing of unique aspects and impacts, you will find that the total number is
much more manageable. In fact, after all is said and done, the significant
environmental aspects of the typical Army installation probably boil down
to some combination of the aspects listed in Step 17.
Review and Update of Significant Aspects
The installation must have a process to systematically identify changes in
activities, products and services that might drive changes to the installa-
tion's significant aspects. Review all functional areas and processes at
least annually to identify any changes. Be sure to ask functional area ex-
perts to identify any new processes or activities, products or functions that
have not been subjected to an aspect and impact analysis.
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Step-by-Step Guidance
Step 20. Develop or revise installation environmental
management programs.
Environmental Management
Programs, ISO 14001, Sec-
tion 4.3.4
Objective
Definition
Determine which environmental management programs (EMPs) are
needed and establish the framework for those programs.
The ISO 14001 definition of "program" differs from the Army's definition. In
ISO 14001, the term "environmental management programs" refers to ef-
forts smaller than Army program-level efforts. An EMP is a plan for ad-
dressing and managing significant aspects and associated objectives and
targets. In this guide, we use the ISO terminology and meaning for EMPs.
The Army recommends aligning EMPs with significant aspects, which
meets the ISO 14001 requirement for establishing and maintaining EMPs
to manage each objective and target.
Required Content
The EMP is a convenient way to organize activities and information within
your EMS. You are likely to have several EMPsone for each significant
aspect identified in Step 19. Each EMP should include the following:
Objectives and targets. How can we improve specific elements of
environmental performance, and how can success be docu-
mented?
Regulatory and other requirements (if applicable). What envi-
ronmental regulations, guidelines, or other agreements apply to the
significant aspect?
Responsibilities. What actions are required to manage the signifi-
cant aspect or achieve objectives and targets, and who is responsi-
ble? How is the EMP kept up to date? When appropriate,
personnel (or positions) should be designated at each relevant
function and level.
Operational controls. What operational controls or SOPs are
relevant in controlling the significant aspect? Where can these be
found?
Training. What training is required by ISO 14001, by environ-
mental or other regulations, or to improve performance and reach
specified targets?
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Resources. What human, technological, or financial allocations
are needed? Include specific funding amounts and sources (refer
to the hotlink in Chapter 1 for current, detailed information about
funding sources).
Action Plans, Milestones, and Timelines. How will the target be
achieved? Are there milestones and timelines to mark your pro-
gress? When are periodic reviews scheduled?
Measuring and monitoring. What must be measured or checked
to ensure EMP effectiveness, progress toward objectives and tar-
gets, or effective monitoring of significant aspects? How can you
be sure the measurements are accurate?
EMS performance records. What progress are we making toward
achieving objectives and targets? Are required actions being per-
formed?
In addition to EMPs for each significant aspect, you might also consider
developing EMPs for emergency preparedness and response procedures
or other issues not covered under significant aspects.
Coordination and Oversight
Updating
The EMSMR should coordinate and oversee the EMPs. In many cases,
Army installations are engaged in strategic planning efforts and have im-
plemented systems to track installation-level goals and objectives. If this
is the case on your installation, make sure that the EMS objectives and
EMPs are included in the strategic planning effort and the EMSMR is in-
volved.
Creating good EMPs is a challenge and may take several iterations to per-
fect. As you develop and use your EMPs, you will acquire new insights on
your significant aspects and associated processes and probably see the
need to make changes. This is why EMSs are built around the concept of
continual improvement. You need to modify your EMPs and related plan-
ning documents when
activities, products, services, and related objectives and targets
change;
objectives and targets are added;
relevant legal requirements are introduced or changed;
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Step-by-Step Guidance
substantial progress in achieving your objectives and targets has
been made (or has not been made); and
services, process, or facilities change or other issues arise.
Documentation and Records
Although the ISO 14001 standard only requires you to establish and main-
tain the EMPs, we recommend you develop and maintain documentation
pertaining to your EMPs in accordance with your installation's EMS docu-
ment control procedures. Records of EMP status and progress should
also be maintained, including summary sheets, meeting minutes, status
reports, in-process review (IPR) input, and other progress indicators.
Keep it simple. You may find it useful to establish a standard form that
summarizes the basic information for each EMP and its current completion
status. Click here to view sample forms for summarizing EMPs.
In Step 19, you identified your significant environmental aspects. In Step 20, you de-
termined your requirements for environmental management programs (from signifi-
cant aspects) and developed a framework for EMP content. Next, Steps 21-26
provide guidance for developing the essential contents of your EMPs.
Objectives and Targets,
ISO 14001, Section 4.3.3
Step 21. Establish environmental objectives and targets.
Objective
The objective of this step is to develop, maintain, and document objectives
and targets for the EMPs established in Step 20.
As stated in the introduction to the environmental aspects and impacts de-
velopment steps, your significant aspects provide the basis for establish-
ing objectives and targets, identifying training requirements, determining
requirements for operational controls and work procedures (such as
SOPs), performing general risk assessments, and completing periodic
management reviews. In this step, you focus on establishing environ-
mental objectives and targets.
Definition
ISO 14001 defines an environmental objective as "an overall environ-
mental goal, arising from the environmental policy, that an organization
sets itself to achieve, and which is quantified where practicable." In other
words, environmental objectives are goals the installation sets for itself,
usually over the long term, at each relevant functional and organizational
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level. For example, an installation that identifies hazardous waste genera-
tion as one of its significant aspects might establish a quantifiable (meas-
urable) reduction in hazardous waste generation as one of its long-term
objectives.
Similarly, ISO 14001 defines an environmental target as "a detailed per-
formance requirement, quantified where practicable, applicable to the or-
ganization or parts thereof, that arises from the environmental objectives
and that needs to be set and met in order to achieve those objectives."
Like objectives, environmental targets should be specific and measurable,
but they should also directly link to a specific time frame for accomplish-
ment. Continuing with the example above, an installation might require a
subordinate organization or organizations to reduce hazardous waste
generation by a specific amount (such as 10 percent or 2,000 pounds) by
a specific time (such as by 1 January 2004, or the end of FY04).
Generally, you want to establish at least one environmental target for each
environmental objective. In addition, your objectives and targets must
support mission accomplishment, be consistent with installation environ-
mental policy, and include a commitment to pollution prevention.
Determining Objectives
When determining environmental objectives, the installation should con-
sider the following:
Mission priorities (Step 9)
Applicable legal and other requirements (Step 15)
Identified significant environmental aspects and impacts, including
known obstacles to effective mission accomplishment
Installation sustainability (25-year) goals, if applicable
Ability to control the activities, products, or services involved
Ability to track, monitor, and measure results
Overall cost to track, monitor, and measure results
Technological options that are or will be available (such as green
bullets, alternative fuels, and hybrid electric vehicles)
Financial, operational, and functional requirements
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Step-by-Step Guidance
Views of interested parties
Linkage to the environmental policy statement.
As a principal consideration, your objectives and targets (at the floor level)
should facilitate mission accomplishment and help ensure continuous
compliance with all applicable legal and other requirements. As a ceiling,
however, installations can seek to go beyond compliance to ensure long-
term sustainability and establish objectives and targets that help them
achieve that end.
Establishing Objectives and Targets
To establish objectives and targets, you must first determine the level or
levels to which they apply (for example, the entire installation, certain units
or organizations, or individual functional areas) and who is responsible for
establishing them. A typical installation-level scenario is to have the CFT
that completed the aspects and impacts analysis recommend objectives
and targets, which the CDR or a designated representative (such as the
EMSMR) then reviews and approves. Another scenario has the CFT de-
veloping environmental objectives for the installation, and designated sub-
ordinate leaders (such as appropriate civilian functional managers and
tactical unit commanders) establishing environmental targets to ensure the
objectives are accomplished. Many alternative scenarios are possible, so
each installation should decide how to proceed at this point.
No "standard" environmental objectives and targets pertain to every instal-
lation. Your objectives and targets should reflect what your installation
does, how well it is performing, and what you want to achieve. Your ob-
jectives and targets must be readily understandable, measurable, and,
above all, realistic (achievable). Generally, you should undertake the fol-
lowing activities as you develop objectives and targets:
1. Involve the CFT. Quality input from the CFT expedites your instal-
lation's efforts to set realistic objectives and targets. Just as the
team provided knowledge and insight during aspects and impacts
analysis, it can quickly identify realistic and readily measurable ob-
jectives and targets consistent with command policy and guidance,
mission-related legal requirements, available resources, and envi-
ronmental aspects and impacts.
2. Gather information from available sources. A great deal of in-
formation should be readily available to the CFT from a number of
sources. Table 2-10 shows some sources. In addition, you can
take a physical walkthrough of facilities (such as heating plants,
motor pools, weapons system production facilities, firing ranges,
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and maneuver training areas) to identify other potential information
sources.
Table 2-10. Information Sources
Information source
Identified environmental aspects
Process maps
Waste and emission data
Site maps
ECAS/EPAS audit reports
Environmental Quality Report (EQR), Instal-
lation Status Report (ISR), Environmental
Program Requirements (EPR), Defense
Site Environmental Restoration Tracking
System (DSERTS), etc.
Possible benefit
Identify and target significant impacts
Identify process steps with environmental aspects
Determine current wastes and sources
Identify environmentally sensitive areas
Identify areas needing improvement
Evaluate environmental performance history
3. Identify preliminary environmental objectives. From the as-
pects and impacts of Steps 16-19, mission support requirements,
and your assessment of other available information, compile a list
of preliminary environmental objectives. It may be helpful to group
them by category as illustrated (Table 2-11). You can prioritize
your objectives, starting with those that relate directly to your sig-
nificant environmental aspects and mission critical tasks, and then
adding others that are less significant but still have mission or envi-
ronmental impact potential.
Table 2-11. Preliminary Environmental Objectives
Energy
use
Increase
alternative
fuel vehicle
use
Decrease
facility en-
ergy use
Raw
materials
Increase
vehicle bat-
tery recy-
cling
Increase
use of recy-
cled paper
Air
impacts
Reduce
VOC emis-
sions
Reduce
visible emis-
sions from
power plant
Water
impacts
Reduce
fuel spills
Eliminate
effluent
from vehi-
cle washing
facilities
Land
impacts
Reduce haz-
ardous waste
disposal from
vehicle main-
tenance fa-
cilities
Reduce land-
filling of solid
waste
Mission
impacts
Reduce op-
erational
noise levels
Address
endangered
species en-
croachment
in training
areas
Other
(specify)
Improve
employee
awareness
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Step-by-Step Guidance
A key question at this point is how many environmental objectives
you should have. Historical EMS implementation project case stud-
ies suggest starting with a limited number of objectives, and then
expanding the list over time. In other words, keep your objectives
simple initially, gain some early successes, and then build on them.
As a realistic starting point, consider limiting your initial list of major
objectives to 12 to 15, fewer if possible.
4. Identify new or proposed regulatory requirements. Identify new
or proposed requirements that affect (or could potentially affect) the
installation's operations or activities. Also, identify potential objec-
tives related to each requirement, as illustrated in Table 2-12.
Table 2-12. Regulatory Requirements and Objectives
New or proposed regulation
or other requirement
Possible objectives
New CAA national ambient air quality standard
(NAAQS) ozone standard
New CAA NAAQS PM2 5 standard
Reduce petroleum fuel consumption in administrative
vehicle fleet.
Reduce emissions of chlorofluorocarbons (CFCs)
from vehicle air conditioning units.
Reduce off-road vehicle travel.
Reduce particulate emissions from coal-and oil-fired
boilers.
5. Identify, review, and evaluate installation communications with
interested parties. Consider the need for additional environmental
objectives related to views of installation neighbors, community
groups, or other interested parties. By definition, an interested
party is "an individual or group concerned with or affected by the
environmental performance of the organization." You can hold an
open house or establish an installation focus group that includes lo-
cal community representatives. Table 2-13 provides an example of
how a local concern might translate into an installation environ-
mental objective:
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Table 2-13. Installation Communications
Communication with
interested party
Response
Possible objectives
Telephone discussion with Jim
Evans, president of Old Bridge
Estates subdivision HOA
(3/15/03, 703-590-5002). Con-
cerned with installation power
plant operation and visible emis-
sions potentially harming local
residents.
Discussed installation policy
regarding power plant opera-
tions and operating permit re-
quirements for controlling and
monitoring emissions. Advised
that we would establish objec-
tives to reduce emissions and
volunteered to attend next HOA
meeting.
Reduce visible emissions from
power plant.
Improve community outreach by
establishing a community advi-
sory panel.
6. Identify appropriate targets for achieving each objective. Envi-
ronmental targets are detailed performance requirements, quanti-
fied where practicable, that arise from the environmental objectives
and that the installation must meet in order to achieve the objec-
tives. Table 2-14 provides a few examples.
Table 2-14. Target Objectives
Objective
Reduce solid waste disposal
Reduce hazardous waste (HW) disposal
Reduce visible emissions from power plant
Reduce energy consumption
Improve employee environmental awareness
Target
Divert 40% of solid waste from landfilling
Reduce HW disposal by 20% from FY02
Reduce visible emissions 60% by 1QFY03
Reduce electricity use by 10% from FY02
Conduct awareness training for all employees by
the end of FY03
For each environmental objective, you should identify at least one
target (some objectives may have more than one). In addition to
being measurable, they should have a specific time frame for com-
pletion. Targets should be achievable, but difficult. The idea is to
motivate the organization to improve environmental performance.
7. Evaluate preliminary objectives and targets. Carefully evaluate
your preliminary objectives and targets to determine whether they
are reasonable, technologically feasible, measurable, consistent
with the environmental policy, and affordable. From your evalua-
tion, compile a final list of objectives and targets (if you identify an
objective but cannot determine an effective way to measure it, put it
on hold for further analysis).
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Step-by-Step Guidance
8. Establish performance measures for final objectives and tar-
gets. As stated earlier, you should quantify your environmental ob-
jectives and targets when practicable. The units commonly used to
quantify objectives and targets are environmental performance in-
dicators (EPIs). An EPI is "an expression that is used to provide in-
formation about environmental performance or the condition of the
environment." Examples of EPIs include the following:
> Quantity of raw material or energy used (total or per unit of pro-
duction)
> Quantity of specific pollutant emissions (for example, nitrogen
oxides (NOX), sulfur oxides (SOX), wastewater)
> Quantity of waste generated or disposed (total or per unit of
production)
> Efficiency of material and energy use
> Number of environmental incidents and accidents
> Number of enforcement actions received
> Number and amount of environmental fines or penalties as-
sessed and paid
> Percentage of waste recycled or reused
> Percentage of recycled material used in packaging
> Number of vehicle miles per unit of production or training
> Investment in environmental protection
> Land area set aside for wildlife habitat.
Continuing with previous illustrations, Table 2-15 shows a few examples.
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Table 2-15. Performance Measures for Final Objectives
Objective
Reduce solid waste dis-
posal
Reduce VOC emissions
Reduce energy con-
sumption
Eliminate enforcement
actions (ENFs)
Improve employee envi-
ronmental awareness
Target
Recycle 50% of solid waste in FY03
Divert 40% of solid waste in FY03
Reduce use of high-VOC paints by
25% in FY03
Reduce use of electricity by 10% in
FY03
No more than two ENFs per FY
Conduct monthly awareness courses
Train all employees by end of FY03
Performance indicator
Tons or % of solid waste recycled
Tons or % of solid waste diverted
Gallons or % reduction in high-
VOC paint used
kWh or % reduction in use
Number of ENFs received
Monthly training is conducted
Number or % of employees who
receive environmental training
9.
When developing your EPIs, be careful to choose those that reflect
the most accurate picture of what is happening on the ground. For
example, suppose that an industrial facility produces 500 main bat-
tle tanks each month and decides to set an objective to reduce
hazardous waste disposal by a certain quantity (tons or percent-
age) by a certain point in time compared with a specific baseline.
progress toward achieving the desired goal.
The facility then makes several process changes and decides to
use less hazardous substances during production to achieve its ob-
jective. If, however, the facility has to substantially increase pro-
duction (to say 750 units) to meet an emergency mission related
requirement, actual hazardous waste disposal might increase in
spite of the process changes. In this case, it probably would have
been better to choose an EPI that measured the tons or percentage
reduction per unit of production to more accurately measure actual
After developing your final list, you should formally document all
your objectives, targets, and EPIs. To view a sample objectives
and targets worksheet that you can use for this purpose, click here.
Identify responsible parties and ensure inclusion in appropri-
ate EM Ps. For each objective and associated targets, designate
CFT members (or other technically competent individuals) to be re-
sponsible for achieving them. Normally, this will be managed as
part of an environmental management program that prescribes
who, what, when, where, why, and how the specific objectives will
be achieved (see Step 20 for detailed guidance for preparing envi-
ronmental management programs).
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Step-by-Step Guidance
10. Document your procedure for developing environmental ob-
jectives and targets. In addition to keeping records of your objec-
tives and targets, you should formally document the specific
procedure you used to develop them. You should then use the
same procedure to complete periodic updates and revise the pro-
cedure as needed to ensure continual improvement. To view an
example procedure that Fort Lewis uses for developing objectives
and targets, click here.
Step 22. Describe structure and responsibilities.
Structure and Responsibility,
ISO 14001, Section 4.4.1
Objective
Confirm and document the organization and structure of EMPs that consti-
tute the installation EMS and the associated individual and organizational
Army installations already have the organization, staffing, programs, and resources to
conform to the ISO requirements for structure and responsibility. This step develops
or provides documentation that describes the existing organization and how it imple-
ments and operates the EMPs and the EMS.
responsibilities for implementing and operating the EMS.
Appointing a Management Representative
ISO 14001 requires top management to appoint a specific management
representative who, regardless of other responsibilities, has the responsi-
bility and authority for
ensuring that EMS requirements are established, implemented, and
maintained in accordance with the ISO 14001 standard, and
reporting on the performance of the EMS to top management for
review and as a basis for improvement of the EMS.
We recommended selecting the EMSMR in Step 1.
Organizational Chart
You probably already have one, and it is a very convenient tool for docu-
menting and explaining your organizational structure and responsibilities.
Include a current organizational chart with your EMS documentation for
roles and responsibilities. Click here to view an example organization al
chart.
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EMS Organizational Responsibilities Table
A table or matrix is a simple and effective way to summarize EMS respon-
sibilities. The table should list the EMSMR, CFT members, and individu-
als responsible for the EMPs. You can then refer the reader to the
individual EMPs for further information. ISO 14001 does not require a ta-
ble or form, but it is probably the simplest way to summarize and docu-
ment EMS-related responsibilities. Include a reference or direction to the
responsibilities table in your EMS manual. Click here to view an example
EMS responsibilities list.
Review and Update
Your document control procedure (Step 13) should describe how informa-
tion on structure and responsibilities is periodically reviewed and updated.
Step 23. Develop SOPs and work practices for activities
associated with significant aspects.
Operational Control, ISO
14001, Section 4.4.6
Objective
Systematically develop, revise, and document the SOPs associated with
all activities, products, and services that have environmental impacts and
associated aspects to describe the appropriate actions for managing those
impacts and aspects.
Installations should already have SOPs or work practice instructions
(called operational controls in the ISO 14001 standard) for most complex
operations or mission activities, including those with associated significant
environmental aspects. This step ensures that SOPs are in place and that
they contain instructions that enable personnel to comply with the envi-
ronmental policy and achieve environmental objectives and targets. This
information should also be consistent with information presented in com-
petency-based training (Step 24).
Where to Start
Begin this step by reviewing your prioritized list of significant aspects and
impacts. Start with the operations or mission activities at the top of that
list (most significant impacts), and identify any SOPs that address those
activities. Make sure the SOPs adequately address all the skills and pro-
cedures needed to perform the activity in an environmentally acceptable
manner. If part of the process is not documented, the area supervisor
needs to create a new SOP or modify the existing one.
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Step-by-Step Guidance
What to Include
Remember that one of the central ideas of the EMS concept is to integrate
sound environmental management practices in day-to-day operations.
Here, you can affect how employees perform their routine daily tasks. For
example, if the goal is to recycle certain used materials, make recycling a
part of the relevant SOPs. The result should be SOPs that get the job
done and mitigate environmental impacts.
Scheduling Work
You may find it useful to develop a schedule for reviewing and revising
SOPs from your prioritized list of significant aspects. Some installations
have found it effective to coordinate the execution of Steps 23 and 24 so
that SOPs are reviewed and updated immediately before or after compe-
tency-based training is conducted.
After all significant impacts and associated aspects are addressed in
SOPs, you should continue by routinely reviewing all SOPs for environ-
mental considerations as they are revised or updated. You can do so by
modifying your installation's staffing procedures to include appropriate en-
vironmental review and approval.
Operational controls and SOPs and work practice instructions should
be easy to understand and use,
list personnel who should receive or have access to them, and
identify the training needed for the appropriate personnel.28
Your document control procedure (Step 13) should include requirements
and responsibilities for developing, maintaining, and reviewing operational
controls, SOPs, and work practices.
Training, Awareness
and Competency, ISO
14001, Section 4.4.2
Step 24. Identify and fulfill environmental competency-based
training requirements for all installation personnel (garrison
and tenants).
Objective
Establish and maintain a system or process to ensure job-specific compe-
tency for all employees whose work activities can cause real or potential
significant environmental impacts.
98
Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 45.
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Who Must Be Trained
We addressed the awareness portion of this requirement in Step 11. Step 24 deals
with the competency-based training. While all installation personnel are required to
complete EMS awareness training, competency-based environmental training is re-
quired only for those whose work activities can significantly impact the environment.
The first step in meeting this requirement is identifying employees who
need competency-based environmental training. Most installations al-
ready have a training office and a centralized system for managing indi-
vidual training requirements. Try to work within your existing system.
Your installation training coordinator can help complete this requirement.
After looking at the existing training management process, review the list
of significant environmental aspects and impacts (Step19). Employees
performing work or mission activities associated with these significant im-
pacts need competency-based training. When reviewing significant im-
pacts, look at the entire work process to identify all employees who need
the training. It may also help to look at the various regulatory require-
ments that mandate special environmental training and include personnel
working in those areas (Step 15). Be sure to include contract and tempo-
rary workers when assessing training needs.
What Must Be Trained
Competency-based training requirements must be relevant to specific
work activities or job descriptions. The level of training required may also
vary according the level of responsibility assigned to various grade levels
or military ranks. At a minimum, the competency-based training must in-
clude the following:
The significant environmental impacts, actual or potential, of their
work activities and the environmental benefits of improved personal
performance
Specific objectives and targets related to their work activities
The potential consequences of departure from specified operating
procedures (Step 23)
Environmental training required by applicable regulatory require-
ments
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Step-by-Step Guidance
Training necessary to obtain or retain required licenses or registra-
tions
Environmental benefits of improved personal performance.29
Organizing Competency-Based Training
Since competency-based training is more specialized than the awareness
training, addressing competency-based requirements process by process,
or mission by mission is useful. Begin by examining the activities that
contribute to your most significant aspect. Look at the processes, identify
the employees and job descriptions involved, and determine what they
need to know to perform their missions or jobs in an environmentally re-
sponsible manner. Get input from experienced employees or supervisors
as you determine training needs. They are the real experts in their par-
ticular areas and can quickly tell you what will work and what will not.
It may take a while to address all significant impacts and processes, so
develop a schedule and stick to it.
Options for Providing the Training
Competency-based training does not always have to take place in a class-
room. On-the-job training, brownbag sessions, and computer-based train-
ing are good alternatives.
Training Records
You must keep records of the training performed in order to conform to the
ISO 14001 standard. Training records must include the following:
Individuals and job descriptions requiring training
Information or skills taught (lesson outline or plan)
Requirements for completion (written test, hands-on exercise, etc.)
Schedule or timetable
Attendance records (include a sign-in sheet)
Results of evaluation (pass or fail, go/no go).
29 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 35.
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ISO 14001 does not require documentation of training procedures, but we
recommend you develop training documentation that includes
the process the installation uses to determine training needs,
the location of the training plans and who is responsible for them,
and
how training is prioritized on the installation.
The Army is one of the most experienced training organizations in the world.
If you follow the training procedures the Army uses to teach soldier skills, you will
meet the ISO requirements. Make maximum use of available assets, including the
training management systems and expert training personnel on your installation.
Your training program is an ongoing function on the installation. You must
continually assess and update installation-specific training needs. Keep
procedures and records in accordance with your installation's document
control and record-keeping procedures.
Obtaining Training Materials
Because of the specialized nature of competency-based training, you may
have to obtain information from a variety of sources or develop lessons "in
house" to meet your needs. However, all Army installations share many
similar functions, and good training materials will become readily available
as more installations implement their EMS. Before developing training
materials in house, check the sources that follow to see whether existing
materials can meet your needs:
Training posted on DENIX
Other installations with similar missions
Training workshops
Training videos
Internal trainers
Experts
Consultants
Community colleges
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Step-by-Step Guidance
Vendors and suppliers
Technical, trade, and business associations
Self-study or study groups
Training consortia (major command or IMA region meetings).
Click here for additional resources regarding competency-based training.
Step 25. Establish monitoring and measurement Monitoring and Measurement,
procedures. ' ISOMOOL section «.i
Objective
Establish and maintain documented procedures as required by ISO
14001, Sec 4.5.1, to
regularly monitor and measure the key characteristics of your op-
erations and activities that can significantly impact the environment;
Key characteristics are the environmental performance indicators established for each
target set in Step 21.
Performance indicators should be simple and understandable, objective, measurable,
verifiable, reproducible, and relevant to your installation's objectives and targets.
They should also be practical, cost-effective, and technologically feasible. The identi-
fication of environmental performance indicators should be an ongoing process (ISO
14004, p. 21). Your performance indicators must provide top management with the
information it needs to make decisions about the EMS (NSF-ISR, p. 62).
track environmental performance (including progress toward meet-
ing objectives and targets and conformance with SOPs);
calibrate and maintain monitoring equipment and maintain records
of the calibration process; and
periodically evaluate compliance with relevant environmental laws
and legislation.
What Should Be Measured?
Two major sets of activities or processes should be measured and moni-
tored:
Processes associated with significant aspects all require some sort
of monitoring or measurement. Sophisticated techniques and
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automated systems are usually not required, but if a process is as-
sociated with a significant aspect, someone should be checking
performance.
The group of processes related to objectives and targets requires
monitoring. These are actually a subset of the first group, and are
probably a higher priority since you specifically identified these ar-
eas for improvement. You can begin by reviewing your installa-
tion's list of objectives and targets and the associated and the
associated performance measures (Step 21).
You must eventually define required measuring and monitoring for all sig-
nificant aspects, but the first priority should relate to the objectives and tar-
gets.
Examine the performance measures (key characteristics) developed in
Step 21. Do you already have an accurate and reliable way to monitor
and measure these variables? At this point, check with the environmental
management staff and with the supervisors in charge of these processes
to determine what is already being measured and monitored. Some of the
monitoring you need is probably already being done.
For each of the key characteristics you need to monitor, think about the
following:
Is the required monitoring already being done?
If so, is the method
> providing accurate data? (Performed using valid, documented
procedures and calibrated equipment?)
> reliable? (Performed successfully on a regular schedule, with
data recorded and maintained according to documented proce-
dures?)
> performed at an appropriate frequency? (You need multiple data
points to track variables and interpret performance over a time
period. Recommended frequency depends on the variable be-
ing measured and the changes you need to demonstrate.)
If your current monitoring procedures do not satisfy these requirements,
you should examine the procedures and equipment to determine needed
improvements. Likewise, if you need to implement new monitoring pro-
grams, be sure that the procedures meet these requirements and provide
the data you need to effectively evaluate performance.
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Step-by-Step Guidance
"Monitoring and measuring can be a resource-intensive effort."30 Be cer-
tain to have clearly defined requirements for data collection and to avoid
collecting data for "data's sake."31
Ensure your installation has a clear, well-communicated schedule for rou-
tine monitoring and measurement and equipment calibration. In your
schedule, include time for proper data management and quality control
procedures.
Record, Analyze, and Understand Data
Monitoring programs are useless if you cannot correlate the measured
data with performance. To do so, you must accurately record the data you
are collecting and maintain it in format that illustrates any changes in per-
formance. Involve the supervisors and employees who work in the proc-
ess being measured; ensure they understand the data being collected and
how it relates to both the performance measures and the objectives and
targets.
Often, your performance measures will accurately document performance
but will not tell why the process is working better or worse. Understanding
the variables or factors that affect performance is critical to analyzing your
data and assessing your progress toward objectives and targets. A root
cause analysis, such as those performed as part of ERAS audits, can be
valuable. Also, supervisors and line employees can often provide quick
analyses of process performance and the factors affecting it. They can
help you identify what to change to obtain the results you want and can
often explain how underlying or uncontrolled variables are influencing per-
formance.
Tracking Performance
The ISO 14001 standard requires you to track performance of your signifi-
cant processes using performance measure data and evaluate your pro-
gress toward objectives and targets. This periodic evaluation ensures that
you are consistently moving toward the established objectives. If the proc-
ess is not meeting the established objectives and targets, you must de-
termine why and make changes to improve performance. For some
processes, you can establish operating parameters that apply to your per-
formance measures. Performance data that fall outside of your estab-
lished operating parameters indicate subpar performance and should
30 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 60.
31 NSF-ISR, Environmental Management S
Small and Medium-Sized Organizations, p. 60.
31 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
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trigger evaluation of and adjustments to the process. Maintain perform-
ance records in accordance with your EMS records procedure.
Also, remember to look at SOPs and make sure they accurately describe
appropriate ways to perform duties and operate the process. After verify-
ing that the SOP is correct, ensure that employees are following it.
Calibration Requirements
Some measurements involve equipment such as scales, meters, and
other measurement devices. Proper and accurate functioning of these
items is critical to your success. Review the manufacturer's recommenda-
tions and document a calibration and testing procedure. Maintain the pro-
cedures, required calibration and testing schedules, and calibration and
testing records in accordance with your document control and records
maintenance procedures.
Evaluate Compliance with Environmental Laws and Regulations
In addition to meeting your objectives and targets, you need to periodically
check your regulatory compliance status. From Step 15, you know the
regulations and laws that apply to your installation and its activities. To
meet the ISO 14001 requirement, you must document the procedures you
use to periodically check compliance. Army installations have been doing
this for many years, and you probably already have these procedures in
place (such as ECAS/EPAS, internal and external assessments, and ISR
II). In most cases, your main task will be to check the documentation and
records for these processes and maintain the information in accordance
with your established procedures. Typical processes for ensuring compli-
ance include periodic inspections, as well daily, weekly, or monthly moni-
toring of critical process (wastewater treatment monitoring to satisfy the
national pollutant discharge elimination system (NPDES) permits, for ex-
ample). Also, internal and external audits performed as part of the EPAS
program can provide periodic snapshots of regulatory compliance. Be
sure to check installation compliance action plans (ICAPs) to verify that
existing compliance problems are being properly addressed.
Click here for example measuring and monitoring procedures.
Step 26. Establish procedures for maintaining EMS records. *enc°rdf' '5° A c,
r r & 14001, Section 4.5.3
Objective
Develop and implement procedures for managing records that document
EMS operation and performance.
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Step-by-Step Guidance
Definition
ISO 14001 requires organizations (such as installations and other appro-
priate facilities) to "establish and maintain procedures for the identification,
maintenance and disposition of environmental records. These records
shall include training records and the results of audits and reviews."32
The records are the information that must be maintained to document the
performance of the EMS and to demonstrate conformance with the ISO
14001 standard (Figure 2-4). Keeping complete and well organized envi-
ronmental records is critical, not only because of the ISO requirement, but
also because the records help you track environmental performance and
improve the EMS.
Figure 2-4. EMS Document Hierarchy
EMS Documentation
provides policy and
direction
Operational Controls
EMS Records describe results
You can organize your records in a variety of ways, such as according to
EMPs. Some types of records, like audit reports, include information cov-
ering multiple EMPs and might be stored in their own specific files. Using
an electronic database with search capabilities greatly increases the flexi-
bility of your record-keeping system and will resolve most file location is-
sues.
32
ISO 14001, Section 4.5.3, p.5.
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Hints for Records
Begin by identifying the records required. Look at your procedures and SOPs
to determine the evidence needed to demonstrate conformance. Also,
consider records that must be generated due to various legal requirements.
Focus on records that add value.
If you generated forms in order to implement the EMS, the forms, once filled
out, become records. Keep forms simple and understandable.
Establish a records retention policy and stick to it. Include records retention
requirements specified in applicable environmental regulations.
When formulating your records management process, consider the people
who need access to the records and the circumstances.
Consider using an electronic EMS records management system.
Think about which records need additional security or restricted access.
Consider a remote backup of critical records at another location.
Records must be
legible;
identifiable and traceable to the activity, product, or service in-
volved;
stored and maintained to be readily retrievable and protected
against damage, deterioration, or loss; and
kept in accordance with established and recorded retention times.
Make sure your records policy answers the following questions:
What records are kept?
Who keeps them?
Where are they kept?
How are they kept?
How long are they kept?
How are they accessed?
How are they disposed of?
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Step-by-Step Guidance
In addition to training records and audit results, records may also include
the following:
Legislative and regulatory requirements
Compliance records
Job descriptions
Permits, licenses, and other approvals
Environmental aspects and their associated impacts
Environmental training records
Equipment inspection, calibration, and maintenance activity and re-
cords
Sampling and monitoring data
Information on emergency preparedness and response
Details of nonconformance, incidents, complaints, external commu-
nications, and follow-up action
Supplier and contractor information33
Results of EMS audits and management reviews.
"The effective management of these records is essential to the successful
implementation of the EMS."34
Click here for examples of EMS record maintenance procedures used
successfully at other Army installations.
Step 27. Develop and review emergency preparedness
and response documents and procedures.
Emergency Preparedness
and Response, ISO 14001,
Section 4.4.7
Objective
Establish and maintain procedures as required by ISO 14001 to:
Identify potential for accidents and emergency situations.
Respond to accidents and emergency situations.
33 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 50.
34 ISO 14004, Section 4.4.4, p. 22.
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Prevent and mitigate the environmental impacts that may be asso-
ciated with accidents and emergencies.
Review and revise emergency preparedness and response proce-
dures where necessary, especially after the occurrence of an acci-
dent or emergency.
Conduct drills and tests of emergency preparedness and response
procedures
Potential environmental accidents and emergency situations include
accidental emissions to the atmosphere,
accidental discharges to water and land,
specific environment and ecosystem effects from accidental releases, and
fire.
(ISO 14004 and Concurrent Technologies Corporation for U. S. Army, Environmental
Management System Guidance Manual: Implementing ISO 14001)
You should also consider emergency situations resulting from terrorist or
other intentional acts that might impact the environment when developing
and reviewing emergency preparedness and response documents and
procedures.
On most Army installations, the required plans and procedures are already
in place as required documentation per Army policy, so reviewing and
documenting the location and maintenance of the plans constitutes most
of your work.
Key Team Members
Emergency preparedness and response normally involve multiple organi-
zations on and off the installation. All participants must work together to
develop detailed plans and execute quick, coordinated responses. The
CDR is ultimately responsible for these operations but, in most cases, re-
lies on the staff to coordinate and execute the technical aspects of the re-
sponse. On medium and large installations, key individuals in this process
are the heads of the fire and emergency services organizations. They are
most likely to manage the execution of any response. Other key organiza-
tions include the following:
Medical services (casualty management)
Military police or public safety (traffic control)
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Step-by-Step Guidance
Public works (infrastructure and utility systems)
Preventive medicine and environmental health (human health risk
issues)
Safety
Environmental management
Public affairs
Off-post responders (local hospitals, fire departments, and hazard-
ous materials (HAZMAT) units)
Counter-terrorism officials (if applicable).
Determine Emergency Plans and Procedures
First, determine the plans and procedures required by laws and regula-
tions. Depending upon the nature of their missions and operations, Army
installations are often required by law to maintain the following:
Risk management plan (a CAA Section 112r requirement for instal-
lations that stock certain chemicals above threshold quantities)
Spill contingency plan (SCP) and spill prevention, control, and
countermeasures plan (SPCCP) to address potential oil spills
RCRA contingency plan
Facility response plan (FRP)
Chemical accident/incident response and assistance (CAIRA) plan.
In addition, your state may require specific plans covering certain contin-
gencies. Check your state's requirements during this process.
To complete your list of required response plans, look at other areas or
operations on your installation that have the potential for environmental
accidents or releases not covered by laws and regulations. One way is to
look at the hazardous or regulated materials used on the installation. In
most cases, they will be addressed under the laws and regulations dis-
cussed earlier and will be included in an existing plan. If not, you should
make sure they are included.
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Review and Update Your Response Plans
Your document control procedures (Step 13) must include requirements
and responsibilities for reviewing and updating emergency response plans
at least annually. Key team members should participate in the review, and
the results should be recorded as part of the review process. The major
purpose of the review is to identify changes on the installation that affect
plan execution. Be sure to review attachments to the plans, such as con-
tact names and phone numbers, maps, facility floor plans, and material
safety data sheets (MSDSs). These details often change and can seri-
ously compromise the plan. As you review the plans, ensure that they
meet the ISO 14001 requirements listed at the beginning of this step.
Posting and Distributing Plans
Make sure that employees can easily access plans and that they under-
stand what they are expected to do in case of an emergency. Maintaining
the plans on your intranet helps document control issues, but you may
also want to post hard copies of the plans in affected organizations and
work areas to ensure easy access. Observe document control procedures
and remove outdated versions of the plans from the involved organiza-
tions and work areas. Include off-post responder organizations.
Training and Exercises
Competency-based training (Step 24) must cover the emergency prepar-
edness or response plans. When feasible, you should conduct no-notice
drills or exercises to test the ability of employees and responders to react
quickly and correctly in case of emergencies. When you conduct an exer-
cise (or after an actual emergency), hold an after-action review (AAR),
keep records of the results, and revise the affected plans as required.
Documentation
Maintain the following documentation in accordance with your EMS docu-
ment control procedures:
A procedure for identifying the potential for environmental accidents
and emergencies (risk assessment)
All installation environmental accident and emergency response
plans and procedures
Documentation on how the installation works to prevent such inci-
dents and the associated environmental impacts (provide the loca-
tion of procedures for fire, safety, HAZMAT storage, and hazardous
waste accumulation point inspections)
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Step-by-Step Guidance
Mitigation procedures for impacts associated with accident and
emergencies (covered in your response plans)
Emergency preparedness and response document review and test-
ing processes.
Click here for example procedures covering emergency preparedness and
response.
Step 28. Establish procedures for nonconformance
and preventive and corrective actions
Nonconformance,
corrective and pre-
ventive action, ISO
14001, Sec. 4.5.2
Objective
Definition
At this point, you have taken great strides in establishing and implement-
ing the EMS, but your EMS is not perfect. To deal with imperfections
some of which may have been identified from measuring, monitoring, au-
dits, and other reviewsand to adapt to changes on the installation, you
must develop procedures for dealing with nonconformance.
Develop and implement procedures that meet the ISO 14001 require-
ments for
defining responsibility and authority for handling and investigating
nonconformance,
taking action to mitigate any resulting impacts,
initiating and completing preventive and corrective actions, and
implementing changes to EMS procedures as a result of preventive
or corrective actions.
Nonconformance refers to situations or actions that do not meet or comply
with the requirements established in the your installation's EMS or the ISO
14001 standard. Nonconformance can also mean that implementation is
not consistent with the EMS description.35
35
NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 65.
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Typical causes of nonconformance include
poor communication,
faulty or missing procedures,
equipment malfunction (or lack of maintenance),
lack of training,
lack of understanding requirements,
failure to enforce rules, and
corrective actions that fail to address root causes of problems.
(NSF p. 66)
Means of identifying potential or real nonconformance include
findings, conclusions, and recommendations reached as a result of
measuring and monitoring;
audits and other reviews;
accidents;
employee comments; and
changes in installation activities or structure.
Responsibilities and Authorities
Processes
Your nonconformance procedures must establish the nonconformance re-
sponsibilities and authorities for the various organizations and individuals
involved in the EMS. Organize this information with a table or separate
paragraphs covering each position or organization, as seen in Army regu-
lations. Click here for some examples. Whatever the format, everyone on
the installation, from the CDR and supervisors to individual employees,
must understand what they can and must do to address nonconforming
situations.
Your procedures must include instructions for completing several standard
actions designed to identify and respond to nonconformances:
Identifying and Reporting. Guidance for individuals who identify a
potential nonconformance, including to whom one reports and how
to document the report.
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Step-by-Step Guidance
Investigation and Analysis. Guidance for determining who has
the authority and responsibility to investigate nonconformance, the
steps to be included in the process, documentation of the results,
and who receives the results of the investigation.
Mitigation of Impacts. For nonconformance that impacts the envi-
ronment, guidance on who is responsible for mitigation and who
approves and provides oversight on the mitigation activities.
Corrective and Preventive Actions. Guidance for preventing the
nonconformance from occurring again, including the individuals or
groups responsible for formulating the preventive actions and en-
suring that the preventive actions are implemented and incorpo-
rated in existing EMS documentation.
General Principles
In any nonconformance situation, the parties responsible for addressing
the nonconformance must perform several key activities to correctly as-
sess and respond to the problem. Ensure that your nonconformance pro-
cedures include the following:
Determine the root cause.
Develop the appropriate corrective or preventive action.
Document the corrective or preventive action. (The amount of plan-
ning and documentation varies with the severity of the problem and
its potential environmental impacts. Try to keep things simple:36)
Implement the corrective or preventive action.
Record the documentation and implementation of the corrective or
preventive action.
Communicate the corrective or preventive action.
Track and verify the effectiveness of corrective or preventive ac-
tions.
By analyzing system deficiencies, attempting to determine the root cause,
or identifying why the problems are actually occurring, you may be able to
detect patterns or trends. "Identifying trends allows you to anticipate and
prevent future problems. Preventing problems is generally cheaper than
36 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 66.
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fixing them after they occur (or after they reoccur)."37 When a problem is
documented, the installation commits to quickly resolving it. Be certain the
corrective and preventive action process developed includes responsibili-
ties and completion schedules. If the action is going to be lengthy or re-
source intensive, review progress regularly.
The corrective action should
resolve the immediate problem,
consider whether the same or similar problems exist elsewhere, and
prevent the problem from recurring.
The corrective action process should also define the responsibilities and schedules
associated with these three steps.
(NSF p. 66)
Furthermore, you must ensure that any corrective or preventive action
taken to eliminate the causes of actual and potential nonconformances
must be appropriate to the magnitude of problems and commensurate
with the environmental impact encountered.38 Changes in the EMS
documented procedures that result from any corrective or preventive ac-
tion must be implemented and recorded. In addition, the installation must
ensure that these corrective and preventive actions have been imple-
mented and that systematic follow-up ensures their effectiveness.39
If your installation has an ISO 9001 management system in place, use the
ISO 9001 corrective and preventive action process as a model for this
EMS corrective and preventive action procedure.40 Consider incorporating
parts of the corrective action process with the management review proc-
ess. For example, use the management review meetings to review non-
conformities, discuss causes and trends, and identify corrective actions
and assign responsibilities.41
ISO 14001 requires only that organizations establish and maintain proce-
dures for nonconformance and corrective and preventive action. We rec-
ommend that you document these procedures to ensure consistency and
understanding across the installation.
37 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 65.
38 ISO 14001, Section 4.5.2, p. 5.
39 ISO 14004, Section 4.4.3, p. 22.
40 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 65.
41 NSF-ISR, Environmental Management S
Small and Medium-Sized Organizations, p. 65.
41 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
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Step-by-Step Guidance
Environmental Management Sys-
Step 29. Conduct periodic EMS audits.
r r tern Audits, IS014001, Sec 4.5.4
Objective
Establish and maintain programs and procedures for periodic EMS audits
to do the following:
Determine whether the EMS operates in accordance with docu-
mented procedures and the ISO 14001 standard.
Determine whether the EMS has been properly implemented and
maintained.
Provide audit results information to management.
Base the audit coverage on environmental importance and previous
audit results.
Include the scope, frequency, methods, responsibilities, and re-
quirements for conducting audits, measures to ensure auditor com-
petence, and reporting results.
Definition
ISO 14001 defines EMS audits as "systematic and documented verifica-
tion process of objectively obtaining and evaluating evidence to determine
whether an organization's environmental management system conforms
to the environmental management system audit criteria set by the organi-
zation, and or communication of the results of this process to manage-
ment."
Who Can Conduct Audits?
EMS audits can be performed by installation personnel or by external par-
ties selected by the installation. The ERAS program, which we detail be-
low, provides internal audit protocols and external audit support for Army
installations. If your installation is ISO 9001-conformant, consider using
your internal quality auditors as your internal EMS auditors.42 Regardless
whom you choose to perform audits, they must be properly trained. Train-
ing can come from a variety of sources, including on the job, on-line or
correspondence courses, or classroom auditor training. Finally, your EMS
42 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 72.
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auditors must be able to audit objectively and impartially.43 To help en-
sure objectivity, select auditors from outside the activity or chain of com-
mand of the activity being audited. When selecting external EMS auditors,
installations should consider using ISO 14012 "Guidelines for Environ-
mental AuditingQualification Criteria for Environmental Auditors" as their
selection criteria. Some installations recommend pairing an auditor from
an external organization (for objectivity) with an auditor within the activity
(for process and procedural knowledge.)
Frequency and Scope
The nature of the installation's environmental aspects and potential im-
pacts, as well as the previous audit's results, should guide the frequency
of the audits. Each organization has considerable flexibility as to how and
when it conducts internal audits. Do not wait until the EMS is fully imple-
mented and documented before conducting the first audit. Audits can oc-
cur simultaneously with implementation.44
You are not required to audit the entire EMS at one time. You may break
the EMS into discrete elements to allow for more frequent audits. In
general, each part of the entire EMS should be audited at least annually,
more often if warranted. Audit coverage should be prioritized using two
criteria: environmental significance and prior audit results. You should
audit areas with significant environmental impacts early and often. Like-
wise, operations or processes with a history of nonconformance (discov-
ered by audit results, regulatory violations, or other reporting) must also be
a high audit priority.
Objectives of EMS Audits
"Your EMS audits should focus on objective evidence of conformance.
During an audit, auditors should resist the temptation to evaluate, for ex-
ample, why a procedure was not followed-that step comes later."46 The
EMS "audit is a check on how well your system meets your own estab-
lished EMS requirements. An EMS audit is not an assessment of how
well employees do their jobs."47 Audits, if done properly, can provide
benefits beyond meeting the ISO requirement. They can identify and help
43 ISO 14004, Section 4.4.5, p. 22.
44 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 51.
45 NSF-ISR, Environmental Management S
Small and Medium-Sized Organizations, p. 71.
46 NSF-ISR, Environmental Management S
Small and Medium-Sized Organizations, p. 72.
47 NSF-ISR, Environmental Management S
Small and Medium-Sized Organizations, p. 73.
45 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
46 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
47 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
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Step-by-Step Guidance
correct nonconformities before any significant environmental impacts re-
sult. Audits can help you fine-tune your EMS to optimize environmental
(and mission) performance.
Figure 2-5. Linkages Among EMS Audits, Corrective Action, and
Management Reviews
48
Results
EMS Established
r Periodic EMS Audits
i
,
(
r
Management Reviews
Corrective Action Process
Records of audit results must be maintained and communicated to con-
form with the requirements of IS014001. Audit results are one form of
EMS performance information that must always be communicated to
management. Recording audit results allows monitoring of corrective ac-
tions.49 Because audit results are EMS records, consider creating and us-
ing a template for documenting audit results. Although not a formal
requirement, it may ease compliance with your EMS's records and docu-
mentation requirements. Furthermore, installations should "ensure that
identified system gaps or deficiencies are corrected in a timely fashion and
that corrective actions are documented."50
You need a documented audit procedure that addresses
audit scope (including the activities and areas considered in audits),
audit protocols,
audit criteria,
audit frequency,
auditor training and competence requirements,
responsibilities and requirements for managing and conducting audits, and
responsibilities and requirements for documenting, reporting, and communi-
cating results.
Source: ISO 14001
48 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 73.
49 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 51.
50 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 72.
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ERAS
For the past several years, EGAS has provided comprehensive environ-
mental compliance audits for installations. EGAS is now transforming into
the ERAS, with a new focus on EMS and management issues. Many de-
tails of the ERAS program are still being developed, but it will provide ex-
ternal audit assistance for at least some elements of your EMS. Due to
resource constraints, annual ERAS audits at all installations are unlikely,
but audit protocols and other audit tools from ERAS will be made available
to installations as the tools are developed and fielded. The ERAS team
leader schedules periodic ERAS external assessments with input from
Army leadership, the IMA, and installation staffs. These ERAS audit tools
can help you establish your internal EMS audit procedures. ERAS will still
provide compliance auditing support to help meet the compliance auditing
requirements of EO 13148.
Click here for ERAS audit procedures, checklists, and example audit re-
sults.
Self-Declaration Procedures
Army EMS policy requires appropriate facilities to achieve full confor-
mance with the ISO 14001 standard by 31 December 2009. Third party
registration to the standard is not required, but facilities must follow Army
procedures for self-declaration of conformance in order to meet the FY09
requirement. The self-declaration procedures require confirmation of con-
formance by either an internal or external ERAS audit before facilities can
self-declare, or publicly assert that they conform to the ISO 14001 stan-
dard. Click here to view the Army self-declaration procedure.
Step 30. Conduct periodic EMS management reviews.
Management Review,
ISO 14001, Section 4.6
Objective
Establish procedures for top management to periodically review the per-
formance of the EMS.
As part of a continual improvement process, the ISO 14001 standard re-
quires an organization's top management (EQCC or similar group) to re-
view the EMS, at intervals that it determines, to ensure that the EMS is
working (suitable, adequate, and effective, given the installation's
needs).51
51 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 75.
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Step-by-Step Guidance
Management Reviews, Quality Management, and IPRs
The management review as described by the ISO standard is basically the
same as the IPR commonly used in the Army. Consider holding man-
agement reviews at least once a year. Depending on the nature of your
objectives and targets, hold IPRs semiannually or quarterly to track pro-
gress and make adjustments in a timely manner. You can combine man-
agement review meetings with other meetings, such as strategic planning
or quality review meetings, or have a standalone EMS management re-
view meeting."52 Management reviews are one key to continual improve-
ment and for ensuring that the EMS will continue to meet your
organization's needs over time."
53
Management Review Questions to Ponder
Did we achieve our objectives and targets? If not, why not? Should we modify
our objectives?
Is our environmental policy still relevant to what we do?
Are roles and responsibilities still clear, do they make sense, and are they
communicated effectively?
Are we applying resources appropriately?
Are our procedures clear and adequate? Do we need other controls? Should
we eliminate some of them?
Are we fixing problems when we find them?
Are we monitoring our EMS (such as via system audits)? What do the results
of those audits tell us?
What effects have changes in materials, products, or services had on our
EMS and its effectiveness?
Do changes in laws or regulations require us to change some of our ap-
proaches?
What other changes are coming in the near term? What impacts (if any) will
these have on our EMS?
What stakeholder concerns have been raised since our last review? How are
concerns being addressed?
Is there a better way? What can we do to improve?
(NSF-ISR, Environmental Management SystemsAn Implementation Guide for Small and Me-
dium-Sized Organizations, p. 76)
52
NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 75.
53 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 75.
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Management Review Objectives
The management review should serve several functions:
Providing general information about the EMS and current environ-
mental issues to top management (continuing awareness)
Discussing the relevancy of the installation's environmental policy,
objectives, and targets in light of changing situations and making
appropriate revisions
Discussing EMS audit results and approving related plans and re-
sources required to improve the EMS
Reviewing progress toward objectives and targets, approving new
or revised objectives and targets.
Who Participates
Two kinds of people should be involved in the management review proc-
ess:
Those who know and are responsible for specific aspects of the
EMS and related environmental issues. This group extends be-
yond the environmental management office and should include in-
dividuals responsible for EMPs, as well as individuals in the various
functional areas where significant impacts occur.
Those who can make decisions about the organization and its re-
sources (top management).54 On an Army installation, these in-
clude the EQCC, chaired by the CDR.
Scope
The review should be comprehensive, though not all elements of an EMS
need to be reviewed at once and the review process may take place over
time. The review of the policy, objectives, and procedures should be car-
ried out by the level of management that defined them. Reviews should
include
minutes from previous management reviews,
results from audits,
the extent to which objectives and targets have been met,
54 NSF-ISR, Environmental Management SystemsAn Implementation Guide for
Small and Medium-Sized Organizations, p. 75.
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Step-by-Step Guidance
the continuing suitability of the EMS in relation to changing condi-
tions and information,
concerns among relevant interested parties (internal suggestions
and external communications),55
other environmental performance measures, and
reports of emergencies, spills, or other incidents or nonconform-
ities.
Evaluate the need to change the environmental policy, objectives, targets,
and other elements of the EMS due to the following factors:
Changing mission
Addition of new facilities
Changing legislation
Changing expectations and requirements of interested parties
Changes in the products or activities of the installation
Advances in science and technology
Lessons learned from environmental incidents
Reporting and communication.56
Management reviews should assess both positive and negative findings
and not only focus on the negative. Ensure the review focuses on the in-
stallation's environmental performance and evaluates the EMS's effec-
tiveness.
Documentation and Followup
Record the minutes of the management review and document resulting
observations, conclusions, and recommendations to prepare for neces-
sary actions. In addition, "if any corrective action must be taken, top man-
agement should follow up to ensure that the action was effectively
implemented."57 Consider maintaining a "due-out" list that documents re-
quired actions, responsible parties, and scheduled dates. Use this list to
55 ISO 14001, Section A.6, p. 10.
56 ISO 14004, Section 4.5.2, p. 23.
57 Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 53.
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track required actions to completion. Maintain all management review
documentation in accordance with your document control procedures.
Continual Improvement
"The purpose and final outcome of the management review should be
continual improvement of the EMS."58 The continual improvement proc-
ess should
identify areas of opportunity for improvement of the EMS that lead
to improved environmental performance,
determine the cause or causes of nonconformance or deficiencies,
develop and implement plans of corrective and preventive action to
address root causes,
verify the effectiveness of the corrective and preventive actions,
document changes in procedures resulting from process improve-
ment, and
make comparisons with objectives and targets".59
Management reviews offer an opportunity to keep the EMS efficient and
cost-effective. If your installation developed procedures or processes that
are no longer needed, eliminate them.60" As your organization's EMS in-
creases in its effectiveness and efficiency, your environmental perform-
ance will likewise increase."61
CONCLUSION
Congratulations! The basic elements of your EMS are now in place, and
you can focus on continual improvement. As you continue to operate and
examine the EMS and its procedures, you will undoubtedly find ways to
streamline the EMS to increase both effectiveness and ease of use. You
will also see that the environmental focus of the installation will shift from a
defensive, reactive posture to one that is proactive and based on sound
Concurrent Technologies Corporation for U. S. Army, Environmental Management
System Guidance Manual: Implementing ISO 14001, p. 53.
59 ISO 14004, Section 4.5.3, p. 24.
60 NSF-ISR, Environmental Management Systems An Implementation Guide for
Small and Medium-Sized Organizations, p. 75.
61 Concurrent Technologies Corporation fo
System Guidance Manual: Implementing ISO 14001, p. 53.
61 Concurrent Technologies Corporation for U. S. Army, Environmental Management
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Step-by-Step Guidance
planning and informed decision-making. In order to keep the EMS rele-
vant and effective, you must ensure that the mission remains the central
focus of the management system and the EMS works to enhance readi-
ness and develop sustainable processes and activities.
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References
We used the following references to compile this guide.
POLICIES AND MEMORANDA
Executive Order 13148, "Greening the Government Through Leadership in
Environmental Management," 21 April 2000
Memorandum for Assistant Chief of Staff for Installation Management,
from Raymond J. Fatz, Deputy Assistant Secretary of the Army (Envi-
ronment, Safety and Occupational Health), OASA(I&E), Subject, Army
Environmental Management System, 13 July 2001. Available from
http://aec.armv.mil/usaec/support/ems-requirements080601.pdf.
Memorandum for Deputy Assistant Secretary of the Army (Environment,
Safety and Occupational Health) from John Paul Woodley, Jr., Assis-
tant Deputy Undersecretary of Defense (Environment), Subject, Envi-
ronmental Management System (EMS) Implementation Criteria and
Metrics, 30 Jan 2003.
DOCUMENTS
ISO 14001:1996, Environmental management systemsSpecification
with guidance for use.
ISO 14004:1996(E), Environmental Management SystemsGeneral
Guidelines on principles, systems and supporting techniques, first edi-
tion.
Concurrent Technologies Corporation for U. S. Army, Environmental
Management System Guidance Manual: Implementing ISO 14001.
National Science Foundation International Strategic Registrations (NSF-
ISR), Ltd., Environmental Management Systems: An Implementation
Guide for Small and Medium-Sized Organizations. Second Edition.
2001.
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WEBSITES
DENIX EMS Subject Area
https://www.denix.osd.mil/denix/DOD/Library/EMS/ems.html
PEER) Center, How to Implement an EMS [on-line document], undated
[cited February 2003]. Available from:
http://www.peercenter.net/howtoimplement/.
CDs
Concurrent Technologies Corporation, Environmental Management Tool-
kitAn Environmental Management System Implementation Tool, Octo-
ber 2002.
Ref-2
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Appendix A
Acronyms
AAR
ABC
ANSI
AR
ARNG
ARTEP
BMP
CAA
CAIRA
CBT
CDR
CERCLA
CFCs
CFR
CFT
CONUS
COTS
CWA
DENIX
DFE
DoD
DPW
DSERTS
EGAS
ECOs
EMP
EMS
after-action review
activity-based costing
American National Standards Institute
Army Regulation
Army National Guard
Army Readiness Training Evaluation Programs
best management practice
Clean Air Act
Chemical accident/incident response and assistance
computer-based training
commander
Comprehensive Environmental Response, Compensation
and Liability Act
chlorofluorocarbon
Code of Federal Regulations
cross-functional team
Continental United States
commercial off-the-shelf
Clean Water Act
Defense Environmental Network Information Exchange
Design for the environment
Department of Defense
directorate of public works
Defense Site Environmental Restoration Tracking System
Environmental Compliance Assessment System
environmental compliance officers
environmental management programs
environmental management system
A-1
-------
EMSMR
ENFs
EO
EPA
ERAS
EPCRA
EPI
EPR
EQCC
EQR
ESA
FIFRA
FRP
FY
GOCO
HAZMAT
HMTA
HOA
HW
ICAPs
IMA
IMRO
IPR
ISR
IT
METL
MSDSs
NAAQS
NCA
NEPA
NLT
NOV
environmental management system management repre-
sentative
enforcement actions
Executive Order
U.S. Environmental Protection Agency
Environmental Program Assessment System
Emergency Planning and Community Right-To-Know Act
environmental performance indicators
Environmental Program Requirements
environmental quality control committee
Environmental Quality Report
Endangered Species Act
Federal Insecticide, Fungicide, and Rodenticide Act
Facility response plan
fiscal year
government-owned, contractor-operated
hazardous material
Hazardous Materials Transportation Act
homeowners association
hazardous waste
installation compliance action plans
Installation Management Agency
installation management regional office
in-process review
Installation Status Report
information technology
mission-essential task list
material safety data sheets
national ambient air quality standards
Noise Control Act
National Environmental Policy Act
no later than
notices of violation
A-2
-------
Acronyms
NOx
NPDES
OB/OD
OCONUS
ODCs
PAO
PM2.5
POC
POL
POTW
RCRA
RDT&E
REOs
SCP
SDWA
SOP
SOx
SPCC
SPCCP
SRS
SS
IDA
TOE
TSCA
USAEC
use
VOC
nitrogen oxides
national pollutant discharge elimination system
open burn/open detonation
Outside Continental United States
ozone depleting chemicals
public affairs office
particulate matter with diameter less than or equal to 2.5
microns
point of contact
petroleum, oil, or lubricant
publicly owned treatment works
Resource Conservation and Recovery Act
Research, development, testing, and evaluation
regional environmental offices
Spill contingency plan
Safe Drinking Water Act
standard operating procedure
sulfur oxides
Spill Prevention, Control, and Countermeasures
Spill Prevention, Control, and Countermeasures Plan
Strategic Readiness System
significance score
Table of Distribution and Allowances
Table of Organization and Equipment
Toxic Substances Control Act
U.S. Army Environmental Center
United States Code
volatile organic compounds
A-3
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DEPARTMENT OF VETERANS AFFAIKS
ASSISTANT SLCRKTAKV FOR ACQUISITION AND MATERIEL
MANAGEMENT
WASHINGTON, DC 20420
IL 049-02-11
July 5, 2002
OFFICE OF ACQUISITION AND MATERIEL MANAGEMENT INFORMATION LETTER
TO: Under Secretary for Memorial Affairs, National Cemetery Administration;
Chief Facilities Management Officer, Office of Facilities Management;
Veterans Integrated Service Network Directors; Directors, VA Medical
Center Activities, Domiciliary, Outpatient Clinics, Medical and Regional
Office Centers, and Regional Offices; Directors, Denver Distribution
Center, Austin Automation Center, Records Management Center, V8A
Benefits Delivery Centers, and the VA Health Administration Center; and
the Executive Director and Chief Operating Officer, VA National
Acquisition Center
ATTN: Head of the Contracting Activity
Alt VA Contracting Officers
SUBJECT: Executive Order 13148, Greening the Government Through Leadership in
Environmental Management
1. The purpose of this information letter (IL) is to provide guidance to acquisition and
procurement professionals regarding Executive Order (EO) 13148, Greening the
Government Through Leadership in Environmental Management, dated April 22, 2001,
2. The primary goal of this EO is to ensure that each Federal agency integrates
environmental accountability into day-to-day decision-making and long-term planning
processes and across its missions, activities, and functions,
3. VA shall strive to reduce or eliminate harm to human health and the environment
from releases of pollutants to the environment. Additionally, VA shall advance the
national policy that, whenever feasible and cost-effective, pollution should be prevented
or reduced at the source. Sound acquisition and procurement practices can assist in
addressing these issues.
-------
IL 049-02-11
July 5, 2002
4. E.G. 13148, Part 7 - Acquisition and Procurement, specifically, provides guidance to
procurement officials and acquisition program managers. EO 13148 Part 7 includes the
following:
Section 701: Limiting Procurement of Toxic Chemicals, Hazardous
Substances and other pollutants.
(b) Each agency shall determine the feasibility of implementing
centralized procurement and distribution (e.g., "pharmacy") programs at its
facilities for tracking, distribution, and management of toxic or hazardous
materials and, where appropriate, implement such programs,
(c) Under established schedules for review of standardized documents,
DOD and GSA, and other agencies, as appropriate, shall review their
standardized documents and identify opportunities to eliminate or reduce
their use of chemicals included on the list of priority chemicals developed
by the EPA,
(d) Each agency shall follow the policies and procedures for toxic
chemical release reporting in accordance with FAR section 23,9 and
policies and procedures on Federal compliance with right-to-know laws
and pollution prevention requirements in accordance with FAR section
23.10.
Section 702. Environmentally Benign Adhesives. Each agency shall
revise its specifications for paper products using adhesives and direct the
purchase of paper products using those adhesives, whenever technically
practicable and cost effective. Each agency should consider products
using the environmentally benign pressure sensitive adhesives approved
by the U.S. Postal Service (USPS) and listed on the USPS Qualified
Products List for pressure sensitive recyclable adhesives.
Section 703, Ozone-Depleting Substances. Each agency shall follow
the policies and procedures for the acquisition of items that contain, use,
or are manufactured with ozone-depleting substances in accordance with
FAR section 23.8 and other applicable FAR provisions.
-------
J.
1L 049-02-11
Julv 5. 2002
Section 704. Environmentally and Economically Beneficial Landscaping
Practices,
(a) Each agency shall have in place acquisition and procurement
practices, including provision of landscaping sen/ices that conform to the
"Guidance for Presidential Memorandum on Environmentally and
Economically Beneficial Landscape Practices on Federal Landscaped
Grounds", for the use of environmentally and economically beneficial
landscaping practices,
(b) In implementing landscaping policies, each agency shall purchase
environmentally preferable and recycled content products, including EPA-
designaled items such as compost and mulch, that contributes to
environmentally and economically beneficial practices.
5, Training programs will be implemented to ensure that agency procurement officials
and acquisition program managers are aware of the requirements of this order and its
applicability to those individuals. The training program dates will be announced at a
later dale.
6, Direct any questions regarding this information letter to Patricia Ellis, Acquisition
Policy Division (049A5A). at (202) 273-6058.
/s/David S. Derr
Associate Deputy Assistant Secretary
for Acquisitions
Distribution: RFC 7029
-------
-------
Wednesday
October 16, 1996
Part VIM
Environmental
Protection Agency
Code of Environmental Management
Principles; Notice
54061
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54062
Federal Register / Vol. 61, No. 201 / Wednesday, October 16, 1996 / Notices
ENVIRONMENTAL PROTECTION
AGENCY
[FRL-5636-4]
Code of Environmental Management
Principles
AGENCY: Environmental Protection
Agency.
ACTION: Announcement of EPA's
Issuance of the Code of Environmental
Management Principles for Federal
Agencies.
SUMMARY: This notice serves as a public
announcement of the issuance of the
Code of Environmental Management
Principles or the CEMP developed by
EPA in consultation with other Federal
Agencies as mandated by Executive
Order 12856 ("Federal Compliance With
Right-to-Know Laws and Pollution
Prevention Requirements") signed by
President Bill Clinton on August 3,
1993. On September 3, 1996, EPA
transmitted the CEMP to Federal agency
executives who signed the Charter for
the Interagency Executive Order 12856
Pollution Prevention Task Force in
September 1995, requesting written
commitment to the principles contained
in the CEMP. EPA also is asking Federal
agency executives to provide a written
statement declaring their agency's
support for the CEMP principles along
with a description of the agency's plans
for implementation of the CEMP at the
facility level.
DATES: EPA has asked for written
responses from Federal agency
executives by October 1, 1996.
Extensions to requesting agencies
have been granted to October 18, 1996.
EPA plans to issue a summary of agency
responses in January 1997.
FOR FURTHER INFORMATION CONTACT:
James Edward, Acting Associate
Director, Federal Facilities Enforcement
Office, Office of Enforcement and
Compliance Assurance, United States
Environmental Protection Agency, 401
M Street, SW., Washington DC 20460,
telephone 202-564-2462 or Andrew
Cherry, U.S. Environmental Protection
Agency, 401 M Street, SW., Washington,
DC. 20460, phone (202) 564-5011, fax
(202) 501-0069
SUPPLEMENTARY INFORMATION:
I. Explanation of the CEMP
A. Background
EPA believes that leadership
opportunities in environmental
management should be fully realized for
the Federal agencies and departments
throughout the U.S. Government.
American citizens and other stakeholder
groups have increasingly sought a more
responsible standard of care toward the
environment from various sectors of
industry and other private
organizations. In response, more and
more companies and trade associations
have begun initiatives that call for
identifying their environmental impacts,
measuring their successes in meeting
environmental objectives, sanctioning
shortcomings, recognizing
accomplishments, and making
continuous improvement. Recently the
growing popularity of national and
international consensus based
environmental management standards
among industry demonstrates this trend.
However, the public has also demanded
that the Federal Government and its
agencies and departments, also
demonstrate a commitment to a
common environmental ethic. EPA
believes that if the Federal Government
is willing to make a public commitment
to voluntarily adopt an appropriate code
of environmental ethics or conduct,
which is at least equivalent to the
commitment demonstrated by
environmental leaders in the private
sector, and hold itself accountable for
implementing these principles, then
significant progress can be made toward
improving public trust and confidence
toward Federal facility environmental
performance.
On August 3, 1993, President Clinton
signed Executive Order No. 12856,
which pledges the Federal Government
to implement pollution prevention
measures, and publicly report and
reduce the generation of toxic and
hazardous chemicals and associated
emissions. Section 4-405 of Executive
Order 12856 requires the Administrator
of the Environmental Protection Agency
(EPA), in cooperation with Federal
agencies, to establish a Federal
Government Environmental Challenge
Program. Similar to the "Environmental
Leadership" program proposed in 1993
by EPA's Office of Enforcement, the
program is designed to recognize and
reward outstanding environmental
management performance in Federal
agencies and facilities. As required
under the Executive Order, the program
shall consist of three components to
challenge Federal agencies to: (1) Agree
to a code of environmental principles
emphasizing pollution prevention,
sustainable development, and "state of
the art" environmental management
programs; (2) submit applications to
EPA for individual Federal facilities for
recognition as "Model Installations";
and (3) encourage individual Federal
employees to demonstrate outstanding
leadership in pollution prevention. The
program is geared toward recognizing
those departments, agencies, and
Federal installations where mission
accomplishment and environmental
leadership become synonymous and to
highlight these accomplishments as
models for both Federal and private
organizations.
On September 12, 1995, senior agency
representatives signed the Charter for
the Interagency Pollution Prevention
Task Force committing the Federal
Government to achieve, among other
items, environmental excellence
through various activities including: (a)
Active agency and facility participation
in the Federal Government
Environmental Challenge Program and,
(b) participation in the establishment of
an agency Code of Environmental
Management Principles.
EPA has been working to develop the
CEMP through the Interagency Pollution
Prevention Task Force, which was
created by the Executive Order, since
January 1995. In June 1995, a
subcommittee of Federal agency
representatives was formed by the Task
Force to work directly with EPA in the
development of the CEMP. Through this
process, several drafts of the CEMP were
forwarded to Federal agencies by the
subcommittee for formal review and
comment. This version of the CEMP
represents the final version as approved
by the subcommittee and incorporates
comments from members of the
Interagency Task Force.
On September 3, 1996, Steve Herman,
the EPA Assistant Administrator for
Enforcement and Compliance
Assurance, signed a letter transmitting
the CEMP to the Federal agency
executives who had signed the Charter
for the Interagency Executive Order
12856 Pollution Prevention Task Force
in September 1995, requesting written
commitment to the Principles contained
in the CEMP. In this letter, EPA also
asked each agency to provide a written
statement declaring their support for the
CEMP principles at the agency level
along with a description of their plans
for implementation of the CEMP at the
facility level.
EPA is seeking endorsement of the
CEMP Principles on an agency wide
basis, with flexibility as to how the
Principles themselves are implemented
at the facility level. For example,
agencies can choose to directly
implement the CEMP Principles at the
facility level or use another alternative
environmental management system
(e.g., ISO 14001). This flexible approach
is in recognition that of the fact that
individual Federal facilities and
installations may already have
environmental management systems in
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Federal Register / Vol. 61, No. 201 / Wednesday, October 16, 1996 / Notices
54063
place or are considering adoption of the
ISO 14001 Environmental Management
Standard.
It is also important to point out that
the term "agency" is used throughout
the CEMP to represent the participation
of individual Federal Government
entities. It should be recognized that
many Cabinet-level "agencies" have
multiple levels of organization and
contain independently operating bodies
(known variously as bureaus,
departments, administrations, services,
major commands, etc.) with distinct
mission and function responsibilities.
Therefore, while it is expected that a
"parent agency" would subscribe to the
CEMP, each parent agency will have to
determine the most appropriate level(s)
of explicit CEMP implementation for its
organization. Regardless of the level of
implementation chosen for the
organization, it is important that the
parent agency or department
demonstrate a commitment to these
principles.
With respect to the other two
components of the Federal Government
Environmental Challenge Program, EPA
will merge the E.O. 12856 Model
Installation Program with EPAs
Environmental Leadership Program
(ELP), which is also open to private
facilities, when the ELP becomes a full-
scale program in 1997. One of the
prerequisites for Federal facility
participation in the ELP will be agency
endorsement of the CEMP principles. In
addition, EPA will also the individual
employee recognition component of the
Challenge Program with the Executive
Order 12873 Closing the Circle Awards
Program beginning in 1996.
B. Overview of the CEMP
Five broad environmental
management principles have been
developed to address all areas of
environmental responsibility of Federal
agencies. More discussion of the intent
and focus of each principle and
supporting elements may be found in
the next section, "Implementation of
The Code of Environmental
Management Principles." The five
Principles are as follows:
1. Management Commitment
The agency makes a written top-
management commitment to improved
environmental performance by
establishing policies which emphasize
pollution prevention and the need to
ensure compliance with environmental
requirements.
2. Compliance Assurance and Pollution
Prevention
The agency implements proactive
programs that aggressively identify and
address potential compliance problem
areas and utilize pollution prevention
approaches to correct deficiencies and
improve environmental performance.
3. Enabling Systems
The agency develops and implements
the necessary measures to enable
personnel to perform their functions
consistent with regulatory requirements,
agency environmental policies and its
overall mission.
4. Performance and Accountability
The agency develops measures to
address employee environmental
performance, and ensure full
accountability of environmental
functions.
5. Measurement and Improvement
The agency develops and implements
a program to assess progress toward
meeting its environmental goals and
uses the results to improve
environmental performance.
II. Implementation of the Code of
Environmental Management Principles
Each of the five principles, which
provide the overall purpose of the step
in the management cycle, is supported
by Performance Objectives, which
provide more information on the tools
and mechanisms by which the
principles are fulfilled. The principles
and supporting Performance Objectives
are intended to serve as guideposts for
organizations intending to implement
environmental management programs or
improve existing programs. It is
expected that each of these principles
and objectives would be incorporated
into the management program of every
organization. The degree to which each
is emphasized will depend in large part
on the specific functions of the
implementing organization. An initial
review? of the existing program will help
the organization to determine where it
stands and how best to proceed.
Principle 1: Management Commitment
The agency makes a written top-
management commitment to improved
environmental performance by
establishing policies which emphasize
pollution prevention and the need to
ensure compliance with environmental
requirements.
Performance Objectives
1.1 Obtain Management Support. The
agency ensures support for the
environmental program by management
at all levels and assigns responsibility
for carrying out the activities of the
program.
Management sets the priorities,
assigns key personnel, and allocates
funding for agency activities. In order to
obtain management approval and
support, the environmental management
program must be seen as vital to the
functioning of the organization and as a
positive benefit, whether it be in
financial terms or in measures such as
regulatory compliance status,
production efficiency, or worker
protection. If management commitment
is seen as lacking, environmental
concerns will not receive the priority
they deserve.
Organizations that consistently
demonstrate management support for
pollution prevention and environmental
compliance generally perform at the
highest levels and will be looked upon
as leaders that can mentor other
organizations wishing to upgrade their
environmental performance.
1.1.1 Policy Development. The agency
establishes an environmental policy
followed by an environmental program
that complements its overall mission
strategy.
Management must take the lead in
developing organizational goals and
instilling the attitude that all
organization members are responsible
for implementing and improving
environmental management measures,
as well as develop criteria for evaluating
how well overall goals are met. The
environmental policy will be the
statement that establishes commitments,
goals, priorities, and attitudes. It
incorporates the organization's mission
(purpose), vision (what it plans to
become), and core values (principles by
which it operates). The environmental
policy also addresses the requirements
and concerns of stakeholders and how
the environmental policy relates to
other organizational policies.
1.1.2 System Integration. The agency
integrates the environmental
management system throughout its
operations, including its funding and
staffing requirements, and reaches out to
other organizations.
Management should institutionalize
the environmental program within
organizational units at all levels and
should take steps to measure the
organization's performance by
incorporating specific environmental
performance criteria into managerial
and employee performance evaluations.
Organizations that fulfill this
principle demonstrate consistent high-
level management commitment,
integrate an environmental viewpoint
into planning and decision-making
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54064
Federal Register / Vol. 61, No. 201 / Wednesday, October 16, 1996 / Notices
activities, and ensure the availability of
adequate personnel and fiscal resources
to meet organizational goals. This
involves incorporating environmental
performance into decision-making
processes along with factors such as
cost, efficiency, and productivity.
1.2 Environmental Stewardship and
Sustainable Development. The agency
strives to facilitate a culture of
environmental stewardship and
sustainable development.
"Environmental Stewardship" refers
to the concept that society should
recognize the impacts of its activities on
environmental conditions and should
adopt practices that eliminate or reduce
negative environmental impacts. The
President's Council on Sustainable
Development was established on June
29, 1993 by Executive Order 12852. The
Council has adopted the definition of
sustainable development as; "meeting
the needs of the present without
compromising the ability of future
generations to meet their own needs".
An organization's commitment to
environmental stewardship and
sustainable development would be
demonstrated through implementation
of several of the CEMP Principles and
their respective Performance Objectives.
For example, by implementing pollution
prevention and resource conservation
measures (see Principle 2, Performance
Objective 2.3), the agency can reduce its
negative environmental impacts
resulting directly from its facilities. In
addition, by including the concepts of
environmental protection and
sustainability in its policies, the agency
can help develop the culture of
environmental stewardship and
sustainable development not only
within the agency but also to those parts
of society which are affected by the
agency's activities.
Principle 2: Compliance Assurance and
Pollution Prevention.
The agency implements proactive
programs that aggressively identify and
address potential compliance problem
areas and utilize pollution prevention
approaches to correct deficiencies and
improve environmental performance.
Performance Objectives
2.1 Compliance Assurance. The
agency institutes support programs to
ensure compliance with environmental
regulations and encourages setting goals
beyond compliance.
Implementation of an environmental
management program should be a clear
signal that non-compliance with
regulations and established procedures
is unacceptable and injurious to the
operation and reputation of the
organization. Satisfaction of this
performance objective requires a clear
and distinct compliance management
program as a component of the agency's
overall environmental management
system.
An agency that fully incorporates the
tenets of this principle demonstrates
maintainable regulatory compliance and
addresses the risk of non-compliance
swiftly and efficiently. It also has
established a proactive approach to
compliance through tracking and early
identification of regulatory trends and
initiatives and maintains effective
communications with both regulatory
authorities and internally to coordinate
responses to those initiatives. It also
requires that contractors demonstrate
their commitment to responsible
environmental management and
provides guidance to meet specified
standards.
2.2 Emergency Preparedness. The
agency develops and implements a
program to address contingency
planning and emergency response
situations.
Emergency preparedness is not only
required by law, it is good business.
Properly maintained facilities and
trained personnel will help to limit
property damage, lost-time injuries, and
process down time.
Commitment to this principle is
demonstrated by the institution of
formal emergency-response procedures
(including appropriate training) and the
appropriate links between health and
safety programs (e.g., medical
monitoring for Federal employees
performing hazardous site work).
2.3 Pollution Prevention and Resource
Conservation. The agency develops a
program to address pollution prevention
and resource conservation issues.
An organization committed to
pollution prevention has a formal
program describing procedures,
strategies, and goals. In connection with
the formal program, the most advanced
organizations have implemented policy
that encourages employees to actively
identify and pursue pollution
prevention and resource conservation
measures, and instituted procedures to
incorporate such measures into the
formal program. Resource conservation
practices would address the use by the
agency of energy, water, and
transportation resources, among others.
Pollution prevention policies and
practices should follow the
environmental management hierarchy
prescribed in the Pollution Prevention
Act of 1990: (1) Source reduction; (2)
recycling; (3) treatment; and (4)
disposal.
Section 3-301(b) of Executive Order
12856 requires the head of each Federal
agency to make a commitment to
utilizing pollution prevention through
source reduction, where practicable, as
a primary means of achieving and
maintaining compliance with all
applicable Federal, State and local
environmental requirements.
Principle 3: Enabling Systems
The agency develops and implements
the necessary measures to enable
personnel to perform their functions
consistent with regulatory requirements,
agency environmental policies and it's
overall mission.
Performance Objectives
3.1 Training. The agency ensures that
personnel are fully trained to carry out
the environmental responsibilities of
their positions.
Comprehensive training is crucial to
the success of any enterprise. People
need to know what they are expected to
do and how they are expected to do it.
An organization will be operating at the
highest level when it has an established
training program that provides
instruction to all employees sufficient to
perform the environmental aspects of
their jobs, tracks training status and
requirements, and offers refresher
training on a periodic basis.
3.2 Structural Supports. The agency
develops and implements procedures,
standards, systems, programs, and
objectives that enhance environmental
performance and support positive
achievement of organizational
environmental and mission goals.
Clear procedures, standards, systems,
programs, and short- and long-term
objectives must be in place for the
organization to fulfill its vision of
environmental responsibility. A
streamlined set of procedures,
standards, systems, programs, and goals
that describe and support the
organization's commitment to
responsible environmental management
and further the organization's mission
demonstrate conformance with this
principle.
3.3 Information Management,
Communication, Documentation. The
agency develops and implements
systems that encourage efficient
management of environmentally-related
information, communication, and
documentation.
Information management,
communication, and documentation are
necessary elements of an effective
environmental management program.
The need for advanced information
management capabilities has grown
significantly to keep pace with the
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Federal Register / Vol. 61, No. 201 / Wednesday, October 16, 1996 / Notices
54065
volume of available information to be
sifted, analyzed, and integrated. The
ability to swiftly and efficiently digest
data and respond to rapidly changing
conditions can be key to the continued
success of an organization.
Organizations adopting this principle
have developed a sophisticated
information gathering and
dissemination system that supports
tracking of performance through
measurement and reporting. They also
have an effective internal and external
communication system that is used to
keep the organization informed
regarding issues of environmental
concern and to maintain open and
regular communication with regulatory
authorities and the public. Those
organizations operating at the highest
level ensure that employees have access
to necessary information and implement
measures to encourage employees to
voice concerns and suggestions.
Principle 4: Performance and
Accountability
The agency develops measures to
address employee environmental
performance, and ensure full
accountability of environmental
functions.
Performance Objectives
4.1 Responsibility, Authority and
Accountability. The agency ensures that
personnel are assigned the necessary
authority, accountability, and
responsibilities to address
environmental performance, and that
employee input is solicited.
At all levels, those personnel
designated as responsible for
completing tasks must also receive the
requisite authority to carry out those
tasks, whether it be in requisitioning
supplies or identifying the need for
additional personnel. Similarly,
employees must be held accountable for
their environmental performance.
Employee acceptance of accountability
is improved when input is solicited.
Encouraging employees to identify
barriers to effective performance and to
offer suggestions for improvement
provides a feeling of teamwork and a
sense that they control their own
destiny, rather than having it imposed
from above.
4.2 Performance Standards. The
agency ensures that employee
performance standards, efficiency
ratings, or other accountability
measures, are clearly defined to include
environmental issues as appropriate,
and that exceptional performance is
recognized and rewarded.
Organizations that identify specific
environmental performance measures
(where appropriate), evaluate employee
performance against those measures,
and publicly recognize and reward
employees for excellent environmental
performance through a formal program
demonstrate conformance with this
principle.
Principle 5: Measurement and
Improvement:
The agency develops and implements
a program to assess progress toward
meeting it's environmental goals and
uses the results to improve
environmental performance.
Performance Objectives
5.1 Evaluate Performance. The agency
develops a program to assess
environmental performance and analyze
information resulting from those
evaluations to identify areas in which
performance is or is likely to become
substandard.
Measurement of performance is
necessary to understand how well the
organization is meeting its stated goals.
Businesses often measure their
performance by such indicators as net
profit, sales volume, or production. Two
approaches to performance
measurement are discussed below.
5.1.1 Gather and Analyze Data. The
agency institutes a systematic program
to periodically obtain information on
environmental operations and evaluate
environmental performance against
legal requirements and stated objectives,
and develops procedures to process the
resulting information.
Managers should be expected to
provide much of the necessary
information on performance through
routine activity reports that include
environmental issues. Performance of
organizations and individuals in
comparison to accepted standards can
also be accomplished through periodic
environmental audits or other
assessment activities.
The operation of a fully-functioning
system of regular evaluation of
environmental performance along with
standard procedures to analyze and use
information gathered during evaluations
signal an organization's conformance
with this principle.
5.1.2 Institute Benchmarking. The
agency institutes a formal program to
compare its environmental operations
with other organizations and
management standards, where
appropriate.
"Benchmarking" is a term often used
for the comparison of one organization
against others, particularly those that
are considered to be operating at the
highest level. The purpose of
Benchmarking is twofold: first, the
organization is able to see how it
compares with those whose
performance it wishes to emulate;
second, it allows the organization to
benefit from the experience of the peak-
performers, whether it be in process or
managerial practices.
Benchmarking against established
management standards, such as the ISO
14000 series or the Responsible Care
program developed by the Chemical
Manufacturers Association (CMA), may
be useful for those agencies with more
mature environmental programs,
particularly if the agencies' activities are
such that their counterparts in the
private sector would be difficult to find.
However, it should be understood that
the greater benefit is likely to result
from direct comparison to an
organization that is a recognized
environmental leader in its field.
5.2 Continuous Improvement. The
agency implements an approach toward
continuous environmental improvement
that includes preventive and corrective
actions as well as searching out new
opportunities for programmatic
improvements.
Continuous improvement is
approached through the use of
performance measurement to determine
which organizational aspects need to
have more attention or resources
focused upon them.
Continuous improvement may be
demonstrated through the
implementation of lessons learned and
employee involvement programs that
provide the opportunity to learn from
past performance and incorporate
constructive suggestions. In addition,
the agency actively seeks comparison
with and guidance from other
organizations considered to be
performing at the highest level.
IV. Responses From Federal Agencies
and Departments
EPA is requesting Federal agencies to
provide a brief written statement
declaring the agency's support for the
CEMP Principles along with a concise
explanation of how the agency plans to
implement the CEMP at the facility
level. To implement the CEMP the
agency may choose to employ voluntary
environmental management standards
developed by national or international
consensus groups or by industry trade
associations as long as the spirit of the
CEMP is evidenced by those chosen
standards. At this time, EPA is seeking
agency level commitment to the CEMP.
EPA recognizes that many Federal
agencies may have already begun
development of environmental
management systems or have chosen to
implement a particular environmental
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54066 Federal Register / Vol. 61, No. 201 / Wednesday, October 16, 1996 / Notices
management standard at their facilities.
EPA recommends that these agencies
leverage the work that has already been
accomplished, and perform some
comparative or gap analysis between the
existing environmental management
system, program or standard and the
CEMP to ensure that the principles of
the CEMP are fully implemented.
Therefore the CEMP can be
implemented concurrently and not in
addition to the work that is already
being performed at the agency.
Dated: September 23, 1996.
Steven A. Herman,
Assistant Administrator for Enforcement and
Compliance Assurance.
[FR Doc. 96-26451 Filed 10-15-96; 8:45 am]
BILLING CODE 6560-50-P
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OFFICE OF THE FEDERAL ENVIRONMENTAL EXECUTIVE
WHITE HOUSE TASK FORCE ON WASTE PREVENTION AND RECYCLING
1200 PENNSYLVANIA AVENUE, NW MAIL CODE 1600S WASHINGTON, DC 20460
(202) 564-1297 WWW.OFEE.COV TASK_FORCE@OFEE.GOV
PROMOTING SUSTAINABLE ENVIRONMENTAL STEWARDSHIP THROUGHOUT THE FEDERAL GOVERNMENT
MEMORANDUM
SUBJECT: EMS Self-Declaration Protocol
FROM: John Howard \JLjf l\^\^
m^^^^^ \.\ f%
Federal Environmental Executive
TO: Agency Environmental Executives
DATE: January 27, 2004
This memorandum formally transmits for your implementation the Environmental Management
System (EMS) Agency Self-Declaration Protocol for Appropriate Federal Facilities (Protocol),
dated September 10, 2003. This document was prepared by the Executive Order 13148
Interagency Environmental Management Workgroup in accordance wili their responsibilities
under Section 306 to develop guidance for implementing the Order. The Protocol establishes the
framework to be used by each agency in formulating the process and guidance for its facilities to
self-declare compliance with the EMS requirements of the Order. The deadline for
implementation of the Protocol is December 31, 2004.
Implementation of the Protocol will ensure that each agency's guidance for declaring
conformance to that agency's selected EMS framework reflects accepted EMS principles and that
facility or organization EMSs have been properly developed and effectively implemented.
Further, the document will allow review of lie entire Federal government's progress in achieving
the EMS goals in the Order while maintaining flexible conformance criteria that can be adapted
for unique application by each agency. The Protocol must be implemented by December 31,
2004 to support each agency's facility-level implementation of the EMS requirement prior to the
December 2005 deadline established in the Order. I encourage agencies to share their agency
self-declaration guidance with EPA or my office as soon as it is available. The E.O. 13148
annual report request for calendar year 2004 will also ask each agency to supply a copy of its
self-declaration guidance.
I appreciate the continued efforts of the E.O. 13148 Workgroup to provide the tools to streamline
progress towards our goal of environmental leadership in the Federal government. As your
agency prepares guidance for facility or organization self declaration, please follow the guidance
in the Self-Declaration Protocol. Thank you for your continued support:.
Minimum 30 percent postconsumer recvcled content paper
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Environmental Management Systems
Agency Self-Declaration Protocol for Appropriate Federal Facilities
Final Version September 10, 2003
Introduction and Purpose:
The process used by federal agencies and their facilities or organizations to self-declare
conformance with their selected environmental management systems (EMS) must ensure
credibility. In order to meet this goal, agencies must develop a process that provides for
effective and objective assessment of these systems in a manner that not only ensures the
system is conformant, but is also designed for ongoing evaluation and continual improvement.
Such a process must not only verify that appropriate documentation is developed, but affirm that
the facility or organization is actually implementing their EMS as defined in their documentation
and doing what they say they are doing. This process must also include the degree of
transparency and objectivity necessary to make the self-declaration credible.
This protocol outlines procedures for federal agencies developing processes that will ensure
the credibility of self-declaration of EMS for their appropriate facilities as set forth in Executive
Order 13148. Specifically, this protocol is designed to satisfy the following principles:
1. Result in accurate and reliable information on federal facilities' progress as they
adopt improved business practices associated with EMS implementation.
2. Focus responsibility for initial EMS verification and on-going quality assurance at the
agency / bureau level.
3. Provide agencies / bureaus flexibility to implement EMS in ways that support their
overall public mission.
4. Provide an independent basis for verifying the status of a facility or organization
EMS, and appropriately communicating that status to internal and external
stakeholders.
5. Ensure that system verification is more than a documentation review, and that the
effectiveness of implementation is also reviewed.
6. Use existing EMS elements where possible so that self-declaration becomes an
integral part of the organization's EMS.
Protocol:
Agencies / bureaus shall direct their facilities or organizations to use one or more EMS
evaluation guide(s) in conducting EMS self-declarations. Examples of evaluation guides
are included in:
Appendix A, The Global Environmental Management Initiative (GEMI) "ISO 14001
Environmental ".'"an age-men t Syotem Self Assessment Checklist" [Hotlink title text to
document]
Appendix B, "Oregon Green Permits Program Guide - Attachment B: EMS
Description and References." [Hotiink title text to document]
Appendix C, The National Aeronautics and Space Administration's "Environmental
Functional Review Checklist." [Hotlink title text to document]
1. In directing use of the selected evaluation guide, agencies / bureaus shall establish a
procedure including the following:
a) direction on the use of the chosen evaluation guide(s).
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b) direction on the frequency of self-declaration internal evaluations; the frequency of
agency / bureau independent reviews, makeup of the independent review team (e.g.,
Headquarters, other facility, other agency, or contractor), and qualifications of
independent reviewers, a requirement for facility or organization management to
make a self-declaration statement that the EMS is in place when that conclusion is
reached.
c) direction on documenting and using the results of EMS evaluations. This shall
include steps for acknowledging adequate facility EMSs, follow-up actions to
address inadequacies in the EMSs, and reporting results of evaluations for inclusion
in agency-wide annual EMS reviews.
d) a schedule for reviewing agency / bureau EMS Self-Declaration Procedures. This
review shall consider changes in agency / bureau programs and missions when
appropriate but on a schedule that does not exceed five years. This is designed to
allow a phased approach and continual improvement. An example of an agency
EMS Self-Declaration Procedure is included in Appendix D, The National
Aeronautics and Space Administration's "Environmental Functional Review Standard
Operating Procedure." [Hotlink title text to document]
2. Agencies / bureaus shall communicate their choice of guide(s) and procedures
described above in accordance with their internal and external EMS communication
procedures.
3 Agencies / bureaus shall establish their procedures for EMS self-declaration as soon as
practical but not later than NLT December 31, 2004.
4. Agencies / bureaus shall include appropriate guidance to ensure that facilities desiring
to participate in a Federal or state EMS recognition program (e.g., National
Environmental Performance Track, Oregon Green Permits Program, New Jersey Silver
Track Program) reflect the respective requirements in their self declaration procedures.
5. Facilities or organizations that wish to self declare their EMS before agency procedures
are in place may:
a) adopt a recognized independent review process such as third-party registration to
ISO 14001 or
b) document the information described in protocol iteml (b), (c) and (d) above and
communicate that information to external parties in accordance with their EMS
communication ore
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RCRA ENFORCEMENT AND COMPLIANCE
CONTENTS
1. Introduction 1
2. Statutory Summary 2
2.1 Enforcement Authorities 2
2.2 Inspections and Information Gathering 2
2.3 Monitoring, Analysis, Testing, and Reporting 5
2.4 Enforcement Mechanisms 5
2.5 Compliance Orders and Penalties 8
2.6 Corrective Action 8
2.7 Imminent Hazard 8
2.8 Citizen Suits 9
3. Special Issues 10
4. Compliance Incentives and Assistance 12
5. Small Business Regulatory Enforcement Fairness Act 14
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RCRA Enforcement and Compliance - 1
1. INTRODUCTION
The effective implementation of the RCRA program depends on whether the regulated
community complies with the various RCRA requirements. The goals of the RCRA
enforcement program are to ensure that the regulatory and statutory provisions of
RCRA are met, and to compel necessary action to correct violations. To achieve these
goals, EPA and the states closely monitor hazardous waste handlers, taking expeditious
legal action when noncompliance is detected. EPA also has various programs to
provide compliance incentives and assistance.
Many of the questions the Hotline receives on enforcement are purely legal and beyond
our purview. We do not interpret the law or legal concepts; we only answer questions
relating to statutory and regulatory programs and how enforcement and compliance
tools are used as part of the RCRA process.
When you have completed this module you will be able to explain RCRA enforcement
and describe the enforcement mechanisms. Specifically, you will be able to:
Describe enforcement procedures and mechanisms and cite the statutory
authorities
Describe the three different types of enforcement actions, administrative, civil,
and criminal
Explain when and how EPA can enforce the RCRA regulations in authorized
states
State the differences between enforcement at interim status and permitted
facilities and describe enforcement at federal facilities
Describe some of EPA's compliance incentive and assistance policies.
Use this list of objectives to check your understanding of this topic after completing the
training session.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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2 - RCRA Enforcement and Compliance
2. STATUTORY SUMMARY
The success of the RCRA program depends on the regulated community's compliance
with the regulations. To ensure compliance with the program, Congress gave EPA
certain distinct powers, or authorities, for enforcement. EPA has the authority to
inspect and collect information from facilities and, if a violation is discovered, employ
any one of several enforcement actions to bring facilities into compliance. EPA uses a
combination of monitoring, administrative actions, and civil actions to reduce the
number of waste handlers that are out of compliance and to deter future violators. EPA
works with the Regional offices, the states, and, where appropriate, the Department of
Justice (DOJ) to implement the RCRA enforcement program.
2.1 ENFORCEMENT AUTHORITIES
EPA's hazardous waste enforcement program is designed to promote compliance with
statutory and regulatory requirements and to abate imminent hazards. Enforcement
provides EPA and citizens with mechanisms for carrying out the RCRA program and
promotes the protection of human health and the environment. Since EPA has not
codified regulations covering enforcement, with the exception of some administrative
procedures found in 40 CFR Parts 22 and 24, RCRA enforcement personnel rely on the
following statutory authorities to enforce the RCRA program:
Section 3007 - Inspections and Information Gathering
Section 3008
(a) Compliance Orders
(b) Public Hearings
(c) Violation of Compliance Orders
(d) Criminal Penalties
(e) Knowing Endangerment
(g) Civil Penalties
(h) Interim Status Corrective Action Orders
Section 3013 - Monitoring, Analysis, and Testing
Section 7002 - Citizen Suits
Section 7003 - Imminent Hazards.
2.2 INSPECTIONS AND INFORMATION GATHERING
An important component of the enforcement process is the authority to monitor
facilities for verification of compliance with the regulations. The Agency collects
compliance monitoring information primarily through facility inspections and
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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RCRA Enforcement and Compliance - 3
information requests. An inspection is a formal visit by an EPA or state representative
to a facility to review records, take samples, and observe facility operations. Congress
granted EPA the authority to conduct such inspections and collect necessary
information to determine compliance under RCRA §3007.
Section 3007 gives EPA the authority to inspect facilities that handle or have handled
hazardous wastes. In addition, the inspection authority is applicable to facilities that
handle mixtures of hazardous wastes and domestic sewage (§3018(d)). Furthermore,
§4005(c)(2)(B) extends EPA's §3007 authority to facilities that handle wastes from
households and conditionally exempt small quantity generators.
A number of different types of inspections are conducted under RCRA authority.
Inspections are conducted by EPA, authorized states, or both, or authorized
representatives of either EPA or authorized states. Typically, either the state or EPA
has overall responsibility, or the lead, for conducting the inspection. The inspector's
role is to gather information that will then be used by the Region and/or state to
determine compliance status. Some of the different kinds of inspections are described
below.
COMPLIANCE EVALUATION INSPECTION
The compliance evaluation inspection (CEI) is an on-site evaluation of a hazardous
waste handler's compliance with RCRA regulations and permit standards. The purpose
of the CEI is to gather information necessary to determine compliance and support
enforcement actions. The inspection may include a characterization of the handler's
activities, identification of the types of hazardous wastes managed on-site, a record
review of reports, documents, and on-site plans, and the identification of any units that
generate, treat, store, or dispose of hazardous waste. Treatment, storage, and disposal
facilities (TSDFs) must be inspected every two years, except facilities owned or operated
by a federal or state agency, which must be inspected every year (§§3007(c), (d), and
(e)).
COMPLIANCE SAMPLING INSPECTION
EPA sometimes finds it necessary to inspect a facility in order to collect samples for
laboratory analysis. These sampling inspections are very resource-intensive because
they require advanced planning for the sampling scheme and laboratory analysis. A
sampling inspection may be conducted in conjunction with a CEI or any other
inspection.
COMPREHENSIVE GROUNDWATER MONITORING EVALUATION
During the comprehensive groundwater monitoring evaluation (CME), enforcement
officials evaluate the adequacy of the design and operation of a facility's groundwater
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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4 - RCRA Enforcement and Compliance
monitoring system. This evaluation should be completed by a hydrogeologist and
includes a review of the owner and operator's characterization of the hydrogeology
underlying the hazardous waste management units; monitoring well placement, depth,
and spacing; and well design and construction. The CME is used to determine whether
a facility implementing detection monitoring should instead be using compliance or
assessment monitoring. CMEs at compliance or assessment monitoring facilities
include a detailed examination of the assessment monitoring plan and implementation
of the plan.
CASE DEVELOPMENT INSPECTION
The case development inspection (GDI) is an intensive investigation that is conducted to
gather sufficient information to support an enforcement action. The GDI can be used to
collect supplemental data to support a forthcoming enforcement action identified
through a CEI, a CME, or a record review.
OPERATION AND MAINTENANCE INSPECTION
The operation and maintenance inspection (OMI) occurs periodically, evaluating
whether a groundwater monitoring system is continuing to function as designed. The
OMI focuses on the condition of the wells and their associated sampling devices. The
findings from an OMI will indicate whether case development is warranted or will
serve to focus future CMEs.
INFORMATION GATHERING
In addition to authorizing EPA to conduct inspections, §3007 allows the Agency to
request specific information from "...any person who generates, stores, treats,
transports, disposes of, or otherwise handles or has handled hazardous wastes." This
means EPA may request information from past generators as well as those parties who
may not have been subject to the RCRA regulations, but who have actually handled
hazardous waste.
Normally the public has access to the information obtained under §3007 authority. The
facility owner and operator may, however, claim records or other information gathered
by EPA as confidential business information by submitting the information with a cover
sheet stamped "confidential," "trade secret," or "proprietary information" (§3007(b)).
EPA will then determine whether or not the material is confidential.
In addition to obtaining information for enforcement proceedings, EPA may use §3007
authority to gather data to assist in the development of regulations and to track
program progress and accomplishments.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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RCRA Enforcement and Compliance - 5
2.3 MONITORING, ANALYSIS, TESTING, AND REPORTING
When EPA receives information showing that hazardous waste is present or has been
released at a facility or site, or that the release of any such waste may present a hazard,
the Agency may issue an administrative order or obtain a judicial injunction requiring
the owner and operator to conduct monitoring, analysis, or testing to ascertain the
extent and nature of the hazard (§3013). Information means some reliable data upon
which a reasonable person would base a decision to take action, and may include
citizen complaints and inspection reports. With respect to §3013 orders, the statutory
definition of hazardous waste is used, rather than the regulatory definition (§1004(5)).
EPA has the authority to issue administrative orders to any past or present owner and
operator who would reasonably have knowledge of the presence of hazardous waste
and potential releases (§§3013(b) and (c)). The orders may compel him or her to
perform monitoring, testing, analysis, and reporting. The Agency also retains the
option of performing the work and recovering costs from the owner and operator. EPA
may sue anyone who fails to comply with a §3013 administrative order for up to $5,500
per day of noncompliance.
The mere presence of hazardous waste at a site or facility is sufficient cause to issue a
§3013 order, provided that the information indicates that the presence of the waste may
present a substantial hazard. Only the potential for harm, as opposed to actual harm, to
human health and the environment must be ascertained to determine whether a
substantial hazard exists.
2.4 ENFORCEMENT MECHANISMS
When the Agency determines that a facility is in noncompliance with the hazardous
waste regulations, an enforcement action may be taken. Under RCRA, EPA uses three
types of enforcement mechanisms: administrative, civil, and criminal actions. The
Agency has substantial latitude in deciding which action or combination of actions to
pursue, depending on the nature and severity of the problem.
ADMINISTRATIVE ACTIONS
An administrative action is a nonjudicial enforcement action taken by EPA or a state
under its own authority. These actions can be broken down into two general categories:
informal and formal. Both of these actions provide for enforcement response outside
the court system. This means the Agency takes direct enforcement action against the
violator based on its authority granted by the statute, and does not rely on a court of
law for enforcement authority.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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6 - RCRA Enforcement and Compliance
Informal Actions
Once a decision is made to utilize an informal enforcement mechanism, the facility
owner and operator should be given notice of its noncompliance and the steps to take to
correct the violations. Examples of informal actions are letters or phone calls to the
facility. For informal actions, EPA or the state notifies the facility owner and operator
that the facility is out of compliance with hazardous waste regulations. Informal
actions are most appropriate where the violation is a minor threat to human health and
the environment. A warning letter, sometimes referred to as a Notice of Violation
(NOV), may be sent, which lays out the specific actions that need to be taken by the
facility owner and operator to correct the violation(s). The letter should require
demonstration of a facility's return to compliance within an appropriate timeframe, not
to exceed 90 days, to ensure that enforcement is escalated appropriately should the
facility fail to return to full physical compliance by the established date.
Formal Actions (Administrative Orders)
In cases where a facility has been classified as a significant non-complier or the facility
owner and operator have failed to respond to an informal action, EPA can issue an
administrative order. Administrative orders impose enforceable legal duties. For
example, orders can be used to compel the facility owner and operator to comply with
specific regulations, to take corrective action, to perform testing, monitoring, or
analysis, or to pay fines.
The four authorities for issuing administrative orders under RCRA are:
Section 3013 Orders to conduct monitoring, analysis, and testing
Corrective Action Orders under §3008(h)
Compliance Orders under §3008(a), including revocation of permits
Section 7003 Orders for imminent hazards.
Each of these authorities is discussed in detail elsewhere in this module.
CIVIL ACTIONS
A civil action is a formal lawsuit filed in a federal district court by DOJ against a person
who has either failed to comply with a statutory or regulatory requirement or
administrative order, or who has contributed to a release of hazardous wastes or
hazardous constituents. The statutory authorities for judicial actions under RCRA are:
Section 3013 - injunctions to conduct monitoring, testing, and analysis
Section 3008 - compliance orders and criminal penalties
Section 7003 - injunctions to address violations which pose an imminent and
substantial endangerment to health or the environment.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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RCRA Enforcement and Compliance - 7
For example, §3008(a) gives EPA the right to take administrative or judicial action for
violations of RCRA that have transpired since November 19,1980. If the facility owner
and operator violate a compliance order, §3008(c) gives EPA the authority to issue a
civil penalty of up to $27,500 per day per violation or to revoke or suspend the facility
permit. Civil penalties are described in §3008(g). Specifically, each violation of a
Subtitle C requirement is subject to a fine of up to $27,500 per day per violation. This
means that each day of noncompliance is considered a separate violation. For detailed
information on penalties, refer to the RCRA Civil Penalty Policy (OSWER Directive
9900.1A). This contains information on the classes of violations, and possible injunctive
relief and other fines and penalties that may be assessed.
CRIMINAL ACTIONS
A criminal action is an action by EPA or the state pursuant to §3008(d) that can result in
the imposition of fines and/or imprisonment. The key to criminal liability is that a
person knowingly violated RCRA requirements. Seven actions identified in §3008 carry
criminal penalties. Six of these seven actions carry a penalty of up to $50,000 per day of
violation and up to 5 years in jail. These acts are:
Knowingly transporting waste to a nonpermitted facility
Knowingly treating, storing, or disposing of waste without a permit or in
violation of a permit or interim status standards
Knowingly omitting information from or making a false statement on a label,
manifest, report, permit, or compliance document
Knowingly generating, storing, treating, or disposing of waste without
complying with recordkeeping and reporting requirements
Knowingly transporting waste without a manifest
Knowingly exporting waste without the consent of the receiving country.
The seventh criminal act is knowingly transporting, treating, storing, disposing, or
exporting waste in a way that places another person in imminent danger of death or
serious bodily injury. This act carries a possible penalty of up to $250,000 and 15 years
in prison for an individual, and a $1 million dollar fine for a corporation (§3008(e)).
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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8 - RCRA Enforcement and Compliance
2.5 COMPLIANCE ORDERS AND PENALTIES
EPA may issue a compliance order assessing a civil penalty for any past or current
violation, requiring compliance immediately or within a specified time period, or both
(§3008). A "person" is defined in §1004(15) as an "...individual, trust, firm, joint stock
company, corporation, partnership, association, state, municipality, commission,
political subdivision of a state, or any interstate body...."
2.6 CORRECTIVE ACTION
Just as the Agency can request or obtain information and can require a facility to
conduct testing and analysis, it can also require a facility to perform a cleanup. The
corrective action program is one of the primary mechanisms to facilitate cleanup of
contamination at TSDFs. EPA can issue an administrative order to compel the owner
and operator to undertake corrective action, or EPA can sue (i.e., bring a civil action) to
have the court order the owner and operator to clean up. The authority for requiring
corrective action at permitted facilities is found in §§3004(u) and (v); EPA uses §3008(a)
to enforce the corrective action requirements found in §§3004(u) and (v).
Interim status corrective action authority is found in §3008(h). The opening clause of
§3008(h) authorizes the Agency to make the determination that there is or has been a
release on the basis of "any information." In practice, EPA will obtain appropriate
information from a variety of sources, including lab analyses, inspection reports, and
photographs. For the purposes of §3008(h), actual sampling is not needed to verify a
release. An inspector may find other evidence that a release has occurred, such as a
broken dike at a surface impoundment or stressed vegetation. Less obvious indications
might also be adequate to make the determination. For example, EPA might have
sufficient information on the hydrogeology of the site to conclude that there may have
been a release.
2.7 IMMINENT HAZARD
Section 7003 gives EPA a broad and powerful enforcement tool to use in abating
imminent hazards caused by hazardous or solid wastes. RCRA §7003 states that upon
receipt of evidence that the past or present handling, storage, treatment, transportation,
or disposal of any solid waste or hazardous waste may present imminent and
substantial endangerment to human health or the environment, EPA may bring suit
against any person who has contributed or who is contributing to the handling of the
waste to restrain the person, order the person to take any action that may be necessary,
or both.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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RCRA Enforcement and Compliance - '
The action taken by EPA may be administrative or civil. To issue a §7003 order, EPA
must possess evidence that the waste handling may present an imminent and
substantial endangerment to human health or the environment. Evidence may be
documentary, testimonial, or physical and may be obtained from a variety of sources,
including inspections, investigations, or requests for production of documents or other
data pursuant to §§3007, 3013, or the Comprehensive Environmental Response,
Compensation, and Liability Act (CERCLA) §104. This evidence must be reliable
enough to enable a reasonable person to conclude that the action is appropriate. The
phrase "may present" indicates that the standard of proof does not require certainty.
That is, an order may be issued if there is sound reason to believe that an endangerment
exists; evidence of actual harm is not required.
2.8 CITIZEN SUITS
Administrative or civil actions are mechanisms that EPA can employ against violators,
but RCRA also offers a course of action for citizens. Section 7002 provides that any
person may sue any past or present generator, transporter, treater, storer, or disposer
who has contributed or who is contributing to the past or present handling of waste
which may present an imminent and substantial endangerment, or may be in violation
of a permit, standard, regulation, condition, requirement, or order. Prior to HSWA, the
only actions allowed under §7002 were suits brought by any person on his or her own
behalf against any person who was alleged to be in violation of any permit, standard,
regulation, condition, requirement, prohibition, or order. HSWA broadened this
provision significantly.
Pursuant to §7002(a)(l)(B), suits may be undertaken by any person against any person,
including the United States or any governmental instrumentality, when that person has
in the past or present handled any solid or hazardous waste in a way so as to present an
imminent or substantial endangerment to health or the environment.
Citizens may sue EPA where the Agency fails to perform any action or duty that is not
discretionary (§7002(a)(2)). Section 7002(a) also gives the courts the power to restrain
any person who is out of compliance or whose actions in handling solid or hazardous
waste present an imminent or substantial endangerment to human health or the
environment. Section §7002(e) allows the court to award, when appropriate, court costs
to the prevailing or substantially prevailing party in the citizen suit.
Some legal actions by citizens are prohibited. According to §7002(b), if the
Administrator of EPA or a state has begun an action to bring the violator into
compliance, no citizen suit will be allowed. Section 7002(d) gives EPA the right to
participate, or intervene, in any action brought under this section as long as EPA is not
a party to the original suit.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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10 - RCRA Enforcement and Compliance
3. SPECIAL ISSUES
Because the majority of enforcement issues are determined on a case-by-case basis
depending on the factual details of a given situation, enforcement is full of anomalies.
Three situations require particular attention.
ENFORCEMENT IN AUTHORIZED STATES
Determining which agency, either EPA or the state, will take the enforcement lead in an
authorized state generally depends on whether the state is fully authorized to enforce
the applicable provisions (state authorization is discussed in detail in the module
entitled State Programs). If the provision being enforced was promulgated as a pre-
HSWA provision, the authorized state has the primary responsibility for ensuring
compliance. As states become authorized for all aspects of HSWA, they will assume
enforcement authority for HSWA enforcement actions. In authorized states, EPA
maintains the authority to take independent enforcement actions. It is EPA's policy to
take enforcement actions in authorized states when (1) the state requests EPA to do so
and provides information on the case-specific circumstances; (2) the state fails to take
timely and/or appropriate action; (3) a case could establish a legal precedent or federal
involvement is needed to ensure national consistency; or (4) it is a federal lead action.
According to §3008(a)(2), in order to enforce a provision for which a particular state has
authorization, EPA shall notify the state prior to issuing an order or starting a civil
action. For provisions promulgated pursuant to HSWA, EPA has the sole authority for
enforcement until the state either becomes fully authorized for that provision (§3006(g)),
or receives interim authority for that provision.
ENFORCEMENT AT INTERIM STATUS VS. PERMITTED FACILITIES
The applicable regulations for interim status facilities are directly enforceable pursuant
to §3008(a). This means that if a facility is not in compliance with a specific regulation,
enforcement actions of any kind may be taken against that facility. For permitted
facilities, however, the site-specific conditions of the written permit are enforceable.
Even if the permit is poorly written or does not conform to the regulations, the owner
and operator need only comply with the requirements detailed in the permit. This is an
example of the "permit as a shield" provision, codified at §270.4(a). This section states
that compliance with a RCRA permit constitutes compliance for purpose of
enforcement. The exceptions to this provision are those requirements that are not
included in the permit; those provisions that become effective by statute subsequent to
the issuance of the permit; and those provisions that are promulgated under the land
disposal restrictions, land disposal unit leak detection requirements, or the air emission
standards.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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RCRA Enforcement and Compliance - 11
ENFORCEMENT AT FEDERAL FACILITIES
Many federal agencies (e.g., Department of Energy, Department of Defense) are
hazardous waste handlers subject to RCRA. Initially in the RCRA program, there was
some question whether sovereign immunity protected federal agencies from some EPA
and state enforcement actions. In the Federal Facility Compliance Act of 1992 (FFCA),
Congress amended RCRA to explicitly waive sovereign immunity for purposes of
RCRA enforcement. RCRA now specifically states that all RCRA penalties or fines
"...punitive or coercive in nature or ... imposed for isolated, intermittent, or continuing
violations" apply to the federal government. Therefore, EPA and authorized states can
issue orders and penalties against federal facilities in the same manner as against
private parties.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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12 - RCRA Enforcement and Compliance
4. COMPLIANCE INCENTIVES AND ASSISTANCE
Given the complexity of the various federal environmental regulatory programs and
the size of the regulated community, EPA's task of enforcing RCRA and other federal
environmental laws is enormous. In reality, EPA can only accomplish the ultimate goal
of ensuring protection of public health and the environment by supplementing a strong
enforcement program with programs designed to encourage and assist compliance.
The Office of Enforcement and Compliance Assurance (OECA) has produced several
policies and programs designed to encourage and assist compliance. While EPA is
aggressively pursuing compliance assistance and incentive programs, a strong, formal
enforcement program is still the best tool to ensure compliance. Therefore, EPA's
compliance incentive and assistance programs are only a complement to, and not a
replacement of, the enforcement tools described elsewhere in this module. Some of the
incentive and assistance programs are described below.
SMALL BUSINESS COMPLIANCE CENTERS
EPA has established four Small Business Compliance Centers (SBCCs) (62 FR18115;
April 14,1997). These are information centers where businesses with less than 10
employees can get regulatory compliance assistance. In cooperation with states,
universities, and trade groups, EPA has established centers for the metal finishing,
printing, auto services, and agriculture industries. EPA plans to establish centers for
transportation, local governments, chemical manufacturers, and printed wiring board
manufacturers.
COMPLIANCE INCENTIVES FOR SMALL BUSINESSES
EPA has also established a policy to encourage businesses to use the SBCCs. Under the
Interim Policy on Compliance Incentives for Small Businesses (61 FR 27894; June 3,
1996), when businesses make a good faith effort to comply with environmental
regulatory programs by utilizing SBCCs or other nonconfidential governmental or
government-supported compliance assistance programs, the businesses can qualify for
reduced civil penalties for violations.
COMPLIANCE INCENTIVES FOR SMALL COMMUNITIES
The EPA Policy on Flexible State Enforcement Responses to Small Community
Violations describes the circumstances in which the EPA will generally defer to a state's
efforts to return small communities to environmental compliance. This deference will
be based on an assessment of the adequacy of the process a state uses to address small
community noncompliance.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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RCRA Enforcement and Compliance - 13
AUDIT POLICY
On December 22,1995, EPA issued the Incentives for Self-Policing: Discovery,
Disclosure, Correction, and Prevention of Violations Policy (60 FR 66706). This EPA-
wide policy (commonly knows as the "Audit Policy") contains incentives for the
regulated community to voluntarily identify, evaluate, disclose, and correct violations.
Incentives include substantially reduced or eliminated penalties and deferral of criminal
enforcement in settlements for violations disclosed and corrected pursuant to the
policy.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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14 - RCRA Enforcement and Compliance
5. SMALL BUSINESS REGULATORY ENFORCEMENT
FAIRNESS ACT
The Small Business Regulatory Enforcement Fairness Act (SBREFA, P.L. 104-121)
addresses the enforcement of environmental regulations against small businesses and
small entities, and amends the rulemaking process to ensure that environmental
regulations do not unreasonably impact small businesses.
For purposes of SBREFA, "small entity" includes small businesses, small governmental
jurisdictions, and not-for-profit organizations that are not dominant in their field. U.S.
Small Business Administration (SBA) defines "small business" in terms of the number
of persons employed and in some case by annual revenues as well. In general,
businesses employing 500 persons of less are considered small, however, businesses
with as many as 1500 employees or up to $25 million in annual receipts may be defined
as small (see 13 CFR §121). Small governmental jurisdictions include towns, cities, and
counties of 50,000 persons or less.
SBREFA was signed into law on March 29,1996, and consists of five subtitles. These
subtitles are:
Subtitle A - Regulatory Compliance Simplification - EPA requirements for
providing assistance to small entities
Subtitle B - Regulatory Enforcement Reforms - process for small businesses to
comment on agency enforcement and compliance activities;
Subtitle C - Equal Access to Justice Act - the award of attorney fees and costs to
prevailing and non-prevailing parties in administrative or civil judicial
enforcement actions
Subtitle D - Regulatory Flexibility Act Amendments - requirement that any final
rule promulgated after June 26,1996 that will have a significant economic impact
on a substantial number of small entities be supported by a final "regulatory
flexibility analysis."
Subtitle E - Congressional Review of Agency Rulemaking - Congress has the
opportunity to review and potentially disapprove rules promulgated on or after
March 1996.
The information in this document is not by any means a complete representation of EPA's regulations or policies,
but is an introduction to the topic used for Hotline training purposes.
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United States
Environmental Protection
Agency
Office of
Enforcement
and Compliance Assurance
(2261A)
EPA 300-B-96-011
Spring 1997
Environmental Audit
Program Design Guidelines
For Federal Agencies
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NOTICE
The Environmental Audit Program Design Guidelines for Federal Agencies on-line
document does not contain any appendices. These are available in the hard copies
only. For more information about this document, please contact Andrew Cherry at
202/564-5011. To obtain a hard copy, call, fax, or write Priscilla Harrington at:
U.S. Environmental Protection Agency
401 M Street, S.W., MC: 2261A
Washington, D.C. 20460
Phone: 202/564-2461
Fax: 202/501-0069
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ACKNOWLEDGMENT
This guidance was prepared by the Federal Facilities Enforcement Office (FFEO), U.S.
Environmental Protection Agency (EPA) for federal facilities to use as guidance in
establishing and implementing environmental audit programs. Much of the work of
creating the publication was performed under Contract No. 68-W4-0005.
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TABLE OF CONTENTS
CHAPTER 1 : INTRODUCTION 1-1
1.1 Overview 1-1
1.2 How to Use This Document 1-2
1.3 EPA's 1986 and 1995 Environmental Audit Policies 1-2
1.4 History of Environmental Auditing 1-6
1.5 Federal Facilities and Environmental Auditing 1-7
1. 6 Trends in Environmental Auditing 1-8
1.6.1 Management Audits 1-8
1.6 .2 Pollution Prevention Opportunity Assessments 1-10
1.6 .3 Auditing Standards 1-10
1.6.4 Professional Recognition 1-11
1.7 Relationship of Auditing to Effective Environmental Program
Management 1-11
PART I. AUDIT PROGRAM DEVELOPMENT AND MANAGEMENT
CHAPTER 2 : UNIQUE ASPECTS OF FEDERAL FACILITY AUDITING 2-1
2 .1 Overview 2-1
2.2 Agency Mission vs. Environmental Compliance 2-2
2 . 3 National Security Concerns 2-4
2 .4 The Federal Budget Cycle 2-5
2 .5 Federal Agency Budget Process 2-6
2.6 Contractor and Tenant Activities 2-8
2.7 Waiver of Sovereign Immunity 2-10
2 . 7 .1 Resource Conservation and Recovery Act (RCRA) .... 2-11
2 . 7 . 2 Comprehensive Environmental Response, Compensation and
Liability Act (CERCLA) 2-11
2 . 7 . 3 Emergency Planning and Community Right-to-Know Act
(EPCRA) 2-12
2.7.4 Pollution Prevention Act of 1992 (PPA) 2-12
2.7.5 Clean Air Act (CAA) 2-13
2.7.6 Clean Water Act (CWA) 2-13
2 .8 Freedom of Information Act Requests 2-14
2.9 Status of Environmental Auditing at Federal Facilities. 2-15
2.9.1 GAO Report 1995 2-16
2.10 Status of Environmental Management at Federal Facilities
(Benchmark
Report) 2-17
2 .11 The Role of EPA's Federal Facility Office 2-18
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TABLE OF CONTENTS (CONTINUED)
CHAPTER 3 : LEGAL CONSIDERATIONS 3-1
3.1
3.2
3 .3
3 .4
3 .5
Policies
3.6
Settlements
Overview 3-1
Document Protection/Freedom of Information Act Requests . 3-2
3 .2 .1 Litigation/Discovery 3-4
EPA Requests for Audit Reports 3-6
EPA's 1995 Audit Policy 3-7
EPA/DOJ Policy Letter on State Audit Privilege Laws and
3-13
EPA Policy Regarding the Use of Auditing in Legal
3-14
CHAPTER 4: AUDITING FEDERAL FACILITIES IN FOREIGN COUNTRIES/OVERSEAS4-1
4 .1 Overview 4-1
4.2 Role of Facility Management 4-1
4.3 Designing an Overseas Environmental Audit Program 4-3
4 .4 Conducting an Overseas Audit Program 4-4
4 .5 Summary of Key Elements 4-6
4.6 Sources of Information 4-7
CHAPTER 5 : DESIGNING AN AGENCY-WIDE AUDIT PROGRAM 5-1
5 .1 Overview 5-1
5.2 Factors Affecting Program Design 5-1
5 .3 Identifying Audit Program Goals 5-3
5.4 Identifying Audit Program Objectives 5-5
5.5 Selecting the Type and Scope of an Environmental Audit.. 5-6
5.5.1 Compliance Audits 5-7
5.5.2 Property Transfer Assessments 5-7
5.5.3 Management Audits 5-9
5.5.4 Waste Contractor/Vendor Audits 5-9
5.5.5 Pollution Prevention Opportunity Assessments 5-10
5.6 Targeting Facilities 5-11
CHAPTER 6 : PROGRAM ADMINISTRATION 6-1
6 .1 Overview 6-1
6.2 Program Initiation (Genesis of the Program) 6-1
6.2.1 Develop An Environmental Audit Policy 6-1
6.2.2 Internal Versus External Audits 6-2
6.2.3 Use Of Contractors Versus Agency Staff 6-3
6.3 Program Management Issues and Activities 6-3
6 .3 .1 Securing Upper Management Support and Resources ... 6-3
6.3.2 Support From Field Offices 6-4
6 . 3 . 3 Obtaining Qualified Personnel 6-5
6.3.4 Medical Monitoring 6-7
6.3.5 Quality Assurance and Audit Program Performance
Measurement 6-7
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TABLE OF CONTENTS (CONTINUED)
6 . 3 . 6 Reporting Responsibilities 6-8
6 . 3 . 7 Post-Audit Activities and Corrective Measures 6-8
6.3.8 Budget Coordination and FEDPLAN 6-8
6 .4 Legal Issues 6-9
6.4.1 Written V. Oral Reports 6-9
6.4.2 Exit Interview 6-10
6.4.3 Document Protection and Retention 6-11
6.4.4 Involvement Of General Counsel 6-11
6. 4. 5 Report Distribution 6-12
CHAPTER 7 : RESOURCES AND TOOLS FOR AUDITORS 7-1
7 .1 Overview 7-1
7.2 Pre-Visit Questionnaire (PVQ) 7-1
7 . 3 Protocols/Checklists 7-2
7 .4 Legal Issues 7-5
7 . 5 Photography Equipment 7-6
7 . 6 Field Assessment Equipment 7-6
7 . 7 Protective Clothing 7-7
7.8 Computer Capabilities for Tracking and Reporting 7-7
7 . 9 Access to Technical References 7-8
7 .10 Chain of Title Reports 7-8
7.11 Aerial Photographs 7-9
PART II. THE AUDIT PROCESS
CHAPTER 8 : PRE-AUDIT ACTIVITIES 8-1
8 .1 Overview 8-1
8.2 Setting the Objectives and Scope of the Audit 8-3
8.3 Planning and Preparing the Audit Team for the Site Visit 8-4
8.3.1 Review Relevant Regulations 8-5
8.3.2 Review and Refine Audit Protocols 8-6
8 .4 Preparing Facility Management for the Audit 8-7
CHAPTER 9 : ON-SITE ACTIVITIES 9-1
9 .1 Overview 9-1
9.2 Introductions with Facility Management 9-1
9.3 Site Interview with Pertinent Facility Staff 9-1
9.4 Site Walk-Through 9-2
9 . 5 Record/Documentation Review 9-4
9 . 6 Exit Interviews 9-5
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TABLE OF CONTENTS (CONTINUED)
CHAPTER 10: POST SITE ACTIVITIES 10-1
10 .1 Overview 10-1
10 . 2 Audit Team Debriefing 10-1
10.2.1 Preliminary Issues 10-1
10.2.2 Develop List of Significant Findings 10-1
10.2.3 Prioritize Audit Findings 10-2
10.2.4 Clarify Assignments for Audit Team Members 10-4
10.3 Substantiation of Significant Findings 10-5
10.3.1 Regulatory Reviews 10-5
10.3.2 Phone Calls/FOIA Requests to Regulators 10-6
10.3.3 Vendors 10-7
10.4 Identify and Gather Additional Data 10-7
CHAPTER 11: REPORT WRITING AND FOLLOW-UP 11-1
11.1 Overview 11-1
11. 2 Field Preparation 11-1
11. 3 Report Preparation 11-2
11.4 Sample Report Format 11-3
11.5 Report Follow-Up (Courtesy Draft to Facility Management 11-4
11.6 Develop Action Plans and Corrective Measures 11-4
11.7 Communications with Senior Agency Officials on Significant
Reports
Findings 11-4
11.8 Enter Audit Findings and Recommendations Into a Formalized
Tracking System 11-5
11.9 Budget for Corrective Actions and Coordinate with Federal
Budget
Cycle 11-6
11.10 Follow-Up Audits and Verification that Corrective Measures
Have
Been Implemented 11-6
LIST OF APPENDICES
APPENDIX A 1986 EPA AUDIT POLICY A-1
APPENDIX B EPA POLICY REGARDING INCENTIVES FOR SELF-POLICING:
DISCOVERY, DISCLOSURE, CORRECTION AND PREVENTION OF
VIOLATIONS B- 1
APPENDIX C DOJ POLICY - FACTORS IN DECISIONS OF CRIMINAL PROSECUTIONS
FOR ENVIRONMENTAL VIOLATIONS IN THE CONTEXT OF SIGNIFICANT
VOLUNTARY COMPLIANCE OR DISCLOSURE EFFORTS BY THE
VIOLATOR C- 1
APPENDIX D UNITED STATES SENTENCING COMMISSION GUIDELINES -
DEFINITION OF EFFECTIVE "DUE DILIGENCE PROGRAM" D-l
APPENDIX E EPA POLICY CONCERNING THE ROLE OF CORPORATE ATTITUDE
IN CRIMINAL DELISTING E-l
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APPENDIX F JOINT EPA-DOJ POLICY LETTER TO FEDERAL AGENCIES REGARDING
STATE AUDIT PRIVILEGE AND IMMUNITY LAWS F-l
APPENDIX G CODE OF ENVIRONMENTAL MANAGEMENT PRINCIPLES (CEMP)
FOR FEDERAL AGENCIES G-1
APPENDIX H SAMPLE PRE-VISIT QUESTIONNAIRE - U.S. ARMY H-l
LIST OF FIGURES
Figure 1 EPA Definition of Environmental Auditing 1-4
Figure 2 Pyramid of Audit Types 1-9
Figure 3 The Expanded Corrective Action Process 1-12
Figure 4 Sample Checklist and Worksheet from EPA's Generic Audit
Protocol 7-4
Figure 5 Schematic Overview of the Audit Process 8-2
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CHAPTER 1: INTRODUCTION
1.1 OVERVIEW
Environmental regulations are becoming increasingly complex and costly for both
private and public sector regulated entities. Federal agencies, however, differ from the private
sector in how they must comply with those regulations. The goal of reducing the national debt
has led to a simultaneous decrease in available Federal agency budgets for environmental and
other program areas. Thus, Federal agencies are being asked to do more with less - comply
with all applicable environmental regulations while utilizing fewer resources to accomplish the
goal of full compliance. An environmental audit is one tool that Federal agencies can use to
comply with the regulations, as well as to improve the efficiency of operations and conserve
limited fiscal and labor resources.
A number of factors must be considered when designing and implementing a Federal
agency environmental audit program. In developing an effective audit program, an agency
environmental manager must always remain aware that: (1) the audit program should
complement and contribute to the agency mission; (2) securing funding for the audit program
and the implementation of audit findings must be an integral part of the agency budgeting
process; (3) national security issues may impact the nature of the audit program; (4) federal
facilities may be owned and operated by different public and private entities; and (5) the
missions and operations of federal facilities vary widely and, as a result, the audit program must
be flexible enough to be applicable to all agency facilities, while still allowing for the comparison
of audit results between facilities.
This document is not a "how to" manual for conducting environmental audits. A detailed
discussion of environmental auditing protocols, i.e., the "how to" of environmental auditing is
contained in EPA's Generic Protocol for Conducting Environmental Audits of Federal Facilities,
("Protocol") (EPA # 300-B-95-002). The Protocol provides specific information on the various
media and statutes implicated in environmental auditing, and provides detailed descriptions of
how to conduct a facility audit and establish an audit program. Careful review and adherence to
the Protocol should allow one to develop a sound audit program. In short, the Protocol is an
environmental auditing instruction manual as well as a design manual for establishing an
environmental auditing program.
1-1
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This document describes the components of a thorough environmental management
program and informs the reader about the kinds of issues that arise and require addressing in
environmental audits. It addresses programmatic issues in that it identifies the elements of a
sound environmental auditing program, including management elements, resources, both
human and capital that are typically required in establishing an auditing system, and provides
general guidance on what is required of a thorough environmental auditing program. However,
this document does not provide detailed descriptions of how to actually conduct an audit nor
does it tell the reader the precise and detailed steps to follow in creating an environmental
management program. This document is intended to be informative not instructional, and
should be used in conjunction with the Protocols in order to create and undertake an
environmental auditing program.
1.2 HOW TO USE THIS DOCUMENT
This guide is organized in two parts: Part I highlights some of the unique issues and
legal considerations related to conducting environmental audits at both domestic and overseas
federal facilities. Part II contains a detailed discussion regarding the design and administration
of effective environmental auditing programs, along with a summary of resources and tools for
environmental auditors. Part II also addresses the specific steps to conducting an
environmental audit, from pre-audit activities through to on-site activities and post-site activities,
including report writing and follow-up. The guide also contains several appendices which
contain text of relevant EPA and Department of Justice (DOJ) policies in this area, U.S.
Sentencing Commission Guidelines governing the definition of effective "Due Diligence," and a
sample audit pre-visit questionnaire.
1.3 ERA'S 1986 AND 1995 ENVIRONMENTAL AUDIT POLICIES
The U.S. Environmental Protection Agency (EPA) recognizes that environmental
auditing ~ and sound environmental management generally ~ can provide potentially powerful
tools toward protection of public health and the environment. In encouraging the use of these
tools, EPA has announced the "Environmental Auditing Policy Statement" on July 9, 1986 (51
FR 25004) (1986 audit policy) and the "Incentives for Self-Policing: Discovery, Disclosure,
1-2
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Correction and Prevention of Violations" on December 22, 1995 (60 FR 66706) (1995 or final
audit or self-policing policy).
The 1986 audit policy states that "it is EPA policy to encourage the use of
environmental auditing by regulated industries to help achieve and maintain compliance with
environmental laws and regulation, as well as to help identify and correct unregulated
environmental hazards." The policy also specifically endorses environmental auditing at federal
facilities. The 1986 EPA policy is presented in Appendix A of this guide.
The 1995 audit policy offers major incentives for entities (including federal facilities) to
discover, disclose and correct environmental violations. Under the 1995 policy, EPA will not
seek gravity-based penalties or recommend that criminal charges be brought for violations that
are discovered through an "environmental audit" (as defined in the 1986 audit policy) or a
management system reflecting "due diligence" and that are promptly disclosed and corrected,
provided that other important safeguards are met. These safeguards protect health and the
environment by precluding policy relief for violations that cause serious environmental harm or
may have presented an imminent and substantial endangerment, for example. The effective
date of the policy is January 22, 1996. More discussion regarding EPA's 1995 Audit Policy is
provided in Chapter 3, Section 3.4 of this document. The 1995 EPA audit policy is presented in
Appendix B of this document.
In the 1986 policy, EPA defines environmental auditing as "a systematic, documented,
periodic, and objective review of facility operations and practices related to meeting
environmental requirements." Figure 1 depicts EPA's definition of environmental auditing. The
policy identifies several objectives for environmental audits:
Verifying compliance with environmental requirements;
Evaluating the effectiveness of in-place environmental management systems; and
Assessing risks from regulated and unregulated materials and practices.
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Figure 1
EPA Definition of Environmentd Audting
Regulated
Entities
i
l\
or >
^
1 T 1
Facility
Operations
Practices
i
l\
To Assure^1
IX
.
Meeting
Environmental
The EPA policy encouraged all Federal agencies subject to environmental laws and
regulations to develop environmental auditing programs to help ensure the adequacy of internal
systems to achieve, maintain, and monitor compliance with environmental requirements. The
policy also notes that Federal agency auditing programs should be designed to identify
environmental problems and develop schedules for remedial actions for audit findings.
Subsequent to the development of EPA's 1986 policy, the Department of Justice
("DOJ") issued a memo explaining DOJ policy on environmental auditing in the
context of criminal prosecutions. This memo1, issued in 1991 (see Appendix C), includes
factors that DOJ considers important in evaluating whether to prosecute environmental
violations. These factors include voluntary disclosure of the violation, cooperation,
preventative measures and compliance programs, persuasiveness of non-compliance,
internal disciplinary action, and subsequent compliance efforts. It was the intent of
DOJ to encourage self-auditing, self-policing, and voluntary disclosure of environmental
violations stating that these activities are considered mitigating factors in the
Department's environmental enforcement activities. The necessity of having a
1 "Factors in Decisions on Criminal Prosecutions for Environmental Violations in the Context of
Significant Voluntary Compliance or Disclosure Efforts by the Violator."
1-4
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thorough environmental auditing program cannot be overemphasized. The priority
that DOJ assigns to auditing and self-disclosure as critical mitigating factors in
environmental criminal prosecutions is an indication of how important it is for federal
facilities to develop and implement sound and thorough auditing programs.
On December 12, 1991, EPA published in the Federal Register (56 FR 64785), a
clarification on its policy concerning the role of corporate attitude, policies, practices
and procedures in determining whether a regulated entity has properly corrected
conditions giving rise to a criminal conviction (See Appendix D). The notice indicates
that if the entity has properly corrected these conditions, the agency may consider
removing the facility from the EPA list of violating facilities. Section IV of this notice
specifies the criteria the entity in consideration must demonstrate as proof of a change
in corporate attitude. These criteria were adapted from the proposed U.S. Sentencing
Guidelines for organizational defendants and were later reflected in the final version of
the Guidelines issued by the Department of Justice in 1994. One of the factors stated in
the 1991 federal register notice as "proof of a corporate change in attitude" included
evidence that the regulated entity has put in place an effective program to prevent
and detect violations of the law and that the entity exercises due diligence by taking
several steps that represent the "hallmark" of an effective environmental
management program. One step outlined as an indicator of due diligence was "..the
establishment of an effective program for enforcing its standards (e.g., environmental
auditing system designed to prevent or detect non-compliance)". Therefore, as a
follow-up to its 1986 audit policy, EPA and the Justice Department again recognized
the value of environmental auditing as an integral part of a sound environmental
management system.
In November 1994, the United States Sentencing Commission issued
amendments to its sentencing guidelines which include mitigating factors to be
applied when handling down criminal sentences. These factors include a definition of
what the Commission considers to be necessary elements of an effective program of
due diligence to prevent and remedy violations of the law and urges the establishment
of self-evaluative programs to prevent and remedy criminal violations. A copy of the
definition "an effective program to prevent and detect violations of law," taken from
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the 1994 Guidelines Manual is provided in Appendix E. Though broadly applicable to
many types of activities, the guidelines specify the kind of programmatic elements
necessary for auditing and self-evaluation that this audit document is emphasizing. It is
the position of the Sentencing Commission that if an organization which has been
implicated in criminal activities, including gratuitous and unsanctioned criminal
activities of its employees, follows the outlined procedures, a court will consider the
implementation of the self-evaluative program to be a mitigating factor when handing
down a sentence. It is clear that there is a broad based effort on the part of federal
enforcement agencies to encourage and in selected cases compel the development
and implementation of environmental audit programs, especially in situations of
environmental deficiency.
By Executive Order 12088, EPA has committed to provide technical assistance to
Federal agencies to facilitate federal agency compliance with environmental laws.
This guidance manual is one form of that assistance. This guide addresses a number of issues
related to environmental auditing, including: the purpose of environmental audits; unique
aspects of environmental auditing at federal facilities; legal considerations in environmental
auditing; as well as audit program design, administration, implementation, and available
resources.
1.4 HISTORY OF ENVIRONMENTAL AUDITING
In the early 1970s, a number of private industry managers recognized the benefits of
internal auditing and established company programs to conduct these audits. By the late 1970s
and early 1980s, governments, consultants, and lawyers had begun to recognize the benefits of
well-designed audit programs as well. Cahill and Kane (1989) trace the beginning of the use of
environmental auditing as a management tool to actions taken by the Securities and Exchange
Commission (SEC) that required three public companies (U.S. Steel, Allied Chemical, and
Occidental Petroleum) to perform internal environmental audits to determine the nature and
extent of the companies' environmental liabilities for presentation to stockholders in corporate
annual reports.
Later, the promulgation of new and complex Federal regulations regarding hazardous
materials and wastes, such as the Resource Conservation and Recovery Act (RCRA) in 1976
1-6
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and the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA)
in 1980, highlighted the need for private sector companies to initiate internal environmental
auditing programs. Many company environmental managers developed and implemented audit
programs as a means of avoiding costs and liabilities associated with non-compliance with
these new environmental requirements.
Recently, with the passage of the Federal Facilities Compliance Act and several
Presidential Executive Orders, federal facilities are now being subject to the same stringent
environmental requirements and liabilities as their private sector counterparts. As a result,
Federal agency managers are coming to recognize the benefits of environmental auditing as
well.
1.5 FEDERAL FACILITIES AND ENVIRONMENTAL AUDITING
Following the passage of RCRA in 1976, and the Supreme Court's decision in Hancock
v. Train, 426 U.S. 167 (1976) which required that Federal agencies must comply with the law,
President Carter issued Executive Order (EO) 12088, Federal Compliance with Pollution
Control Standards (1978). This Order required Federal agencies to comply with all substantive
and procedural requirements of Federal, state, and local environmental regulations. The EO
was a landmark event because for the first time head of agencies were responsible for
environmental compliance, and environmental compliance became a measure of agency
performance. The EO also stipulates that EPA must aid this effort by providing Federal
agencies with technical guidance and assistance to achieve compliance. One way in which
EPA complied with this directive was by issuing the Federal Facility Compliance Strategy in
1984 and a revised version of the Strategy in 1988. These documents, commonly referred to
as the Yellow Books, describe the usefulness and importance of audits, stressing the benefits
of developing a proactive approach to achieving environmental compliance. EPA's
Environmental Auditing Policy Statement of 1986 (described above) is another example of
EPA's resolve to use environmental audits as tools for attaining high rates of compliance.
1.6 TRENDS IN ENVIRONMENTAL AUDITING
The chemical industry was the first to embrace the environmental audit concept in the
1970s. As regulations became more complex, non-compliance costs increased, and EPA
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stressed the importance of conducting environmental audits to reduce compliance costs,
environmental managers of several Federal agencies began to incorporate audits as essential
tools in their operations. As environmental auditing has continued to gain acceptance in both
the private and public sectors, new trends in auditing have emerged. Some of the recent
national and international developments in the field of environmental auditing include
management audits, pollution prevention opportunity assessments, auditing standards, and
professional registration.
Figure 2 depicts the variety of audits typically conducted at facilities. Ascending up the
pyramid the audit type selected becomes less common but more comprehensive in scope. For
example, more compliance audits and property conveyance audits are selected as
environmental management tools than audits assessing "Green" practices (recycling and
procurement of environmentally preferable products) or "Total Risk" where the auditors assess
unregulated risks in addition to regulatory requirements. Also, by ascending up the pyramid,
the audit scope also becomes more complex and issues such as non-compliance with
regulatory requirements are used as indicators for the findings reported in environmental
management systems audits."
1.6.1 Management Audits
Management audits are used to look at the strengths and weaknesses of facility
environmental management systems (EMSs). Management audits differ from compliance
audits in that management audits evaluate the overall effectiveness of an environmental
management program. EPA has developed a comprehensive guidance document which
outlines procedures for conducting management audits. The Generic Protocol For Conducting
Environmental Audits of Federal Facilities, (EPA #300-6-95-002) includes the concept of
conducting EMS audits and is designed to help federal agency environmental managers
determine the overall effectiveness of their EMS programs. The procedures recommended in
"Phase 3" of the EPA Protocol include an assessment of (1) organizational structure, (2)
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Figure 2
Pyramid of Audit Types
/ Management Systems \
/ Regulatory Comrdicnoe \
/ \ )
/ Property Conveycnoe \ /
environmental commitment, (3) formality of environmental programs, (4) internal and external
communication program, (5) staff, resources, training and development, (6) program evaluation,
reporting and corrective action, (7) environmental planning and risk management, and (8)
environmental protection program. In addition, an environmental management audit should
assess the organizations ability to assure that the right mix of resources, organization, policies,
and procedures are in place.
Management audits are a critical tool in uncovering the "root causes" of environmental
management deficiencies and are a more effective method to implement thorough and
permanent corrections. For example, a compliance audit observation that waste drums are not
properly labeled results in a deficiency report. This problem could turn up repeatedly. A
management audit may uncover that due to an insufficient training budget, personnel are not
familiar with proper labeling procedures. In this case the "root cause" of an environmental
deficiency is not mislabeling but rather budgetary problems. A management audit is intended to
identify the problem at a systemic level and recommend corrective action such as increasing
the training budget.
1.6.2 Pollution Prevention Opportunity Assessments
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Pollution prevention opportunity assessments (or PPOAs) are used by environmental
managers to identify opportunities to change facility operations to save money, increase worker
safety and morale, and decrease regulatory liability through source reduction techniques.
Source reduction techniques include process efficiency improvement, material substitution,
improved inventory control, housekeeping, and preventive maintenance. EPA has developed a
Pollution Prevention Opportunity Assessment manual, Facility Pollution Prevention Guide,
EPA/600/R-92/008, 1992, that describes a procedure for identifying pollution prevention
opportunities through a formal audit process and continues to conduct training workshops
throughout the country to assist federal facilities in conducting the assessments.
1.6.3 Auditing Standards
Many industry organizations have established auditing standards as a means of
providing guidelines regarding the conduct and content of thorough environmental audits. In
1993, the International Organization for Standardization (ISO) began work on the ISO 14001,
Standards for Environmental Management Systems (EMSs). Incorporated within these
standards are guidelines for environmental audit tools and procedures. ISO 14001 is expected
to be available in final form on or about the summer of 1996.
The International Organization for Standards (ISO) has recently published specific
auditing standards that address General Principles for Environmental Auditing (ISO 14010);
Auditing of Environmental Management Systems (ISO 14011); and Qualification Criteria for
Environmental Auditors (ISO 14012). General Principles include such information as definitions
of basic terms, and the principles that should be adhered to in order to undertake a proper
audit. An example of what is required by the principles includes the need to establish
objectives and scope for an audit; maintaining objectivity, independence and competence of the
audit team; use of due professional care and the use of systematic procedures. These are
some of the general principles that are recommended in setting up an audit program.
These ISO 14000 standards are the basic framework around which an auditing program
may be developed. They are not audit protocols; they provide the standards necessary for
establishing specific elements of audit programs and as such are the foundational elements for
developing environmental audit programs. The ISO standards are of particular importance
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because they represent a formal international standard, accepted by many nations, rather than
an ad hoc auditing standard.
1.6.4 Professional Recognition
The trend toward reducing environmental regulatory costs and liabilities through auditing
procedures has led to the formation of organizations that focus on the concept of environmental
audits. The Environmental Auditing Roundtable (EAR), the Institute for Environmental Auditing
(IEA), and the American Society for Testing Materials (ASTM) are a few of the groups that have
greatly influenced the field of environmental auditing.
An ASTM technical subcommittee on environmental compliance auditing recently
approved (September 10, 1995) two provisional standards regarding environmental compliance
audits and evaluations of Environmental Management Systems (PS 11 and PS 12,
respectively). PS 11 is designed to explain to all regulated entities the definition and description
of accepted practices, procedures, and policies associated with environmental regulatory
compliance audits (ASTM, Standard Provisional Practice for Environmental Regulatory
Compliance Audits, working document, Jan. 1995). Agency and federal facility environmental
managers should keep apprised of the new standards being set by the various organizations to
ensure that their audit programs reflect the latest environmental auditing developments.
1.7 RELATIONSHIP OF AUDITING TO EFFECTIVE ENVIRONMENTAL PROGRAM
MANAGEMENT
An environmental audit is only one part of an agency's environmental management
system. Each agency EMS should be designed to create an organizational culture that strives
toward continuous environmental improvement. With the world marketplace becoming more
competitive, budgets being reduced, federal facilities increasingly needing to comply with state
and local environmental requirements, and citizens demanding more accountability for the
activities of facilities in their communities, managers are becoming increasingly aware of the
importance of developing an agency-wide philosophy of environmental stewardship. This
means not only improving on how a facility achieves environmental compliance, but moving
beyond compliance to include issues of environmental management and organization, public
satisfaction, worker safety and productivity.
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To successfully correct problems, keep problems corrected, and head off finding the
same problems at other facilities, the audit process needs to be expanded (see Figure 3).
When the audit process is expanded, the agency's corrective action part of its environmental
management system becomes more effective. As Figure 3 shows, audit findings are evaluated
for underlying or "root" causes, and corrective actions involve developing management
solutions to resolve root causes. When the focus of corrective actions is on correcting common
root causes, the effectiveness of the audit is increased tremendously. The expanded audit
process can be applied at any level (i.e., facility, field division, or bureau or overall agency).
Rarely does the root cause for facility problems stop at the facility gate; it usually extends
upward into the division or parent agency.
Figured
T he Expended Corrective Action Process
Audt
i
*v
r
Improve
Environmental
Management
System
Effectiveness
\
Identify
Problems
i
Fix Problems
Develop Actions
to Correct
Underlying
Causes
Andyze
Exceptions for
Cause/Effect
j!
Group Findings
for Common
Causes
\<
Examine Each
Group for
Underlying
Causes
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To set goals and measure environmental progress, agency managers must determine
their starting point for environmental improvements. Environmental auditing can help to provide
a benchmark against which environmental programs can be measured (Environmental Auditing,
Banff Centre for Management). Audit findings also can be used by agency and facility
managers to aid in effective and efficient decision-making on environmental and other agency
issues.
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CHAPTER 2: UNIQUE ASPECTS OF FEDERAL FACILITY AUDITING
2.1 OVERVIEW
The private sector has realized significant benefits from conducting environmental audits
for many years. Many of these same benefits can be obtained by Federal agencies, however,
several factors that are unique to Federal agencies must also be considered when developing
and implementing agency-wide audit programs. One example of these additional
considerations is funding. For Federal agencies, unlike the private sector, the allocation of
resources is determined in large part by government policy and regulations that are beyond
agency control. For example, the President and Congress, through the Federal budget setting
process, have a significant influence on the amount of resources that are available to pursue
audit programs and address audit findings. In addition, the process of obtaining funding for
environmental programs is time and resource intensive, and follows a complex process
predefined by authorities outside the control of the agency, such as the Office of Management
and Budget (OMB).
This chapter describes some of the unique issues that Federal agencies may encounter
when designing or upgrading agency-wide environmental audit programs. Issues considered in
this chapter include:
Agency mission vs. environmental compliance;
National security concerns;
The Federal budget cycle;
The Federal agency FEDPLAN process;
Contractor and tenant activities;
Waiver of sovereign immunity;
Freedom of Information Act requests;
Status of environmental auditing at federal facilities; and
The role of EPA's Federal Facility Enforcement Office.
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2.2 AGENCY MISSION VS. ENVIRONMENTAL COMPLIANCE
Private sector business operations are driven by the economics of production, with the
costs associated with environmental compliance factored into the overall profit-loss equation. In
an effort to maximize profits, the private sector has begun to recognize the value of
environmental audits and pollution prevention programs. The unnecessary use of raw materials
in production processes and the increased costs associated with waste and emissions
management are significant factors in motivating the private sector to establish proactive
environmental programs that encourage auditing and pollution prevention. Additionally, liability
risks and costs have increased dramatically due to government and third party lawsuits.
Federal agencies, on the other hand, are driven by statutorily-defined missions. These
missions are established in the statutes that created each agency, and are further clarified by
each agency's mission statement. Environmental compliance has only begun to be "factored"
into the agency's bottom line within the last 20 years. Many Federal agencies have now
adopted their own formal environmental policy statement.
In addition to internal agency policy statements, other specific statutes and Executive
Orders (EOs) require Federal agencies to abide by applicable environmental regulations and
policies. For example, the Federal Facilities Compliance Act of 1990 (FFCA) requires Federal
compliance with all of the hazardous waste requirements to which private industry is held under
the Resource Conservation and Recovery Act (RCRA). Further, EO 12856 requires that federal
facilities comply with the provisions of the Emergency Planning and Community Right-to-Know
Act (EPCRA), including Toxics Release Inventory (TRI) program reporting requirements. The
Executive Order also requires that Federal agencies comply with the Pollution Prevention Act of
1990 (PPA) and prepare pollution prevention strategies and plans to reduce releases of toxic
chemicals by specified levels.
Several Department of Defense (DoD) agencies, as well as the Department of Energy,
are developing progressive environmental programs that go beyond compliance with Federal
requirements by emphasizing environmental audits, pollution prevention, and other proactive
programs such as the Total Quality Environmental Management (TQEM) concept created by
the Global Environmental Management Institute (GEMI).
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Political considerations, changes in agency budget authority and mission, and the
current efforts to "reinvent government," have all placed tremendous pressure on Federal
agencies to downsize while simultaneously improving delivery of services. In such an
atmosphere, agency environmental officials and programs may be caught between the
necessity to maintain a sufficiently responsive environmental program and reduced resources.
In some cases, agency environmental managers must be able to justify a considerable upfront
expense associated with a new program or technology that will prevent future environmental
problems and explain how it will yield a long-term payback in reduced costs and liabilities.
When dealing with hazardous materials, the expression an ounce of prevention is worth a
pound of cure might best be rephrased as, an ounce of pollution prevention is worth millions of
dollars in avoided liability and clean up costs. Unfortunately, justifying this to senior
management in a period of tight budgets is not easy.
Federal environmental managers are tasked with the responsibility to monitor and
evaluate an agency's environmental compliance status and must be conscientious about
assessing the degree of regulated and unregulated environmental risk associated with agency
activities. This requires an ongoing environmental audit program and a parallel effort to
evaluate audit results. The results of this effort will assist agency management and legal staff
in their determination of how environmental issues pose a risk to the successful conduct of an
agency's mission, and serve as an aid in planning to address such risks.
Finally, environmental audit program objectives must reflect the agency's primary
mission and internal environmental policies, while remaining relevant and responsive to an
agency's needs. Thus, the manager of an environmental audit program must understand the
program objectives for all elements of the agency's primary mission to ensure that the audit
program complements, and does not interfere with, the agency's main mission goals. The
primary goal of a Federal agency audit program should be to increase understanding of
environmental requirements to allow the agency to accomplish its mission in an environmentally
sound manner. At a minimum, Federal agencies should use an audit program to improve
compliance with Federal, state, and local regulations while carrying out their main mission.
Ideally, agencies also should use audit findings to identify and address management,
organizational, and operational issues that create inefficiency and allow compliance violations to
occur. Chapter 5 of this report provides a more detailed discussion of designing an agency-
wide environmental audit program.
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2.3 NATIONAL SECURITY CONCERNS
Federal facilities frequently encompass military, intelligence, nuclear-related, and law
enforcement functions which present unique security concerns with respect to environmental
audit programs. In these cases, managers with audit oversight responsibility must address
issues such as facility security regulations and audit team access to associated documents.
This may require advanced planning to ensure that necessary security clearances to conduct
audits can be obtained. Audit program planners must consider national security issues during
the audit design phase to ensure that such issues do not cause delays when the audit is being
performed. Ideally, an internal audit program should be designed to provide an adequate
number of auditors with the necessary security clearances to expedite the auditing process. If
contractor personnel are to perform the audit, clearance status should be one factor in
contractor selection. In certain cases, audit planners can design the audit process such that
secure areas and documents are not accessed by contractors. With adequate planning, an
audit can proceed without compromising national security. In accordance with good audit
practices, the audit report should identify any areas or materials that were not inspected or
evaluated during the audit. This will prevent inaccurate conclusions to be drawn based upon
missing data.
An additional considerations associated with performing audits of facilities or operations
with national security missions is the degree to which audit results become publicly available.
Section 2.8 of this guide includes discussions relating to the release of audit documents to the
public via the Freedom of Information Act (FOIA). This statute exempts documents with
national security concerns from the FOIA process. Case law supports the concept that if there
is a reasonable danger that disclosure would expose military or state secrets, the materials in
question will be protected, even when there is "the most compelling necessity" to disclose the
materials (United States v Reynolds, 345 U.S. 1 (1953); Northrop Corp. v McDonnell Douglas
Corp., 751 F.2d 395 (DC Cir. 1984)).
2.4 THE FEDERAL BUDGET CYCLE
Assuring funding for environmental auditing programs and addressing audit findings
requires a thorough understanding of the Federal budget and appropriations process.
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Responsibility for Federal agency budget planning and appropriation rests with Congress and
the Executive branch. Within the Executive branch, OMB and the White House play crucial
roles, while congressional committees handle this responsibility for the legislative branch.
Agency budgets are the result of an extensive deliberative process that includes the input from
an agency's budget officers, the chief financial officer, and administrators at all levels of the
agency, including federal facilities.
Agency managers must understand the process and timing of the budget process to
ensure that funds required to address compliance violations or for critical environmental
projects are available. Typically, capital expenditures are line items in an agency's budget.
Funding requests for environmental projects generally will arise at the facility level and work
their way through the agency hierarchy before eventually being forwarded to the Executive
Branch for approval. Where environmental auditing programs have uncovered compliance
problems or unregulated risk, it is the responsibility of the facility environmental manager to
quantify and submit a budget request in a timely fashion.
Environmental managers must communicate to top management the need to include
funding for environmental compliance and control of unregulated risk into the facility or agency
budget process. To accomplish this objective, environmental managers must assure that their
requests are adequately justified and prioritized. Proper conduct of this task will ensure that
budget reviewers understand the implications of rejecting such requests. As part of this
process, it is important to distinguish the particular facility need and not hide the request within
other budget categories such as operations and maintenance budgets. Because budget
planning is a long-term process and can extend over many years, it is critical for agency
managers to prioritize projects on both a short and long-term time line and place requests into
the appropriate budgetary period.
2.5 FEDERAL AGENCY BUDGET PROCESS1
1 Much of the information for this section was obtained from an EPA guidance document entitled
Federal Agency Environmental Management Program Planning Guidance (EPA 300-B-95-001, October
1994). This document provides a more detailed discussion of the FEDPLAN process as well as guidance
on getting through the regional review process.
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EO 12088 (October 13, 1978) directs the head of each Executive agency to ensure that
sufficient funds for compliance with applicable Federal, state, and local environmental
requirements are requested in the agency budget. Each agency must submit an annual
FEDPLAN report to OMB, through the EPA, which describes the agency's plan for the control of
environmental pollution.
To help Federal agencies comply with the Executive Order requirements, EPA has
offered guidance in the form of a process known as the Federal Agency Environmental
Management Program Plan (FEDPLAN). FEDPLAN is a reporting mechanism defined by EPA
consisting of a combination of written guidance and a PC-based desktop management
information system known as FEDPLAN-PC. The guidance for using the FEDPLAN system is
contained in a recently issued EPA guidance document, Federal Agency Environmental
Management Program Planning Guidance (EPA Publication 300-B-95-001).
The FEDPLAN guidance suggests that Federal agency compliance officers requesting
funds for environmental projects should do so by including program management costs in their
environmental plans. The program cost definition includes inventories, assessments, surveys,
studies, plans, and environmental audits. EPA proposes to make this category a subject of
special analysis during agency reviews of individual federal facilities by EPA Regional offices.
However, overall Federal agency funding in this area will be reviewed and monitored by EPA
Headquarters personnel.
The FEDPLAN planning process is used to develop cost estimates for complying with
environmental requirements, and thus is a crucial tool for developing agency budgets for
submittal to Congress. The FEDPLAN system tracks environmental requirements from the time
they are first identified until they are executed. The process also provides a methodology for
analysis of both current and projected funding requirements. It should be understood that,
although this system by itself is not the budget request, it is a significant budget support
document to the request. FEDPLAN provides the data necessary to verify that Federal
agencies are adequately planning and programming for environmental compliance, and to
ensure that agencies are requesting funding for all their environmental requirements. It is also
used to assess progress in implementing environmental programs at all levels of the
organization.
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The information generated by the process is used for different purposes, depending on
the time periods in the budget cycle that are being addressed. For projects scheduled for
implementation during the current fiscal year, the data in the system is used to ensure that the
projects for which monies have been budgeted actually get funded. For the budget year, the
purpose of FEDPLAN is primarily to reprioritize and reprogram projects consistent with funding
levels provided by OMB and/or expected to be received from Congressional appropriations.
It is important to understand that once the current fiscal year begins, normally no "new"
money is available. This means that funds for new environmental requirements that develop
during the current year must come from other uncommitted environmental funds, or from some
other non-environmental program. This is why it is very important to carefully budget estimated
costs for audits as well as costs for possible responses to audit findings (e.g., disposal costs,
PCB transformer removal, asbestos abatement).
The review process followed by EPA in reviewing Federal Agency Plans has several
steps, involving both EPA Headquarters and Regional offices. EPA Headquarters ensures that
the required information is submitted by each Federal agency in a timely manner, and also
performs a quality control check on the data. Federal agencies submit their Plan to EPA by
September 1st, the same date that the agencies normally submit their budgets to OMB. This
helps to ensure that the information in FEDPLAN correlates as closely as possible with the
information in the agency budget submitted to OMB. EPA Headquarters then conducts an
analysis of each agency's environmental plan focusing on each of the media programs and
environmental categories. Concurrently, EPA Regions begin their review of projects and
programs at the installation or facility level. Using the information provided by the Federal
agencies, the EPA Administrator prepares several reports for OMB, each with a different but
explicit purpose.
The following is a schedule of the various components of the FEDPLAN review cycle:
Date
Milestone
September 1
September 1
Most Federal agencies submit their total/entire agency budget request to
OMB
Federal agencies submit both their new and updated FEDPLAN project data
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September 7
October 1
November 15
January 15
to EPA HQ for review
Federal agency FEDPLAN plans are forwarded to EPA Regions for review.
Regions schedule meetings with individual federal facilities to discuss key
aspects of plans, as appropriate
Selected analysis of Federal agencies previous fiscal year funding profile is
forwarded to OMB
Completed reviews of Federal agency plans are forwarded by EPA Regions to
EPAHQ
Summary of detailed EPA FEDPLAN comments and suggestions forwarded
to Federal agencies for consideration
2.6 CONTRACTOR AND TENANT ACTIVITIES
Most environmental statutes assign responsibility for compliance to "owners or
operators." Since the terms owner/operator may include both the landlord and the
tenant/contractor, confusion may result when attempting to determine who is ultimately
responsible for environmental compliance or who bears responsibility for remediation. For
Federally-owned facilities that are operated by government personnel, the U.S. government is
the owner/operator (such facilities are referred to as "GOGO" facilities - "government
owned/government operated"). However, many federal facilities have tenant relationships with
private parties, local or state governments, or other Federal agencies. The following are typical
contractor/tenant relationships found at federal facilities:
Government owned/contractor operated (GOCO)- a facility owned by a Federal
agency but operated by private contractors for government services;
Government owned/privately operated (GOPO)- a facility or lands leased by the
Federal government to private operators for their own operation and profit; and
Privately owned/government operated (POGO)- a facility owned by a private entity
where the government leases buildings or space for Federal agency activities.
In a criminal prosecution for violation of an environmental law, the person who
committed the crime is the person that is held responsible, regardless of who employs them.
However, for administrative and civil actions, responsibility for environmental compliance in
landlord/tenant situations often is not clear. The tenant may be held liable (either through direct
action or by a previous written agreement) for the consequences of their activities.
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Alternatively, the facility owner/operator may be ultimately held responsible by regulators if the
owner/operator knew or should have known of the non-compliance, or if the violation or
contamination is discovered after the tenant is gone. Prior to conducting an environmental
audit at a joint tenant/owner or multiple tenant facility, the following questions should be
answered:
Who owns the property and how many tenants are involved with onsite activities that
will be evaluated during the audit?
Whom does the statute hold responsible for noncompliance? If liability attaches to
the owner/operator, both the agency and the other party to the agreement may be
held responsible.
Are there any instruments, including permits, contract provisions or indemnification
agreements, lease provisions, operating agreements, etc. that specify or assign
responsibility for environmental compliance?
Landlord/tenant and contractor activities typically are bound by the terms of a
host/tenant agreement. Contracts for M&O (Management and Operating) contractors at GOCO
facilities often define the environmental compliance responsibilities of the contractor and
contain other agreements such as a Federal government commitment to reimburse the
contractor operator for cleanup charges if the operation is in compliance with the contract, or
environmental compliance is in whole or in part an award-fee item. In some instances, Federal
agencies should consider conducting environmental audits of the contractor or requiring the
contractor to conduct self audits and apprise the agency of the results. This is especially
important because the degree of non-compliance could be a factor in assessing liability. If a
tenant/contractor commits gross environmental violations, the Federal agency could be held
legally responsible if it is determined the agency was "willfully blind" to the non-compliance
activities of the tenant/contractor. Likewise, if a tenant/contractor enters bankruptcy, the
agency may be held financially responsible for any clean up costs resulting from the
tenant's/contractor's acts.
If a Federal agency occupies a private facility (e.g., a GSA-leased facility), it is still
responsible for a complying with environmental laws and auditing for environmental compliance.
Whatever the landlord/tenant situation, the audit should not proceed until the applicable
agreements are carefully reviewed and responsibilities for environmental compliance are
assigned to the appropriate party or parties.
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2.7 WAIVER OF SOVEREIGN IMMUNITY
Sovereign immunity is a long standing, judicially created legal doctrine which prohibits
the bringing of a suit against the government. In the United States, the doctrine of sovereign
immunity is based upon the Supremacy Clause of the Constitution which provides that the acts
of the Federal government are operative as the supreme law of the land. However, Congress
may, by legislative action, waive sovereign immunity and permit suits against the Federal
government. In those instances where Congress waives sovereign immunity, EPA, States,
localities, or private citizens (based upon the specific terms of the waiver) may bring suit against
the government for improper activities, including those associated with environmental releases.
The Westfall Act (28 U.S.C. Sec. 2679 et seq.) grants sovereign immunity protection to
the decisions and conduct of Federal employees acting in the course and scope of their
employment. However, sovereign immunity does not act to protect Federal employees who
commit criminal acts such as knowing violations of environmental laws. Further, injured parties
are not necessarily precluded from bringing actions against Federal employees. In cases
where there is a finding that the individual acted outside the scope of their authority, the Justice
Department may withdraw certification that the Federal employee was acting within the scope of
employment (28 U.S.C. Sec. 2679(d)(2)). For example, if a third party is injured as a result of
an environmental excursion incident at a Federal facility, and a Federal employee is found to be
responsible and to have acted outside the scope of their employment, the employee may be
personally liable.
The following is a discussion of the doctrine of sovereign immunity as it is embodied in
major Federal environmental statutes and applied to Federal agencies.
2.7.1 Resource Conservation and Recovery Act (RCRA)
The waiver of sovereign immunity found in the Resource Conservation and Recovery
Act (RCRA), as amended by the Federal Facilities Compliance Act (FFCA) of 1992, constitutes
a complete waiver of sovereign immunity with respect to both EPA and states authorized by
EPA to administer and enforce their hazardous waste management program. Prior to passage
of the FFCA, EPA could not enforce directly against other Federal agencies; and instead could
only negotiate Federal Facility Compliance Agreements to bring other Federal agencies into
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compliance with RCRA. With passage of the FFCA, Congress gave EPA and authorized state
enforcement agencies the power to "initiate an administrative enforcement action against such
a department ... in the same manner and under the same circumstances as an action
would be initiated against any other person" (42 U.S.C. 6961 (b)(2) (1995)).
2.7.2 Comprehensive Environmental Response, Compensation and Liability
Act (CERCLA)
The CERCLA waiver of sovereign immunity, contained in 42 USC §962, requires each
department, agency, and instrumentality of the United States (including the executive,
legislative, and judicial branches of government) to comply with CERCLA in the same manner
and to the same extent, both procedurally and substantively, as any nongovernmental entity. In
addition, all guidelines, rules, regulations, and criteria which are applicable to: (1) standards of
liability (2) assessments; (3) evaluations of facilities under the National Contingency Plan; (4)
inclusion on the National Priorities List and (5) remedial actions are applicable to the Federal
government.
CERCLA also requires Federal agencies to comply with state laws concerning removal
and remedial actions, including laws pertaining to enforcement, for removal and remedial action
at facilities owned or operated by a government agency when such facilities are not included on
the National Priorities List. However, federal facilities are not subject to state authority where a
state law or regulation applies a standard or requirement that is more stringent than the
standards and requirements applicable to nongovernment facilities.
2.7.3 Emergency Planning and Community Right-to-Know Act (EPCRA)
Executive Order 12856 requires that all federal facilities comply with the EPCRA
emergency planning requirements, including emergency planning notification to local
emergency planning committees (LEPCs), provision of information to LEPCs for preparation of
comprehensive emergency response plans, emergency notification of releases of extremely
hazardous substances, collection and submission of Material Safety Data Sheets (MSDSs), and
submission of Toxic Release Inventory Forms (commonly referred to as the "Form R"). The
TRI reporting requirements apply to all federal facilities with ten or more full-time employees
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that exceed the threshold for manufacture, processing, or use for listed toxic chemicals,
regardless of Standard Industrial Classification (SIC) code. In implementing Executive Order
12856, each Federal agency is responsible for identifying all facilities (GOCO and GOGO)
subject to TRI reporting, preparing yearly progress reports, and self-monitoring for compliance
with the order.
Executive Order 12856 also gives EPA the responsibility for conducting inspections and
monitoring agency compliance with the Order, and preparing an annual report to the President
on Federal agency compliance. However, section 7-701 of Executive Order 12856 expressly
states that the Order does not create any right or benefit, substantial or procedural, that is
enforceable against the United states or any federal agency. So, while EPA has the authority to
monitor federal agency compliance with the Order, there is no waiver of sovereign immunity as
to compliance enforcement.
2.7.4 Pollution Prevention Act of 1992 (PPA)
Section 3-304 of Executive Order 12856 requires federal facilities to comply with Section
6607 of the Pollution Prevention Act. This section requires that federal facilities submit a toxic
chemical source reduction and recycling report for each chemical release form (Form R)
submitted pursuant to EPCRA Section 313. As with EPCRA, Executive Order 12856 requires
compliance by Federal agencies, but specifically does not provide for direct enforcement.
2.7.5 Clean Air Act (CAA)
The Clean Air Act requires "[e]ach department, agency and instrumentality of the
executive, legislative, and judicial branches of the Federal government (1) having jurisdiction
over any property of facility, or (2) engaged in any activity resulting, or which may result, in the
discharge of air pollutants, and each officer, agent, or employee thereof, shall be subject to,
and comply with, all Federal, state, interstate, and local requirements, administrative authority,
and process and sanctions respecting the control and abatement of air pollution in the same
manner, and to the same extent as any nongovernmental entity" (42 U.S.C. §7418(a) (1995)).
All Federal agencies also must comply with all applicable provisions of a valid motor vehicle
inspection and maintenance program established under the CAA except for vehicles that are
designated as tactical military vehicles (42 U.S.C. §7418(c) and (d) (1995)). This section also
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waives sovereign immunity with respect to federal facilities' obligation to pay air pollution
regulatory fees imposed pursuant to local air pollution district's rules and regulations.
2.7.6 Clean Water Act (CWA)
The Clean Water Act contains a comprehensive and explicit waiver of sovereign
immunity as to all departments, agencies, or instrumentalities of the executive, legislative, and
judicial branches of the federal government (1) having jurisdiction over any property or facility,
or (2) engaged in any activity resulting, or which may result, in the discharge or runoff of
pollutants. This waiver subjects Federal agencies to compliance with all "Federal, state,
interstate, and local requirements, administrative authority, and process and sanctions
respecting the control and abatement of water pollution in the same manner, and to the same
extent as any nongovernmental entity including the payment of reasonable service charge" (33
U.S.C. §1323 (Supp. 1995)).
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2.8 FREEDOM OF INFORMATION ACT REQUESTS
The Freedom of Information Act, or FOIA (5 USC: par. 552), applies to all Federal
agencies and governs the disclosure of Federal agency documents to the public. For this
reason, careful consideration must be given by agency employees in determining how audit
reports and audit-generated information will be filed and distributed within the agency.
Generally, draft audit reports, preliminary information and auditor notes that contain the
auditor's thoughts and observations recorded during an audit site visit may be exempt from
FOIA requests. Federal agencies are allowed under the statute to write their own policies and
regulations that influence the agency FOIA officer in his or her decision as to whether the
information is releasable when it is requested by the public.
To the extent that draft copies of audit reports are pre-decisional and it can be shown
that they reflect the agency's deliberative process, they may be exempt from release for
reasonable limited periods of time. However, if factual material (e.g., observations made on
site during the audit) is requested under FOIA, the agency may have to extract this material
from the draft audit report and release it to the requesting party. To protect draft copies within
the deliberative process, all reports and related paper should be clearly marked "pre-decisional,
FOIA Exempt" or "draft" and circulation should be limited to those offices or audited facilities
reviewing the report before producing a final version.
Legal advice from an agency's general counsel may provide additional help when
processing FOIA requests for audit-related information. In addition, the effect of FOIA on audit-
related information should be considered when designing an audit program or creating a scope
of work for Federal agency audits. A more detailed discussion of legal considerations of
document protection and FOIA requests is presented in Chapter 3 of this guide.
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2.9 STATUS OF ENVIRONMENTAL AUDITING AT FEDERAL FACILITIES
Purpose
As the estimated cost of cleaning up contamination on federal lands rise to hundreds of billions of dollars,
environmental auditing is increasingly viewed as a way to foster better environmental practices in
operating federal facilities. Environmental audits are comprehensive and systematic reviews of
environmental performance used to improve compliance with environmental laws and minimize future
environmental damage and cleanup costs.
The Ranking Minority Member of the Senate Committee on Governmental Affairs asked GAO to examine
the potential for increasing the use of environmental auditing in the management of federal agencies'
operations. Specifically, he requested that GAO (1) examine the experience of organizations that
distinguish their programs, (2) determine the extent to which federal agencies use environmental auditing
and the benefits that could accrue from its wider use, and (3) identify obstacles and disincentives to the
more effective use of environmental auditing by these agencies.
Environmental auditing and EPA's policy providing encouragement and assistance on
this matter is relatively new. On July 9, 1986, EPA publicly addressed environmental auditing
for the first time when the agency published it's environmental audit policy in the Federal
Register (51 FR 25004). At that time, EPA encouraged regulated entities to initiate
environmental audit programs to achieve and maintain compliance with environmental
regulations. In the 1986 Policy Statement, EPA also encouraged Federal agencies to develop
audit programs and stated that EPA would provide assistance to help Federal agencies
establish such programs.
Since then, EPA has accelerated it's efforts at encouraging and assisting Federal
agencies to design and initiate environmental audit programs. These efforts have included:
Conducting a survey of Audit Activities at Federal Facilities (1987);
Sponsoring a nationwide Environmental Auditing Conference for Federal agencies
(1988, 1995);
Issuing guidelines to assist Federal agencies in establishing audit programs
("Environmental Audit Program Design Guidelines for Federal Agencies," EPA
#130/4-89-001) (1989); and
Issuing generic environmental audit protocols as guidance for Federal agencies and
encouraging further audit program development ("Generic Protocol for
Environmental Audits of Federal Facilities," EPA 1307 4-89/002 (1989) and "Generic
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Protocol for Conducting Environmental Audits of Federal Facilities," EPA #300-6-95-
002 (1995)).
Background
During a typical environmental audit, a team of qualified inspectors, either employees of the organization
being audited or contractor personnel, conducts a compliance examination of a plant or other facility to
determine whether it is complying with environmental laws and regulations. Using checklists and audit
protocols and relying on professional judgment and evaluations of site-specific conditions, the team
systematically verifies compliance with applicable requirements. The team may also evaluate the
effectiveness of systems in place to manage compliance and assess the environmental risks associated
with the facility's operations.
No laws currently require environmental auditing. Environmental auditing has been and remains largely a
voluntary activity. Companies and public agencies that have adopted the practice have done so for
sound business reasons. The adoption of environmental auditing by these organizations represents a
management decision to seek compliance proactively, instead of simply reacting to crises. The
Environmental Protection Agency's (EPA) 1986 policy of environmental auditing encouraged federal
agencies subject to environmental laws to adopt environmental auditing to achieve and maintain
compliance. The agency also acknowledged its own responsibility to provide technical assistance to help
federal agencies design and initiate audit programs.
2.9.1 GAO Report 1995
The most recent and comprehensive report regarding the status of environmental
auditing at federal facilities was released in April 1995 by the Government Accounting Office
(GAO). The report, entitled Environmental Auditing; A Useful Tool That Can Improve
Environmental Performance and Reduce Costs; GAO/RCED-95-37) is the result of an 18-
month study. The report details the experiences of both private organizations and Federal
agencies in reducing liabilities by performing environmental audits. The report also addresses
the extent to which environmental auditing is practiced among Federal agencies and discusses
the potential benefit from more extensive use of environmental auditing. The GAO report made
a number of findings, including:
Environmental auditing is rare at most Federal agencies;
Environmental auditing is least developed at smaller Civilian Federal Agencies
(CFAs), which lack the expertise and resources of DoD and DOE;
EPA's 1986 Audit Policy and the lack of inspections by EPA act as disincentives with
respect to CFA senior management attitudes toward implementing audit programs;
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CFA's lack of interest in implementing audit programs has resulted in funding
shortfalls for training and developing audit expertise; and
Federal agencies have been discouraged from auditing due to several incidents in
which EPA Regions requested audit reports for reasons other than those allowed
under EPA's audit policy.
The GAO report also made a number of recommendations for furthering audit program
development at CFAs, including:
Enforcing EPA's current stated policy of limiting requests of audit reports by
personnel in EPA Regions;
Changing EPA's existing audit and enforcement policies to encourage
regulated entities to perform more environmental audits;
Providing sustained technical assistance to CFAs; and
Providing a greater show of enforcement at CFA facilities throughout the
EPA Regions
2.10 STATUS OF ENVIRONMENTAL MANAGEMENT AT FEDERAL AGENCIES
(BENCHMARK REPORT)
In December of 1994, EPA published a report entitled Environmental Management
System Benchmark Report: A Review of Federal Agencies and Selected Private Corporations
(EPA-300R-94-009). This report set forth a benchmark representing ideal organizations,
managerial, and operational attributes that Federal agencies should employ as they work to
fulfill their environmental responsibilities. Six benchmark elements were identified:
Organizational Structure; Management Commitment; Implementation; Information Collection,
Communication, Management, and Follow-up; Internal and External Communication; and
Personnel Practices. The report detailed characteristics that make up each benchmark element
and provided a list of organizational activities and attributes (key indicators) that demonstrate
adherence to each benchmark element.
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Benchmarking Federal Agencies
An EPA study compared the environmental management systems of CFAs, the Department of Energy,
the Army, Navy, and Air Force, and three private sector corporations (Chevron, Xerox, and 3M). As part
of the study, a series of detailed "Best in Class" descriptors were established in six key areas of
environmental performance: organizational structure; management commitment; implementation of
programs; information collection, use, and follow-up; internal and external communications; and
personnel management. The overall "Best in Class" benchmark elements are as follows:
Organizational Structure: Best in Class organizations have an organizational structure that gives
authority, input, and voice to environmental performance.
Management Commitment: Best in Class organizations possess and demonstrate a commitment to
environmental excellence at each and every stage of the management hierarchy, and insist on
integration of environmental awareness and concerns into all relevant business operations.
Implementation: Best in Class organizations carry out their daily business operations in ways that
integrate environmental protection into their business conduct.
Information Collection/Management/Follow-Up: Best in Class organizations continually monitor
environmental performance through the use of formal tracking and reporting mechanisms.
Information acquired through these mechanisms is evaluated, disseminated, and used to
continually improve environmental performance.
Internal and External Communication: Best in Class organizations foster and use formal and informal
channels to communicate environmental commitment and performance information. Employee
communications is encouraged to develop cooperation and commitment, including bringing
together employees from different disciplines.
Personnel: Best in Class organizations ensure that employees are capable of developing and
implementing environmental initiatives. Employees are hired, trained, and deployed in ways that
ensure that staff understand their environmental responsibilities and receive the training and support
necessary to achieve environmental excellence.
Source: U.S. EPA, Environmental Management System Benchmark Report: A Review of Federal
Agencies and Selected Private Corporations (EPA 300R-94-009), December 1994.
The report provides information that can help agencies use audits in ways that move
beyond the simple identification of compliance violations. Agencies and facilities that include
the review of organizational, managerial, and performance elements into audits can often
identify opportunities to improve organizations in ways that reduce the potential for future
violations.
2.11 THE ROLE OF ERA'S FEDERAL FACILITY OFFICE
The environmental performance expectations that have been placed on Federal
agencies in recent years have required EPA to focus on monitoring federal facility activities and
assisting agencies in developing and improving their compliance programs. The relationship
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between EPA and other Federal agencies was first prescribed by Presidential Executive Order
No. 12088. Signed by President Carter in 1978, the Order directs all departments and agencies
of the Federal government to comply with Federal, state, and local environmental laws and
regulations. In addition, EPA is directed by the Order to provide technical assistance and
guidance to Federal agencies to assist them in complying with these environmental
requirements.
To ensure that federal facilities receive the appropriate level of monitoring and guidance,
EPA established a separate office reporting directly to the Administrator Assistant for
Enforcement and Compliance Assurance (OECA). This office is the Federal Facility
Enforcement Office (FFEO). FFEO is responsible for ensuring that federal facilities take all
necessary actions to prevent, control, and abate environmental pollution. FFEO coordinates
OECA's federal facility enforcement, compliance assurance, and assistance efforts. It also has
the lead role for communicating with Congress, other Federal agencies, states, and other
stakeholders (e.g., the public) on federal facility matters.
The design of EPA's FFEO embodies many of the principles embraced by EPA's
Common Sense Initiative (CSI). It has a sector-orientation, uses strong enforcement combined
with compliance assistance, and promotes proactive technical programs such as pollution
prevention and environmental auditing. FFEO continually seeks new and innovative ways of
working with Federal agencies by offering technical assistance within a partnership setting to
other Federal agencies, states, and localities to foster a more collegia! approach to
environmental problem solving.
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CHAPTER 3: LEGAL CONSIDERATIONS
3.1 OVERVIEW
Designing and implementing an environmental audit program requires consideration of a
number of legal issues. Chief among these is the protection of audit findings from premature
disclosure. A comprehensive environmental audit typically accomplishes three objectives: (1)
verify compliance/noncompliance with environmental regulations; (2) evaluate the effectiveness
of environmental control systems; and (3) assess potential environmental liabilities from
regulated and unregulated materials and practices. To achieve these objectives, the audit
findings must be candid, detailed, and accurate. As such, environmental audits often describe
actual or potential violations of law, unfavorable situations such as management deficiencies or
inadequate staffing, or situations that do not constitute violations per se, but that nevertheless
gives rise to potential environmental liabilities. This kind of information can be used to the
detriment of a facility or agency, and should be protected to the extent allowed by law.
Public access to Federal agency documents and information in non-litigation situations
is controlled by the Freedom of Information Act (FOIA) (5 USC §552 et seq.). Once an agency
audit report becomes final, it is an agency record and subject to disclosure through a FOIA
request. As a result, the amount of time that an agency has to handle an environmental audit
as an internal matter, free from outside scrutiny, is limited to that time between the conduct of
the audit and the delivery of the audit final report. Typically, a comprehensive environmental
audit will contain information adverse to the audited facility. It is therefore important that the
audit program be designed to provide for the protection of the audit findings from premature
disclosure. Facility and agency personnel should have the opportunity to review and comment
on audit findings, and develop a corrective action plan free from public scrutiny so that they can
engage in free and frank discussions of regulatory opinion, interpretation and applicability. An
understanding of privilege, as it pertains to audit reports, the FOIA law and process, and other
legal considerations surrounding audit report handling and preparation will help in designing
such a program.
Please note that this discussion does not discuss document requests or subpoenas that
arise from civil litigation. Such requests must be handled through agency legal counsel on a
case-by-case basis.
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3.2 DOCUMENT PROTECTION/FREEDOM OF INFORMATION ACT REQUESTS
Subject to specific exceptions, any person can have access to government factual and
investigatory reports, data, and surveys pursuant to the FOIA. A final environmental audit
report from a Federal agency does not fall into any of the enumerated exceptions, and the
courts uniformly interpret the FOIA exceptions very narrowly1. Although there is a
governmental official information privilege that protects the suggestions, advice,
recommendations, and opinions of government officials, factual and investigatory reports, data
and surveys are not protected. Unless exempted by FOIA or some other statute, all Federal
agency records are available to the public upon request. There are nine exceptions to this
general rule contained in FOIA that are listed at 5 USC §552(b). Subsection (5) exempts "inter-
agency or intra-agency memorandums or letters which would not be available by law to a party
other than an agency in litigation with another agency." From this exemption, the courts have
created categories of agency documents that are exempt under FOIA, that is they are not
available to the public. These documents are referred to as "predecisional" and "deliberative"
and must satisfy both criteria to qualify for the exemption and be justified.
Predecisional documents include recommendations, draft documents, proposals,
suggestions, and other subjective documents which reflect the personal opinions of the writer
rather than the policy of the agency. A predecisional document is deemed a part of the
deliberative process if the disclosure of the materials would expose an agency's decision
making process in such a way as to discourage candid discussion within the agency, thereby
undermining the agency's ability to perform its functions.
The deliberative process is exemplified in a situation where an employee writes a draft
document and the agency uses the consultative process, by circulating the draft for comments,
or having the draft reviewed up the supervisory or organizational chain to determine what the
final version will include. Courts have ruled that when the final document is released, the draft
is exempt from disclosure under the FOIA exemption for intra-agency memoranda2. Courts
have characterized draft reports as predecisional if they are written before the agency decides
what the final version will include, and have characterized the process as deliberative if the draft
1 Sea Nadlerv. U.S. Dept. of Justice, 955 F.2d 1479 (11th Cir. 1992), dealing with what constitutes
the "deliberative" process; Assembly of the State of California v. U.S. Dept. Of Commerce, 968
F.2d 016 (9th Cir. 1992) addressing what is "predecisional."
2 Marzen v. Dept. of Health and Human Services, 632 F.Supp 785, off d 825 F.2d 1148 (7th Cir.
1987).
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was submitted to others as the author's input to the decision-making process (the comment and
clearance process).
Ultimately, each Federal agency's Freedom of Information Act Officer is responsible for
determining whether or not materials are FOIA exempt. Generally, in the context of an
environmental audit, the draft audit report, preliminary information and auditor notes concerning
his or her thoughts and observations recorded during an audit will be considered predecisional.
There is a question, however, as to what extent factual material contained in a predecisional
draft is also protected. The U.S. Supreme Court has held that information that is purely factual,
even though it may have been used by decision makers in their deliberations, is usually not
protected from disclosure under FOIA (EPA v Mink, 410 U.S. 73 (1973)). In cases where
deliberative process material and unprotected factual material are commingled in a single
document, the agency normally must still produce the factual material by producing a document
containing only the factual material. If the factual material can not reasonably be separated
from material in documents that would reveal the opinions of agency personnel in the
deliberative process, it may be exempt from disclosure under FOIA. However, this should not
be attempted in order to avoid disclosure as courts take a dim view of such efforts3.
An environmental audit program should be designed so the audit report is circulated for
predecisional review and comment between the audit team and facility personnel, and then
forwarded to senior agency personnel for predecisional review and comment, prior to becoming
final. The draft report should be segmented and circulated to those personnel appropriate to
each section. For example, personnel responsible for hazardous waste management should
review that section. If those individuals are not responsible for air issues, they should not
review the section dealing with air quality. Given these limitations, the report should be
circulated from the bottom-up, with any input or comment clearly marked as "Draft" or "Pre-
decisional," and the deliberative process clearly defined within the context of the environmental
audit program (i.e., the process is standardized and written into or as an agency policy).
Circulation of the draft should be limited. If a document which an agency claims exemption
from a FOIA request has been released or disseminated to personnel outside the agency, or if
a document otherwise subject to the attorney client privilege is widely disseminated within the
agency, then the agency may be precluded from asserting the exemption. The use of
consultants, however, does not necessarily constitute release to an outside party so long as the
United States v. Nixon, 418 U.S. 683 (1974).
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consultant has a "need to know" (e.g., the consultant is conducting or taking part in the audit),
and agrees not to further disclose information.
Some aspects of an environmental audit also may be protected from disclosure under
the attorney-client, or the attorney work-product privileges. The attorney work-product and the
attorney-client privileges should not be looked at as a means for comprehensive document
protection, because to routinely conduct an environmental audit program so that is falls under
the rubric of the attorney privileges would be a cumbersome and inefficient use of agency
attorneys and is not likely to be successful (see discussion of Litigation/Discovery below). In
any event, situations that invoke attorney-client and attorney-work product privileges must be
approached on a case-by-case basis with full involvement by agency counsel.
In the final analysis, the government carries the burden of proving that audit
documentation in draft form falls within an exemption under FOIA . This essentially entails
showing that the record is oriented toward the agency's ongoing development of its position on
a specific issue. The case law pertaining to FOIA requests and exemptions offers enough
guidance to design and implement information gathering and report drafting procedures to
provide protection for audit materials prior to the issuance of the final report. However, as with
any case law, the courts are continually refining the law of FOIA. Therefore, the agency
Freedom of Information Act Officer and legal counsel should be consulted as to the most
current case law and legal precedents in this area.
3.2.1 Litigation/Discovery
In addition to FOIA requests, audit materials may be subject to disclosure as a result of
litigation undertaken by an agency or by third parties against an agency. Should an agency
become involved in a civil action over an environmental issue, all audit materials that involve
observations of facility practices or matters subject to statutory or regulatory reporting
requirements (e.g., spill incidents, waste handling or discharge practices, emissions reports) will
be discoverable through requests for production of documents, or subpoenas.
There are a number of privileges which, to a limited extent, may be available to protect
audit materials. However, agencies should conduct their audits with the understanding that all
materials are potentially discoverable. The three legal doctrines that may provide limited
protections for audit materials are:
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(i) the attorney-client privilege;
(ii) the attorney work-product rule; and
(iii) the self-evaluation privilege.
It is necessary to consult with agency legal counsel to determine appropriate procedures
for employing any of the above confidentiality doctrines.
The use of attorneys in conducting audits, or the communication of audit results solely to
attorneys, will not protect underlying facts, or matters subject to legal reporting requirements, from
discovery. Court pronouncements on this matter have been unequivocal.
While courts may be willing to protect the attorney's notes and memoranda, as well as
related communications with non-lawyers, these protection have limits. Wide dissemination of
audit results undermines the privilege doctrines. For example, dissemination of the air
monitoring section of an audit to the wastewater treatment personnel for review and comment
might be grounds for waiver of a confidentiality privilege with respect to the air monitoring
results.
When developing and carrying out an audit program, agency management should
anticipate that any underlying facts, observations, or data regarding facility environmental
practices, will be fully discoverable. Therefore, it is in the best interest of the agency to
thoroughly investigate, document, and remedy any problems uncovered in an audit. This
appropriately devotes limited resources to corrective action rather than to attempting to protect
audit findings from discovery. In addition, attempts to shield audit materials from discovery may
be interpreted as bad faith and sour relationships with regulatory agencies.
EPA has developed internal policy regarding the release of environmental audit
reports originating at other federal agencies. The policy developed by EPA's Office of
General Counsel requires EPA personnel to respond to the FOIA request by either
consulting with and obtaining written permission from the agency which originated the
document or EPA will transfer the responsibility for responding to the request for records
back to the originating agency. Therefore, EPA will not forward audit reports originating
from other federal agencies without explicit permission from the affected agency.
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3.3 EPA REQUESTS FOR AUDIT REPORTS
In the 1995 audit policy, EPA reaffirms and clarifies its policy outlined in the 1986 audit
policy to refrain from routine requests for audits. Eighteen months of public testimony and
debate have produced no evidence that the Agency has deviated, or should deviate, from this
policy. In general, an audit which results in prompt correction clearly will reduce liability, not
expand it. In addition, a review of the criminal did not reveal a single criminal prosecution for
violations discovered as a result of an audit self-disclosed to the government.
The 1995 policy states:
"EPA will not request or use an environmental audit report to initiate a civil or criminal
investigations of the entity. For example, EPA will not request an environmental audit
report in routine inspections. If the Agency has independent reason to believe that a
violation has occurred, however, EPA may seek any information relevant to identifying
violations or determining liability or extent of harm."
The EPA's authority to request some or all of an audit report will be exercised on a
case-by-case basis where the agency determines that the information is necessary to
"accomplish a statutory mission, or where the Government deems it to be material to a criminal
investigation" (59 FR 38455 (July 28, 1994)). Examples of this include situations where: (1)
audits are conducted pursuant to a consent decree or other settlement agreement; (2) a
company has placed its management practices at issue by raising them as a defense in an
enforcement action; or (3) where state of mind or intent is at issue as during a criminal
investigation or prosecution.
With respect to inspections of self-audited facilities and requests for audit reports, EPA
generally will respond to environmental audits conducted by federal facilities in the same
manner as it does for any other regulated entity.
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3.4 EPA's 1995 AUDIT POLICY
On December 22, 1995, EPA announced the "Incentives for Self-Policing:
Discovery, Disclosure, Correction and Prevention of Violations," (final audit or self-
policing policy).4 Under the new policy, the Agency will greatly reduce civil penalties
and limit liability for criminal prosecution for regulated entities that meet the policy's
conditions for discovery, disclosure and correction.6 The final audit policy represents a
refinement of the "Voluntary Environmental Self-Policing and Self-Disclosure Interim
Policy Statement" (interim auditing policy) announced on April 3, 1995.6
Policy Incentives: Full and 75% Gravity Mitigation of Civil Penalties; No Criminal Referral
toDOJ
Under the policy, EPA will not seek gravity-based7 civil penalties for violations that
are discovered through an environmental audit or through a management system
reflecting due diligence, and that are promptly disclosed and expeditiously corrected,
provided the other policy conditions are met. Where violations are discovered by
means other than an audit or due diligence system, but are promptly disclosed and
expeditiously corrected, EPA will reduce gravity-based penalties by 75% provided the
other policy conditions are met. The Agency will generally not recommend to the
Department of Justice (DOJ) that criminal charges be brought against entities that
meet all of the policy conditions.
Safeguards
While the final self-policing policy contains significant incentives for encouraging
discovery, disclosure and correction of violations, it also contains very important
safeguards to deter irresponsible behavior and protect the public and the
environment. For example, the policy requires entities to take steps to prevent
recurrence of the violation and to remediate any harm caused by the violation. In
4 The policy appeared in the Federal Register on December 22, 1995 (60 FR 66706).
5 A copy of the policy and its comprehensive preamble appears as Appendix B.
6 60 FR 16875, April3, 1995.
7 The "gravity" component of a penalty represents the "seriousness" or "punitive" portion of
penalties. The other major part of a penalty, the economic benefit component, represents the
economic advantage a violator gains through its non-compliance.
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addition, the policy does not apply to violations which resulted in serious actual harm or
may have presented an imminent and substantial endangerment to human health or
the environment. Moreover, entities are not eligible for relief under the policy for
repeated violations. The policy acts arising from conscious disregard or full will blindness
to violations. Finally, EPA retains its discretion to collect any economic benefit gained
from non-compliance in order to preserve a "level playing field" for entities that invest
in timely compliance.8
Incentives and Behavior
The final self-policing policy provides additional incentives for entities to utilize the
critical compliance tools of environmental auditing and compliance management
systems. These incentives add to the many existing reasons for entities to develop and
maintain environmental auditing and compliance management systems. A 1995 Price
Waterhouse survey on environmental auditing practices showed that 90% of the
corporate respondents that conduct audits did so to find and correct violations before
they were found by government inspectors.
In 1986, EPA announced that it was the Agency's policy to encourage
environmental auditing as a means to help achieve and maintain regulatory
compliance.9 Toward that end, the 1986 policy sets forth the basic elements of
effective environmental auditing programs.
As memorialized in the 1995 final self-policing policy, EPA's policy toward
encouraging the use of compliance tools such as auditing and management systems
8 Under the final self-policing policy, EPA may waive the entire penalty for violations which, in
EPA's opinion, do not merit any penalty due to the insignificant amount of any economic
benefit.
Some environmental statutes require EPA, in assessing penalties, to consider the economic
benefit a violator gains from non-compliance. See, e.g., CWA 309(g), CAA 113(e), and SDWA
1423(c). EPA's longstanding policy has been to collect significant economic benefit gained
from non-compliance. See A Framework for Statute-Specific Approaches to (Civil) Penalty
Assessments, EPA General Enforcement Policy #GM-22, February 16, 1984; see also the
approximately 24 EPA media and program-specific penalty and enforcement response policies.
The reason for collecting economic benefit is to preserve a level playing field for entities that
make the timely investment in compliance. Recovery of economic benefit can be likened to
the IRS requirement of paying interest or fees on taxes paid late.
9 Environmental Auditing Policy Statement, July 9, 1986 (51 FR 25004).
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had evolved into providing penalty incentives and a safe harbor from criminal
prosecution. It is important to recognize that this evolution is likely to continue as
organizations develop more effective tools to manage the environmental aspects and
impacts of their activities, services and products. Environmental management system
(EMS) standards such as ISO 14001 and supporting standards hold promise as a means
of improving environmental performance. EPA is exploring possible incentives for
encouraging the use of such standards insofar as the incentives do not jeopardize
protection of human health and the environment.
Policy Conditions
1. Entity Must Discover the Violation through an Environmental Audit or Due
Diligence System to Obtain Full Gravity Penalty Mitigation and Criminal
Safe Harbor
The final self-policing policy provides full mitigation of gravity-based civil
penalties and a criminal safe harbor for entities that discover violations through an
environmental audit or system reflecting due diligence, provided the other policy
conditions are met. Note that entities that do not discover the violations through an
audit or due diligence, i.e., "random discovery," would still obtain 75% gravity
mitigation as long as the other conditions are met.
The final policy defines an "environmental audit" the same as it is defined in the
1986 auditing policy: "a systematic, documented, periodic and objective review by
regulated entities of facility operations and practices related to meeting environmental
requirements." Note that this definition covers several types of environmental audits
including risk audits and EMS audits as well as compliance audits.
With respect the due diligence systems, the final self-policing policy provides
relief to entities that discover violations through an "objective, documented systematic
procedure or practice reflecting the regulated entity's due diligence in preventing,
detecting, and correcting violations," provided the other conditions are met. "Due
diligence" is defined as systematic efforts meeting criteria based on the 1991 U.S.
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Sentencing Commission Sentencing Guidelines.10 The Sentencing Guidelines have had
an enormous impact in encouraging the development and implementation of due
diligence systems in the U.S.
The "due diligence" criteria in the self-policing policy include the following:
. the development of compliance policies, standards and procedures to meet
regulatory requirements;
. allocation of responsibility to oversee conformance with these policies,
standards and procedures;
. mechanisms including monitoring and auditing of compliance and the
establishment of a compliance management system (CMS) to assure the
policies, standards and procedures are being carried out;
. training to communicate the standards and procedures;
. employee incentives to perform in accordance with the compliance policies,
standards and procedures; and
. procedures for the prompt and appropriate correction of violations including
program modifications needed to prevent future violations.
The inclusion of "due diligence" systems in the final policy represents a very
positive and significant revision to the interim auditing policy. Stakeholder written and
oral comments indicated that ongoing, comprehensive, and systematic efforts to
prevent, detect, and correction violations should be rewarded at least as much as
environmental auditing. The difference between a compliance audit and a CMS can
be likened to the difference between a "snapshot" and a "video."
It is also very significant that EPA may require as a condition for penalty
mitigation that a description of the entity's due diligence system be made publicly
available. This may entail submission of the system to a national electronic docket. This
type of public disclosure has the potential to push the state-of-the-art in management
systems development and encourage benchmarking. The public availability of systems
10 United States Sentencing Commission Guidelines Manual, Chapter 8 - Sentencing of
Organizations, Part A - General Application Principles (effective November 1, 1991).
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descriptions can also provide valuable information for insurers, financial markets,
investors and lenders - providing the basis for "quasi" market-based incentives.
2. Policy Applies to All Violations Except Those Discovered Through
Mandated Monitoring or Sampling Requirements, Ce.a., CEM, DMRs)
In order to provide maximum opportunity to encourage compliance, and to do
so without sacrificing the integrity of critical reporting systems, the policy provides relief
on all violations except those discovered through mandated monitoring or sampling
requirements, provided the other policy conditions are met. Examples of violations not
covered by the policy include emissions violations detected through continuous
emissions monitor, violations of NPDES discharge permits detected through required
monitoring or sampling, or violations discovered through a compliance audit required
to be performed by the terms of a consent order or settlement agreement.
3. Entity Promptly Discloses the Violation in Writing to EPA
Under the policy, the entity must fully disclose in writing to EPA that a violation
has occurred or may have occurred, within 10 days after discovery. The inclusion of the
"may have occurred" language recognizes that in situations where the entity is unsure
whether a violation had occurred it is best for the entity to disclose the potential
violation to EPA for a definitive determination. EPA may accept disclosures more than
10 days after discovery if more time is needed to make a compliance determination of
a complex violation and circumstances do not present a serious threat.
4. Entity Must Disclose the Violation Prior to Imminent Discovery by the
Government
The entity must identify and disclose the violation before the regulatory agency
has discovered or will discover the violation. Thus, the entity must disclose the violation
prior to: commencement of a government inspection or investigation, issuance of an
information request, notice of citizen suit, filing of a third-party compliant, or reporting
by a "whistle-blower."
5. Entity Must Expeditiouslv Correct the Violation and Remedy Harm
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The entity must correct the violation expeditiously and within 60 days, certify
correction, and take appropriate measures to remedy any harm caused by the
violation. If more than 60 days is needed to correct the violation, the entity must notify
EPA before the 60-day period has passed. Where appropriate, EPA may require a
written agreement, order or decree to satisfy requirements for correction, remediation
or prevention measures especially where such measures are complex or lengthy.
6. Entity Must Agree to Take Steps to Prevent Recurrence of the Violation
The entity's efforts to prevent recurrence of the violation may involve modifying
its environmental auditing program or compliance management system.
7. The Violation Had Not Occurred at the Same Facility Within the Past Three
Years and Was Not Part of a Pattern of Violations at the Parent Company
Within the Past Five Years
The policy does not apply to repeat violators. EPA has established "bright lines"
to determine when repeat violators should not be eligible for relief under the policy.
Under the policy, the same or closely-related violation had not occurred at the same
facility within the past three years or is not part of a pattern of violations at the facility's
parent organization within the past five years. This policy exclusion provides entities with
continuing incentives to prevent violations and avoids the unfairness of granting policy
relief repeatedly for the same or similar violation.
8. The Violation Is Not One Which Resulted in Serious Actual Harm or May
Have Presented an Imminent and Substantial Endangerment, or Does Not
Violate the Specific Terms of an Order or Agreement
The policy does not apply to violations which resulted in serious actual harm or
may have presented an imminent and substantial endangerment to human health or
the environment. Coverage of the policy to such violations would undermine
deterrence and reward entities for delinquent management of its environmental
activities. The policy also does not apply to violations of the specific terms of any
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administrative or judicial order or consent or plea agreement. This is necessary to
preserve incentives to comply with the orders or agreements.
9. The Entity Must Cooperate with EPA
At a minimum, the entity must provide information that is necessary and
requested by EPA to investigate the violation and any non-compliance problems and
environmental consequences related to the violation.
3.5 EPA/DOJ POLICY LETTER ON STATE AUDIT PRIVILEGE LAWS AND POLICIES
EPA will work with states to encourage adoption of policies that reflect the
incentives and conditions outlined in the 1995 audit policy described above. In an
effort to address some of the perceived concerns regarding government and third
party use of audit information, some in the regulated community have turned to state
and federal legislation. Since October 1993, twenty states have enacted legislation to
create audit privileges and/or penalty amnesty provisions.
As the 1995 audit policy indicates, EPA opposes environmental audit privileges
that provide a cloak of secrecy over evidence of environmental violations and that
contradict the public's right to know. EPA also opposes blanket immunities or amnesty
for violations that reflect criminal conduct, present serious threats or actual harm to
health or the environment, allow noncomplying entities to gain an economic
advantage over their competitors, or reflect a repeated failure to comply with federal
law. Both EPA and DOJ have testified before Congress opposing proposed federal
audit privilege legislation and existing state audit privilege and immunity laws. Vice
President Gore has also written to Congress opposing the pending House and Senate
audit privilege bills. In February, 1997, EPA and DOJ issued a joint policy letter to the
General Counsels of Federal departments and agencies stating the administration's
position and clarifying that Federal facilities in Executive Branch agencies and
contractor operators should not claim that information acquired through self audits is
privileged under any state audit privilege laws. In addition, this policy letter points out
that no privilege exists between and among EPA and other agencies. The policy letter
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encourages Federal facilities to utilize the 1995 EPA audit policy and similar state laws
and policies. This policy letter is contained in Appendix F.
In the 1995 policy, EPA restates its pledge to work with states to address any
provisions of state audit privilege or penalty immunity laws that are inconsistent with the
policy and which may prevent a timely and appropriate response to significant
environmental violations. Six states have passed privilege/immunity statutes since the
Agency issued its final audit policy in December 1995.
3.6 EPA POLICY REGARDING THE USE OF AUDITING IN LEGAL
SETTLEMENTS
Although not explicitly addressed in the final audit policy, EPA will not forgo inspections,
reduce enforcement responses, or offer other such incentives in exchange for the
implementation of an environmental auditing program.11 EPA will, however, take into account a
facility's efforts at self-auditing for environmental management and compliance in setting
inspection priorities and crafting enforcement responses to violations. Specifically, it is the
EPA's stated policy to take into account, on a case-by-case basis, the honest and genuine
efforts of regulated entities to avoid and promptly correct violations and underlying
environmental problems.
Similarly, although not explicitly addressed in the final policy, EPA should not limit its
non-penalty enforcement authorities as a provision of settlement. While EPA may consider
such a facility to be a lower inspection priority than a facility that is not known to be auditing,
whether and when to conduct an inspection should remain a matter of Agency discretion. If the
Agency's inspection or other enforcement authorities were limited, this could compromise the
Agency's ability to respond to citizen complaints or site conditions posing a potentially serious
threat to human health or the environment.
EPA's 1995 audit policy requires discovery of violations to be voluntary in order to obtain
any penalty mitigation, and it defines such voluntariness so as to exclude situations where the
violations are "discovered through a compliance audit required to be performed by the terms of
a consent order or settlement agreement." 60 Fed. Reg. 66706, 66708 (Dec. 22, 1995). This
11 As stated in the 1986 Policy, and reiterated in the 1994 Clarification on Policies Related to
Environmental Auditing.
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language, however, should not be read in isolation, because doing so would unduly preclude
penalty mitigation under the policy and create a significant disincentive for future settling parties
to bind themselves in settlement documents to doing compliance audits. In the same section of
the final policy, two key goals are expressed: (1) to encourage the conduct of audits; and (2) to
"reward those discoveries that the regulated entity can legitimately attribute to its own voluntary
efforts." Id. at 66708.
Where a violator, without any legal obligation to do so, commits to conducting a
compliance audit prior to any formal or informal enforcement response (e.g., complaint filing or
other circumstance described in Section II.D.4 of this policy), such actions can be considered
by EPA to be voluntary and EPA will not automatically disqualify them from obtaining penalty
mitigation under the "voluntary discovery" requirement of the final policy, even though the
violator later agreed to include such an auditing obligation as an enforceable settlement
provision (e.g., in a consent decree or consent order). In such cases, EPA should describe the
voluntary nature of the audit provisions that are not eligible for penalty mitigation under the
policy. By allowing audit provisions in settlements to be considered voluntary in these limited
circumstances, EPA is able to shape the content and timing of audits, ensure their performance
through enforceable terms, and more effectively achieve the goals of the final policy.
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CHAPTER 4: AUDITING FEDERAL FACILITIES IN FOREIGN
COUNTRIES/OVERSEAS
4.1 OVERVIEW
The most important component in designing an environmental audit program for
overseas federal Facilities is determining the standards against which compliance is to be
evaluated. Such standards may include particular provisions of U.S. law, applicable multilateral
or bilateral treaty provisions, regional or community requirements (e.g., European Union), or
host-country specific substantive provisions which typically include technical limitations on
discharges, emissions, production processes, products, or specific management practices.
Ultimately, overseas facilities must comply with the most stringent requirements; these
standards, referred to by the Department of Defense (DoD) as "Final Governing
Standards" or "FSG," implement DoD Directive 6050.16 (DoD Policy for Establishing and
Implementing Environmental Standards at Overseas Installations, September 1991) and
DoD Directive 6050.7 (Environmental Effects of Major Department of Defense Actions,
March 1979) and supplement Executive Order 12088 (October 13, 1978). For the
purposes of this guide, the term "final governing standards" refers to the country-specific
requirements with which a facility must comply. In cases where a host country has not enacted
environmental regulations for a particular media, the applicable U.S. requirements are the final
governing standards. Although the role of non-governmental organizations (NGOs) is not
delineated in the FSG, such organizations can be valuable sources of information in
conducting overseas audits.
4.2 ROLE OF FACILITY MANAGEMENT
Each DoD installation commander must establish an Environmental Protection
Council (EPC) (or equivalent) that is responsible for establishing and implementing the
installation auditing program. Agency senior management and facility management
personnel are ultimately responsible for the environmental compliance of their facility.
However, if compliance with the applicable FSG would seriously impair a facility's
operations, adversely affect relations with the host country or require immediate,
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substantial expenditure of funds not available for such purposes, facility management
may request a waiver or authorization to deviate from the particular standards or
guidelines.
Administrative procedures at all levels of command should be designed to
expedite implementation of the most current directives on environmental matters.
Adequate management controls must be in place and in operation to ensure sound
environmental performance and avoid potential liability. These controls may include:
. Drafting environmental policies and procedures to ensure compliance with
the FSG;
. Following procedures for implementing federal agency overseas
environmental policy;
. Developing and implementing employee training programs;
. Incorporating installation environmental compliance auditing into their
inspection programs;
. Providing oversight of contractors, subcontractors, and suppliers operations;
Including provisions requiring the contractor to comply with the FSG in
contracts for services or construction, where performance takes place on the
installation, and in contracts for the disposal of hazardous waste;
Purchasing, operating, and maintaining environmental control equipment;
Developing, budgeting and planning systems for environmental compliance;
Implementing, monitoring, record keeping, and reporting systems;
Establishing emergency response plans; and,
Maintaining internal and external communications and control systems.
These controls must be tailored to fit within the framework of overseas environmental
requirements specific to the facility. Thus, facility management must be cognizant of all final
governing standards that pertain to that facility. Facility management also must be aware of a
host country's national, regional, and local environmental laws and regulations which are not
covered in the final governing standards. In cases where the final governing standards are
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entirely based on the environmental requirements of the host country, facility management
personnel should be familiar with the host country's institutional structure for the implementation
and enforcement of environmental requirements. Some countries operate their environmental
protection programs on the national level, while others delegate most environmental authority to
regional and local offices. In federalist countries, different hierarchies of environmental offices
may exist on both the Federal and state levels. An understanding of the environmental
regulatory structure of the host nation is necessary for facility management to stay current on
environmental regulations, to report situations such as spills and releases that migrate offsite,
to request assistance when appropriate, and to be aware of sensitive local environmental
concerns.
In some cases, overseas facilities are located in countries that are members of regional,
integrated political organizations (such as the European Union). The environmental regulations
and requirements of such supranational organizations always must be taken into account when
developing an overseas compliance and audit program. Most supranational organizations have
an entity solely responsible for environmental protection issues, and often develop
environmental requirements that set minimum standards, or are themselves binding on member
states. Member nations also may be obligated to adopt or respond to legislation adopted by
supranational organizations, causing the member states to modify their environmental
regulations. Personnel responsible for an overseas compliance and auditing program will
benefit by keeping abreast of legal developments at both the supranational and national levels.
4.3 DESIGNING AN OVERSEAS ENVIRONMENTAL AUDIT PROGRAM
Determining and keeping abreast of the final governing standards for a particular
country is a time consuming and labor intensive process. There is no single source of up-to-
date information pertaining to overseas regulatory compliance. However, some Federal
agencies are farther along in developing overseas environmental programs due to the large
number of facilities located overseas. Most notable is DoD, which developed the Overseas
Environmental Baseline Guidance Document (OEBGD) October 1992 and is in the process of
developing final governing standards for all locations where U.S. military installations are
located. The OEBGD is one example of how a Federal agency with extensive overseas
operations determines the environmental compliance baseline for its facilities.
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Ultimately, each federal agency is responsible for developing auditing and
environmental criteria and standards for its own overseas operations. The OEBGD sets
out interpretive guidance and criteria for environmental compliance at DoD
installations outside the United States, and contains specific DoD environmental criteria
that are used to develop the FSG to be implemented by overseas DoD installations.
The actual auditing process is then developed by the responsible personnel for each
facility. For DoD installations, the Environmental Protection Council (EPC) (or
equivalent) is responsible for establishing and implementing the installation auditing
program.
A variety of sources of information exist on procedures for conducting
environmental audits. EPA's Environmental Auditing Policy Statement (51 FR 25004)
defines elements of an effective environmental auditing program. EPA's Federal
Facility Enforcement Offices (FFEO) is co-chairing an inter-agency workgroup to revise
auditing guidelines and protocols for federal agencies. Several departments within
DoD, including the Department of the Army and the Department of the Air Force, have
written procedures for conducting audits. The International Standards Organization
(ISO) has developed environmental management standards (ISO 14000) that include
auditing procedures. The National Sanitation Foundation in Ann Arbor, Michigan is
working on auditing schemes that are intended to be compatible with and augment
the ISO standards. In addition, EPA maintains an extensive and current bibliography of
environmental auditing publications.
4.4 CONDUCTING AN OVERSEAS AUDIT PROGRAM
Conducting environmental audits of overseas facilities raises a host of logistical and
budgetary issues that do not typically pertain to domestic environmental audit programs. Early
resolution of these issues will help to prevent problems and delays from occurring before and
during the audit process. Some of the issues that should be addressed before the audit
process are:
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Who will conduct the audit?
Choices include domestic personnel to be sent overseas, personnel already
stationed at the overseas facility, as well as outside consultants. The agency also
should consider whether or not it is cost-effective to have personnel stationed
permanently or temporarily at overseas locations to conduct audits in regions with a
high concentration of agency facilities. Costs to consider include travel, lodging and
per diem, communications, and if necessary, visas and temporary work permits. If
foreign nationals are used, costs associated with payroll taxes, insurance, and
benefits also must be considered. It is often cost-effective to contract with a
consulting firm to conduct or assist in some aspects of overseas environmental
audits. Many consulting firms have offices around the world, and thus have
proximity to facilities as well as knowledge of the legal and institutional framework of
the host country. This can be particularly useful in countries experiencing frequent
and unexpected changes in legislation and institutional arrangements.
How are auditors trained?
Personnel conducting audits must be trained on the final governing standards of the
nation(s) where they will be conducting the audits. Special training, such as health
and safety, radiological health, and security, must also be considered for some
facilities.
What are the applicable standards?
The most important component in designing an overseas environmental
auditing program is determining the standards against which compliance is
evaluated. The audit team will need to evaluate and determine the
applicable criteria and standards and clearly define those criteria and
standards in their audit report. In cases where a FSG or other baseline
guidance document has not been adopted, facility management will need
to determine the appropriate point of contact in the host country (e.g.,
officials in the host country's Ministry of Foreign Affairs, Ministry of Defense,
and Ministry of Environment) to keep the audit team abreast of
environmental requirements. In working with facility management, the audit
team will need to examine the host country's laws (national, regional and
local), applicable international agreements as well as the applicable base
rights agreement and Status of Forces Agreement.
How will communications be handled?
The audit team will need to consult with facility management well in
advance of the audit in making arrangements for handling communications
during the audit. Computer-based forms of communication will often be the
most reliable and easily implemented. However, the audit team may require
special approval for the use of portable electronic equipment from facility
management. Special documentation for the portable electronic
equipment may also be needed for bringing the equipment into the host
country.
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What is the schedule for pre-audit preparations?
Preparations for overseas audits will be more complicated and time-
consuming than for domestic audits. The audit team will need to be in
contact with facility management as soon as possible after the audit team
has been selected and a date set for the audit. By not allowing sufficient
time for the obtaining of visas and immunizations, the audit team may be
precluded from conducting the audit on schedule. A schedule for sending
the necessary information to the overseas federal facility should be
developed to ensure that facility management is well prepared for the audit
team and that all required documentation has been obtained well in
advance of the scheduled audit.
What languages, customs, or traditions may affect the audit team or process?
Facility management should take into account the host country's language, religious
observances, and national or local holidays. The audit team should be briefed on
local customs and common courtesies to avoid embarrassment or
misunderstanding. Care also should be taken to avoid placing audit team members
of a specific gender, or religious or ethnic group in uncomfortable or inhospitable
surroundings. Advise team members of the possibility of such situations during the
audit team planning process.
Will the audit program be subject to regional instability or conflict?
Prior to sending a team overseas to conduct audits, the agency should consult with
facility management personnel stationed overseas to determine regional stability.
This is not an issue with most Western countries, but may arise when conducting
audits of facilities in non-western and third world nations. The Department of State
issues advisories that contain information about potential "hot spots" for U.S.
citizens.
4.5 SUMMARY OF KEY ELEMENTS
Facility management will encounter a range of issues in conducting audits of overseas
facilities which are not generally applicable to domestic auditing programs. Some special
factors to consider include:
Early and thorough preparation is important to ensure an effective overseas
compliance and audit program. Environmental management and control practices
must be adapted to conform to applicable final governing standards. Such
standards may differ for each facility, particularly in cases of facilities located in
federated countries with environmental structures and requirements varying between
the federal and state levels. Sufficient time must be allocated for not only identifying
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the applicable final governing standards but also staying abreast of relevant legal
developments.
Budgetary constraints and logistical issues must be considered to determine the
ideal means for developing an understanding of the host country's legal, institutional,
and regulatory structure, as well as any supranational environmental organizations
and requirements. International consulting firms may provide the in-depth
knowledge necessary for conducting overseas audits and may prove useful in
conducting the actual audit as well.
Logistical issues should be resolved well in advance of commencing the audit.
Failure to take into account such matters as the host nation's political stability, work
permit and visa requirements, and local customs can delay and unnecessarily
complicate an overseas audit program.
4.6 SOURCES OF INFORMATION
There are a wide array of documents, governmental, private, and non-governmental
organizations (NGOs) which can assist or provide useful information on a host country's
environmental management and protection requirements. Some of these sources are
described below.
Organization for Economic Cooperation and Development (OECD): An organization
comprising approximately 30 countries, the OECD has an Environment Committee
which adopts both binding "Decisions of the Council" and non-binding
"Recommendations and Declarations." Both types of instruments serve as guidelines
for the development of environmental laws and policies of member nations. Both the
OECD's Headquarters office and the Environment Committee are located in Paris,
France.
International Chamber of Commerce (ICC): The ICC, which represents a number of
countries world-wide, has become more active in promoting voluntary environmental
auditing. The ICC, headquartered in Paris, maintains information on the problems
encountered by U.S. companies which have conducted audits of their overseas
subsidiaries. The ICC published a Position Paper on Environmental Auditing, which was
adopted by the ICC Executive Board on this 56th Session in November 1988. In 1991,
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the ICC developed and presented The Business Charter for Sustainable Development to
serve as a guideline for world wide corporate environmental management.
U.S. Agency for International Development (USAID): USAID is headquartered in
Washington, D.C. and has local offices in almost every country in the world. USAID
personnel typically are placed in-country on a long-term basis and have substantial
contacts with host government officials. Often, host country nationals are employed by
local USAID offices to handle day-to-day activities in specific sectors, including
environmental protection matters.
U.S. Department of Defense: DoD has developed the Overseas Environmental
Baseline Guidance Document (OEBGD) (October 1992) and is in the process of
developing final governing standards for all locations where U.S. military installations are
located. The OEBGD sets out interpretive guidance, procedures and criteria for
environmental compliances at DoD installations outside the United States, and contains
specific DoD environmental criteria which are used to develop the final governing
standards to be implemented by overseas DoD installations.
United Nations (UN): With over 150 member nations, the UN is headquartered in New
York City but is comprised of various organizations and institutions around the world.
The United Nations Center on Transnational Corporations, also in New York City,
examines corporate environmental practice and develops international codes of
conduct. Headquartered in Nairobi, the United Nations Environment Programme
develops international environmental policies and assists countries in the development
of their environmental protection schemes. The UNEP's Industry and Environment
Office, located in Paris, promotes sound environmental management practices. In
1990, UNEP joined the ICC and over 20 major U.S. corporations to form the Global
Environmental Management Initiative (GEMI). GEMI develops guidelines for
environmental management and sustainable development, promotes the exchange of
information on environmental auditing techniques and concerns, and encourages public
access to information.
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U.S. Environmental Protection Agency, Federal Facility Enforcement Office
(FFEO): Under the authority of EPA's Office of Enforcement and Compliance
Assurance, FFEO manages the program for monitoring compliance by federal facilities
with their environmental obligations. FFEO, located in Washington, D.C., also offers
technical assistance and policy guidance on environmental compliance matters at
federal facilities.
U.S. Diplomatic Missions: The U.S. embassy or consulate in the host nation can assist
facility management and audit team members with logistical matters associated with the
overseas audit. Local U.S. embassies and consulates maintain contacts with
governmental officials of host countries, including national and local environmental
authorities, and often have libraries containing information on a host country's legal
requirements. Local embassies and consulates can also assist with the obtaining of
temporary work permits, visas, and translation services.
International Standards Organization (ISO): Based in Geneva, the ISO formed the
Technical 207 Committee to develop standards for a voluntary international
environmental management system. The Committee has prepared two drafts; ISO
14001 covers certification and registration, while ISO 14000 provides practical advice on
implementing or improving an Environmental Management System (EMS). ISO member
organizations are in the process of voting on the drafts. Subcommittees are continuing
to work on drafting standards for Environmental Auditing (14010-12), Environmental
Performance Evaluation (14031), and Life Cycle Assessment (14040), among others.
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CHAPTER 5: DESIGNING AN AGENDY-WIDE AUDIT PROGRAM
5.1 OVERVIEW
As previously discussed, the environmental audit is an important tool that agency
managers can use in building and maintaining effective environmental management programs.
However, in designing these programs, environmental program managers must ensure that
scope and goals of the program reflect and complement the agency's overall mission and
environmental priorities. A well-designed audit program will allow program managers to use
audit findings as a means of evaluating progress toward agency environmental program goals.
In contrast to the 1980s, when auditing was narrowly defined as a check-list based
approach for evaluating compliance, auditing now includes the review of environmental
management programs as a whole. As this section describes in greater detail, the audit
program can serve both to identify barriers to meeting environmental goals as well as solutions
for resolving problems. In addition, through the incorporation of environmental management
strategies, the emphasis in environmental auditing has shifted away from a reactive approach in
favor of a preventive approach to environmental problem-solving.
5.2 FACTORS AFFECTING PROGRAM DESIGN
Proper design of an environmental audit program requires careful consideration of
desired program goals and objectives, as well as development of a strategy for conducting pre-
audit on-site and follow-up activities. A well-designed environmental audit program should meet
the needs of the facility or agency environmental management program. Thus, the specified
goals and objectives of these programs should be complementary.
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Design factors that should be considered when developing an environmental audit
program include:
Scope of audits;
Frequency of audits;
Level of effort required;
Type(s) of audits; and
Relationships with other inspection agencies.
Considerations that influence these audit design factors are similar to those affecting the
overall environmental program. These considerations fall into five general categories: (1)
resources available for carrying out the program; (2) the nature of the agency's facility
operations and associated environmental issues; (3) the scope of the environmental
management program; (4) agency support for environmental programs; and (5) perception of
agency environmental commitment. Each of these factors is described in greater detail below.
Available resources - The audit program is subject to the same financial
constraints that apply to all government programs. Resources needed to effectively
operate an audit program include labor, equipment, and supplies -- with labor
comprising the majority of the necessary resources. In considering costs, an agency
must evaluate how much auditing it can afford, i.e., whether it can afford both
compliance audits and management audits. In addition, agencies must consider if it
is necessary to plan their audit activities to coincide with federal budget cycles.
Nature of agency operations and environmental issues - The design of the audit
program depends to a great extent on the types of operations carried out by an
agency's facilities and their associated environmental issues. Agencies comprised
of facilities with primarily administrative functions should require fewer and more
limited audits than agencies with industrial operations utilizing a large quantity of
hazardous materials. To the greatest extent possible, site-specific factors such as
facility location and local environmental issues also should be taken into
consideration.
Scope of the environmental management program - The purpose of the audit
program is to measure success in achieving the environmental management
program's goals, thus program managers should design the audit program to review
all aspects of the program, including management systems, standard operating
procedures, organizational structure, and compliance with specific environmental
requirements. Depending on the nature of the agency's operations, certain
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requirements may not apply. As such, the nature and scope of the agency's mission
and operations both have a direct influence on the audit program.
Agency support - The level of agency environmental awareness, as well as it's
compliance history are factors that affect the frequency of audits. Agencies that
have invested in awareness training programs may find that they can conduct audits
less frequently because facility personnel have a positive attitude toward
environmental protection and that Senior management and other stakeholders will
play a leadership role in developing the audit program.
Perception of agency environmental commitment - How an agency views itself
and how it is viewed by others with respect to environmental issues is an important
aspect affecting audit program design. Whether senior executives are reactionary,
compliance oriented, or visionary is a significant element in designing an audit
program. While an agency may have a mission that is reactionary by nature, i.e.
responding to an environmental disaster, a more visionary posture when dealing with
inter-agency environmental issues will affect the overall audit program. Likewise,
how others view the agency, stakeholder expectations, is also important in audit
program design. It is important to identify who the stakeholders are, i.e. the general
public, other agencies, etc., and to adequately consider their expectations with
respect to audit program design. This can be especially important with respect to
such activities as cleaning up contaminated sites that will be turned over to the
public.
5.3 IDENTIFYING AUDIT PROGRAM GOALS
At the outset, environmental audit program managers should clearly establish long-term
goals for the audit program. As discussed above, audit program goals should be a
complementary sub-set of an agency's goals for achieving a sound environmental management
system. Environmental management goals will vary from agency to agency and must be
examined within the context of each agency's mission and activities, but may include:
In conformance with Executive Order 12856 (Federal Compliance With Right-to-
Know Laws and Pollution Prevention Requirements"), EPA has developed and issued a
Code of Environmental Management Principles (CEMP) for federal agencies. On
September 3, 1996, EPA transmitted the CEMP to federal agency executives requesting
written commitment to the principles contained in the CEMP.
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The CEMP consists of five broad management principles that have been
developed to address all areas of environmental responsibility of federal agencies.
These five principles include:
1. Management Commitment: The agency makes a written top-management
commitment to improved environmental performance by establishing policies
which emphasize pollution prevention and the need to ensure compliance with
environmental requirements.
2. Compliance Assurance and Pollution Prevention: The agency implements
proactive programs that aggressively identify and address potential compliance
problem areas and utilize pollution prevention approaches to correct
deficiencies and improve environmental performance.
3. Enabling Systems: The agency develops and implements the necessary
measures to enable personnel to perform their functions consistent with
regulatory requirements, agency environmental policies and its overall mission.
4. Performance and Accountability: The agency develops measures to address
employee environmental performance, and accountability of environmental
functions.
5. Measurement and Improvement: The agency develops and implements a
program to assess progress toward meeting its environmental goals and uses the
results to improve environmental performance.
A copy of the CEMP Principles is presented in Appendix G of this document.
Complementary long-term environmental audit program goals should include:
Development and implementation of a cost-effective audit program;
Integration of environmental management systems (e.g., pollution prevention) into
audit protocols and facility operations to help an agency to prevent compliance
problems by reducing wastestreams and environmental releases to the greatest
extent possible;
Conducting environmental audits to identify environmental problems and develop
solutions to enhance agency compliance and overall environmental management.
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Establishing an audit program that effectively fulfills its stated goals requires that some
groundwork be laid. Laying this groundwork may be one aspect of an overall implementation
strategy designed for the audit program. The strategy may specify activities for modifying
current environmental policies to incorporate the audit program, securing adequate resources
and funding, and assigning responsibilities for carrying out the program. Agencies also should
examine internal management practices and organizational structures to determine if changes
are warranted. Agencies that currently lack environmental audit programs may consider
adopting a "phased-in" approach to program implementation by gradually increasing the scope
and/or number of audits conducted over time.
5.4 IDENTIFYING AUDIT PROGRAM OBJECTIVES
Having established goals for the environmental audit program, environmental program
managers should continue to develop an implementation strategy by determining short and
long-term program objectives. As in the case of the audit program goals, objectives will vary
from agency to agency.
The primary short-term objective of the audit program should be to bring the agency into
full compliance with existing environmental requirements. Standard audit protocols can be
used to determine compliance with each applicable regulation (e.g., RCRA, Clean Air Act, etc.).
Using these checklists, audit team members can conduct interviews with shop personnel and
record their observations. Compliance audits conducted in conjunction with the assistance of
facility staff provide an excellent opportunity to informally train personnel in correct procedures
and to raise awareness regarding environmental compliance issues.
Other short term program objectives should be to identify projects for funding under the
requirements of E.O. 12088 or agency funds earmarked for environmental compliance projects
and to collect or verify environmental information that may be needed for other aspects of the
environmental management program (such as hazardous waste generation rates or hazardous
materials consumption), or other internal metrics.
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Long-term audit program objectives should broaden the program focus from strict
compliance with current requirements to include eliminating underlying (root cause)
environmental problems and conducting more detailed evaluations of environmental problems
and management systems. Standard compliance audits alone cannot meet these long-term
objectives. Instead, program managers must use audits tailored to these purposes. Examples
of long-term auditing objectives are described below.
Eliminate underlying environmental problems - Auditing can be used to identify
the root causes of environmental problems and allow program managers to take
steps to eliminate them rather than continuing to rely on temporary stop-gap or
control measures. For example, recurrent spills in maintenance shops may be
temporarily addressed by using larger quantities of absorbent products.
Alternatively, a long-term solution to the problem would be to purchase better fluid
handling equipment and improve worker training and supervision.
Identify systemic environmental problems - Agency environmental managers can
use audit results to identify systemic environmental problems that must be resolved
in cooperation with individual facilities. Strategic planning may be needed to
address these systemic environmental problems.
Forecast future compliance - Audits provide an understanding of the current state
of agency compliance, but also can be used to determine what activities are
necessary to remain in compliance with upcoming or anticipated future regulations.
Evaluate effectiveness of internal environmental management program - This
review may identify issues such as insufficient resources, lack of vision, or poor
training that may compromise future compliance.
5.5 SELECTING THE TYPE AND SCOPE OF AN ENVIRONMENTAL AUDIT
Over the past decade, the field of environmental auditing has become increasingly
specialized. Audits are no longer limited to determining compliance with current requirements.
Instead, audits can be used to identify and resolve underlying causes of compliance issues,
particularly recurring problems. Federal agencies have a variety of auditing tools at their
disposal to evaluate current compliance status, future risk of non-compliance, and opportunities
for minimizing the potential for non-compliance.
One such tool is EPA's Generic Audit Protocol. The Protocol is an environmental
auditing guide and an environmental management tool specifically developed to assist federal
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agencies in assessing or benchmarking their environmental performance. It is also intended to
be a resource for identifying and correcting deficiencies and to evaluate and manage
environmental risk including the risk of non-compliance with statutes, government regulations,
and federal executive orders. This Protocol is especially helpful in providing guidance on how
agencies may identify the "root cause" of environmental deficiencies such that these problems
will not recur. The Protocol provides federal facilities and agencies with a comprehensive
explication of the environmental auditing basics such as compliance audits, as well as auditing
of specific environmental management systems, and overall audits of environmental programs.
When designing an audit program, agency environmental management staff should first
determine goals and objectives and then select the types of audits to be conducted to best
meet the audit program goals. This section provides a discussion of five types of commonly
conducted environmental audits: compliance, property transfer assessments, management
audits, waste contractor/vendor audits and pollution prevention opportunity assessments.
These audits can be used in combination at a facility if appropriate.
5.5.1 Compliance Audits
Agencies use compliance audits to evaluate facilities' compliance status vis-a-vis current
environmental requirements. Compliance audits may be performed using in-house staff or a
third party, such as a contractor. Typically, the scope of compliance audits is limited to
identifying areas of non-compliance and does not include environmental management as a
long-term approach for coming into compliance. The remainder of this guide focuses on this
type of environmental audit.
5.5.2 Property Transfer Assessments
These types of audits are used by agencies to identify any undisclosed environmental
problems associated with a piece of property prior to purchase. The scope of property transfer
assessments often is much broader and focuses more on business risks and liabilities as
opposed to regulatory compliance. Assessors typically spend more time reviewing records and
conducting on-site monitoring than they would during a compliance audit. Examples of the
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kinds of environmental issues examined during a property transfer assessment include:
asbestos, soil or groundwater contamination, underground storage tanks, PCBs, lead-based
paint, urea, formaldehyde, radon, and contaminated drinking water. The level of detail and
scope of the assessment will depend greatly on the site history. Sites that were formerly
occupied by military or industrial facilities or located near abandoned waste disposal sites will
require more extensive site characterization work than sites that are relatively undeveloped.
The conduct of property transfer audits in the context of federal facilities may also raise
issues similar to those typically encountered in the corporate sphere of merger/acquisition
efforts. This type of property transfer assessment is a "total risk profile" that is focused on the
legal and financial risks that can arise in the sale or purchase of properties with the potential for
significant environmental liability. For example, military base closure activities may result in the
transfer of property to either public or private entities. The entity acquiring the site is likely to
insist on a thorough site characterization before accepting title to any portion of a facility that
could have an environmental risk potential. Many former military facilities had site activities
such as operation of process and production lines that implicate major environmental statutes
such as RCRA or CERCLA. If these facilities produced such items as printed circuit boards
there could be significant issues surrounding the use of solvents and degreasers with the
associated risks particular to those type of industrial activities. A few years back a major
federal agency was found by a court to be a potential responsible party under CERCLA for site
contamination that occurred almost fifty years in the past. The property in question was a
private industrial site at which that agency had exercised management oversight for purposes
of war production activities. The present day moral is that an agency that doesn't know what its
role was in site environmental issues may face serious future liabilities.
Therefore, it is important for a federal agency or facility to be thoroughly familiar with site
activities including historical activities in order to not only characterize its possible contribution
to site environmental issues, but to be able to identify situations for which it is not responsible.
This is critical in both a divestiture situation as well as an acquisition situation.
5.5.3 Management Audits
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These audits are a distinct type of audit designed to evaluate an organization's ability to
carry out it's environmental management program. Management audits can be conducted in
many ways and utilize either in-house staff or a third-party. Management audits typically
involve the review of: organizational structure; staffing levels and resources; roles and
responsibilities; standard operating procedures; ability to fulfill the organization's assigned
mission; and staff training and expertise. EPA's Generic Audit Protocol describes
environmental management audits, referred to as Phase 2 and Phase 3 audits, as audits that
target specific management issues and assist facilities in identifying the root causes of
environmental deficiencies. Most importantly, because these types of audits focus on the root
cause of deficiencies, they help the facility and agency in implementing permanent corrective
action measures. The Generic Protocol provides guidance on how to evaluate such programs.
5.5.4 Waste Contractor/Vendor Audits
Some Federal agencies require facilities to audit commercial treatment, storage, and
disposal (TSD) facilities prior to issuing a waste management contract. The purpose of this
type of audit is to minimize the long-term risk and liability associated with off-site hazardous
waste treatment and disposal. Superfund allows EPA, under certain conditions, to impose
severe, retroactive, joint and several liability upon any party responsible for the release of
hazardous substances into the environment, including environmental damage resulting from
TSD operations. Federal agency personnel should be aware that "responsible parties" may
include hazardous waste generators.
Federal agencies should seriously consider conducting waste contractor audits at both
RCRA-regulated TSDs and non-RCRA facilities such as solid waste and oil recovery facilities.
By thoroughly assessing the capabilities and operations of a TSD facility, generators often can
reduce the number of facilities utilized for waste treatment and disposal, resulting in a more
focused and cost-effective waste management program. In addition, these audits can be used
to identify and eliminate the use of facilities that present unreasonable environmental risks that
otherwise would not have been evident.
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TSD facility audits can be conducted using in-house staff or independent environmental
consultants. These audits focus on four primary areas: (1) assessing the risks associated with
facility operations; (2) reviewing the financial strength of the TSD facility; (3) understanding
current past and present compliance issues; and (4) assessing the facility's management. After
completing the audit, the team should prepare a report that allows a comparison of the positive
features of the facility and the existing or potential environmental, operational, and financial
risks of the site.
5.5.5 Pollution Prevention Opportunity Assessments
Over the last five years, Federal agencies have begun to use pollution prevention
opportunity assessments (PPOAs) as a tool for identifying and eliminating the underlying
causes of compliance problems. By adopting a pollution prevention approach, agencies can
reduce waste generation and environmental releases, and thus prevent compliance problems
from occurring. Compliance problems may be resolved through a combination of best
management practices, organizational or management changes, or technical modifications
(e.g., material substitution or process modifications). PPOAs are broad in scope and combine
aspects of both compliance audits and management audits. During the PPOA site visit, the
assessment team may examine: facility operations; waste streams and environmental releases;
management practices and systems; floor plans and facility lay-out; inventory control
procedures; energy and water consumption; and materials usage.
As with other types of audits, PPOAs can be conducted either by in-house staff or
independent environmental consultants. However, unlike other audits, conducting PPOAs
requires staff with specialized skills and expertise. Assessment team member should have
received training in how to conduct PPOAs and should be aware of the resources and technical
assistance available for identifying and evaluating pollution prevention options. The
assessment team should produce a report which contains a ranked list of pollution prevention
options, including cost benefit analysis and an evaluation of the technical feasibility of each
opportunity identified.
5.6 TARGETING FACILITIES
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In most cases, agencies must set priorities for conducting audits at their facilities due to
manpower and resource limitations. Depending on the nature of facility operations, some
facilities will require more frequent and more extensive auditing than others. The following
factors are frequently used in prioritizing facilities:
Size of the facility - The physical area (both improved and unimproved areas),
production levels, waste generation, and/or the number of employees.
Risk - The likelihood of harm to human health or the environment caused by facility
operations. Facility risk may include factors such as the type and quantity of toxic
chemicals used, the type of products manufactured or processed, the age of the
facility and history of accidents, the danger associated with the operations
conducted at the facility, and the proximity and density of human population.
Environmental factors - Certain site characteristics may make a location more
susceptible to wide-spread environmental damage. Examples include aquifer
recharge areas, porous soils, subsurface geology and hydrology, steep grades,
prevailing wind direction, and close proximity to bodies of water. In addition, agency
environmental staff should consider the presence of endangered or protected
species in the area of the facility.
Record of compliance - Facilities with poor compliance records may require more
frequent auditing than those with good records (e.g., facilities operating under
consent decrees, settlement agreements, etc.). Poor compliance may result from
high worker turn-over rates, inadequate training, or a lack of attention to
environmental issues on the part of upper management. In this case, environmental
management audits may be helpful in demonstrating root causes to non-compliance.
Agency environmental staff should begin to set auditing priorities by compiling
information on these factors for each facility. If the agency has many facilities, staff may need
to develop a matrix for ranking each facility based on the factors. By ranking the facilities,
agency staff can prepare a prioritized list of facilities for auditing and a long-range auditing
schedule.
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CHAPTER 6: PROGRAM ADMINISTRATION
6.1 OVERVIEW
This chapter discusses the process of initiating and administering an environmental
audit program based on the framework and procedures outlined in Chapter 5 of this guidance
document. The success of an agency environmental audit program hinges on building a strong
program foundation, including launching the program in a positive manner and carefully
planning a strategy for each phase of the audit program.
6.2 PROGRAM INITIATION (GENESIS OF THE PROGRAM)
Program initiation activities take as a starting point the work done in establishing the
audit program long and short-term goals and objectives. A number of initial steps must be
completed prior to formally launching the audit program. These steps should be carried out by
the environmental staff under the direction of senior management.
6.2.1 Develop An Environmental Audit Policy
The genesis of an agency environmental audit program often is the development of an
audit policy or mission statement. This policy will set help to lay a solid foundation for future
agency audit activities, establish the program's purpose and function, and educate and gain the
support of agency facilities and employees. An agency audit policy should include:
A detailed description of the scope, goals, and objectives of the program;
A management statement that the program is intended to help facility managers
improve compliance and reduce the potential for liabilities and is specifically not for
the purpose of "checking on" facility managers;
A discussion of how the audit program will be managed and administered; and
A signature of an appropriate agency official, with a senior agency official named as
head of the program.
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In addition to the agency audit policy, environmental managers also should develop a
strategy for program implementation. Some of the issues that should be addressed include:
Securing resources for funding the program;
Assigning roles and responsibilities for implementation of the program;
Supporting the audit policy through agency actions; and
Determining the best way to communicate the goals, objectives, and results of the
audit program to interested parties within and outside the agency.
6.2.2 Internal Versus External Audits
Agency environmental staff should determine whether facility audits will be conducted
using in-house or external staff early in the planning process. It may be possible to rely on
facility staff to conduct audits at larger facilities, while audits at smaller facilities may require the
involvement of agency headquarters staff. This decision is important with respect to program
success because of the budgetary and internal management issues raised. However, if agency
staff are used they should not report directly to line management as this presents the potential
to jeopardize the audit's objectivity and ultimately its credibility. Another key issue is the
objectivity of audits conducted by facility staff. This is especially important when using in-house
staff and in such cases caution should be used to assure the objectivity of the audit.
Additionally, agencies may consider the possibility of using outside agency personnel. If budget
and personnel constraints permit, it may be desirable to use these personnel to conduct audits
at other facilities and simultaneously train agency staff to allow them to conduct their own audits
in the future. Finally, agencies should be aware that there is considerable expertise within the
Federal government with respect to auditing. Therefore a federal agency may want to involve
personnel from other federal agencies to conduct peer reviews of third-party audits to provide
credibility and objectivity to the audit. Involving other agency personnel may also provide
opportunities to benchmark other audit programs and make improvements to the agency's
overall programmatic approach.
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6.2.3 Use Of Contractors Versus Agency Staff
Agency managers also should consider the option of using contractor support for
conducting environmental audits. Advantages to using contractors for conducting audits
include; audit objectivity, auditor qualifications, staffing issues, audit quality assurance, and
such issues as medical monitoring for audit personnel. Contractors also may be used as a
short-term alternative while agency staff are being trained on audit procedures and protocols.
6.3 PROGRAM MANAGEMENT ISSUES AND ACTIVITIES
Program managers will have to make decisions regarding a wide range of issues as part
of the administration of the audit program. Building a program centers around the completion
of eight basic activities that are closely related to the activities discussed in the preceding
section on program initiation. These include: (1) securing upper management support and
resources; (2) securing support from agency field offices; (3) obtaining qualified personnel; (4)
conducting medical monitoring of audit personnel; (5) conducting quality assurance and
measuring audit program performance including ensuring consistency and objectivity of audit
findings; (6) delineating and following audit reporting responsibilities; (7) conducting post-audit
activities and implementing corrective measures; and (8) Integrating audit findings into the
agency budget process..
6.3.1 Securing Upper Management Support and Resources
Success of an audit program requires a commitment from agency management to
support the development, performance, and follow-up of audit findings and recommendations.
Senior agency officials' commitment to the program helps to ensure the availability of resources
and manpower and a willingness to follow-up on corrective measures in a timely manner.
Upper management commitment can be expressed by signing the environmental audit policy,
holding briefings with organizational directors and other stakeholders, and publishing articles in
Agency newsletters. Management support should include commitments to the following areas
of support:
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Adequate resources and staffing: This includes such issues as a training of audit
staff in environmental technical and regulatory matters and proper interview
techniques. It also includes providing equipment and facilities (monitoring and
safety equipment, appropriate questionnaires and checklists, and if appropriate
office space) so that audits are properly conducted. This aspect of a successful
audit program is foundational. Upper management support is irrelevant without
properly trained and equipped audit staff.
Budget for program development and performance: This includes setting aside
sufficient staff man-hours to plan and develop audit program objectives and overall
goals. It is beyond training and staffing issue and is focused on the planning
process such that audit program objectives are anticipated and provided for in future
years. This might include a commitment to bring more costly audit program
activities (but no corrective actions) on-line in a phased approach or expanding
beyond compliance audits to management audits. This element is necessary in
order for the audit program to develop and thrive over time and is evidence of
management's commitment to an audit process rather than a one-shot audit effort.
Follow-up with corrective action measures in both a budgetary and
programmatic fashion: This involves the commitment to fund and support the
actions necessary to correct deficiencies identified by having committed to the two
prior activities. This includes a commitment to systematic permanent or long-term
corrective action measures as appropriate. Without a commitment to correct the
deficiencies uncovered by the audit findings, the audit program becomes an added
liability to the agency as opposed to reducing its overall risk profile.
6.3.2 Support From Field Offices
In addition to the support of agency headquarters management, the success of an
environmental audit program requires commitment from the agency's field offices. This support
is particularly important because the performance of audit activities generally occurs at the field
level office level. This requires the cooperation of facility managers in furthering program
objectives and diligence in addressing corrective action recommendations. Because agency
senior management at headquarters is frequently far removed from the field office activities,
and is more concerned with broader agency issues, it is essential that the field office
management take a proactive role in advancing the agency's environmental auditing objectives.
One method for ensuring facility level commitment to the agency's program is to appoint one or
more individuals to the task of coordinating and tracking field office support for the audit
program and then having those individuals report directly to upper management.
6.3.3 Obtaining Qualified Personnel
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To a great extent, the quality of the audit program depends on the competency
of the auditors conducting the audit. If auditors and audit team members are not
proficient in their duties, the audit being conducted will likely be flawed and reflect on
the organizations overall environmental management system. Agency management
and, in some cases, facility management and their staff will be looking to the audit
team for guidance in improving their compliance posture, environmental management
systems and overall risk profile. Therefore, it is imperative that the audit team be able to
demonstrate having both appropriate knowledge of the issues included in the scope
of the audit, and sufficient training and proficiency prior to participating in
environmental audits.
The qualifications of the staff assigned to conduct the audit should be
commensurate with the objectives, scope and complexities of that particular audit
assignment. Although audits will vary in scope, as previously mentioned, they all will
require some degree of professional assessment of on-site conditions, and risks related
to apparent problems such as areas of non-compliance, and weaknesses in
management systems. Auditors must also be able to verify and document observations
and findings and use professional judgement to form recommendations for correcting
any observed deficiencies. These often include areas outside the scope of compliance
requirements and extend to environmental management issues at the facility. Key
areas of technical experience and training for environmental auditors should include at
a minimum:
technical training and experience appropriate to the scope of the audit,
including an understanding of basic audit concepts, practices and
procedures;
knowledge of environmental regulations, the lines of inquiry and
performance objectives contained in the audit protocol, and general
standards called for in the scope of the audit;
general familiarity with the type of process operations to be audited at
the site and with the environmental issues likely to be associated with the
various processes and related management issues.
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Above all the auditor must be flexible and know when and how to apply certain
auditing approaches and theories in different situations. During the course of an
environmental audit, auditors may encounter situations that are outside their
experience or preparation for the audit. In such circumstances it is important for the
auditor to adapt to varied and unfamiliar situations and not be limited to a particular
approach.
The auditor also should receive training in agency administrative procedures (e.g.,
procedures for reporting findings) to ensure that audits will be as consistent as possible from
year to year. Along with audit protocols, program managers should develop quality assurance
procedures to review each audit and determine whether audit protocols were followed.
The audit team should include individuals whose skills and expertise are
complementary. For example, one team member may specialize in air regulations while
another specializes in wastewater issues. The optimal skill mix of team members will depend
on the type of audit conducted and the Facility being audited. If the audit program involves the
conduct of multiple audits, program managers may plan on obtaining resources for preparing
and fielding more than one audit team.
In addition to assuring that qualified personnel are involved in the audit, the roles and
responsibilities of the audit team leader and audit staff should be clearly identified. The team
leader is responsible for the actions of the audit staff and is responsible for any audit staff
debriefings and exit interviews, as well as the overall conduct of the audit, and should take the
lead in resolving any concerns or issues that might arise between the audit staff and the facility.
In addition, the team leader is the contact point for any questions the facility personnel may
have regarding the scope and purpose of the audit. The team leader should be qualified to
manage a group of auditors and have sufficient experience to address any questions that might
arise during the course of the audit. Finally, the team leader is responsible for communication
with the facility regarding the report contents as well as the final report. Audit staff are to follow
the specific tasks assigned to them prior to the beginning of the audit. Also, they should look to
the team leader if they have questions about appropriate activities while on site.
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6.3.4 Medical Monitoring
If in-house staff will conduct most of the audits, program managers should secure
resources for medical monitoring of team personnel. Medical monitoring is particularly
important if team members conduct several audits a year at facilities where occupational
exposure is an issue. Medical monitoring of audit staff has as its primary objective the
protection of the auditors. Evidence of exposure of audit team members to hazardous
substances is an indication of deficiencies in the auditor safety training program and should
receive the highest corrective action priority from management. This is especially important
because of the potential for liability due to worker exposure.
6.3.5 Quality Assurance and Audit Program Performance Measurement
It is important to adequately document and analyze audit findings and observations to a
high degree of quality and competence. This is necessary so that facility management, staff,
and/or subsequent environmental auditors can refer to the audit report and can either concur,
or if they disagree, understand the original findings and recommendations sufficiently.
Therefore, once an environmental audit program is underway, there is a need to assess the
consistency and objectivity of the audit findings. This can be accomplished by conducting a
periodic (e.g., annual) review of the performance of the audit program. To accomplish these
reviews, agency management should consider the use of third parties to evaluate audit program
performance. This is a useful method for assessing program objectivity. Program performance
review should include examination of past efforts as a tool for implementing future
improvements and include assessments of:
What has the program accomplished?
Were the program goals and objectives met?
What were the strengths and weaknesses of program protocols and results?
What program corrections are needed to improve future audit efforts?
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6.3.6 Reporting Responsibilities
Environmental managers should implement a strategy for communicating the results of
the audit report to upper management and facility personnel. Upper management and facility
personnel should be informed immediately if the team identified any situations that pose an
imminent danger either to shop personnel or the environment. In addition to discussing the
findings, program managers should prepare an explanation of recommended corrective actions
and an estimate of manpower and financial resource needs. Something as simple as an
organizational chart with an attached matrix of facilities and identification of corrective action
measures by facility may be helpful in informing management of audit program status.
6.3.7 Post-Audit Activities and Corrective Measures
Environmental managers should streamline the process for resolving compliance
problems and other issues identified during the audit. Corrective action may involve obtaining
funding, preparing new standard operating procedures, site remediation, purchasing new
equipment, training, and/or sampling and monitoring. Program managers should create a
matrix for comparing and prioritizing corrective action projects. A system for tracking and
monitoring corrective action projects may be needed for large facilities with numerous projects.
Corrective measures for compliance problems range from temporary "quick fixes" to
long-term preventive action (i.e., pollution prevention). For example, recurring spills in a
particular shop may be resolved in the short term by replacing leaking containers. In the long
term, depending on the economic feasibility, the shop may invest in improved secondary
containment, better bulk storage and materials transfer equipment, as well as worker training
and environmental awareness.
6.3.8 Budget Coordination and FEDPLAN
Funding for projects (including environmental compliance and corrective action) typically
is initiated at the installation or facility level, usually by the facility compliance officer or person in
charge of environmental management. Projects requiring capital expenditures are usually
considered line items in an agency's budget. Because of lag times in requesting and securing
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funds, it is necessary for agency environmental management to ensure that facilities are
audited and budget requests for corrective action measures are submitted in a timely manner.
Therefore, scheduling of audits and development of budget needs in response to audit findings
should take into consideration the priority of the problems identified in the audit and the budget
year cycle. This is critical because a costly compliance problem identified after submittal of an
agency's budget could lead to significant problems for the agency.
Once the budget needs have been identified, the agency must submit a report to OMB
which describes the agency's plan for addressing environmental problems (refer to Chapter 2,
Section 2.5). Agency management must develop a process for communicating the needs
identified in the audit process into a report. Identification of compliance problems and
development of budget needs based on audit findings will be moot if this is not translated into a
request for funds to conduct needed corrective actions. As with the budget process, in
scheduling facility audits, management should consider the timing of audits within the calendar
year, this will allow sufficient time to address corrective action plans for serious deficiencies
within the budget process.
6.4 LEGAL ISSUES
6.4.1 Written V. Oral Reports
The use of oral versus written reports is a consideration when dealing with the
disclosure of sensitive materials and/or the discovery of unregulated risk. As discussed in
Chapter 3, it is virtually impossible to guarantee that internal investigatory reports will remain
confidential. Therefore, in matters concerning possible liability, the use of oral reports is of little
value and should not be encouraged. If an agency becomes involved in litigation, the
underlying facts and the response to any problems identified by an audit will be uncovered
through the civil discovery process. Audit reports will, however, have protection from FOIA
requests while they remain in draft or preliminary stage.
An additional problem with oral reports is that they do not exhibit the rigor and careful
analysis of a well written report. Without notes, it is difficult to accurately recall and report
specific facts discovered in an audit. Also, with oral reports, their immediacy may lead to an
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inclination to report in an emotional and opinionated fashion regarding an issue that requires
reasoned examination. Further, the oral report and any notes made to produce the oral report
may be subject to discovery as previously discussed
In limited circumstances, agencies that deal with high security or matters of unusual
sensitivity will be confronted with situations that argue against the written memorialization of an
issue. Either the sensitive materials should be recorded in a separate notebook with limited
distribution, or the less sensitive information should be written and sensitive material
transmitted orally. This is a rare situation applicable to those agencies dealing with national
security issues. The security related issues should be developed separately from the primary
audit report and must be overseen in their entirety by agency legal counsel. The specifics of
invoking national security protections is outside the scope of this document and is best
undertaken by agency counsel. Also, there are legitimate procedures for protecting sensitive
materials from disclosure and these procedures do not necessitate the use of oral reports.
6.4.2 Exit Interview
Oral reports are appropriate at the exit interview, but must remain focused on facts
rather than opinions. For example, it is appropriate to report that the audit team found a red
and green substance flowing out of the unbermed hazardous waste storage area, or found
crumbling white insulation material adjacent to the HVAC intake structure and will test this
substance to determine if it is asbestos. It is not appropriate to report that the team found red
and green hazardous waste flowing out of the illegal hazardous waste storage area in violation
of state and Federal regulations. Such statements are conclusory and not sufficiently
supported by analysis.
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6.4.3 Document Protection And Retention
All audit findings should be recorded in indelible ink in bound notebooks with pages that
can be neither inserted nor deleted. In addition, all notes should become part of the site file.
There are two distinct purposes behind these requirements. First, it provides a single source
for audit results, there will be no question about the existence of additional materials. Second,
it assures a measure of certainty regarding the recordation of the audit findings. It will be
difficult to second-guess the findings with respect to completeness of the audit record if all
entries are in bound notebooks written in indelible ink. Subsequent questions about whether
some finding was deleted or changed, or whether a particular issue was addressed during the
audit can be determined by reference to the notebooks.
Audit team members should clearly identify the time and date the audit began, where on
the facility it began, and clearly identify the point where the final walk-through ended. Auditors
also should sign the notebooks when the audit is completed. These measures will provide
some protection against alteration of audit findings. If there is a need to segregate audit
findings because of security reasons, the audit team should not record the sensitive materials in
the same notebook with the rest of the audit.
6.4.4 Involvement Of General Counsel
The agency general counsel should be involved in the audit planning and conduct from
the beginning to the final report. The general counsel's office role includes furthering agency
policy of complying with all applicable Federal, state and local regulations, and this requires
involvement at the earliest stages of the audit. The participation of the general counsel is also
important in the event significant violations are uncovered, especially those that trigger statutory
or regulatory reporting requirements. It is best to consult with the general counsel's office prior
to the audit in order to plan for the discovery of violations or unregulated risk.
If violations or significant unregulated risks are discovered, it is important that the
general counsel carefully reviews the findings and takes an active role in notifying the
appropriate regulatory agency. Violations must not be mischaracterized or omitted such that
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the audit be interpreted as an affirmative act of concealment. The perception that concealment
is occurring can lead to additional and severe legal consequences. It is counsel's role to stress
to audit team members and facility personnel that purposeful failure to report or be informed
about violations or negligent conditions could be construed as "willful blindness" and possibly
lead to civil or even criminal prosecution. In 1984, a Federal Court upheld the criminal
convictions of a plant foreman and service manager finding that the RCRA penalty provisions
apply "if they knew or should have known that there had been no compliance with the permit
requirement" (United States v. Johnson & Towers, Inc., 741 F.2d 662, 664-665 (3rd Cir. 1984)).
As is evident from this decision, turning a "blind eye" to violations may lead to severe legal
liability.
An additional and critical role for the general counsel is to assure that compliance is fully
documented. It is essential that the agency leave a clear paper trail establishing that it has
devoted resources to the management of environmental matters. The agency should ensure
that corrective actions taken to address discovered violations are carefully documented in the
final report. A prompt and thorough response to problems discovered in an audit is important
with respect to minimizing the potential for future liability.
6.4.5 Report Distribution
The audit notebooks and questionnaires should be retained in a central file by the audit
team members. These notebooks are not to be disseminated or reproduced for non-audit team
members, but should be available to the general counsel's office. The notebooks and the
observations they contain are the factual basis for the final report. While it is appropriate to
disseminate sections of the audit report to facility personnel for comment, it is best to limit
distribution to those individuals qualified to comment on them. For example, the audit report
section dealing with the facility wastewater treatment system should be circulated to the
personnel responsible for that area, and to facility management. The purpose of the limited
distribution is to maintain the confidentiality of the document during its development, while at
the same time allowing an opportunity for open discussion of the issues among the responsible
parties.
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CHAPTER 7: RESOURCES AND TOOLS FOR AUDITORS
7.1 OVERVIEW
This chapter discusses the types of resources and tools auditors should have available
to them when conducting environmental audits. All of these materials will not be required for
every audit. However, auditors should be aware of and utilize all potential information
resources appropriate to the scope and type of audit they are performing.
7.2 PRE-VISIT QUESTIONNAIRE (PVQ)
A PVQ consists of a series of written questions directed at the facility environmental
manager to determine the nature and extent of any facility environmental issues, as well as to
alert the facility manager as to facility areas and documents to be reviewed during the audit. A
PVQ typically is sent to the facility several weeks prior to the audit and should be returned in
time to provide the audit team with sufficient opportunity to review the facility's responses and
prepare for the site visit. It also is extremely important for facility personnel to fully respond to
the questions raised in the PVQ and contact the audit team with any concerns or questions.
The PVQ is an important tool for both the audit team and the audited facility in
identifying particular areas of concern and setting priorities for audit efforts. A well crafted PVQ
can significantly reduce the on-site time required to conduct the audit, thereby saving valuable
and resources for other audit activities. The PVQ is useful in:
identifying priority areas to review during the site visit;
budgeting time for physical areas to be visited and issues to be reviewed;
providing facility personnel with an opportunity to prepare documents and records;
providing guidance to the facility on subjects that will be of interest to auditors; and
alleviating the concerns of facility personnel regarding the audit process and results.
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To gain the full benefit from a PVQ, the questionnaire should be tailored to the facility
being audited, as well as the type of audit being conducted. For example, the questions in a
compliance audit PVQ should seek to collect information about the major environmental
statutes and media that are of concern at the facility. Questions might include:
Does the facility generate, treat, store, or dispose of hazardous wastes?
Where is the facility located in proximity to potential receptor populations?
Is the facility currently undergoing any regulatory enforcement actions?
What are the main mission (industrial process) activities at the facility?
Has the facility been notified of possible involvement at a Superfund site?
Have analyses of hazardous waste streams been conducted and are the results
available?
These types of questions should be developed for each media and issue of
environmental significance (such as air, water, PCBs, pesticides, and underground storage
tanks). In addition, the PVQ may inquire as to whether the state or the Federal government has
primary responsibility for a particular media, or whether local ordinances apply to the facility.
Further, the types of questions asked in PVQs for different types of facilities also will
vary. For example, an office complex PVQ might focus on asbestos and the presence of PCB-
containing transformers, while an industrial facility PVQ likely would emphasize hazardous
waste handling and disposal issues. A sample PVQ used by the U.S. Army in conducting
environmental audits is exhibit in Appendix H.
7.3 PROTOCOLS/CHECKLISTS
Protocols and checklists are the actual working documents which provide the audit team
with an outline for conducting on-site audit activities. These documents allow the team to
evaluate the recordkeeping, operational, and procedural elements of a facility's activities with
respect to the regulatory requirements for a particular compliance area. For example, an audit
protocol might include a pre-typed form which details facility statutory or regulatory
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requirements, the types of issues that should be addressed, where and by whom records are
kept, questions or issues to raise to evaluate each of the above matters, and an area for the
auditor's notes and comments.
Protocols and checklists are essential tools for assuring that an audit has adequately
addressed all Federal and state regulatory matters, including all permits, facility records, and
facility environmental practices. They provide a consistent approach that promotes
comparison between differing facilities and environmental practices, as well as evaluating the
same facility over a period of time. However, protocols and checklists are not a substitute for
critical thinking and should be used only as a reference point to affirm that an issue has been
examined. In reviewing an environmental audit program, agency management should evaluate
protocols and checklists to assure that they:
are applicable to each type of agency facility;
are pertinent to of the type(s) of audit(s) to be conducted;
are periodically reviewed and modified to address new regulatory requirements and
changes in audit program objectives; and
include a review of facility management structure and procedures, especially with
respect to chain of command and responsibility for remedial action.
EPA, other government agencies, as well as private companies, have developed audit
checklists, protocols, and software to assist auditors in conducting complete and efficient
environmental audits. The products, such as EPA's Generic Audit Protocol, can be used as a
starting point for audit teams in developing more targeted audit checklists and protocols that
meet agency and facility-specific needs. The Generic Audit Protocol, as discussed elsewhere
in this document, (See Section 5.5) is an excellent tool developed specifically for federal
facilities for the purpose of assessing and managing a sound environmental program. Figure 4
contains portions of a sample checklist and worksheet from EPA's Generic Audit Protocol.
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Figure 4
Sample Checklist and Worksheet from EPA's Generic Audit Protocol
Compliance Category:
Hazardous Waste Management
Regulatory Requirements:
Reviewer Checks:
HW.54. The handling of
incompatible wastes, or
incompatible wastes and
materials in containers at
generators must comply
with safe management
practices (40 CFR 262.34
(a)(l)(i) and 265.177).
Verify that incompatible wastes or incompatible wastes and materials are
not placed in the same containers unless it is done so that it does not:
generate extreme heat or pressure, fire, or explosion, or violent reaction
produce uncontrolled toxic mists, fumes, dusts, or gases in sufficient
quantities to threaten human health
produce uncontrolled flammable fumes or gases in sufficient quantities to
pose a risk of fire or explosions
damage the structural integrity of the device or facility
by any other like means threaten human health or the environment
(NOTE: Incompatible wastes as listed in Appendix 4-6 should not be placed
in the same drum.)
Verify that hazardous wastes are not placed in an unwashed container that
previously held an incompatible waste or material.
Verify that containers holding hazardous wastes incompatible with wastes
stored nearby in other containers, open tanks, piles, or surface
impoundments are separated or protected from each other by a dike,
berm, wall or other device.
HW.55. Containers used to
store hazardous waste at
generators should be
managed in accordance
with specific management
practices (MP).
Verify the following by inspecting container storage areas:
containers are not stored more than 2 high and have pallets between
them
containers of highly flammable wastes are electrically grounded (check
for clips and wires and make sure wires lead to ground rod or system)
at least 3 ft (0.91 m) of aisle space is provided between rows of containers
Satellite Accumulation Points
HW.56. Generators may
accumulate as much as 55
gal of hazardous waste or 1
qt of acutely hazardous
waste in containers at or
near any point of initial
generation without
complying with the
requirements for onsite
storage if specific
standards are met (40 CFR
262.34(c)).
(NOTE: The type of storage is often referred to as a satellite accumulation
point.)
Verify that the satellite accumulation point is at or near the point of
generation and is under the control of the operator of the waste generating
process.
Verify that the containers are in good condition and are compatible with the
waste stored in them and the containers are kept closed except when
waste is being added or removed.
Verify that the containers are marked HAZARDOUS WASTE or other
appropriate identification.
(NOTE: See Appendices 4-1, 4-2, 4-3, 4-4, and 4-5 for a guidance list of
hazardous and acute wastes.)
Verify that when waste is accumulated in excess of quantity limitations, the
following actions are taken by interviewing the shop managers:
the excess container is marked with the date the excess amount began
accumulating
the waste is transferred to a 90 day or permitted storage area within 3
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Compliance Category:
Hazardous Waste Management
Regulatory Requirements:
Reviewer Checks:
days.
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7.4 LEGAL REFERENCES
Legal references are source materials that provide agency and facility personnel with
the text of regulatory or statutory language, or provide interpretation of statutes or regulations.
Such references are necessary to determine compliance requirements and to guide
environmental staff in carrying out their duties. Without adequate statutory and regulatory
references, facility environmental staff cannot conduct a proper environmental management
program and the audit team cannot properly assess facility compliance status.
Agency management ultimately will bear the responsibility for the quality and
effectiveness of their agency's environmental programs. Environmental staff should have ready
access to source material and be knowledgeable about environmental statutes and regulations.
It may be useful to have facilities identify those environmental statutes and regulations that
impact their operations and organize these materials in a comprehensive file for facility
reference. Facilities should have a single location that can be accessed for all facility statutory
and regulatory guidance. The following is a list of basic print references that environmental
staff should, at a minimum, have at their disposal:
Code of Federal Regulations (CFRs) - Regulations specific to media and subject
areas.
Environmental Statutes - Federal, state, and local that apply to facility compliance
areas.
Additional selected materials that may be investigated as facility source materials include:
Bureau of National Affairs (BNA) - Published annotated guides and references on
environmental matters by media and cross-media issues which address legal
concerns and Executive Orders that are either topical or fundamental to sound
environmental management. The Environmental Reporter is a particularly useful
source.
CD ROM Software - Many Federal and state regulations and statutes are now
available on CD and dramatically increase efficiency in searching for statutory or
regulatory citations.
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Environmental newsletters specific to media compliance areas which provide
abstracts of impending regulations or alert environmental personnel to upcoming
issues. Examples include Inside EPA and Hazardous Waste News.
7.5 PHOTOGRAPHY EQUIPMENT
An instamatic camera is an invaluable aid in documenting facility conditions and serving
as a reminder to the auditor of specific areas and issues that require analysis in the audit
report. Photographs are also useful for making a point regarding facility conditions without
reference to a lengthy explanatory text. With a photograph, it is possible for subsequent
auditors or even facility personnel to see exactly what conditions existed at the time of the audit.
Further, photographs can be a valuable permanent record for the facility file. The audit team
should obtain written permission to take photographs and should be briefed about areas where
photographs are not permitted (i.e., high security or sensitive areas). The issue of photographs
should be addressed prior to the actual site visit, either in the PVQ or at the initial on site
meeting.
7.6 FIELD ASSESSMENT EQUIPMENT
Typically, field assessment equipment is not a major component of an audit. However,
field sampling equipment can provide a snapshot of particular conditions at the time the sample
is collected. Sampling is most useful in verifying an auditor's assessment, but is not a
substitute for critical and thorough review of facility records, site assessment, and interviews
with facility personnel. Agencies should assess the cost of field sampling equipment, some of
which is quite expensive to acquire and maintain and may require special training for personnel,
prior to including site sampling in the agency audit protocol. If the use of field assessment
equipment is deemed necessary, the facility should be informed of any planned sampling in the
PVQ.
Field sampling equipment may be useful in uncovering hidden problems that would
normally escape detection. For example, field equipment capable of detecting organic vapors
either in the soil or near suspect areas of contamination (e.g., stained soil or concrete) may
lend more evidence to an audit observation and finding. Explosimeters, instruments that
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measure the concentration of methane gas, can alert auditors to the presence of such gases in
concentrations before they become dangerous. If a facility is on a former sanitary landfill site,
methane gas build-up, especially in confined spaces could be a problem. A simple device like
an explosimeter can alert the audit team to the need for remedial measures such as proper
venting of gas away from structures. Likewise, a portable gas chromatograph can allow
auditors to determine whether a soil stain is or isn't evidence of serious contamination.
7.7 PROTECTIVE CLOTHING
Protective clothing may be necessary in certain situations to protect audit team
members from exposure to hazardous materials. Such clothing may be as simple as hard hats
and protective eye wear, or as elaborate as respirators and chemical suits. For facilities that
handle hazardous materials or conduct industrial operations, protective clothing may be
required for entry into facility. For example, a facility that repairs military equipment may
conduct complex industrial activities such as metal fabrication and chemical handling that would
require hard hats, protective eye wear, steel toed boots, tyvek suits, and respirators. The need
for protective clothing should be identified and audit personnel should be trained in the proper
use of such equipment prior to arrival on site.
7.8 COMPUTER CAPABILITIES FOR TRACKING AND REPORTING
The volume and complexity of environmental information collected during an
environmental audit makes the use of automated information systems helpful in the effective
management of an agency's environmental audit program. A number of commercial software
packages have been developed to assist auditing efforts. Based on auditor inputs, these
systems can: assist the audit team in developing PVQs and checklists/protocols; identify
situations of non-compliance with statutes or regulations and flag these for further review; and
provide report outputs that identify deficiencies, assist in corrective action recommendations,
and detail positive attributes of the facility environmental program. Many systems also have
data management capabilities that allow for the tracking of audit results and corrective actions,
and alert the reviewer if the corrective action is not addressed. In addition, automated systems
often have an extensive library of environmental statutes and regulations, as well as a glossary
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of statutory/regulatory terms. Most systems are user-friendly and provide on-screen help
capabilities.
Audit software should allow for customization of investigatory efforts and permit the
development of outputs and report formats that are appropriate to a particular agency's mission
and environmental issues. For example, a software package that does not have the ability to
review and address pathological or infectious waste handling issues, or cannot be easily
customized for that purpose, will be of little value for an audit of a health care facility.
7.9 ACCESS TO TECHNICAL REFERENCES
Technical references such as U.S. Geological Survey (USGS) maps and soil survey
maps/booklets can be useful in evaluating details about potential environmental risks posed by
a facility. Such risks may include surface and groundwater contamination, as well as air
emissions to local communities. Maps are useful for review of topographic features such as
direction of water flow which could be important with regard to a facility's stormwater
management plan or possible impact of facility operations on a nearby wetland. Local area
maps displaying the location of structures such as schools and recreation areas may be
important in assessing facility planning in response to accidental release of chemicals. A wind
rose is a graphical representation of prevailing wind direction and intensity. It is useful in
situations where facilities have significant air emissions issues, including defining areas
potentially impacted by the emissions plume. These materials should be reviewed prior to each
facility audit and kept as a permanent part of the facility audit record.
7.10 CHAIN OF TITLE REPORTS
Chain of Title reports provide a sequential record of the ownership of a property based
upon land title records. Land title records usually are maintained at the county courthouse in
which the facility is located. Local firms often specialize in researching and writing such reports.
A Chain of Title report is mandatory in a property transfer assessment, but can be equally
valuable when conducting other types of audit activities. These reports can be an important
component of audit findings, particularly if they reveal that the facility is located on property
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formerly owned by an industry or entity with significant environmental issues. If an audit
uncovers onsite contamination, the Chain of Title report will be necessary in determining who
owned the property at the time of the contamination and is therefore potentially responsible for
site remediation. A Chain of Title report need not be undertaken for each audit event. Rather,
a single report kept in a facility's permanent record is adequate.
7.11 AERIAL PHOTOGRAPHS
Aerial photographs are invaluable as a reference point for reviewing facility structures
and land use status. Review of aerial photographs over a period of years can reveal changes
in land use activities and significant modifications in buildings and grounds at the facility, as well
as adjacent land uses that could significantly impact facility operations. For example, historical
photographs could reveal a former drum storage area or a wetland that is now filled in.
Aerial photographs are available from a variety of Federal, state and local sources.
These include Federal land stewardship agencies such as the Bureau of Land Management
(BLM), the Department of Agriculture (USDA), or the Forestry Service (USFS). State and local
sources include county zoning agencies and agriculture extension services. If appropriate and
available, aerial photographs should be made a permanent part of a facility's audit record.
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CHAPTER 8: PRE-AUDIT ACTIVITIES
8.1 OVERVIEW
An environmental audit is conducted in basically three major parts or phases
including: (I) pre-audit activities; (2) on-site activities; and (3) post-site activities. Figure
5 provides a schematic overview of the audit process. Although accurately defining
the objectives and scope of the audit are critical to its success and determining the
depth of the investigation, it is important to understand that the numerous activities of
the audit are not restricted to only a site visit. Careful planning prior to the on-site
investigation and appropriate verification of audit findings and observations are just as
critical to the success of the audit as the proper conductance of a site visit and related
inspections.
Careful preparation helps to ensure that the audit team accomplishes its goals during
the site visit while using the least possible resources and labor time. Pre-audit preparation
involves: (1) setting the objectives and scope of the audit; (2) planning and preparing the audit
team for the site visit; and (3) preparing facility management for the audit. All pre-audit
activities should be conducted based on a thorough understanding of the entire audit process.
This chapter addresses the importance of setting the objectives and scope of the audit
and the specific pre-audit activities that should be conducted by the audit team prior to the site
visit. These activities include: developing the objectives and scope, planning and preparing the
audit team for the site visit by developing a pre-visit questionnaire, reviewing relevant
regulations, reviewing and refining protocols, and developing a detailed audit agenda. In
addition, the importance of properly preparing facility management for the audit to ensure the
success of the site visit will also be discussed.
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Figure 5
Schematic Overview of the Audit Process
PRE-AUDIT ACTIVITIES
ON-SITE INVESTIGATION
Set Objectives and
Scope of Audit
Select Audit Team
Send Pre-Visit
Questionnaire
Review Completed
Questionnaire
> Review Operations
and Regulations
> Review and Refine
Audit Protocols
Prepare Facility
Management for the
Audit
Review objectives
and scope of audit
Define specific
informational
needs
Schedule the audit
with facility
management
ANALYSIS AND
REPORTING
Entrance
Briefing
Facility
Orientation Tour
Detailed Review of
Facility Practices and
Management Systems
In-depth Interviews
> Additional Tours
> Examine Records
Review Procedure
Record Site
Observations
Develop List of
Preliminary Finding
Exit Briefing with Facility
Management
I
Detailed
Information Analysis
Preparation of Draft
Audit Report
i
r
Review of Draft
Report by Facility
I
Final Audit Report
with Corrective
Action Plan
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8.2 SETTING THE OBJECTIVES AND SCOPE OF THE AUDIT
Accurately defining the objectives and scope of the audit are necessary in order
to ensure that the audit achieves the desired results. Clear and explicit objectives
define the needs and expectations of the audit and establishes a benchmark against
which the performance of the auditors or audit team can be judged. The scope
determines the depth and boundaries of the investigation and determines what will be
assessed and verified through the audit process. It is critical to the success of the audit
that both facility management and the audit team members clearly understand and
agree upon the scope and objectives of the audit. In addition, the audit objectives
and scope should be clearly communicated along with the results of the audit to those
who authorized it as well as to all recipients of the audit report.
The objectives define the purpose of the audit and establish performance
criteria for the auditors or audit team. The objectives are often determined by agency
management or policies and reflect the needs of the agency environmental program
and related policies. Facility management representing the facility to be audited may
also have objectives for the audit. For example, the audit site visit may serve as a
training mechanism for facility environmental staff, or a new storm water management
plan may have been recently developed and facility management may be interested
in a review and critique by the audit team members. Therefore, in addition to
evaluating and documenting areas of apparent environmental problems and risks, the
audit may provide the training of facility staff and an evaluation of the new document.
After the audit objectives are determined, it is necessary to define the scope of
the audit. The scope of an audit usually defines a specific procedure or area of
investigation and can be influenced by factors such as facility conditions, cost, staff
availability or other resource constraints. For example audits can focus on basic media
areas (e.g., air, water, solid waste) if the environmental aspects and impacts of that
facility obviate the need for investigating other areas of concern, (e.g., there are no
underground tanks or petroleum storage vessels at the facility). However, for other
facilities, a more comprehensive scope may be necessary to fully assess all
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environmental risks. In another example, a scope may focus only on areas on non-
compliance if the environmental program at the agency is relatively new and limited
funding for an audit program requires agency environmental management to prioritize
immediate informational needs. Conversely, a more mature program at another
agency may determine that the scope should focus on management systems
(environmental management system audits) rather than compliance issues in order to
identify root causes of the symptomatic problems at the site (e.g., persistent non-
compliance with regulations).
8.3 PLANNING AND PREPARING THE AUDIT TEAM FOR THE SITE VISIT
Environmental staff responsible for organizing the audit will spend a significant amount
of time planning for an audit. Careful planning is crucial to ensuring that the limited time
typically available for the site visit is used most effectively. Careful planning also minimizes the
time necessary for follow-up activities after the site visit. Some of the factors environmental
staff typically consider when planning an audit are: (1) the goals and scope of the audit; (2) the
size and complexity of facility operations; (3) the facility's compliance history; (4) the audit
team's familiarity with the site; (5) resources available for conducting the audit; and (6) the
desired form and content of the final audit report.
If a contractor will be conducting the audit, environmental management staff should
develop a scope of work that clearly establishes roles and responsibilities for each phase of the
audit (i.e., pre-audit, on-site, post-audit). If in-house staff are conducting the audits, the team
leader should select team members and assign roles and responsibilities. Many of these roles
as well as other important planning activities can be addressed in the pre-audit meeting. In
addition to defining the roles and responsibilities of each audit team member, the audit team
can strategize on important areas to be evaluated at the site and review necessary precautions
such as the need for protective clothing and equipment (e.g., respirators) and procedures for
entering controlled areas at the site. In addition, other concerns such as security clearances
and the site visit agenda should be reviewed by the team to ensure conformance with
established policies and agreements required by facility management. Regardless of who
performs the audits, as part of the planning phase, the lead auditor or team leader should
ensure that the members of the audit team:
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clearly understand the goals and scope of the audit;
understand audit team roles and responsibilities vs. team leader;
understand the facility's operations, wastestreams, and environmental releases;
are aware of potential health and safety issues and are prepared to handle them
while on-site;
have the correct checklists and protocols and understands how to use them;
agree to follow the detailed audit agenda;
understand how information collected on-site will be managed and presented in the
final report; and
have received a correct and completed PVQ from facility management.
8.3.1 Review Relevant Regulations
Prior to the site visit, audit team members should review the environmental statutes and
regulations pertinent to the facility activities. As discussed in Chapter 7, the PVQ can be useful
in determining which statutes and regulations are significant. Special attention should be given
to high risk activities and major facility activities. Regulations should be reviewed down to the
level of specific audit items. For example, regulatory review for wastewater discharges should
include:
Federal Regulations:
NPDES Permit Requirements (40 CFR 122)
General Pretreatment Regulations for Existing and New Sources (40 CFR 403)
Toxic Pollutant Effluent Standards (40 CFR 129)
Oil Spill Prevention Control and Countermeasures (SPCC) Requirements (40 CFR
112)
Designation of Hazardous Substances (40 CFR 116)
Determination of Reportable Quantities for Hazardous Substances (40 CFR 117)
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State Regulations:
Water Quality Standards
Effluent Limitations for Direct Discharges
Permit Monitoring/Reporting Requirements
Operator and Superintendent Classifications and Certification
Collection, Handling, Processing of Sewage Sludge
Oil Discharge Containment, Control and Cleanup
Standards Applicable to Indirect Discharges (Pretreatment)
Regulatory review should include Federal, state, and local regulations. This may, at
times, require a determination of which regulatory authority has jurisdiction over a particular
issue. In some cases, this will require contacting local authorities to obtain sewer ordinances or
local air quality management district regulations.
As noted in the previous chapter, many Federal and state regulations are now available
on CD ROM or on-line data services that also provide key word search capabilities. Agencies
may wish to consider obtaining these services as a means to achieve significant savings in
research time.
8.3.2 Review and Refine Audit Protocols
Audit protocols should be reviewed prior to each site visit. Based upon the PVQ
completed by the facility, the audit team should revise the protocols to emphasize those areas
that are high risk, involve complex issues unique to the facility, or which pertain to major facility
activities. For example, if a facility has 100 above ground storage tanks, but does not store or
treat hazardous waste, the audit team may wish to modify the protocol to devote additional
effort to the review of the facility Spill Prevention, Control, and Countermeasure plan (SPCC) or
tank integrity testing issues, but minimize or eliminate those sections of the protocol covering
40 CFR 264 and 265 requirements under RCRA.
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Audit protocols are not static, one size fits all documents. They are as different as each
facility, although they may involve review of similar issues. Protocols also will change over time
as regulations are revised and updated. As a result, protocols should be reviewed whenever
major regulatory or statutory revisions occur, and revised as necessary. In addition, audit
objectives may change over time. This is especially true if an agency achieves a high level of
compliance and turns its attention to management audits or audits of unregulated risk.
Protocols should be periodically reviewed to reflect these changes.
After the audit is completed, audit team members should set aside a few moments to
review the audit protocols to determine if they adequately addressed audit objectives. Based
upon that review, the agency should consider making changes to the protocols as appropriate,
or expand the site visit agenda to allow for an investigation or additional areas that were not
reviewed.
8.4 PREPARING FACILITY MANAGEMENT FOR THE AUDIT
Agency environmental staff should contact the facility first by telephone and follow-up
with a letter prior to the site visit. Developing a positive relationship with the facility point of
contact (POC) is vital to the success of the audit. Environmental staff should take care to set
the right tone when contacting facility personnel. Environmental staff should communicate:
Review Objectives and Scope of the Audit - Facility staff should be fully aware of
the audit's objectives and scope. In addition, facility staff should understand how the
audit results will be used both by their agency and, if appropriate, other outside
agencies (e.g., EPA). Facility understanding of how the audit results will be used is
particularly important in the case of compliance audits and management audits. A
facility's expectations about the audit and its subsequent use should follow from any
up-front agreements reached with the audit team.
Critical person(s) needed for interview - Agency environmental staff should work
with the facility to develop a list of persons to be interviewed during the site visit.
Examples of typically individuals interviewed as part of a site visit include
environmental staff, satellite accumulation point managers, and shop supervisors
and personnel.
Information needs - Agency environmental staff should provide the facility with a
list of records and documents that will be reviewed during the site visit (e.g., permits,
hazardous waste manifests). Providing the list of information needs prior to the
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audit helps to ensure that the facility has time to collect the documents and have
them available for review during the site visit.
Time schedules - Agency environmental staff should work with the facility to
develop a detailed agenda and schedule for the audit. The time schedule will
depend on the size and complexity of the facility and the number of individuals that
need to be interviewed.
As discussed in Chapter 7 of this guide, the audit team should submit a Pre-Visit
Questionnaire (PVQ) to the facility prior to the site visit to inform the facility about the audit.
The PVQ also alerts the facility environmental manager as to reports and documents that
should be available to the audit team and the facility personnel that the audit team will want to
interview. A timely and well crafted PVQ will save the audit team considerable time by
answering fundamental questions about facility practices and allows the audit team to focus the
site visit on high risk issues or matters requiring a more detailed investigation.
It is important to stress to the facility environmental manager the need to have the PVQ
returned several weeks prior to the site visit. The PVQ and a follow-up phone call can aid the
audit team in developing a good working relationship with facility personnel prior to the site visit
and reassure the environmental manager about the purpose and goals of the audit.
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CHAPTERS: ON-SITE ACTIVITIES
9.1 OVERVIEW
This chapter provides a discussion of some of the primary issues that an audit team must
address during a site visit. The emphasis in this chapter is on developing a consistent procedure
for on-site activities. By developing and implementing a consistent audit policy, agency
environmental managers will be able to compare and contrast the effectiveness of audit efforts
across a spectrum of facility types, including those with distinctly different environmental concerns
and compliance issues.
9.2 INTRODUCTIONS WITH FACILITY MANAGEMENT
Agency environmental staff should provide the facility with sufficient advanced notice of
the upcoming audit and should arrange a meeting time prior to the arrival of the audit team on
site. The pre-audit meeting serves a number of purposes - it reassures the facility's management
about the purpose of the audit and provides an opportunity to adequately schedule site walk-
through and interview times, and ensure the availability of documents and reports needed by the
audit team. The meeting also provides an opportunity to discuss issues that the facility managers
wish to raise and allows auditors to gauge facility management cooperation with the audit
process.
9.3 SITE INTERVIEW WITH PERTINENT FACILITY STAFF
A sound audit program should identify the structure and chain of command (names and
titles) for environmental issues at the facility prior to the initiation of the audit. When addressing a
specific environmental issue, audit team members must be careful to direct their questions to the
appropriate individuals. This is particularly important with respect to line staff who are involved in
the day-to-day conduct of activities, but will likely be unaware of detailed environmental
regulations. Auditors also must determine if the personnel they are interviewing have
environmental responsibilities as a primary or secondary job assignment, and identify who is
responsible for remedial action or remediation of violations if any are discovered.
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Examples of pertinent facility staff to interview may include:
environmental staff;
production supervisors;
purchasing personnel; and
accounting department staff.
The interview provides an opportunity to develop a dialog with facility personnel prior to the
site walk-through. It also affords the audit team a chance to review audit checklists and protocols
as a means of planning for the walk-through. The audit team also can use interviews to clarify
unclear PVQ responses and answer any questions the facility may have regarding information
needs prior to the records review.
Additionally, it is important to review with facility management audit objectives and scope.
Not only will this make facility management feel they are part of the audit effort, it also may
produce a more thorough audit. Facility managers that fully understand the audit scope and
objectives may be able to provide information or insights that they would not otherwise realize are
important to the audit effort.
Finally, it cannot be sufficiently emphasized how important it is to identify all facility staff
needed for audit interviews as well as confirming that resources needed by the audit team will be
available. Also, as mentioned in Chapters 7 and 8, safety requirements (the need for hard hats,
steeled toed boots, respirators, etc.) should be fully discussed prior to the site visit.
9.4 SITE WALK-THROUGH
With the exception of the post site visit contacts with regulators and vendors, the site walk-
through is the culmination of the data collection phase of an audit. The success of the walk-
through is, in part, a product of leveraging the information collected in the PVQ, interviews with
facility staff, and the other pre-site visit efforts. Ideally, the auditors should be sufficiently familiar
with the facility and applicable regulations so that the walk-through helps to complete and
enhance a previously developed understanding of the facility. Therefore, in developing a sound
audit program, the agency should view the site walk-through as only one of many critical
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components of an audit. The walk-through should include a physical inspection of facilities, as
well as observation for evidence of spills or other unpermitted releases or environmental
impairment such as stained soil and pavement, or discolored vegetation or water bodies.
During the site walk through it is a requirement that auditors stop at various points along
the walk through and actively document their observations and findings in writing and not wait to
return to a briefing or assembly room to record their notes. This is also the appropriate time to
take any photographs, if permitted by facility management.
The physical inspection should cover all environmental media and areas of concern
(water, air, solid and hazardous wastes, PCBs, asbestos, and chemical and waste storage areas).
If applicable, treatment systems (e.g., air scrubbers, wastewater treatment equipment) also
should be inspected. The physical inspection should include an examination of all emission
points, emission control devices and equipment, chemical handling areas including process
chemicals, and environmental monitoring equipment. Also, auditors should examine the
appearance of berm walls for cracks or staining, as well as tanks and piping for signs of
deterioration. Both positive and negative observations and findings regarding facility conditions
should be recorded at the time of inspection.
It is important that reports regarding observations of release or environmental impairment,
such as stains, be as factual as possible without resorting to subjective opinions. Information that
should be collected regarding observed impairments includes:
What is the physical observation made at the site (e.g., leak, spill)?
What is the evidence of the nature and extent of contamination?
When did it occur?
How did it occur?
Who is/was responsible for reporting it?
Did corrective action occur and what was the outcome?
Who is/was responsible for corrective action?
Inspection of remote facility areas also is critical to the success of the walk-through
process. Remote areas often are unintentionally neglected with respect to compliance and risk
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review, or may unknowingly be subject to dumping by third parties. This is particularly important
for those agencies that oversee large facilities with many structures or significant acreage.
As previously noted, agencies should encourage the taking of photographs of areas and
equipment that will likely become principle findings (both positive and negative) if appropriate.
This provides a convenient record for future reference and, in the event of liability issues, can be
useful in establishing that the photographed area was inspected. As previously noted, audit team
members should verify permission to take photographs prior to commencing the audit.
9.5 RECORD/DOCUMENTATION REVIEW
The site visit at the facility should include a record and documentation review addressing
Federal, state and local permits including air, water, and solid and hazardous materials and
wastes (such as pesticides, PCBs, asbestos, and radioactive materials). If the facility is involved
in the handling of hazardous materials, the audit should include a review of documentation such
as MSD sheets, RCRA waste manifests, monitoring data, and regulatory permits. The records
should include a review of all permit limits and conditions, permit renewal dates, and any
monitoring required by the permit. Monitoring data should be carefully reviewed and reconciled
against permit limits for that particular source. In addition, the audit team should evaluate the
facility's environmental record-keeping procedures. Facility management should be alert as to the
accuracy and completeness of the reporting data, and whether the monitoring has been reported
to the appropriate agency. A sound monitoring program should include systematic inspection
activities for all media sources.
Documentation and record reviews should also include review of correspondence and/or
notices pertaining to past or present enforcement actions or agreements, notices of violation, or
compliance schedules. This is particularly important for two reasons. First, it provides a history of
how the facility has performed and an indication of where it is headed, especially with respect to
how the environmental enforcement agencies perceive that facility. Second, if the facility has
inadequate records related to any of the above issues, it serves as a warning that the facility is not
properly documenting is environmental status and may be keeping inadequate records in other
respects.
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Manifests and bills of lading for chemical and waste materials also should be reviewed by
the audit team. Environmental managers should have accurate records of who is removing
wastes and/or hazardous materials from the facility, where the wastes are sent, and who at the
facility is responsible for monitoring this activity. The review should include a meeting with the
individual who signs the manifests/bills of lading. This is particularly important with respect to the
disposal of hazardous waste and non-hazardous wastes. Removal of wastes by unauthorized
haulers or removal to unauthorized treatment/disposal facilities is a violation of the law for which
the agency can be held responsible.
If a facility is using chemicals which require that MSDSs and other safety records be kept
on site, it is important that the audit team identify these materials and assess their availability to
personnel that are handling the chemicals. The audit team also should determine if the facility is
placing adequate warning labels on chemical containers.
9.6 EXIT INTERVIEWS
If the audit team leader chooses to conduct an exit interview, he or she should be careful
about what is said and to whom. In these cases, the audit team leader must exercise sound
judgment. Exit interviews should be conducted by the team leader, they should be limited to a
brief oral summary of findings and should be conducted with facility management present.
Auditors should avoid conclusory statements about possible violations and potential liability unless
there is imminent danger of harm or release of hazardous materials. Conclusions regarding
facility status typically should be discussed in final audit reports rather than in exit interviews. In
most cases, conclusions are the product of careful and reasoned analysis of audit findings.
Therefore, any discussion of audit findings should be confined to a recapitulation of the facts. This
is especially important with respect to unregulated risks, as such issues may require additional
review by agency management including consultation with the agency's general counsel.
In some cases, it may be necessary for audit findings to be kept confidential until the
agency has an opportunity to address matters uncovered by the audit. If confidentiality is
important, sensitive issues should be reserved solely for examination and discussion by top level
facility personnel and any written communications should be marked as draft or provisional. For
example, if an auditor has strong suspicions about possible criminal violations of environmental
laws, he or she should not use such pejorative terms in an exit interview but must call the
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agency's or facility's attention to the gravity of the situation. In such cases, it may be necessary to
inform facility management that there are additional issues that require confidential reporting. In
these situations, it is critical that the information be fully disclosed so that an investigation can be
undertaken. It is especially important that sensitive matters not be discussed at exit interviews,
except with those individuals that will bear responsibility for acting on them. Dissemination of
information, either verbally or in writing, to large numbers of facility personnel could compromise
confidentiality privileges.
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CHAPTER 10: POST SITE ACTIVITIES
10.1 OVERVIEW
This chapter will address the post site activities that should be conducted upon
completion of the on-site activities discussed in Chapter 9 of this guide. Post site activities
include audit team debriefing, substantiation of significant findings, and gathering additional
audit data.
10.2. AUDIT TEAM DEBRIEFING
10.2.1 Preliminary Issues
Prior to the audit team debriefing, a meeting agenda should be circulated to all team
members. The audit team debriefing should review the list of significant findings, discuss audit
findings that requiring immediate action (i.e., the priority issues), and confirm report writing
responsibilities, including regulatory reviews and contacts with vendors and regulators. The
audit team should also begin formulating recommendations for corrective action while the audit
experience is still fresh in their minds. Time should be set aside for team members to raise
questions about the audit and/or request additional resources. The debriefing also is an
excellent opportunity for regular review of audit protocols. A question and answer session can
inform other audit team members of issues about which they have information requirements
and is an opportunity to critique the audit effort and identify means for strengthening the audit
program. Keep in mind that this debriefing is solely for the audit team. Facility exit interviews
were discussed in the previous chapter.
10.2.2 Develop List of Significant Findings
The audit team should organize it's significant findings in a manner that reflects the
intent of the audit and the type of audit conducted. A compliance audit should be organized
around compliance areas, while a risk liability audit may be best organized by media and level
of risk, or by facility function and level of risk. For example, the audit findings for a compliance
audit could be reported as follows:
Record Keeping
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Overall environmental management
Water and wastewater
Hazardous materials
Hazardous wastes
Toxics (e.g., PCBs)
Other areas (e.g., EPCRA, pathological wastes)
By contrast, a risk liability audit might focus on the most significant liability areas
regardless of any other issues, or evaluate risk by media or governing environmental statute.
Risk liability audits might also be reported by facility area, i.e. liabilities concerning a process
operation that encompasses air, water, and solid waste issues might be discussed as a discrete
unit rather than be divided among separate discussions of air, water, and solid waste.
The audit team debriefing should address all of these areas, including a discussion of
positive findings for each area, as well as areas of deficiency or negative findings. The list of
findings also should consider whether deficiencies are regulatory or procedural. Procedural
deficiencies are those that are not in keeping with agency or facility practices but do not involve
reportable violations of Federal or state regulations or statutes. It may also be helpful to break
out or separate deficiencies into different media areas such as waste management, air
emission management, etc.
10.2.3 Prioritize Audit Findings
Each agency should develop a system for setting priorities among audit findings that
allows for a consistent approach to addressing deficiencies. A consistent approach for
addressing deficiencies includes targeting areas that pose the greatest liability potential or risk
to the facility or agency such as immediate endangerment to human health and the
environment. This requires a high degree of experience and professional judgment. These
high priority issues will require an immediate response. If the most serious problem is a minor
one, such as a recordkeeping violation, it should still be given the highest priority and dealt with
as soon as possible. The system also should recognize excellence in environmental
management. It also is important to identify and highlight sound environmental practices as
these set an example for other facilities and departments.
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Two possible systems for setting priorities are described in greater detail below. Both
systems take into consideration the specific activities and media/compliance matters at a
facility. The first sets priorities on the basis of overall risk, regardless of the media at issue.
The second establishes priorities on the basis of deficiencies within a specific media, without
distinguishing whether deficiencies of equal rank within one media are more serious than those
of equal rank in another media.
The first system takes into consideration the specific activities and media/compliance
matters at a facility and rates them on a hierarchy of risk. For a compliance audit, the media or
compliance area that poses the greatest risk at the facility should be ranked first overall in
terms of priority. Determination of the most important area can be made by the audit team
alone or in conjunction with agency legal staff, and may be based upon any number of factors
such as the media of concern or degrees of mass compliance area with the most number of
problems or issues of concern; the area with the highest volume of waste production; or the
area with the greatest potential for liability because of unique hazard characteristics (e.g., acute
toxic or hazardous waste or proximity to receptor populations). The level or significance of the
deficiency is then ranked (prioritized) in descending order from the highest to lowest. This is a
subjective ranking which rates risks and deficiencies on the basis of specific facility activities.
For example, if the asbestos abatement program is considered to be the greatest area of
vulnerability or risk at the site, then a high level deficiency in this area would be the most
significant one at the facility. This approach requires auditors to draw conclusions about which
deficiencies pose the greatest overall risk potential, regardless of media or compliance area,
and rates them accordingly.
The second system is to rate the audit findings from the highest risk (a significant
deficiency) to lower risks (such as major or minor deficiencies), within each media area, without
assigning an overall highest risk. A significant deficiency is one that poses an imminent risk of
release, endangerment of human health, threat to the environment, or threat to the successful
conduct of the facility's mission. A major deficiency is one that requires action, but not
necessarily immediate action. Major deficiencies typically are of a magnitude to result in a
reportable violation to a regulatory agency but do not pose an imminent threat of release or
endangerment. A minor deficiency is one that is primarily administrative such as recordkeeping
violations (e.g., failure to sign a waste manifest form).
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The two suggested systems are quite different. The first subjectively prioritizes
deficiencies on the basis of overall risk regardless of the media and defines a single worst risk.
The second system uses environmental media as general categories and prioritizes risk by
media without establishing an absolute hierarchy of which risk is most significant. The second
system provides the agency or facility with flexibility in carrying out corrective action because it
does not prioritize or rank deficiencies which are of the same category, but in different media
areas. Thus, a significant deficiency in the water program would be of equal weight to a
deficiency in the air program. However, for facilities with serious deficiency problems, such a
system may not provide sufficient structure and direction with respect to corrective action.
10.2.4 Clarify Assignments for Audit Team Members
An audit report typically contains an executive summary, a discussion of the audit
process, an overview of the facility, and a discussion of findings and recommendations. The
assignment of responsibility for writing these sections is up to the audit team leader, however,
all audit team members should have the opportunity to review and comment upon the final
report.
With respect to writing the audit findings section, the auditor that reviews a particular
area should be responsible for preparing the report section for that area (i.e., the report writing
responsibilities should mirror the auditing process). For example, if one auditor reviewed all
machine shop activities and its related media issues, the report may include a discussion of air,
water, and hazardous materials issues for the shop prepared by that auditor. Ideally, report
writing responsibilities should be allocated prior to the audit so that the individuals conducting
the audit are aware of their responsibilities while on site. Assigning report writing
responsibilities prior to the site visit also helps to better focus the auditors attention on details
and the need to be thorough.
If the report authorship is divided by functional areas as stated above, the audit team
might consider a two-tiered review process in which selected individuals have responsibility for
report review by environmental media. These individuals would review all findings for their
assigned media (such as air, water, or solid waste), regardless of who actually audited or wrote
the report section for a particular physical area of the facility. Finally, completion schedules for
draft and final report sections should be determined at the time the assignments are made.
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10.3 SUBSTANTIATION OF SIGNIFICANT FINDINGS
10.3.1 Regulatory Reviews
A regulatory review should include a determination of what regulations apply to the
facility, whether the facility is in compliance with the regulations, how the facility assesses or
evaluates it's compliance, and whether and how facility environmental managers stay informed
of regulatory changes.
As a first step, the audit team should establish which federal, state, and local regulations
(i.e., compliance areas) apply to the facility. For each compliance area, the auditors should
determine who are the primary and secondary regulatory authorities (i.e., Federal, state, or
local) and determine if there are overlapping authorities. Typical compliance areas include:
Air
Water and wastewater
Solid waste
Hazardous materials (PCBs, pesticides, organic chemicals)
Hazardous wastes
Community right to know
Underground storage tanks
There may be numerous issues at a given facility for each compliance area. For
example, at a large Federal facility, water and wastewater issues may include NPDES permits,
sludge permits, monitoring reports, indirect discharge issues, stormwater discharges, treatment
plant operations, certification/licensing of plant operators, drinking water sampling and analysis,
and related drinking water reporting requirements. If germane, each of these issues should be
examined.
The regulatory review should address whether the facility is in compliance with
appropriate regulations and cover all media, including an affirmation if a particular media is not
of concern. The review also should document records of all reportable non-compliance
situations and corrective actions. Depending upon the scope of the audits to be performed, the
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audit team should ensure the existence of management procedures to prevent future non-
compliance issues.
A sound regulatory review also should include inquiries as to how facility personnel are
kept informed of changes and updates in regulations and how regulatory evolution affects their
responsibilities.
10.3.2 Phone Calls/FOIA Requests to Regulators
Contact with regulators is helpful in substantiating audit findings. At the Federal and
state levels, it is likely that responsibility for each environmental media will be handled by a
different regulator. FOIA requests may take weeks or months to complete and therefore should
be planned accordingly. Local health and/or environmental departments also should be
contacted if findings indicate deficiencies or overlapping authority for a particular media area.
As a general rule, these calls should:
state identity and purpose of caller;
avoid divulging unconfirmed non-compliance situations;
determine when the facility was last inspected;
ask about next planned inspection date;
ask about any past or recent violations or enforcement actions;
inquire into outstanding attributes about facility environmental practices;
ask who the regulator deals with at the facility; and
inquire if any of the facility vendors have been investigated or cited.
10.3.3 Vendors
Improper or illegal environmental practices on the part of waste management or
disposal vendors can be a source of facility liability with respect to cleanup costs if the facility is
identified as a potentially responsible party under CERCLA. When investigating hazardous
waste disposal vendors, auditors should make sure that vendors are properly handling and
disposing of facility wastes. Auditors should also evaluate whether the vendor is competent to
handle facility wastes. This is particularly important for liability purposes if it is later determined
that the agency/facility failed to investigate the technical competence of the vendor. Also,
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auditors should carefully evaluate the prices charged by disposal vendors. Waste disposal
prices that are unusually low or below market rates may be reason for further investigation.
In addition there are a number of data bases that can be valuable in investigating
vendors. CERCLIS is a data base that allows for identification of treatment/disposal facilities or
even abandoned sites that are PRPs. This is particularly useful in identifying vendors that have
CERCLA liability problems including those vendors that may have moved or opened a new
location. Also, RCRIS is a data base that identifies RCRA facilities that have committed Class I
violations of RCRA. If a RCRA facility is facing five-million dollars in RCRA clean-up liability but
only has two-million dollars available to clean-up the violations, the auditors should be aware of
the potential for the audit facility to become liable for future clean-up expenses. Keep in mind,
however, that vendors also can be an information source to confirm facility management
practices and audit findings, or a source of technical and/or compliance assistance for a facility.
Vendor contacts should include verification that they in fact provide the reported
services or equipment to the facility. Also, in the case of waste transportation or disposal
vendors, the call should verify who the vendor deals with at the facility, how long they have
been under contract, and where wastes are being sent.
10.4 IDENTIFY AND GATHER ADDITIONAL DATA
It is not unusual for an audit team to identify additional data needs following the site visit.
Typically, this involves verification of findings and observations on a particular issue or may
include the need to follow a "paper trail" regarding reporting or monitoring requirements. In
these situations, the need to collect additional data should be established as early as possible
and one team member should coordinate all requests for the additional data, collect all
questions from audit team members, and forward these to the facility for immediate action. The
audit team should avoid repeated calls to the facility for additional data.
As stated above, additional data needs typically should focus on securing monitoring
data, reports, and other documentation and records. It is not usually intended that sampling
and analysis be performed. For certain situations, such as stains on the ground, a sample can
be useful in determining if a serious problem exists. If review of the audit findings indicates the
need for sampling, this activity will require a significant lead time to complete and should be
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scheduled as a separate follow-up activity after the completion of the audit. Post-audit
sampling is not intended to be an audit activity. Post-audit sampling is usually conducted in
discrete phases. For example, an audit can be considered a Phase I investigation to evaluate
and document the general range of apparent problems associated with the facility. A Phase II
investigation is used to evaluate and characterize the nature and scope of environmental
contamination and is beyond the scope of an audit or Phase I activity. A Phase III investigation
is the point usually where field samples are collected and analyzed to confirm the nature and
extent of contamination.
In addition, post-audit sampling creates uncertainty regarding the situation at the time of
the audit compared to the time of the sample collection. For example, an auditor may report
the presence of discoloration in the effluent from the wastewater treatment system but return to
the facility to find that the water is no longer discolored and that sampling reveals the
wastewater well within permit limits for all parameters. Post-audit sampling, like securing
written documentation should be limited to verifying observations and audit findings and is not
intended as a means of expanding the scope of the audit. In those cases in which limited
sampling is necessary and appropriate, as an assurance on validity, samples should be
collected by experienced sampling technicians and preserved and analyzed in accordance with
EPA sampling and analysis procedures. This includes the use of specialized sampling
containers, the use of preservation techniques such as keeping samples cooled below a certain
temperature, and in some cases, observing requirements for limited holding times.
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CHAPTER 11: REPORT WRITING AND FOLLOW-UP
11.1 OVERVIEW
The audit report is the culmination of the environmental audit. The primary purpose of
the report is to describe the findings of the audit team and provide a blueprint to assist facility
staff in achieving and maintaining compliance. It is necessary to prepare properly both during
and after the audit to produce a report that meets these needs. This chapter addresses a
number of issues that should be considered in writing the audit report and conducting audit
follow-up activities.
11.2 FIELD PREPARATION
Audit team members can take several steps while still in the field to ease the report
writing process. These include:
Review and update notes on a daily basis to ensure that information is complete
and identify any compliance areas that may have been overlooked.
Schedule a few minutes following interviews to summarize the results in
writing. The effort should be aimed at memorializing specific sets of facts and
impressions regarding the interview. This will be invaluable in writing the report
when the team has returned to the office and the interviews begin to run together in
the auditor's recollection.
Develop an annotated outline of findings. This also will prepare the auditor for
the audit team debriefing, assure that all areas of the audit have been covered, and
will help to organize field notes for later report writing.
Assemble and critically evaluate the audit findings as a means of tightening and
focusing collected information. This will aid in exposing flaws in the audit
methodology and in identifying inadequately supported conclusions.
Prepare a well developed audit team debriefing. These debriefing materials can
form the nucleus of the audit report to be prepared.
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11.3 REPORT PREPARATION
It is essential that the audit report be prepared as soon as possible upon the conclusion
of the site visit and post site activities. As discussed above, an annotated outline is helpful in
this regard. Auditors should consider organizing notes by compliance area and writing
introductory paragraphs for each section as soon as possible, perhaps even prior to the
debriefing. Regardless of the format used, each agency should adhere to a consistent format
to ensure that subsequent audit reports are prepared in the same manner. This allows for
comparison of reports between different facilities to be made against common elements. It also
allows for an easier assessment of how a specific facility is (or is not) improving its compliance
status over time by comparing findings in one report to the findings in subsequent audit reports.
The audit report should be written in clear concise language, with adequate supporting
information. Indefinite adjectives such as "very," "some," "significant," "small," "high," "large,"
should not be used. Sensational language or hyperbole, such as "dangerous," "negligent,"
"willful," "criminal" also should be avoided. Auditors should actively avoid unsupported
conclusions and inadequate descriptions. Nothing should be left to the subjective interpretation
of the reader. All acronyms used in the report should be spelled out at their first usage.
The report should contain accurate descriptions (distance and compass direction) of
locations where specific items or situations are noted. When items are described, the specific
item(s) being discussed is(are) should be identified (e.g., do not say that three drums were
leaking; rather, identify precisely which three drums are leaking, either by indicating the exact
location of the drums or be referencing something unique about those three drums such as an
identification number).
A good rule of thumb to use when writing a report is to provide a level of detail that is
adequate to allow someone else to go into the facility and accurately identify what is being
described in the report and understand the auditor's concerns with the issue(s). Overall, the
report should be as short as possible without compromising on necessary details.
11.4 SAMPLE REPORT FORMAT
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Audit reports can take many forms and be organized in a number of ways, depending on
agency needs and audit scope and goals. The following is a description of generic audit report.
Section I: Description of administrative aspects of the audit. This includes the date
the audit was conducted, who at the facility was interviewed, who
performed the audit, what office or department was responsible for
conducting the audit, and any limitations or exclusions regarding the audit
scope or methodology, e.g., if the facility management refused auditors
access to certain areas.
Section II: Brief executive summary written for upper-level facility and agency
personnel that highlights the key findings and recommendations of the
audit report including a summary of compliance status.
Section III: Description of each audit findings, priority rank or media category, and
regulatory citation. This section should include the physical description of
the facility and provide a detailed description of related facility media
management areas and emission sources as well as a discussion of how
there are controlled.
Section IV: Recommendations or suggested corrective actions for the facility to come
into compliance. These may range from simple administrative suggestions
to recommendations for a capital improvement. The recommendations
also may focus on the need for additional investigation or further analysis
before a final solution is proposed. When presenting recommendations in
the audit report, keep in mind that the final report is subject to public
disclosure under the Freedom of Information Act. As a result,
recommendations for corrective actions must be implemented by the facility
or the facility may face increased liability risk. If there is some doubt
regarding the implementation of the audit team's recommendations due to
lack of resources, staffing or funds, then agency management and legal
counsel should be consulted about the situation and plans for corrective
action.
Section V: Supporting data and information to provide relevant backup information
(such as analytical data, any enforcement actions taken by regulatory
agencies, copies of Notices of Violations, plot plans or maps, schematic
diagrams, or photographs) should be presented here. The benefits of
including supplementary material should be weighed against the impact
that such material could have when the audit report is subject to public
release.
11.5 REPORT FOLLOW-UP (COURTESY DRAFT TO FACILITY MANAGEMENT)
All environmental compliance audit reports should undergo rigorous review by agency
counsel, who should ensure that legal references are correctly stated and applied. The draft
report written in the weeks following the audit also should be submitted to and signed by the
11-3
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facility manager, who should solicit comment from facility staff as appropriate. The draft report
should then be submitted up the agency chain of command as appropriate. Chapter 2 of this
guide addressed a number of recommendations for protecting draft reports from premature
disclosure under FOIA under the predecisional and deliberative draft exemptions. Chapter 2
also discussed EPA's new audit policy regarding incentives to audit and that careful
consideration should be given by facility management, agency general counsel, and agency
senior management regarding the benefits of seeking treatment of audit findings under the
1995 EPA audit policy. Report distribution should be limited to those individuals with a "need to
know." Numbering of draft reports is one method for controlling distribution. Each agency also
should develop a formal records retention policy for auditors notes, draft reports, associated
documents, and final reports.
11.6 DEVELOP ACTION PLANS AND CORRECTIVE MEASURES
A sound audit program includes provisions for follow-up action on audit findings and
recommendations. Audit reports should include a list of action items and an individual
designated with responsibility for seeing the these items are addressed. Tracking can be as
simple as follow-up phone calls to facility managers or may involve conducting a follow-up audit.
Rather than setting a final date for a corrective action, it may be useful to set milestones for
beginning, conducting, and completing corrective measures.
11.7 COMMUNICATIONS WITH SENIOR AGENCY OFFICIALS ON SIGNIFICANT
REPORTS FINDINGS
Communicating with agency officials regarding findings that have high potential for
affecting agency liability, image, and budget is critical. As discussed previously, if the agency
becomes involved in litigation concerning an audited facility, the audit report and supporting
materials will be subject to discovery. If there are matters which appear to raise serious liability
issues, agency legal staff or general counsel's office should take the lead in managing the
distribution and dissemination of sensitive materials. This is done not as an attempt to conceal
findings, but to inform and allow counsel adequate time to develop a response. The report
should be written and sufficiently detailed such that agency management can make informed
decisions regarding the audit findings and recommendations. Dissemination of sensitive
11-4
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findings to other than counsel and senior agency officials may compromise the agency's ability
to address compliance or liability problems and should therefore be tightly controlled.
11.8 ENTER AUDIT FINDINGS AND RECOMMENDATIONS INTO A FORMALIZED
TRACKING SYSTEM
The environmental audit process should include the use of a formalized tracking system
for recommendations. This is necessary to assure that findings and recommendations are
specifically addressed on a definite schedule. The tracking system should identify the item, the
planned action, and the anticipated date for completing action on that item even if the schedule
calls for a long-term, multi-year effort.
A number of commercial software audit packages are available that generate "tickler
reports" on a predetermined schedule to alert facility or agency personnel regarding compliance
or action item deadlines. Tickler reports are time sensitive reports that selected software
packages can generate automatically, if instructed by the user, so as to alert the user that an
important deadline is upcoming. Some of these systems will actually flash a message on the
users computer screen on predetermined dates, alerting the user to a deadline. If an agency
has responsibility for a large number of facilities, or is responsible for a few facilities with a
significant number of issues, such products should be investigated. Further, it is important for
an individual to be charged with specific responsibility for this task. If no one is specifically
tasked with this responsibility, it may never be adequately addressed.
11-5
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11.9 BUDGET FOR CORRECTIVE ACTIONS AND COORDINATE WITH
FEDERAL BUDGET CYCLE
Budgeting for corrective action and coordination with the facility budget requires
cooperation between the audit team and either facility or agency financial staff. As an aid to
federal facility personnel, EPA has developed the FEDPLAN program which is described in
Chapter 2. In developing a budget for corrective actions, environmental audit team members
should consider all aspects of the audit including non-compliance issues and unregulated risk
that require funding.
Audit team leaders should consider developing a hierarchy of compliance problems and
unregulated risks and assign these to one of two budget needs categories; (i) capital
expenditures, and (ii) management/training needs. These two categories should be prioritized
to identify the most pressing problems within each category. Timely development of budget
requests and integration with the agency budget planning process is essential for securing
needed funds for corrective action and control of unregulated risks. To assure that the budget
is developed and forwarded to management in a timely fashion, it may be necessary to assign
responsibility for this activity to one or more persons. These individuals should identify all
corrective action and unregulated risk issues that require immediate funding and forward these
to agency management. Audit team members involved in this effort should be aware of the
Federal year budget cycle and anticipate budget needs accordingly.
11.10 FOLLOW-UP AUDITS AND VERIFICATION THAT CORRECTIVE
MEASURES HAVE BEEN IMPLEMENTED
By developing action items and using tracking systems, an agency will have put in place
only part of what is necessary to assure that corrective actions have been implemented. As
discussed above, follow-up phone calls or even secondary audits addressing specific action
items may be included in the audit process.
11-6
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Verification that corrective measures have been taken should include a paper trail. For
example, if there is an action item to remove two leaking drums of hazardous waste, the
verification should include manifests for where the waste was sent and paper work on the
disposal or destruction of the leaking drums. Failure to implement corrective actions may result
in outside pressure and adverse public relations if the final report is publicly released pursuant a
FOIA request, or serious liability problems if legal proceedings are initiated against the agency.
11-7
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ENVIRONMENTAL SELF-ASSESSMENT
FOR
HEALTH CARE FACILITIES
A QUICK AND EASY CHECKLIST OF
POLLUTION PREVENTION MEASURES
FOR HEALTH CARE FACILITIES
February 2000
Prepared for Health Care Facilities in New York State
by
New York State Department of Environmental Conservation
Pollution Prevention Unit
George E. Pataki, Governor
John P. Cahill, Commissioner
-------
ACKNOWLEDGMENTS
The New York State Department of Environmental Conservation (NYSDEC), Pollution
Prevention Unit would like to acknowledge the cooperation of the U.S. Environmental Protection
Agency Region n Office; NYS Department of Health, Albany, NY; Strong Memorial Hospital,
Rochester, NY; Citizens' Environmental Coalition, Albany, NY; Beth Israel Medical Center,
New York, NY; and the New York State Nurses Association, Latham, NY in the preparation of
this document. The Pollution Prevention Unit would also like to acknowledge the following
NYSDEC programs for their assistance in the preparation of the final copy: Division of Solid and
Hazardous Materials; Division of Air Resources; and the Division of Public Affairs and
Education, Bureau of Publications and Internet.
-------
TABLE OF CONTENTS
Introduction 1
The Environmental Self-Assessment for Health Care Facilities 2
Self-Assessment Checklists 3
Getting Started 3
Procurement of Commodities and Services 4
Medical Waste Incinerators 8
Hazardous and Solid Wastes 9
General Recommendations 9
Ethylene Oxide (EtO) 11
Glutaraldehyde 12
PVC (polyvinyl chloride) Plastics 13
Solvents 14
Mercury 16
Chemotherapy & Antineoplastic Chemicals 18
Batteries 19
Lamps 21
Photographic Chemicals & Scrap Film 23
Formaldehyde/formalin 24
Radioactive Waste 25
Medical Waste Stream 26
Recycling & Reuse 29
Housekeeping 30
Facility Maintenance 31
Next Steps 34
A Resource Guide 35
Trade Organizations 35
Local Assistance 37
State Assistance NYSDEC 38
Other State Agencies 40
Federal Assistance 41
Resources on the Internet 41
Appendices
A. Health Care Facilities Instruments and Products That May Contain Mercury ... 43
B. Alternative Treatment Technologies 45
References 46
If you have any questions or comments regarding
the use of this self-assessment please contact:
NYS Department of Environmental Conservation
Pollution Prevention Unit,
50 Wolf Road, Room 298
Albany, NY 12233-8010
Phone: (518) 457-2553 or (800) 462-6553
FAX: (518) 457-2570
Internet Address: http://www.dec.state.ny.us
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INTRODUCTION
The purpose of this manual is to assist
New York State Health Care Facilities in the
development of an effective pollution
prevention program or improve programs
which may already be in place. Implementing
an effective pollution prevention program
requires a continuous commitment by a wide
range of health care personnel.
Health care facilities that practice
pollution prevention benefit the environment
by reducing the volume and toxicity of
material at its source before it becomes a
waste. In addition, there are many benefits
that health care facilities attain for
implementing pollution prevention practices.
Some of these include:
* Improved environmental compliance.
* Protection of human health by reducing
the exposure of employees to chemicals in
the workplace.
* Enhanced community relations by
demonstrating a commitment to
environmental protection.
* Economic benefits resulting from
pollution prevention products that reduce
and recycle waste.
* Avoidance of long term liability.
(Remember, you are responsible for
proper management and disposal of the
wastes that you generate.)
* Positive press coverage for the health care
facility.
* Increased employee morale resulting from
a healthier and safer work environment.
The Environmental Self-Assessment for
Health Care Facilities is a tool to help
evaluate a health care facility's present
performance in preventing pollution and
identify opportunities for additional pollution
prevention measures. If your facility has
limited resources, the self-assessment should
serve as a preliminary self-diagnostic tool that
can be used before seeking any outside
assistance.
Technical assistance and pollution
prevention approaches may be available from
vendors, consulting engineers, professional
organizations and the Internet. Assistance is
also available from state and local
environmental agencies, such as the New
York State Department of Environmental
Conservation's Pollution Prevention Unit and
the NYSDEC regional multimedia pollution
prevention coordinators. The New York State
Environmental Facilities Corporation also
provides free, confidential technical assistance
to health care facilities that qualify under its
Small Business Assistance Program (see "A
Resource Guide," page 35, for a list of
agencies, organizations and sites on the
Internet that can provide technical information
and assistance).
An environmental self-assessment can
prove worthwhile as a preventive strategy. It
can identify procedure changes and
housekeeping measures that will prevent
damage to the environment and help your
health care facility comply with environmental
requirements.
The checklists found in the self-
assessment are designed to test a facility's
performance in pollution prevention, waste
reduction and recycling. For information
regarding compliance with environmental
rules and regulations, contact your regional
NYSDEC multimedia pollution prevention
coordinator and the NYS Department of
Health (see "A Resource Guide," page 35).
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
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THE ENVIRONMENTAL SELF-ASSESSMENT
FOR HEALTH CARE FACILITIES
The following checklist is a guide
primarily intended for use by laboratory
managers, administrators, environmental
compliance personnel, purchasing officers,
safety professionals, housekeeping managers,
waste management supervisors and industrial
hygienists involved with the day-to-day
activities in a health care facility. To
have a successful pollution prevention
program, routine environmental
self-assessments should be conducted. The
self-assessments will help identify
opportunities to incorporate pollution
prevention measures in all aspects of
administering medical services. Examples of
health care facility areas and activities to be
investigated can include, but are not limited
to, laboratory services, patient floors,
hemodialysis, intensive care and isolation
units, cafeteria, purchasing, radiology and
surgery areas.
Review each section of the self-
assessment with the manager and staff
members who are most familiar with that
particular activity in the facility. Responses to
the questions should show whether potential
hazards or polluting activities are occurring
that may be addressed by purchasing and
operational changes, equipment substitution or
changes to housekeeping procedures.
This self-assessment is only one in a series
of steps that your facility should take to
determine its regulatory compliance and to
identify suitable methods of waste reduction.
The checklist would be most effective when
used with related tools, such as workshops and
publications. For many facilities, the
self-assessment will likely be as useful as a
thermometer would be for a person with a
fever: the symptoms may be measured, but an
expert opinion may be needed to diagnose the
problem and develop corrective measures.
Following the completion of the self-
assessment, consult this guide for additional
information on the nature and type of
pollution prevention techniques successfully
applied by other health care facilities.
Progressive health care facilities will use
the environmental self-assessment to achieve
the following goals: evaluate current pollution
prevention practices and develop an ongoing
pollution prevention program or strengthen a
program which has already begun.
Don't be discouraged by the sometimes
difficult process of identifying and addressing
environmental problems. Over the long haul,
the measurable benefits of conducting and
responding to regular environmental
self-assessments may include reductions in:
environmental hazards, exposure to
enforcement, fines, insurance rates, waste
handling costs and accidents. Benefits may
also include an improved compliance record,
improved worker safety and a healthier work
environment. Making the effort to reduce the
generation of materials at the source, or
recycling waste on- or off-site demonstrates
that you are being environmentally
responsible. In addition, pollution prevention
programs support a health care facilities
mission of protecting the health of it's patients
and staff.
The Environmental Self-Assessment for
Health Care Facilities provides useful
information, but there is no guarantee,
expressed or implied, that the information will
identify all possible conditions and
opportunities for pollution prevention.
Compliance with environmental and
occupational safety and health regulations is
not the focus of this document and is the
responsibility of the individual health care
facility.
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
-------
SELF-ASSESSMENT CHECKLISTS
Review each question carefully and check the appropriate box. A Yes answer indicates that your
health care facility has incorporated pollution prevention, waste reduction and recycling measures
into its day-to-day activities. A No or Can't Determine answer indicates that an opportunity to
prevent or reduce pollution may exist. Take notes on the questions that received a No or Can't
Determine response.
Use this self-assessment to create a working list of pollution prevention, waste reduction and
recycling opportunities that should be explored in greater detail. You are encouraged to consult with
the Department of Environmental Conservation's regional multimedia pollution prevention (M2P2)
coordinators, the Pollution Prevention Unit located in Albany, medical associations, vendors and
other pollution prevention coordinators for additional information and assistance (see "A Resource
Guide," page 35, for a list of agencies and organizations that provide technical assistance on
pollution prevention).
Getting Started
Yes No Not Can't
Applicable Determine
Has a project leader been designated who will Q
be responsible for collecting information and
organizing the self-assessment?
Have all of the areas in the health care facility Q
that will undergo the self-assessment been
identified? (Some facility areas to consider
include nursing, surgery, analytical and
clinical laboratories, patient floors, burn units,
hemodialysis, ICU, pathology, histology,
purchasing, maintenance, radiology,
admissions, medical equipment, cafeteria,
chemotherapy and antineoplastics, pharmacy,
nuclear medicine and autopsy.)
Have you established short-term and long- Q
term audit and implementation goals? (It may
be easier and more rewarding to initially
focus pollution prevention activities on
specific areas or waste streams at the health
care facility. The long-term goal should be to
eventually establish pollution prevention
programs for all applicable areas and waste
streams throughout the facility.)
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
-------
Has a coordination team consisting of staff
members familiar with the daily operations of
their area been asked to assist in the self-
assessment?
Will the audit consist of a thorough review of
each area to identify the types, quantities and
rates of the waste generating activities?
(Preparing material balances for the targeted
activities is helpful for tracking the waste
streams.)
Yes
a
No
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
Procurement of Commodities and Services
Does the health care facility have a central
system in place for tracking and quantifying
the amount of chemicals purchased,
dispensed and disposed of?
Does the current inventory system minimize
the amount of waste that will be generated
due to overpurchasing ?
Upon arrival of purchased materials, is a
central receiving department or person in
charge for verifying that the order is correct?
Are records kept of chemicals, medical
supplies and equipment beginning with their
arrival, the history of their use and final
destination?
Are procurement of chemicals and medical
supplies done through a central department or
a person familiar with the health care
facility's pollution prevention and waste
reduction goals?
Yes
a
No
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
-------
Are products and materials that are brought
into the facility by practitioners, who have
acquired them from vendors, identified and
tracked through a central department or a
person familiar with the health care facility's
pollution prevention goals?
Are the acceptance of free samples, which
most likely become waste, minimized?
Are smaller quantities, as compared to past
purchases, of infrequently used materials
purchased?
Is the inventory system designed to ensure
that purchased materials are used in a first-in
first-out order to avoid expiration of their
shelf life?
Are Material Safety Data Sheets (MSDS)
maintained and made readily available to
employees for all materials used in the health
care facility? (This is an OSHA requirement.)
Have employees been trained to safely handle
the types of packages and chemicals that the
health care facility receives?
Does the health care facility have a
procurement policy that requires vendors use
minimal, reusable, recyclable, or returnable
packaging containers when possible?
Does the health care facility have a system in
place to monitor the flow of shipments within
the facility from receipt of raw material to
disposal?
Has the health care facility considered
establishing a computer tracking system for
monitoring chemical inventories and wastes?
Does the health care facility use a standard
procedure for the labeling of chemicals and
wastes?
Yes
a
No
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
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Do you use a supplier which will allow the
health care facility to return unopened,
surplus, obsolete or outdated supplies? (Note:
Returning some medical supplies may be
prohibited if the material is a hazardous waste
and destined for disposal instead of
evaluation/recycling by the manufacturer.
Please contact the NYSDEC, Division of
Solid and Hazardous Materials for further
guidance.)
Do you perform an inventory of the amount,
type, purchase date and location of all
chemicals on a regular basis?
Is the chemical inventory used to assure that
excess chemicals are not purchased?
Do you perform an inventory of all waste
streams on a regular basis?
Is the waste inventory used to keep track of
the types, amounts, locations and storage
times for wastes?
Does the health care facility have a
procurement policy that requires using
environmentally responsible products and
purchasing least toxic alternatives when
possible?
Does the health care facility have a
procurement policy that requires the purchase
of postconsumer recycled-content paper and
plastic where available?
Does the health care facility have a program
in place to phase out the purchasing of
devices and products containing PVC plastic
when alternatives exist?
Yes
a
No
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
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Yes No Can't Not
Determine Applicable
Is the health care facility working towards Q Q Q
eliminating mercury waste generation by the
year 2005 as outlined in the Memorandum of
Understanding Voluntary Partnership
between the American Hospital Association
and the Environmental Protection Agency?
(More information on this partnership can be
found on http://www.epa. gov/grtlakes/
toxteam/ahamou.htm )
Has the health care facility made a Q Q Q
commitment to purchase mercury-free
products whenever alternatives exist?
Are these efforts and commitments reviewed Q Q Q
regularly and are the results provided to the
staff?
Is there acknowledgment of pollution Q Q Q
prevention improvements and successes?
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 7 February 2000
-------
Medical Waste Incinerators
Emissions from medical waste incinerators can be a source ofdioxin, mercury, lead and
hydrochloric acid pollution. According to the Environmental Protection Agency, the
incineration of medical waste is one of the major contributors ofdioxin to the environment. In
September 1997, the Environmental Protection Agency issued guidelines to control air
emissions from hospital/medical/infectious waste incinerators. The New York State
Department of Environmental Conservation (NYSDEC) has implemented these regulations.
To meet these emission standards, hospitals may need to upgrade their incinerators with
effective air pollution control devices or switch to affordable and effective alternative
treatment technologies combined with pollution prevention strategies. Waste management
plans must be developed and submitted to the NYSDEC from those facilities with regulated
hospital/medical/infectious waste incinerators, as required in 40 CFR Part 60. (See
Appendix Bfor NYS Department of Health information regarding Alternative Treatment
Technologies.)
Have alternative technologies for treating
regulated medical waste*, such as autoclave
treatment, chemical/enzyme disinfection,
plasma/pyrolysis, thermal, biological,
heat/steam/electro/radiation or microwave
irradiation been explored to replace
incineration? (* Refers to regulated medical
waste as defined in the Public Health Law
1389
AA-GG-.
Has staff been informed of the environmental
and human health impacts of improper waste
segregation and disposal? (The improper
disposal of certain wastes can result in toxic
releases, therefore, employee education is
vital.)
Can your health care facility determine how
much of its waste stream is incinerated?
Lbs. per year:
Percentage of all waste: %
Has the health care facility taken steps to
eliminate the nonessential incineration of
medical waste?
Yes
a
No
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
-------
Hazardous and Solid Waste
One of the best means of reducing and eliminating hazardous wastes that are generated or result
from a spill is through better operating procedures and preventive maintenance. When conducting
the self-assessment, keep in mind the follow ing pollution prevention ideas and practices which can
be applied at health care facilities of all sizes.
General Recommendations
Has your health care facility assessed whether
nontoxic alternatives exist for each hazardous
material utilized?
Has the quantity of hazardous waste being
generated each month been determined? (The
amount of hazardous waste generated and
stored each month will determine which of
the three categories of hazardous waste
generator applies to your health care facility.
The environmental compliance requirements
will differ for each category. Assistance in
determining your generator status and the
applicable regulatory requirements should be
directed to your regional NYSDEC office.)
Have all the wastewater discharges been
identified and evaluated to determine whether
they are managed properly? (If the facility
discharges directly into a municipal sewer
system you should check with your local
publicly owned treatment works (POTWS) to
determine if there are certain discharge
restrictions. Wastewater that is directly
discharged into surface water or groundwater
requires a State Pollutant Discharge
Elimination System (SPDES) Permit.)
Have employees been trained in the
hazardous waste regulations (e.g., labeling,
storage, spill prevention and manifesting
requirements) related to the job they are
doing?
Do you have a written spill prevention plan?
Yes
a
a
No
a
a
Not
Applicable
a
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
A Checklist for Pollution Prevention
February 2000
-------
Have employees been trained in spill
reporting requirements? (Contact your
regional NYSDEC office for spill reporting
information.)
Are spill and cleanup kits available nearby?
Have employees been trained in identifying
waste types and appropriate waste
segregation?
Are all waste streams properly segregated and
labeled?
Are chemicals stored in accordance with
OSHA and manufacturers' recommendations?
Are chemical containers returned to the
supplier for reuse?
Are hazardous wastes stored in a central
location?
Are mechanical aids used in handling drums
to reduce spills?
Is one person responsible for tracking the
waste that is generated?
Do you label everything to avoid
contaminating waste streams that would
normally be nonhazardous? (Large quantities
of hazardous waste can be generated by
inadvertently mixing waste streams.)
Are containers kept closed, well organized
and away from people and equipment that can
cause it to spill? (Improper storage may cause
a health risk.)
Do you maintain a waste stream tracking
system which includes information on the
area of generation, quantity, waste
constituents, storage time, container and
ultimate disposal?
Yes
a
a
a
a
a
a
a
a
a
a
No
a
a
a
a
a
a
a
a
a
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
10
A Checklist for Pollution Prevention
February 2000
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Yes No Can't Not
Determine Applicable
Do you return obsolete or surplus supplies to Q Q Q Q
the vendor? (Note: Returning some obsolete
or surplus supplies may be prohibited if the
material is a hazardous waste and destined for
disposal instead of evaluation/recycling by the
manufacturer. Please contact the NYSDEC,
Division of Solid and Hazardous Materials
for further guidance.)
Do the virgin/waste materials storage areas Q Q Q Q
have a berm and sump drain to contain spills
and leaks?
If your storage area does not have a berm, do Q Q Q Q
you use a self-contained spills management
method, such as pallets that have built-in spill
containment?
Have you sealed all floor drains in areas that Q Q Q Q
are used for the storage of hazardous
materials (when practical) or made other
preparations for containment?
Does the health care facility store all Q Q Q Q
hazardous materials and empty containers
separate from nonhazardous materials and
containers?
Ethylene Oxide (EtO)
Ethylene oxide or a mixture of EtO and chlorofluorocarbon (CFC) is used to sterilize medical
devices. Ethylene oxide is a probable human carcinogen, as well as being flammable and explosive.
In addition, chlorofluorocarbon (CFC) is an ozone depleting chemical.
Yes No Not Can't
Applicable Determine
Are OSHA regulations and manufacturers Q Q Q Q
recommendations for ethylene oxide being
followed?
Is the ethylene oxide equipment inspected Q Q Q Q
regularly including checking the seal on the
sterilizer doors and maintained according to
manufacturers' recommendations?
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 11 February 2000
-------
Is the ethylene oxide equipment and air
quality in the room tested regularly for
possible leaks?
Has the health care facility investigated the
utilization of other sterilization methods?
(Some possible alternatives include:
radiation, vapor-phase hydrogen peroxide,
steam, ozone and microwave radiation.)
Does the health care facility have an EtO spill
cleanup policy?
Have the employees been properly trained in
the use of EtO sterilization equipment and
handling of EtO cylinders and cartridges?
Yes
a
a
No
a
a
Can't
Determine
a
a
Not
Applicable
a
a
a a
a a
a
a
a
a
Glutaraldehyde
Glutaraldehyde is primarily used in the cold sterilization of surgical, medical and dental equipment.
It is also used in embalming, electron and light microscopy as a tissue fixative and in x-ray film
processing solutions as a fixative.
Yes
Have the employees who work with
glutaraldehyde been trained in its hazards,
safe use, proper handling, spill cleanup
procedures and waste reporting practices?
No
a
Not
Applicable
a
Can't
Determine
a
Is emergency response equipment suitable for Q Q Q
glutaraldehyde incidents available nearby?
Are the containers storing glutaraldehyde kept Q Q Q
closed when not in use?
Is glutaraldehyde stored in appropriate Q Q Q
containers which are in good condition?
Are glutaraldehyde containers always checked Q Q Q
for leaks and damage before moving or
manipulating?
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
12
A Checklist for Pollution Prevention
February 2000
-------
Yes No Can't Not
Determine Applicable
Is appropriate first aid equipment (i.e., eye Q Q Q Q
wash) available in the areas were
glutaraldehyde is being used?
Are the employees handling glutaraldehyde Q Q Q Q
provided with personal protective equipment?
Is appropriate first aid equipment (i.e., eye Q Q Q Q
wash) available in the areas where
glutaraldehyde is being used?
Is air monitoring being performed to prevent Q Q Q Q
worker exposure to glutaraldehyde?
Are the areas where glutaraldehyde is being Q Q Q Q
used and stored equipped with proper
ventilation systems?
Are glutaraldehyde solutions being used in Q Q Q Q
accordance with manufacturer's directions?
Are employees instructed to use only the Q Q Q Q
smallest amount necessary of glutaraldehyde
solution?
Has the health care facility investigated the Q Q Q Q
utilization of other sterilization methods?
PVC (polyvinyl chloride) Plastics
Concerns about the health impact from the incineration of disposable chlorinated products, due to
the potential formation and release ofdioxin to the environment, has prompted the USEPA to issue
guidelines to control hospital medical and infectious waste air emissions.
Products that may contain PVC plastic include:
IV bags and tubing Patient ID bracelets
endotracheal tubes Compression sleeves
oxygen tents Thermal blankets
vinyl gloves Resuscitation bags
catheters Blood bags
basins Packaging
Mattress covers Bedpans
Catheters Inflatable splints
The use of alternatives products, an effective waste segregation program and pollution prevention
strategies can help eliminate this discharge.
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 13 February 2000
-------
Has the health care facility developed and
implemented a PVC free purchasing policy?
Have all of the products which contain PVC
plastic been identified?
Have PVC products been replaced by non-
PVC products where possible?
Have alternatives to PVC plastics products
been explored?
Has the health care facility considered
switching from vinyl gloves to nitrile gloves?
Does your health care facility recycle unused
PVC plastic apparatus? (i.e., washbins, water
pitchers, cups, etc.)
Are sharps containers PVC-free (i.e.,
polyethylene or reusable)?
If not, have these alternatives been
considered?
;s
a
a
a
a
a
a
a
a
No
a
a
a
a
a
a
a
a
Not
Applicable
a
a
a
a
a
a
a
a
Can't
Determine
a
a
a
a
a
a
a
a
Solvents
Health care facilities typically generate solvents in a variety of their daily functions, including
pathology, histology, maintenance, embalming and laboratories. Many of these solvents may be
classified as hazardous waste, and therefore are required to be properly treated and/or disposed.
Pollution prevention strategies can be used to eliminate solvent use by using nontoxic alternatives,
or to reduce both the toxicity and the quantity of spent solvents.
Yes
Has the use of aqueous reagents, simple Q
alcohols and ketones (instead of petroleum
hydrocarbons) and sonic or steam cleaning
been considered to replace solvent-based
cleaning?
Are different solvent waste streams Q
segregated so that they can be recycled?
Are waste solvents being recycled off-site? Q
No Not
Applicable
a a
a a
a a
Can't
Determine
a
a
a
Environmental Self-Assessment
For Health Care Facilities
14
A Checklist for Pollution Prevention
February 2000
-------
Has the use of an on-site distillation unit to
recover waste solvents been considered?
(Contact the NYSDEC for distillation unit
regulatory information. Also, the quality and
effectiveness of the recovered solvent should
be evaluated before purchasing a distillation
unit.)
If different solvents are used for cleaning,
can they be replaced with a multipurpose
solvent that can be used for a variety of
applications?
Have you investigated nontoxic alternatives
to replace solvents, where possible?
Have you considered switching to less-toxic
and less-flammable solvents?
Has the use of premixed containerized kits
for tests involving solvent fixation been
explored?
Have you investigated alternatives to using
xylene in histology?
Have you considered using calibrated solvent
dispensers for routine tests?
If solvents are utilized for cleaning, is it
possible to reuse used solvent for initial
cleaning of other areas and fresh solvent only
for final cleaning?
Yes
a
No
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
15
A Checklist for Pollution Prevention
February 2000
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Mercury
Mercury is bioaccumulative and persists in the environment. It is toxic to humans in all forms
(organic and inorganic). The inappropriate disposal of mercury can cause it to be released to the
air, water or land from wastewater discharges, spills, landfilling and incineration. The release of
mercury to the environment can be reduced by using alternatives to medical devices containing
mercury, cleaning up spills properly, recycling mercury containing products and properly handling
and disposing of mercury containing equipment. See Appendix A for medical products and
equipment that may contain mercury.
Does the health care facility have a Mercury
Management Program?
Does the health care facility have a
purchasing policy which includes a
commitment to purchase mercury-free
products whenever possible?
Is the health care facility working towards
eliminating mercury waste generation by the
year 2005 as outlined in the Memorandum of
UnderstandingVoluntary Partnership
between the American Hospital Association
and the Environmental Protection Agency?
(More information on this partnership can be
found on http://www.epa.gov/grtlakes/
toxteam/ahamou.htm )
Have equipment and supplies that contain
mercury been identified? (See Appendix A
for a listing of potential mercury sources.)
Have laboratory chemicals been identified
that may contain mercury? (See Appendix A
for a listing of potential mercury sources.)
Are mercury-free laboratory reagents being
used that will achieve the same diagnostic
results?
Has the health care facility stopped sending
mercury containing thermometers home with
new mothers?
Are mercury thermometers being phased out
through the use of electronic sensors or
temperature strips?
Yes
a
a
No
a
a
Not
Applicable
a
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
16
A Checklist for Pollution Prevention
February 2000
-------
Is mercury-containing equipment, such as
thermometers and blood pressure
instruments, being replaced with mercury-
free alternatives? (Possible alternatives for
thermometers and blood pressure
instruments include digital or disposable
strips and electronic vacuum gauge,
expansion or aneroid, respectively.)
Does the health care facility completely drain
and recycle all residual mercury from
thermometers, blood pressure reservoirs, and
other medical devices prior to discarding the
equipment?
Have you replaced mercury containing
esophageal dilators (bougie tubes), cantor
tubes, feeding tubes and Miller Abbott tubes
with mercury-free alternatives?
Are mercury vacuum apparatus (with the
proper mercury vapor controls) and spill
absorbent kits readily available to clean up
mercury spills? (Residue from mercury
cleanups must be properly disposed or
recycled.)
Have employees been trained in the hazards
of mercury, spill cleanup and the proper
handling and reporting of mercury waste?
Have employees been trained on the correct
procedures for segregating mercury waste?
Are cantor tubes from the operating rooms
and surgical units being disposed of properly
by personnel?
If mercury still exists in your hospital, is
there a regular inspection of sewer traps and
catch basins to prevent release of mercury to
the environment?
Yes
a
No
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
17
A Checklist for Pollution Prevention
February 2000
-------
Chemotherapy & Antineoplastic Chemicals
Chemotherapy and antineoplastic chemical waste can be generated during drug preparation, drug
administration and spills.
Yes
Are the procedures outlined in OSHA
Instruction PUB 8-1.1, January 28, 1986,
Guidelines for Cytotoxic (Antineoplastic)
Drugs being followed?
Are unopened, surplus, obsolete or outdated
drugs returned to the manufacturer? (Note:
Returning some medical supplies may be
prohibited if the material is a hazardous
waste and destined for disposal instead of
evaluation/recycling by the manufacturer.
Please contact the NYSDEC, Division of
Solid and Hazardous Materials for further
guidance.)
Are separate distinctively labeled containers
available to keep chemotherapy wastes apart
from other waste streams?
Are chemotherapy wastes placed into a
leakproof, rigid container and kept
segregated from other wastes?
Are drug containers purchased in amounts
that minimize the amount of out-of-date
material?
Are drugs purchased in container sizes that
permit formulation of daily dosages with the
least quantity of excess product leftover?
Can chemotherapy compounding stations be
centralized to improve management of
chemotherapy waste?
Are appropriate personnel trained to
transport and handle chemotherapy waste in
a safe manner to prevent exposure?
Are chemotherapy drugs prepared under a
biological safety hood?
No
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Can't
Determine
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
18
A Checklist for Pollution Prevention
February 2000
-------
Have employees been trained in
chemotherapy drug handling, safety, waste
minimization and, spill containment and
cleanup procedures?
Are spill cleanup kits available in the
compounding area that contain both small
and large absorbent devices?
Yes
a
No
a
Not
Applicable
a
Can't
Determine
a
a
a
a
a
Batteries
Batteries are used in a number of medical devices, such as defibrillators, hearing aids, fetal
monitors, pagers, temperature alarm, blood analyzer, spirometer alarm, telemetry transmitter,
hofler monitor and pacemakers. The batteries used in a health care facility can include: alkaline,
mercuric oxide (mercury zinc), lead acid, lithium, zinc air button batteries, silver oxide button
batteries and rechargeable nickel-cadmium. The inappropriate disposal of batteries may result in
toxic releases occurring from medical waste incinerator emissions or landfill leachate.
Yes
Does the health care facility have written
procedures regarding the proper management
of used batteries?
Do employees receive training on the health
care facility's procedures for proper
management of used batteries?
Has the health care facility determined which
types of used batteries are hazardous waste?
(A battery is a hazardous waste if it exhibits
one or more of the characteristics defined in
section 371.3 of 6NYCRRPart 371,
Identification and Listing of Hazardous
Wastes. Some used batteries are likely to be
classified as hazardous waste due to the
various amounts of heavy metals such as lead,
mercury and cadmium that they contain.)
Are used batteries that are determined to be a
hazardous waste handled in accordance with
6NYCRR Subpart 374-3 Standards for
Universal Wastes? (Assistance with
applicable regulatory requirements should be
directed to your Regional NYSDEC office.)
a
a
No
a
a
a
Not
Applicable
a
a
a
Can't
Determine
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
19
A Checklist for Pollution Prevention
February 2000
-------
Yes No Not Can't
Applicable Determine
Is it determined before purchasing batteries, Q Q Q
which ones contain the lowest levels of heavy
metals? (Possible alternatives include lithium,
zinc-air, silver-oxide and alkaline.)
Are all batteries inventoried and tracked? Q Q Q
Does the health care facility use rechargeable Q Q Q
alkaline and nickel-cadmium batteries? (A
hazardous waste determination must be made
on spent rechargeable batteries if they are no
longer rechargeable and will be discarded.)
Has the health care facility implemented a Q Q Q
battery collection program? (Batteries that
are determined to be hazardous must be
managed in accordance with 6NYCRR
Subpart 374-3 Standards for Universal
Wastes. However, the collection program
should take in all batteries. The hazardous
waste manager can then sort through the
batteries to determine appropriate waste
management options. The NYSDEC,
Division of Solid and Hazardous Materials,
Bureau of Waste Reduction & Recycling at
(518) 457-7337 maintains a list of battery
recyclers.)
Are employees trained in the proper Q Q Q
management and segregation of used
batteries?
Are employees required to exchange a spent Q Q Q
battery in order to receive a new battery?
Note: For medical devices, there are Food and Drug Administration and Underwriters
Laboratory certification concerns with replacing a battery. Please contact the
equipment manufacturer before replacing a battery with a substitute to ensure that the
device has been approved for use with the alternative battery.
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 20 February 2000
-------
Lamps
Many lamps frequently contain mercury and sometimes lead, principally because of the use of lead
solder. Various lamps used in a health care facility include fluorescent, mercury vapor, high
pressure sodium vapor, incandescent, high intensity discharge, metal halide, cathode ray tubes and
ultraviolet. Mercury is a toxic, bioaccumlative pollutant; therefore, the proper management of spent
mercury-containing lamps is essential for minimizing mercury releases. Management controls
include safe handling to prevent breakage and keeping hazardous waste lamps from being disposed
of in landfills and incinerators.
Yes
Have all of the various types of lamps used at
the health care facility been identified? (These
can include, but are not limited to,
fluorescent, mercury vapor, high pressure
sodium vapor, metal halide, incandescent,
high intensity discharge and neon lamps.)
Has the health care facility determined which
types of spent lamps are hazardous waste? (A
spent lamp is a hazardous waste if it exhibits
one or more of the characteristics defined in
section 371.3 of 6NYCRRPart 371
Identification and Listing of Hazardous
Wastes. Many fluorescent, mercury vapor,
high intensity discharge and other lamps
frequently contain mercury, and sometimes
lead, principally because of the use of lead
solder.)
Are there several convenient collection points
for spent lamps throughout the health care
facility? (Spent lamps from the collection
points should be taken to a secure area for
sorting and to prevent accidental breakage.)
Are spent lamps being collected for
recycling? (Contact the NYSDEC-Division
of Solid and Hazardous Materials, Bureau of
Waste Reduction & Recycling at (518) 457-
7337 for a list of recyclers.)
Are employees trained in the proper
management and safety procedures for
reporting and responding to broken or
nonworking lamps?
No
a
Not
Applicable
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
21
A Checklist for Pollution Prevention
February 2000
-------
Yes
Are spent lamps that are determined to be a
hazardous waste being handled in accordance
with the Standards for Universal Wastes?
(On July 6, 1999, the USEPA issued a final
rule for inclusion of hazardous waste lamps in
the Universal Waste Rule of 40 CFR Part
273. New York State has established a policy
of enforcement discretion, effective January
6, 2000, with regard to the management of
hazardous waste lamps as universal waste.
This enforcement discretion policy will
remain in effect until New York adopts the
provisions of 40 CFR Part 273, for lamps,
into6NYCRRSubpart374-3. Broken or
crushed lamps determined to be hazardous
cannot be handled as Universal Wastes and
must be handled in accordance with
applicable hazardous waste regulations.
Assistance with applicable regulatory
requirements can be directed to the NYSDEC
Division of Solid and Hazardous Materials.)
Are new as well as waste lamps being stored
to prevent breakage?
Are broken lamps separated, placed in a
heavy plastic bag and put inside a sturdy
container for disposal?
Has the health care facility developed a plan
to phase out mercury-containing lamps?
Can lighting systems be upgraded to be more
efficient? (The New York State Energy
Research and Development Authority
(NYSERDA) works with businesses,
institutions, and municipalities to provide
energy engineering and technical assistance.
In addition, the Environmental Protection
Agency's Green Lights program promotes
energy efficiency in buildings. Participants
are provided with unbiased technical
information, customized support services,
public relations assistance, and access to a
broad range of resources and tools.)
No
a
Can't
Determine
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
22
A Checklist for Pollution Prevention
February 2000
-------
Photographic Chemicals and Scrap Film
The radiology department may generate wastewater containing photographic chemicals and silver
from film processing, scrap film, fixer solution and outdated chemicals.
Yes
Are all employees whose jobs involve
contact with photographic chemicals and
scrap film trained in the safety and the
appropriate handling and disposal of these
substances?
Do you store photographic chemicals
correctly to prolong their shelf life? (Some
photographic chemicals are light and
temperature sensitive.)
Are lead foil film packets sent to a recycler?
Are damaged and used x-ray films sent to a
recycler?
Is the silver from x-ray fixture solution
recovered by an on-site silver recovery unit?
If not, is the fixture solution collected and
sent off-site for recycling?
In nonautomated processing systems, is a
squeegee used to wipe excess liquid from the
film? (This procedure helps minimize the
chemical contamination of baths and
increases bath life.)
Is countercurrent washing used in
photographic processors to reduce
wastewater generation?
Are materials that have an expired shelf life
tested for effectiveness prior to being
disposed of or returned? (Note: Returning
some medical supplies may be prohibited if
the material is a hazardous waste and
destined for disposal instead of
evaluation/recycling by the manufacturer.
Please contact the NYSDEC, Division of
Solid and Hazardous Materials for further
guidance.)
No
a
Not
Applicable
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
23
A Checklist for Pollution Prevention
February 2000
-------
Are the usefulness of the solutions in the
photographic processing baths being
extended by the following methods?
- adding ammonium thiosulfate
- using acid stop bath prior to fixing
- adding acetic acid to fixing bath to keep pH
low
- Keeping baths in covered, airtight
containers to reduce evaporation and
oxidation
Do you require that all photographic
containers be clearly labeled with their
contents?
Yes No Can't Not
Determine Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Formaldehyde/formalin
Formaldehyde is used in embalming, autopsy, dialysis (formalin), specimen preservation and
pathology.
Have all areas been identified where
formaldehyde/formalin is being used?
Have you standardized formalin cleaning
solutions in order to use the minimum
strength required?
Are proper air emission controls being used?
Have you considered automating the
dispensing of formalin to reduce excess
amounts generated?
Do you collect waste formaldehyde and
formalin for proper disposal?
Has the use of reverse osmosis waste
treatment to reduce the dialysis cleaning
demands with formaldehyde been explored?
Has the reuse of formaldehyde in pathology
and autopsy labs been explored?
Yes
a
a
a
a
a
a
a
No
a
a
a
a
a
a
a
Not
Applicable
a
a
a
a
a
a
a
Can't
Determine
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
24
A Checklist for Pollution Prevention
February 2000
-------
Radioactive Waste
In health care facilities, radioactive material is used in conducting in-vitro and in-vivo biomedical
research work, clinical laboratory studies, and medical diagnostic and therapeutic procedures
performed on patients. The types of radioactive waste that may be generated include solids, liquids,
animal carcasses, or equipment contaminated with short-lived or long-lived radionuclides. Every
health care facility that uses radionuclides may only do so in accordance with the authorization
granted under its radioactive material license. The license requires that all resultant radioactive
waste be properly managed and that waste minimization procedures be practiced. The health care
facility's radiation safety officer is the person listed on the radioactive materials license who is
responsible for ensuring that radioactive materials and wastes are properly managed, and that any
disposal or discharge of radioactive materials to the environment is conducted in accordance with
the 6 NYCRR Part 3 80 regulations issued by the NYS Department of Environmental Conservation.
Any questions regarding the Part 380 regulations should be directed to the Department's Radiation
Section at (518) 457-2225.
Yes
Is radioactive waste managed in accordance
with the facility's waste minimization plan, as
required by the radioactive materials license?
Are all radioactive waste generating
procedures periodically evaluated to ensure
that radioactive waste is not created
unnecessarily?
Is radioactive waste disposed of by any of the
following methods, in accordance with
Section 380-4?
Is radioactive waste disposed of by any of the
following methods, in accordance with
Section 380-4?
- Returned to vendor
- Decayed in storage
- Released to the municipal sanitary sewer
system
- Under the biomedical exemption
- Another method as authorized in a Part 380
permit
- Shipped to a licensed disposal facility
a
a
a
a
a
a
a
a
No
a
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Can't
Determine
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
25
A Checklist for Pollution Prevention
February 2000
-------
Medical Waste Stream
Segregating nonregulated medical waste from regulated medical waste, at the point of generation,
can significantly reduce the impact it has on the environment. Regulated medical waste should
always be kept separate from hazardous, radioactive and chemotherapy wastes, whenever possible,
to avoid mixtures that are difficult to treat and properly dispose of. In addition, the incineration of
regulated medical waste should be limited to those waste streams requiring incineration as a
treatment technology. Alternative technologies that are more environmentally friendly should be
used for all other regulated medical waste streams. (Regulated medical waste is defined in Public
Health Law 1389M<3G,)
Has the health care facility established
written standards for handling and disposing
of regulated medical waste?
Have all appropriate health care facility
employees received training on proper waste
stream characterization and segregation?
Are employee's made aware of the reasons
and need for segregating wastes properly?
Are training programs provided to all
appropriate staff on the proper management
and safety procedures for handling and
disposing of radioactive waste, hazardous
waste (including chemotherapy), hospital
waste and regulated medical waste streams?
Has a comprehensive survey been conducted
at the health care facility to determine the
location of waste containers, the items
deposited in each bag or container and the
waste liner color? (Overuse of red bags may
be taking place in some areas.)
Is the health care facility staff separating
waste streams into the correct waste stream
categories?
Are regulated medical wastes that contain
hazardous or radioactive wastes segregated
from nonhazardous and nonradioactive
regulated medical wastes for proper
disposal?
Yes
a
a
a
a
No
a
a
a
a
Not
Applicable
a
a
a
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
26
A Checklist for Pollution Prevention
February 2000
-------
Is the regulated medical waste stream further
separated into "sharps" and "nonsharps"
waste to accommodate the proper treatment,
recycling and disposal destinations?
Are human pathological wastes and sharps,
in the regulated medical waste stream,
further segregated to accommodate proper
treatment and disposal destinations?
Whenever possible is regulated medical
waste stored separate from hazardous or
radioactive waste?
Is regulated medical waste properly
containerized as close as is practical to the
point of generation?
Has a modification of the regulated medical
waste container layout at the facility been
considered to reduce the volume of red bag
waste resulting from the improper
segregation of wastes?
Have clear bag-receptacles been provided in
appropriate areas to prevent the disposal of
nonregulated medical waste into regulated
medical waste red bags?
Have you renegotiated contracts with
regulated medical waste haulers to provide
decontaminated, clean reusable containers?
(Reusable containers should not be used for
any other purpose).
Do you use cadmium-free red bags?
(Cadmium is used as a colorant in some red
bags that can then be released during
incineration.)
Are waste containers clearly marked and
easily accessible to facilitate proper waste
segregation?
Are soiled, broken or rusted waste
receptacles replaced on a regular basis?
Yes
a
a
a
a
a
a
a
a
a
a
No
a
a
a
a
a
a
a
a
a
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
27
A Checklist for Pollution Prevention
February 2000
-------
Yes
Has the health care facility considered
reducing the volume of infectious waste by
placing alternative receptacles in the
operating rooms? (Receptacles can be used
to collect, under sterile conditions, the
plastic packaging material that is used to seal
the surgery supplies and instruments. These
receptacles can then be closed and isolated
from the main area to eliminate the risk of
contamination from infectious/medical
waste.)
Are soiled, broken or rusted waste
receptacles replaced on a regular basis?
Are the appropriate size receptacles being
used for the volume of waste generated?
Are regulated medical waste containers
properly sealed and labeled before they are
moved to another location at the health care
facility for storage, treatment or disposal?
Is there a designated biohazard waste storage
area clearly labeled with the word biohazard
or the universal biohazard symbol!
Is the biohazard waste storage area securely
controlled with access limited to authorized
personnel?
Does the storage area have proper ventilation
and mechanical controls (i.e., refrigeration)
to maintain waste in a nonputrescent state?
Is liquid biohazard waste discharged to a
sanitary sewer in compliance with applicable
state and/or local regulations?
Is the biohazard waste storage area protected
from the weather to ensure that the storage
containers remain intact?
Is the biohazard waste storage area
maintained in a sanitary condition, free of
rodents and insects and secure from
vandalism?
No
a
Not
Applicable
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
28
A Checklist for Pollution Prevention
February 2000
-------
Recycling and Reuse
Reuse and recycling programs can significantly reduce the amount of waste that your health care
facility has to ship off-site for disposal, in addition to conserving our natural resources and
eliminating the generation of hazardous waste that would otherwise result during manufacturing.
Does the health care facility have a
purchasing policy that requires postconsumer
recycled content products be purchased when
available?
Has the health care facility replaced
disposable supplies with reusable products,
when the safety and health of patients and
staff are not compromised? (Some reusable
products to consider include: utensils and
plates, sharp containers, rechargeable
batteries, sterilization trays, bed pans, emesis
basins, cloth gowns and drapes, slippers,
male urinal basins, packaging totes,
biohazard containers, recharged toner
cartridges, bedpans, diapers and underpads).
Does the health care facility use reusable
decubitus mattresses to eliminate the need
for disposable egg-crate pads?
Does the health care facility currently have
recycling programs in place for the
administrative offices, waiting rooms and
cafeterias? (Some of the items which can be
considered for recycling programs include:
office paper, newspaper, books, magazines,
aluminum, bottles, glass, plastics, corrugated
cardboard, junk mail. Contact the NYSDEC,
Division of Solid and Hazardous Materials
to find out how to start a recycling program
at your facility.)
Has the possibility of sending unused
medical equipment overseas been explored?
(Items suitable for donation can include
syringes, gauze, gowns, sponges, operating
room tables, wheelchairs and stretchers.)
Yes
a
No
a
Not
Applicable
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
29
A Checklist for Pollution Prevention
February 2000
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Housekeeping
Yes No Not Can't
Applicable Determine
Are housekeeping employees trained in the Q Q Q
proper management and safety procedures
for radioactive waste, hazardous waste
(including chemotheraphy), hospital waste,
regulated medical waste and cleaning
chemicals?
Have employees been trained in spill Q Q Q
containment and cleanup procedures?
Are employees aware of the health care Q Q Q
facility's recycling programs?
Can multiple brands of cleaning compounds Q Q Q
be replaced by a few detergents whose
disinfecting strength is adjusted by the
housekeeping staff?
Has the health care facility considered Q Q Q
limiting the variety of housekeeping
solutions used? (i.e., Implementing a
metering dispensing system for dispensing
fewer chemicals in the proper amount and
concentration.)
Have less toxic cleaning products been Q Q Q
identified and used?
Have alternatives to cleaning chemicals and Q Q Q
degreasers that contain mercury been
explored? (To ascertain the mercury content
of materials being used, request a copy of the
Certificates of Analysis from all suppliers.
Certificates of Analysis should list the
mercury content in parts per billion (ppb),
not as a percentage.)
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 3 0 February 2000
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Facility Maintenance
Yes
Are mercury thermostats, covered under the
requirements of 6 NYCRR Subpart 374-3
Standards for Universal Wastes, being
managed in accordance with these
regulations? (Assistance with applicable
regulatory requirements should be directed to
the NYSDEC Division of Solid and
Hazardous Materials.)
Are pesticides, covered under the
requirements of 6 NYCRR Subpart 374-3
Standards for Universal Wastes, being
managed in accordance with these
regulations? (Assistance with applicable
regulatory requirements should be directed to
the NYSDEC Division of Solid and
Hazardous Materials.)
Has the health care facility developed and
implemented an integrated pesticide
management plan that reduces to the greatest
extent possible the use of chemical
pesticides?
Is it possible to reduce the amount of
pesticide applications and/or use
nonchemical pest control methods?
If the health care facility generates used oil,
are they in compliance with 6 NYCRR
Subpart 374-2 Standards for the
Management of Used Oil!
Does the maintenance department collect
and recycle waste cleaning solvents?
Has an on-site solvent distillation system
been considered as a way to recycle waste
solvent? (Check with your local NYSDEC
office regarding regulations that apply to
distillation systems.)
Are vendors required to take back pallets
and/or packaging material?
No
a
Not
Applicable
a
Can't
Determine
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
31
A Checklist for Pollution Prevention
February 2000
-------
Yes
Are the concrete floors of the maintenance Q
areas sealed with an impervious material to
facilitate cleanup without using solvents?
Are maintenance areas cleaned with a Q
biodegradable detergent?
Are your employees required to wipe up Q
small spills as soon as they occur?
Do maintenance personnel use dry methods Q
for clean-up of small spills?
Are maintenance personnel required to pick Q
up absorbent material as soon as possible
after the leak or spill has been immobilized?
Has the maintenance department considered Q
using water-based paints?
Are waste towels being stored in a closed, Q
metal safety container?
Are instruments and products which contain Q
mercury being collected and properly
managed? (See Appendix A for additional
maintenance equipment that may contain
mercury).
Does your maintenance department send its Q
dirty shop towels to a commercial laundry
service for cleaning?
No
Can't
Determine
a
a
a
a
a
a
a
a
Not
Applicable
a
a
a
a
a
a
a
a
a
a
Environmental Self-Assessment
For Health Care Facilities
32
A Checklist for Pollution Prevention
February 2000
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P2 Pays
The University of Rochester's Strong Memorial Hospital implemented an effective mercury
reduction program in which mercury-containing equipment was substituted with electronic and
mercury-free equipment, and mercury compounds were eliminated from certain activities
within the clinical labs.
Mercury thermometer usage was the primary target of the mercury reduction program. Even
though Strong Memorial Hospital performed approximately 750,000 temperature readings per
year using electronic thermometers, there were still areas or situations where significant usage
of mercury thermometers existed. These situations were evaluated and mercury thermometers
were replaced wherever possible with electronic thermometers. During the course of the
implementation, there were other opportunities to replace mercury containing items with
mercury-free equipment. For example, mercury-filled sphygmomanometers were replaced
with aneroid sphygmomanometers during the course of new construction, renovation, or as
existing equipment was replaced. Also, mercury-filled gastrointestinal tubing was replaced
with tungsten-filled tubing. Existing staff educational programs were upgraded to include
mercury specific facts and handling procedures. In addition, the nursing policy was revised to
discourage the practice of allowing patients to take mercury thermometers home with them.
Other mercury reduction initiatives included the elimination of mercury compounds within the
clinical labs whenever there is an alternative. Histopathology discontinued the use of mercury
compounds in 1992. The same was also true for the installation of energy efficient lighting
and the management of mercury-containing fluorescent lamps.
In addition to the economic benefit to Strong Memorial Hospital as a result of the mercury
reduction program, the real driver, in their opinion, was the win-win situation afforded by
being mercury-free. All of the problems associated with using and disposing of a hazardous
material were eliminated by replacement with nonhazardous materials.
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 33 February 2000
-------
NEXT STEPS
Following the completion of the self-assessment, you should be left with a list of operational
areas where there are opportunities for pollution prevention. The next step is to obtain additional
information to allow you to explore these opportunities and to determine which are cost effective and
technically feasible without reducing service quality. A good first step is to consult the publications
listed in the references section (see page 46). You should also check with vendors and request
information about hospital supplies and medical equipment that are more "environmentally friendly."
Other sources of information regarding pollution prevention are the trade organizations and local,
state and federal programs listed in "A Resource Guide," page 35.
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 34 February 2000
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RESOURCE GUIDE
The following organizations provide technical assistance, publish information, conduct
workshops and conferences; and provide telephone and on-site information on pollution prevention
and better management of medical waste, air, water, solid and hazardous waste issues.
Trade Organizations
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Phone: (630) 792-5000
Fax: (630) 792-5005
Internet: http://www.j caho.org
Greater New York Hospital Association
(GNYHA)
555 West 57th Street, 15th Floor
New York, New York 10019
Phone: (212)246-7100
Fax: (212)262-6350
Internet: http://www.gnyha.org
American Hospital Association (AHA) -
Chicago Headquarters
One North Franklin
Chicago, IL 60606
Phone:(312)422-3000
Fax:(312)422-4796
Internet: http://www.aha.org
Healthcare Association of New York State
(HANYS)
74 North Pearl Street
Albany, New York 12207
Phone:(518)431-7600
Fax:(518)431-7915
Internet: http ://www.hanys. org
New York State Nurses Association (NYSNA) Western New York Healthcare Association
11 Cornell Road
Latham, New York 12110-1499
Phone:(518)782-9400
Fax: (518)782-9530
E-mail: infor@nysna.org
Internet: http://www.nysna.org
North Metropolitan Hospital Association
400 Stony Brook Court
Newburgh, NY 12250-5162
Phone: (914) 562-7520
Fax: (914)562-0187
Internet: http://www.normet.org
1876 Niagara Falls Blvd.
Tonawanda, NY 14150
Phone:(716) 695-0843
Fax:(716) 695-0073
E-mail: wnyha@wnyha.com
Internet: http://www.wnyha.com
Lowell Center for Sustainable Production
Sustainable Hospitals Project
Kitson Hall, Room 2000
One University Avenue
Lowell, MA 01854
Phone: (978) 934-3259
E-mail: lcsp@uml.edu
Internet:
http://www.uml.edu/centers/LCSP/hospitals/
Environmental Self-Assessment
For Health Care Facilities
35
A Checklist for Pollution Prevention
February 2000
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Iroquois Healthcare Organization
Clifton Park Office
17 Halfmoon Executive Park Drive
Clifton Park, NY 12065
Phone: (518)383-5060
Fax: (518)383-2616
Syracuse Office
5740 Commons Park
East Syracuse, NY 13057-9400
Phone: (315)445-1851
Fax: (315)445-2293
Internet: http://www.iroquois.org
Health Care Without Harm
National contact: Health Care Without Harm
c/o Center for Health, Environment and Justice
P.O. Box 6808
Falls Church, VA 22040
Phone: (703) 237-2249
Fax: (703)237-8389
E-mail: noharm@iatp.org
Internet: http://www.noharm.org
NYS Nurses Association
11 Cornell Road
Latham, NY 12110
Phone: (518)782-9400
Fax: (518)782-9530
E-mail: info@nysna.org
Internet: http://www.nysna.org
Physicians for Social Responsibility/NYC
475 Riverside Drive #551
New York, NY 10115
Phone: (212) 890-2980
Fax: (212) 890-2243
E-mail: psrnyc@igc.apc.org
Internet: http://www.psr.org.index.html
Medical Society of the State of New York
(MSSNY)
MSSNY Office
420 Lakeville Road, P.O. Box 5404
Lake Success, NY 11042-5404
Phone:(516)488-6100
Fax:(516)488-1267
E-mail: mssny@mssny.org
Albany Office
1 Commerce Plaza
99 Washington Avenue, Suite 2103
Albany, NY 12210
Phone:(518)465-8085
Fax:(518)465-0976
E-mail: mssnyalb@ix.netcom.com
Internet: http://www.mssny.org
Health Care Without Harm
New York State contact:
Citizens' Environmental Coalition
33 Central Avenue
Albany, NY 12210
Phone:(518)462-5527
Fax:(518)465-8349
E-mail: cechcwh@juno.com
New York Committee on Occupational
Safety & Health (NYCOSH)
275 7th Avenue
New York, NY 10001
Phone: (212) 627-3900
E-mail: nycosh@nycosh.org
Internet: http://www.nycosh.org
Environmental Self-Assessment
For Health Care Facilities
36
A Checklist for Pollution Prevention
February 2000
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Local Assistance
NEW YORK STATE:
University at Buffalo
Center for Integrated Waste Management
Jarvis Hall, Room 207
Buffalo, NY 14260-4400
Phone: (716) 645-3446, Ext. 2340
FAX: (716) 645-3667
METROPOLITAN AREA:
NYC Dept. of Environmental Protection
Environmental Economic Development
Assistance Unit
59-17 Junction Boulevard, 11th Floor
Corona, NY 11368-5107
Phone: (718)595-4462
FAX: (718) 595-4479
MONROE COUNTY:
Monroe County Department of
Environmental Services
444 East Henrietta Road, Bldg, #15
Rochester, NY 14620
Phone: (716) 760-7523
FAX: (716) 324-1213
ONONDAGA COUNTY:
Onondaga County Resources Recovery
Agency
100 Elwood Davis Road
North Syracuse, NY 13212
Phone: (315)453-2866
FAX: (315) 453-2872
Hotline #: (315) 453-2870
BROOME COUNTY:
Broome County
Division of Solid Waste Management
Edwin L. Crawford County Office Building
P.O. Box 1766
44 Hawley Street
Binghamton, NY13902
Phone: (607) 778-2250
FAX: (607) 778-2395
ERIE COUNTY:
Erie County Department
of Environment & Planning
Office of Pollution Prevention
95 Franklin Street, Room 1077
Buffalo, NY 14202-3973
Phone: (716) 858-7583
FAX: (716) 858-7713
CHAUTAUOUA. CATTARAUGUS AND
ALLEGANY COUNTIES:
The Southwestern New York
Environmental Compliance Network
Jamestown Community College
525 Falconer Street, P.O. Box 20
Jamestown, NY 14702-0020
Phone: (716) 665-5220 ext. 446
FAX: (716) 665-2585
The Center for Business and Industry
SUNY at Fredonia
Lograsso Hall
Fredonia, NY 14063
Phone: (716)673-3177
FAX: (716) 673-3175
Environmental Self-Assessment
For Health Care Facilities
37
A Checklist for Pollution Prevention
February 2000
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New York State Department of Environmental Conservation
Pollution Prevention Unit
Phone: (518)457-2553
Small Quantity Generator P2 Hotline
(800)462-6553, Out of State: (518)485-8471
This technical assistance unit provides P2
information, develops industry sector
manuals and other publications, offers
workshops/training, holds annual pollution
prevention conferences, coordinates NYS
Governor's P2 Awards, and prepares annual
toxic release inventory (TRI) reports.
Division of Solid and Hazardous Materials
Bureau of Hazardous Waste Management
(518)485-8988
This bureau is responsible for making
hazardous waste determinations, for
reviewing hazardous waste reduction plans,
hazardous waste permitting, and for
hazardous waste compliance.
Bureau of Waste Reduction & Recycling
(518)457-7337
This bureau is responsible for the waste tire
program, the beneficial use program, the
composting program, and other solid waste
recycling and waste reduction issues.
Bureau of Solid Waste & Land Management
(518)457-1859
This bureau administers the Part 360
Program, performs enforcement and
monitoring, and conducts regulatory
compliance inspections for landfills, waste-
to-energy facilities, transfer stations and
regulated medial waste facilities. Provides
information on transporting and/or disposal
of regulated medical waste as well as
regulated medical waste generated in non-
Article 28 and non-Part 58 facilities.
Division of Water
Bureau of Water Facilities Design
(518)457-1157
Responsible for managing the State Pollutant
Discharge Elimination System (SPDES)
permits, the SPDES program for storm water
discharges, the water resources programs,
and the municipal water supply permits.
Division of Environmental Remediation
Bureau of Spill Prevention and Response
(518)457-9412
This office is responsible for the registration
of tanks, presenting workshops and training,
developing publications, receiving spill
notifications, and serves as an information
clearinghouse for industries and the public.
Spill Response Hotline
(800) 457-7362
To report releases of petroleum products or
hazardous substances to air, land or water in
New York State. Regulations require
reporting within 2 hours if certain conditions
are not met. Also, the National Response
Center should be notified (see listing on page
41).
Petroleum Bulk Storage Hotline
(888)457-4351
Provides technical assistance on chemical
and petroleum aboveground and
underground storage tanks.
Environmental Self-Assessment
For Health Care Facilities
38
A Checklist for Pollution Prevention
February 2000
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Division of Environmental Permits
Phone: (518)457-2224
This office is responsible for issuing
permits to waste haulers that transport
solid and hazardous, industrial &
commercial, sewage andseptage waste.
Division of Air Resources
Bureau of Stationary Sources
(518)457-7688
This bureau is responsible for source review,
permitting, MACT, NASHAP implementation,
and air toxics assessments.
NYSDEC - Regional Offices
REGION 1
Nassau & Suffolk Counties
SUNY Campus
Loop Road, Building 40
Stony Brook, NY 11790-2356
Phone: (516)444-0354
REGION 2
Bronx, Kings, New York, Queens &
Richmond Counties
1 Hunters Point Plaza
47-40 21st Street
Long Island City, NY 11101-5407
Phone:(718)482-4900
REGION 3
Dutchess, Orange, Putnam, Rockland,
Sullivan, Ulster & Westchester Counties
21 South Putt Corners Road
New Paltz, NY 12561-1696
Phone:(914)256-3000
REGION 4
Albany, Columbia, Delaware, Greene,
Montgomery, Otsego, Rensselaer,
Schenectady & Schoharie Counties
HSOWestcottRoad
Schenectady, NY 12306-2014
Phone:(518)357-2234
REGION 5
Clinton, Essex, Franklin, Fulton, Hamilton,
Saratoga, Warren & Washington Counties
Route 86, PO Box 296
Ray Brook, NY 12977-0296
Phone:(518)897-1200
REGION 6
Herkimer, Jefferson, Lewis,
Oneida & St. Lawrence Counties
State Office Building
317 Washington Street
Watertown, NY 13601
Phone:(315)785-2238
REGION 7
Broome, Cayuga, Chenango, Cortland,
Madison, Onondaga, Oswego,
Tioga & Tompkins Counties
615 Erie Blvd. W.
Syracuse, NY 13204-2400
Phone:(315)426-7400
REGION 8
Chemung, Genesee, Livingston, Monroe,
Ontario, Orleans, Schuyler, Seneca,
Steuben, Wayne & Yates Counties
6274 East Avon-Lima Road
Avon, NY 14414
Phone:(716)226-2466
REGION 9
Allegany, Cattaraugus, Chautauqua,
Erie, Niagara, & Wyoming Counties
270 Michigan Ave.
Buffalo, NY 14203-2999
Phone:(716)851-7000
Environmental Self-Assessment
For Health Care Facilities
39
A Checklist for Pollution Prevention
February 2000
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Other State Agencies
Empire State Development (BSD),
Small Business Division,
Clean Air Act Small Business Ombudsman
633 3rd Avenue, 32nd Floor
New York, NY 10017
Phone: (800) STATENY
For assistance in determining how
regulations may affect a business and in
communicating with state regulatory
agencies; sets up workshops; and handles
complaints.
NYS Department of Health
Corning Tower
Empire State Plaza
Albany, NewYork 12237
Phone:(518)485-5378
For questions concerning the management
of regulated medical waste as it pertains to
the Public Health Law 1389 AA-GG.
NYS Environmental Facilities Corporation
Small Business Assistance Program
50 Wolf Road, Albany, NY 12205
Hotline: (800) 780-7227
Phone:(518)457-9135
FAX: (518)485-8494
Provides fee-free technical assistance, interprets
requirements, provides advice on pollution
prevention and control strategies and conducts
environmental audits. EFC also provides
fee-based contractual technical advisory
services for a broad range of environmental
issues.
NYS Department of Health
Wadsworth Center -
Regulated Medical Waste Program
Phone:(518)485-5378
Provides a list of approved treatment
technologies and information on the application
procedures to obtain approval for alternative
treatment systems, as well as questions related
to efficacy test methods and results.
Federal Assistance
Pollution Prevention Information
Clearinghouse
Phone: (202)260-1023
Fax: (202) 260-9780
E-mail:ppic@epamail.epa.gov
Provides a library and an electronic
bulletin board dedicated to information on
pollution prevention.
U.S. EPA Region II
Compliance Assistance & Program
Support Branch
290 Broadway, 22nd Floor
New York, NY 10007-1866
Phone: (212) 637-3268
To receive technical assistance and
guidance on compliance, pollution
prevention and waste minimization issues
on a multimedia basis.
U.S. EPA Asbestos and Small Business
Ombudsman Hotline
Phone: (800)368-5888
Helps private citizens, small businesses and
smaller communities with questions on all
program aspects with EPA.
National Response Center
Phone: (800)424-8802
EPA's 24-hour hotline for reporting oil and
chemical spills to the Federal Government. This
hotline is manned by the U.S. Coast Guard.
RCRA/Superfund/EPCRA Hotline
Phone: (800)424-9346
To obtain information on matters related to
solid waste, hazardous waste, or underground
storage tanks. Also can be used to order EPA
publications.
Environmental Self-Assessment
For Health Care Facilities
40
A Checklist for Pollution Prevention
February 2000
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Internet Resources
Organization
Joint Commission on Accreditation of Healthcare
Organizations
American Hospital Association
Greater New York Hospital Association
Healthcare Association of New York State, Inc.
Iroquois Healthcare Alliance
Medical Society of the State of New York
Northern Metropolitan Hospital Association
Western New York Healthcare Association
World Health Organization
Health Care Without Harm
Centers for Disease Control and Protection
U.S. Department of Veterans Affairs
New York State Nurses Association
Tellus Institute
North Carolina's Division of Pollution
Prevention and Environmental Assistance
NEW YORK STATE
Empire State Development Services to Business
NYS Department of Environmental Conservation
NYS Environmental Facilities Corporation
NYS Energy Research and Development
Authority
U.S. EPA
Green Lights Partnership
Enviro$en$e
Technology Transfer Network
Climate Wise
U.S. DEPARTMENT OF ENERGY
Pollution Prevention Information Clearinghouse
Internet Address
http://www.jcaho.org
http://www.aha.org
http://www.gnyha.org
http://www.hanys.org
http://www.iroquois.org
http://www.mssny.org
http ://www.normet. org
http ://www. wnyha. com
http://www.who.int
http ://www. noharm. org
http://www.cdc.gov
http://va.gov
http://www.nysna.org
http ://www.tellus. org
http://www.p2pays.org
http://www.empire.state.ny.us
http://www.dec.state.ny.us
http ://www.nysefc. org
http ://www.nyserda. org
http://www.epa.gov/greenlights.html
http://www.es.epa.gov
http://www.epa.gov/ttnsbapl/index.html
http://www.ega.gov/climatewise
http: //epi c. er. doe. gov/epi c
Environmental Self-Assessment
For Health Care Facilities
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A Checklist for Pollution Prevention
February 2000
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PACIFIC NORTHWESTLABORA TORIES
Green Guide http://www.pnl.gov
Pollution Prevention Resource Center http://www.pprc.org
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 42 February 2000
-------
Appendix A
Health Care Facilities Instruments And
Products That May Contain Mercury
The following information was obtained from: Reducing Mercury Use in Health Care, Promoting
a Healthier Environment, A How-to Manual, prepared by Monroe County Department of Health,
in cooperation with Strong Memorial Hospital, Rochester, NY and the Monroe County Department
of Environmental Services, with funding by a grant from the U.S. Environmental Protection Agency.
This list should not be assumed to be complete.
Thermometers
Body temperature thermometers
Clerget sugar test thermometers
Heating and cooling system thermometers
Incubator/water bath thermometers
Minimum/Maximum thermometers
National Institute of Standards and Technology calibration thermometers
Tapered bulb (armored) thermometers
Sphygmomanometers
Gastrointestinal tubes
Cantor tubes
Esophageal dilators (bougie tubes)
Feeding tubes
Miller Abbott tubes
Dental amalgam
Pharmaceutical supplies
Contact lens solutions and other opthalmic products containing thimerosal
phenylmercuric acetate or phenlymercuric nitrate
Diuretics with mersalyl and mercury salts
Early pregnancy test kits with mercury containing preservatives
Merbromin/water solution
Nasal spray with thimerosal, phenylmercuric acetate or phenylmercuris nitrate
Vaccines with thimerosal (primiarily in hemophilus, hepatitis, rabies, tetanus, influenza,
diphtheris and pertussis vaccines)
Cleaners and degreasers with mercury-contaminated caustic soda or chlorine
Batteries (medical uses)
Alarms
Blood analyzers
Defibrillators
Hearing aids
Meters
Monitors
Pacemakers
Pumps
Scales
Telemetry transmitters
Ultrasound
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 43 February 2000
-------
Appendix A - Continued
Health Care Facilities Instruments And
Products That May Contain Mercury
Ventilators
Batteries (nonmedical uses)
Lamps
Fluorescent
Germicidal
High-intensity discharge (high pressure sodium, mercury vapor, metal halide)
Ultraviolet
Electrical equipment
Tilt switches
Air flow/fan limit control
Building security systems
Chest freezer lids
Fire alarm box switches
Lap-top computer screen shut-off
Pressure control (mounted on bourbon tube or diaphragm)
Silent light switches (single-pole and three-way)
Temperature control (mounted on bimetal coil or attached to bulb devices)
Washing machine (power shut off)
Float control
Septic tanks
Sump pumps
Thermostats (nondigital)
Thermostat probes in electrical equipment
Reed relays (low voltage, high precision analytical equipment)
Plunger or displacement relays (high current/high voltage application)
Thermostat probes in gas appliances (flame sensors, gas safety valves)
Pressure gauges
Barometers
Manometers
Vacuum gauges
Other
Devices, such as personal computers, that utilize a printed wire board
Blood gas analyzer reference electrode (Radiometer brand)
Cathode-ray oscilloscope
DC watt hour meters (Duncan)
Electron microscope (mercury may be used as a damper)
Flow meters
Generators
Hitachi Chem Analyzer reagent
Lead analyzer electrode (ESA model 301 OB)
Sequential Multi-Channel Autoanalyzer (SMCA) AU 2000
Vibration meters
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 44 February 2000
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Appendix B
Alternative Treatment Technologies
The following information was obtained from: New York State Department of Health
(NYSDOH), Managing Regulated Medical Waste, Interpretive Guidelines for Implementing
Revisions to Public Health Law 1389AA-GG.
There are numerous alternative technologies which are currently available from over forty
manufactures within the United States and Europe. They vary in capacity from those designed
for use in physician/dentist offices, capable of treating twenty-five to one hundred pounds per
cycle, to systems to be used in major medical centers or regional treatment facilities, which are
able to treat one ton or more of waste per cycle (generally a cycle is one to one and one/half
hours in length). In many instances these alternative technologies simultaneously treat, destroy,
and reduce the volume of regulated medical waste through the use of pre- or post-treatment
grinders/shredders orby the use of extremely high temperatures (upwards of 15,000 °F) to reduce
the waste to ash. They vary in cost from less than $2,000 per unit to approximately $750,000
per system. The larger the capacity, the greater the waste reduction and the more automated the
technology, the higher the initial cost of the unit. However, regardless of the capacity, the extent
of the automation, or overall volume reduction, all alternative systems treat regulated medical
waste using one of three methods; (a) heating the waste to a minimum of 210 °F by means of
microwaves, radio waves, hot oil, hot water, steam or superheated gases; (b) exposing the waste
to chemicals such as sodium hypochlorite (household bleach) or chlorine dioxide; or (c) by
subjecting the waste to heated chemicals.
All alternative technologies must be approved by the NYS Department of Health prior to being
offered for sale in New York State. The Regulated Medical Waste Program (RMWP) is the unit
within the Wadsworth Center which evaluates all alternative treatment systems for the
Department of Health. Each manufacturer seeking approval of an alternative treatment system
for use in the State must test the efficacy of the product in accordance with the recommendations
contained in the Technical Assistance Manual: State Regulatory Oversight of Medical Waste
Treatment Technologies. A list of such approved treatment technologies and information on the
application procedures to obtain approval for alternative systems, as well as questions related to
efficacy test results can be obtained by calling the Regulated Medical Waste Program at (518)
485-5378.
It is important to understand that a form that evidences treatment by an approved technology
must accompany the treated waste to a solid waste management facility authorized to accept the
treated regulated medical waste. The Department of Health has developed a form for this
purpose which must be used by those facilities that treat on-site by incineration or autoclaving.
The Department of Health does not require the use of this specific form with waste treated by
some alternative treatment technologies.
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 45 February 2000
-------
REFERENCES
U.S. Environmental Protection Agency (August, 1991). Project Summary, "Hospital Pollution
Prevention Case Study." EPA/600/S2-91/024.
U.S. Environmental Protection Agency (June, 1990). Guides to Pollution Prevention: Selected
Hospital Waste Streams. EPA/625/7-90/009.
Riggle, David (February, 1994). "Solid Waste Surgery: Advanced Hospital Recycling."
BioCycle, pages 34-37.
North Carolina Department of Environment, Health, and Natural Resources (August, 1996).
Waste Reduction and Disposal Options for Specific Hospital Wastes.
Tickner, Joel, Lowell Center for Sustainable Production, University of Massachusetts Lowell
(revised June 14, 1999). The Use of Di-2-Ethylhexyl Phthalate in PVC Medical Devices:
Exposure, Toxicity, and Alternatives.
Monroe County Department of Health, in cooperation with Strong Memorial Hospital,
Rochester, New York and the Monroe County Department of Environmental Services (1998).
Reducing Mercury Use in Health Care: Promoting a Healthier Environment.
Federal Register, Environmental Protection Agency (July 6, 1999). "40 CFR Parts 260, 261,
264, etc. Hazardous Waste Management System; Modification of the Hazardous Waste
Program; Hazardous Waste Lamps; Final Rule."
Waste Management Assistance Division; Nelson, Julie A., Gibson, Larry A. (January, 1996).
Pollution Prevention Works for Iowa: Health Care Case Summaries. From: Iowa Waste
Reduction Assistance Program, Waste Management Assistance Division, Iowa Department of
Natural Resources, 900 East Grand Avenue, Des Moines, IA 50319-0034; (515)281-8927.
Boston University Corporate Education Center (1998). A New Prescription: Pollution
Prevention Strategies for the Health Care Industry, proceedings of a workshop held in October,
1998. From: Boston University Corporate Education Center, Tyngsborough, Massachusetts.
Department of Veterans Affairs (1998). VHA Program Guide 1850.1 Recycling Program.
From: Environmental Management Programs Office, Veterans Health Administration,
Washington, D.C.
New York State Department of Health (December, 1995). Managing Regulated Medical Waste,
Interpretive Guidelines for Implementing Revisions to Public Health Law 1389M-GG. Kansas
Small Business Environmental Assistance Program. Medical Facility Waste.
U.S. Environmental Protection Agency Fact Sheets:
#1 Keeping Mercury Out of Medical Waste (1995)
#3 Use of Alternative Products (1995)
Keep Mercury Out of the Wastewater Stream
City of Palo Alto Regional Water Quality Control Plant. Best Management Practices for
Hospitals and Medical Facilities. From: Palo Alto Regional Water Quality Control Plant, 2501
Embrarcadero Way, Palo Alto, CA 94303; (415) 329-2598.
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 46 February 2000
-------
City of Palo Alto Regional Water Quality Control Plant. Pollution Prevention for Hospitals and
Medical Facilities. From: Palo Alto Regional Water Quality Control Plant, 2501 Embarcadero
Way, Palo Alto, CA 94303; (915) 329-2598.
Health Care Without Harm (August, 1997). Healing the Harm: Eliminating the Pollution from
Health Care Practices. From CCHW Center for Health, Environment and Justice, P.O. Box
6806, Falls Church, VA 22042, (703) 237-2249; email: noharm@,iatp.org
PRO-ACT Fact Sheet: Management of Medical/Infectious Waste (October, 1998). From: Air
Force Environmental Exchange, Environmental Quality Directorate HQ Air Force Center for
Environmental Excellence.
U.S. Environmental Protection Agency, Persistent, Bioaccumulative, and Toxic (PBT)
Chemicals Initiative, Office of Pollution Prevention and Toxic's, Dioxins andFurans.
Environmental Self-Assessment A Checklist for Pollution Prevention
For Health Care Facilities 47 February 2000
-------
Major Federal Environmental
Regulations Applicable to Hospitals*
1. Air Programs
Part 52
Part 60
Part 61
Part 62
Part 63
Part 68
Part 70
Part 82
2. Water Programs
Part 112
Part 122
Part 141
Part 142
Part 143
Part 144
Part 145
Part 146
Part 147
Part 148
Part 403
3. Pesticide Programs
Part 160
Part 162
Part 170
Part 171
Part 172
Clean Air Act
Section 21 Prevention of Significant Deterioration of Air Quality
Standards of Performance for New Stationary Sources
National Emission Standards for Hazardous Air Pollutants, Subpart M,
National Emission Standard for Asbestos
Subpart HHH - Federal Plan Requirements for
Hospital/Medical/Infectious Waste Incinerators
National Emission Standards for Hazardous Air Pollutants for Source
Categories (all applicable provisions)
Chemical Accident Prevention Provisions
State Operating Permit Programs
Protection of Stratospheric Ozone
Clean Water Act
Oil Pollution Prevention
EPA Administered Permit Programs: The National Pollutant Discharge
Elimination System
National Primary Drinking Water Regulations
National Primary Drinking Water Regulations Implementation
National Secondary Drinking Water Regulations
Underground Injection Control ("UIC") Program
State UIC Program Requirements
UIC Program: Criteria and Standards
State UIC Programs
Hazardous Waste Injection Restrictions
General Pretreatment Regulations for Existing and New Sources of
Pollution
Federal Insecticide, Fungicide, and Rodenticide Act
Good Laboratory Practice Standards
State Registration of Pesticide Products
Worker Protection Standard
Certification of Pesticide Applicators
Experimental Use Permits
4. Solid and Hazardous Wastes
Resource Conservation and Recovery Act
Part 260 Hazardous Waste Management System:
Part 261 Identification and Listing of Hazardous Waste)
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Part 262 Standards Applicable to Generators of Hazardous Waste
Part 263 Standards Applicable to Transporters of Hazardous Waste
Part 264 Standards for Owners and Operators of Hazardous Waste Treatment,
Storage, and Disposal Facilities
Part 265 Interim Status Standards for Owners and Operators of Hazardous
Waste Treatment, Storage, and Disposal Facilities
Part 266 Standards for the Management of Specific Hazardous Wastes and
Specific Types of Hazardous Waste Management Facilities
Part 268 Land Disposal Restrictions
Part 273 Standards for Universal Waste Management
Part 279 Standards for the Management of Used Oil
Part 280 Technical Standards and Corrective Action Requirements for Owners
and Operators of Underground Storage Tanks ("USTs")
5. Hazardous Substances and Chemicals, Environmental Response, Emergency Planning,
and Community Right-to-Know Programs
Comprehensive Environmental Response, Compensation, and Liability Act
Part 302 Designation, Reportable Quantities, and Notification
Part 355 Emergency Planning and Notification
Part 370 Hazardous Chemical Reporting: Community Right-to-Know
Part 372 Toxic Chemical Release Reporting: Community Right-to-Know
6. Toxic Substances Programs Toxic Substance Control Act
Part 745 Lead-Based Paint Poisoning Prevention in Certain Residential
Structures
Part 761 Polychlorinated Biphenyls (PCBs) Manufacturing, Processing,
Distribution in Commerce, and Use Prohibitions
* Relevant state regulations may exist and may differ from federal regulations. Please
review the applicable state regulations.
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1
a
WASHINGTON, D.C.
MAR ! 7
OFFICE OF
SOLID WASTE AND EMERGENCY
RESPONSE
MEMORANDUM
SUBJECT: Frequently Asked Qu
FROM: /JfceBerfSpringer,TOec
TO:
//Office of Solid Waste
out Satellite Aecamulation Areas
RCRA Directors, EPA Regions 1-10
Purpose
The purpose of this memo is to reiterate and clarify the Environmental Protection Agency's
(EPA) regulations under the Resource Conservation and Recovery Act (RCRA) hazardous waste
management program regarding satellite accumulation areas (SAAs). For convenience, this
memo pulls together answers to many of the frequently asked questions EPA receives regarding
SAAs. Many, but not all, of the questions in this memo have been answered by EPA in previous
letters and documents. For those questions that have been answered previously, citations to
relevant memos and Federal Register preambles are provided in numbered endnoles.
Summary of Generator Accumulation Regulations
When accumulating hazardous waste on-site, large quantity generators (LQGs) must comply with
40 CFR 262.34(a) and small quantity generators (SQGs) must comply with 40 CFR 262.34(d) to
avoid the requirement to obtain a hazardous waste treatment, storage, or disposal permit.8 LQGs
may accumulate hazardous waste on-site without interim status or a permit for up to 90 days,
while SQGs have up to 180 days to accumulate hazardous waste without interim status or a
a Generators of > 1000 kg/month of hazardous waste or >1 kg/month of acute hazardous
waste are large quantity generators (LQGs). Generators of >100 kg/month but <1000 kg/month
of hazardous waste are small quantity generators (SQGs). Generators of < 100 kg/month of
hazardous waste and < I kg/month of acute hazardous waste are conditionally exempt small
quantity generators (CESQGs) and arc regulated under 40 CFR 261.5. The regulations for
CESQGs are not discussed in this memo.
Recycled/Recyclable «Printed with Vegetable OH Based Inks on 100% Recycled Paper (20% Postconsumer)
-------
permit,b The Agency to as "90-day" or
"180-day" or "central accumulation" areas.
The allow to up to 55 of
(or 1 of acute waste) in
» at or point of generation,
» under the control of the operator,
for accumulation provided the complies
with the requirements of 262,34(c),
When a accumulates hazardous waste on-site in containers, the regulations for 90-day
areas, 180-day SAAs all refer generators to the container management standards in Part
265 Subpart I, The table below identifies the sections of Part 265 Subpart I that must be
followed in each case:
1
Container for
265 I
265.171
265,172
265.173
265,174
265.176
265.177
265.178
Condition of containers
Compatibility of waste
(a)
waste
(b) to
Inspections
of or reactive
for wastes
Air
Satellite
aceum.
area
YES
YES
YES
no
no
no
no
no
180-day
area
(SQG)
YES
YES
YES
YES
YES
no
YES
no
90-day
area
YES
YES
YES
YES
YES
YES
YES
YES
bSmall quantity generators who must transport hazardous waste >200 miles for treatment,
storage or disposal may accumulate waste on-site for 270 days without a permit or interim status
(262.34(e)). Large quantity generators of P006 may accumulate hazardous waste on-site for 180
days without a permit or interim status provided the conditions of 262.34(g)(l)-(4) are met.
2
-------
Ill addition to the container indicated above, the regulations for both SQGs LQGs
have requirements for container labeling;
on-site to
the (LDR) LQGs
while SQGs not 6000 kg waste on-site at time.
In contrast, additional requirements for SAAs are limited to:
1, Generators must satellite containers of hazardous waste with the words
"Hazardous Waste" or "with the
containers," (262.34(c)(l)(ii))
2, When a 55 of hazardous (or 1
waste), the (262.34(c)(2)):
» mark the container with the date on which 55 gallons (or 1 quart of acute
hazardous waste) is exceeded,
» remove the of 55 gallons (or 1 of acute
within or comply with the 90-day or 180-day
as
Frequently Satellite Accumulation Areas
I- Question: Can small quantity generators establish SAAs according to 262.34(c) for their
waste?
Yes, Both LQGs SQGs of the
while is in SAAs, provided it is in with all the
of 40 CFR 262.34(c).' If an SQG or LQG accumulates 55 gallons
of hazardous (or 1 quart of acute hazardous waste) at an SAA, the must be
removed within three days. If after that period, the excess is not removed, LQGs must
comply with 262.34(a) SQGs must comply with 262»34(d), with to the
amounts.
2. If a generator 55 of hazardous (or 1 quart
of acute waste) at an SAA, when should the generator date the container(s)?
When 55 gallons of hazardous waste (or 1 quart of acute hazardous waste) is exceeded, or
when the container is moved to the central accumulation area?
Answer: When 55 gallons of hazardous waste (or 1 quart of acute is
exceeded in an SAA, the needs to the container, so that the
-------
move the to the 90-day or 180-day within (262.34(c)(2)). Then
3 days have or the is to the
area, the to the again, so it can be
90 or 180 days and 262.34(d)(4), the
not to be it is the SAA
is directly to a permitted or unit.) This an LQG has up
to 93 a SQG has up to 183 for ori-site accumulation time once 55 gallons of
(or 1 quart of acute hazardous waste) has at the SAA - up
to three days in the SAA, followed by up to 90 or 180 days in the central accumulation
area.2
3. Question; When a generator accumulates more than 55 gallons of hazardous waste (or 1
quart of acute hazardous waste) at an SAA, the excess of 55 gallons (or the of 1
quart of waste) to be removed from the SAA days.
What is by "three days"?
Three It not
or the to use 72 as the
limit but 72
the of day on containers. In the the switched
to using so only to containers that hold the of
55 (or 1 of acute waste).3
4. Question: If an SAA has a full 4-gallon container of hazardous waste, does the generator
have to remove the container from the SAA within three days of being filled?
Answer: No. There is no federal that full be
removed from an SAA within three of being filled. Only the of 55 of.
(or the of 1 of acutely be
within
5. The of 265.173(a) "A
be during storage, when it is
to or remove waste." that to be
managed and/or in the containers in which they were originally accumulated?
Answer: No, Generators may transfer hazardous waste between containers to facilitate
storage, transportation, or treatment.4 For example, a generator may wish to consolidate
several partially full containers of the same hazardous waste from an SAA into
container before transferring it to a central accumulation area. Generators also may
-------
transfer hazardous between containers in central accumulation However, the
90-day or 180-day "clock" for not if the is
to
6- Question: Do containers in SAAs have to comply with the air of Part
265 AA, BB, and CC?
Answer: No. Containers in SAAs are not required to comply with the air emission
standards of Part 265 Subparts AA, BB, and CC,5 Likewise, SQGs are not required to
comply with the air at their 180-day LQGs,
however, are to the RCRA air at 90-day
Therefore, when an LQG transfers waste from an SAA to a 90-day
accumulation area, the applicable portions of the air emission standards of Part
265 Subparts AA, BB, and CC must be met at the 90-day central accumulation
7. Section 265.174 of I be at
weekly for leaks and deterioration caused by corrosion or other factors. Both LQGs and
SQGs must inspect containers in their central accumulation areas. Are SQGs or LQGs
to in SAAs?
Answer; No. Inspections of containers (whether weekly or some other frequency) in
SAAs are not required, so long as the provisions of 262,34(c) are met.6 Section 265.174,
which requires inspections, is not among the provisions listed in 262,34(c) for SAAs
Table 1). However, the SAA regulations do require waste in an SAA
be the the in
condition (265.171), compatible with its contents (265,172), and closed except when
adding or removing waste (265.173), which should achieve the goal of inspections:
are of leaks deterioration.
8. Question; SQGs must conduct training in accordance with 262.34(d)(5)(iii) and LQGs
must conduct training in accordance with 265.16. Do the RCRA regulations require
training of personnel working in SAAs?
Answer: No. The RCRA regulations do not require training of personnel working in
SAAs.7 Personnel that have to or work in central accumulation areas, including
those that move hazardous waste from a SAA to a central accumulation area, be
trained. As the ones actually waste, however, working in
SAAs to be the with are to
know when they have a hazardous waste so that it will be managed in
accordance with the RCRA regulations.
-------
9. Question; The preamble to the final rule that added 262.34(c), states, "...only one
will normally be accumulated at each satellite area."8 Can there be more than one
hazardous waste at an SAA? Can there be more than one container at an SAA?
Answer? Yes, It's permissible to have more than one hazardous waste in an SAA.
Likewise, it's permissible to have more than one container of hazardous in an SAA.
The regulations do not limit the number of hazardous or the of containers
that can be placed in an SAA. The regulations limit only the total volume
waste at a single SAA to 55 gallons (or 1 of acute waste). If there are
in an SAA, be in
with.262.34(c)(l)(ii).
the did not
in an SAA, a to the for the
not as of the
for SAAs, clearly
incompatible wastes be stored separately. Furthermore, in the event any
are in a an
to or the §7003 of RCRA the
to to the
10. Can a facility multiple SAAs?
Answer: Yes. The do not limit the total number of SAAs at a generator's
facility. the do not limit the total amount of hazardous that
be at various SAAs a facility. The regulations limit only the
volume of hazardous waste that can be accumulated at a single SAA to 55 gallons (or 1
quart of acute hazardous waste). _ .
It's not possible in a memo for the Agency to delineate for all situations what constitutes
a SAA versus what constitutes separate SAAs. The regulations state that a
generator may accumulate hazardous waste "in containers at or near any point of
generation where wastes initially accumulate, which is under the control of the operator
of the process generating the waste." For additional guidance about the Agency's intent,
refer to the preamble to the final rule for SAAs, which states, "Certainly...a row of full 55
gallon drums spaced 5 .feet apart along the factory wall," is not a row of distinct SAAs,
but is SAA.9
-------
11. If a facility has multiple S AAs, can be SAA
to
No. not move SAAs,10 Once a
an SAA, it be for a central accumulation
is under 262.34(a) or (d) or for final or at a facility with a
permit or interim status
However, a single SAA may have multiple points of generation. Movement or
consolidation of hazardous waste within an SAA is'permissible, as long as it "at
or near" the "point of generation" "under the control of the of the
generating the waste,"
In a 90-day or 180-day
the do not the fully
to as as the
on-site. However, the 90-day or 180-day "clock" for not if the
is to
12. Qugstjo.li« Do generators have to include the hazardous waste in SAAs in the monthly
quantities for determining generator status (i.e., SQG or LQG)?
Answer: Yes, include all the in the SAAs in
their monthly for '' 261.5(c) (d)
identify do not have to be
in is not on this list; in
SAAs be in the
13. When a has to
containers, do the containers that collect such wastes have to be in compliance with the
SAA
Answer: Yes. Even if the discharging unit is not regulated under RCRA, the attached
containers that collect hazardous wastes from such equipment must be in compliance
with the SAA regulations, if those containers collect that are or
characteristic Waste containers in SAAs be:
* in good condition (265.171)
* with (265,172)
"words identify the of the container" or the
words "hazardous waste" (262.34(c)(l)(ii)).
-------
In addition, the in SAAs be or
(265.173(a)). Generators would not be to
is to the but would
to the is not to the
container.
The to is a point of generation. It is for
there to be multiple of equipment within SAA, and thus multiple points of
within a SAA, provided all the of equipment are "at or near"
"under the control of the operator of the process generating the waste."
Under this scenario, the total amount of hazardous waste in the SAA would be limited to
55 gallons (or 1 quart of acute hazardous waste) and a generator would be allowed to
consolidate like hazardous wastes from multiple discharging units.
14. If a facility has very (e.g., or
are too to with the words waste" or "other
the of the container," the be
we the to be in
larger would the
the However, would achieve the
would be
Please note that this letter discusses only the federal hazardous waste regulations. that are
authorized to implement the RCRA program may have regulations that are different than the
federal regulations provided they are not less stringent than the federal program. Please consult
your regulatory requirements. If you have questions the
regulations in contact Kristin Fitzgerald at (703) 308-8286 or
Fitzgerald.Kristin@epa,gov.
-------
for of
1, April 1990; #1
2, #13410,
3. December 20, 1984; 49 FR Final Rule; Docket # RCRA-19844)028.
4. 1, 1993; to #11791.
5. February 1996; RCRA/Superfund Hotline Monthly Report; RCRA Online #13777,
6. 1999; Hotline
7. 20, 49 FR #
8. December 20, 1984; 49 FR 49570; Final Rule; Docket # RCRA-
9. 20, 49 FR #
10, February 1999; RCRA/Superfund Monthly Report; RCRA Online #14337.
11. February 10, 1994; Shapiro to Dolce; RCRA Online #11812.
To obtain Federal Register notices, search EPA's E-docket at www.epa.gov/edocket.
To notices, RCRA Online at
www. epa. go v/rcraonline.
-------
United States
Environmental Protection
Agency
Enforcement and
Compliance Assurance
(2224-A)
EPA 305-B-01-002
March 2001
Protocol for Conducting
Environmental Compliance
Audits under the Emergency
Planning and Community
Right-to-Know Act and
CERCLA Section 103
EPA Office of Compliance
-------
Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Notice
U.S. EPA's Office of Compliance prepared this document to aid regulated entities in developing programs at
individual facilities to evaluate their compliance with environmental requirements arising under federal law. The
statements in this document are intended solely as guidance to you in this effort. Among other things, the
information provided in this document describes existing requirements for regulated entities under the Emergency
Planning and Community Right -to-Know Act (EPCRA) and under CERCLA Section 103 and their implementing
regulations at 40 CFR 355 through 372 under EPCRA and 40 CFR 302 under CERCLA While the Agency has
made every effort to ensure the accuracy of the statements in this document, the regulated entity's legal obligations
are determined by the terms of its applicable environmental facility-specific permits, and underlying statutes and
applicable state and local law. Nothing in this document alters any statutory, regulatory or permit requirement. In
the event of a conflict between statements in this document and either the permit or the regulations, the document
would not be controlling. U.S. EPA may decide to revise this document without notice to reflect changes in EPA's
regulations or to clarify and update the text. To determine whether U.S. EPA has revised this document and/or to
obtain additional copies, contact U.S. EPA's National Center for Environmental Publications at (1-800-490-9198).
The contents of this document reflect regulations issued as of January 31,2001.
Acknowledgments
U.S. EPA would like to gratefully acknowledge the support of the U.S. Army Corps of Engineers Construction
Engineering Research Laboratory (CERL) for providing suggestions for overall format of this document. The Office
of Compliance at U.S. EPA gratefully acknowledges the contribution of U.S. EPA's program offices and the U.S.
EPA's Office of Counsel in reviewing and providing comment on this document.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
-------
Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Table of
Notice inside cover
Acknowledgment inside cover
Section 1: Introduction
Background ii
Who Should Use These Protocols? ii
U.S. EPA's Public Policies that Support Environmental Auditing iii
How To Use the Protocols iv
The Relationship of Auditing to Environmental Management Systems vi
Section II: Audit Protocol
Applicability 1
Review of Federal Legislation 1
State and Local Regulations 1
Key Compliance Requirements 2
Key Terms and Definitions 4
Typical Records to Review 10
Typical Physical Features to Inspect 10
List of Acronyms and Abbreviations 10
Index for Checklist Users 13
Checklist 15
Appendices
Appendix A: Lower Thresholds for Chemicals of Special Concern Al
Appendix B: User Satisfaction Questionnaire and Comment Form Bl
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Section I
Introduction
The Environmental Protection Agency (U.S. EPA) is responsible for ensuring that businesses and organizations
comply with federal laws that protect the public health and the environment. U.S. EPA's Office of Enforcement and
Compliance Assurance (OECA) has begun combining traditional enforcement activities with more innovative
compliance approaches including the provision of compliance assistance to the general public. U.S. EPA's Office of
Compliance Assistance was established in 1994 to focus on compliance assistance-related activities. U.S. EPA is
also encouraging the development of serf-assessment programs at individual facilities. Voluntary audit programs
play an important role in helping companies meet their obligation to comply with environmental requirements. Such
assessments can be a critical link, not only to improved compliance, but also to improvements in other aspects of an
organization's performance. For example, environmental audits may identify pollution prevention opportunities that
can substantially reduce an organization's operating costs. Environmental audits can also serve as an important
diagnostic tool in evaluating a facility's overall environmental management system or EMS.
U.S. EPA is developing 13 multi-media Environmental Audit Protocols to assist and encourage businesses and
organizations to perform environmental audits and disclose violations in accordance with OECA's Audit and Small
Business Policies. The audit protocols are also intended to promote consistency among regulated entities when
conducting environmental audits and to ensure that audits are conducted in a thorough and comprehensive manner.
The protocols provide detailed regulatory checklists that can be customized to meet specific needs under the
following primary environmental management areas:
Generation of RCRA
Hazardous Waste
CERCLA
Safe Drinking Water Act
Managing Nonhazardous
Solid Waste
Treatment Storage and
Disposal of RCRA
Hazardous Waste
Clean Air Act
TSCA
Pesticides Management
(FIFRA)
RCRA Regulated Storage
Tanks
EPCRA
Clean Water Act
Universal Waste and Used Oil
Management of Toxic
Substances (e.g., PCBs,
lead-based paint,
and asbestos)
Who Should Use These Protocols?
U.S. EPA has developed these audit protocols to provide regulated entities with specific guidance in periodically
evaluating their compliance with federal environmental requirements. The specific application of this particular
protocol, in terms of which media or functional area it applies to, is described in Section II under "Applicability".
The Audit Protocols are designed for use by individuals who are already familiar with the federal regulations but
require an updated comprehensive regulatory checklist to conduct environmental compliance audits at regulated
facilities. Typically, compliance audits are performed by persons who are not necessarily media or legal experts but
instead possess a working knowledge of the regulations and a familiarity with the operations and practices of the
facility to be audited. These two basic skills are a prerequisite for adequately identifying areas at the facility subject
to environmental regulations and potential regulatory violations that subtract from the organizations environmental
performance. With these basic skills, audits can be successfully conducted by persons with various educational
backgrounds (e.g., engineers, scientists, lawyers, business owners or operators). These protocols are not intended to
This document is intended solely for guidance. No statutory or regulatory ii
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
be a substitute for the regulations nor are they intended to be instructional to an audience seeking a primer on the
requirements under Title 40; however, they are designed to be sufficiently detailed to support the auditor's efforts.
The term "Protocol" has evolved over the years as a term of art among the professional practices of auditing and
refers to the actual working document used by auditors to evaluate facility conditions against a given set of criteria
(in this case the federal regulations). Therefore these documents describe "what" to audit a facility for rather than
"how" to conduct an audit. To optimize the effective use of these documents, you should become familiar with basic
environmental auditing practices. For more guidance on how to conduct environmental audits, U.S. EPA refers
interested parties to two well-known organizations: The Environmental Auditing Roundtable (EAR) and the Institute
for Environmental Auditing (IEA).
Environmental Health and Safety Auditing Roundtable The Institute for Environmental Auditing
35888 Mildred Avenue Box 23686
North Ridgeville, Ohio 44039 L'Enfant Plaza Station
(216) 327-6605 Washington, DC 20026-3686
U.S. EPA's Public Policies that Support Environmental Auditing
In 1986, in an effort to encourage the use of environmental auditing, EPA published its "Environmental Auditing
Policy Statement" (see 51 FR 25004). The 1986 audit policy states that "it is EPA policy to encourage the use of
environmental auditing by regulated industries to help achieve and maintain compliance with environmental laws and
regulation, as well as to help identify and correct unregulated environmental hazards." In addition, EPA defined
environmental auditing as "a systematic, documented, periodic, and objective review of facility operations and
practices related to meeting environmental requirements." The policy also identified several objectives for
environmental audits:
verifying compliance with environmental requirements,
evaluating the effectiveness of in-place environmental management systems, and
assessing risks from regulated and unregulated materials and practices.
In 1995, EPA published "Incentives for Serf-Policing: Discovery, Disclosure, Correction and Prevention of
Violations" - commonly known as the EPA Audit Policy - which both reaffirmed and expanded the Agency's 1986
audit policy (see 60 FR 66706 December 22, 1995). The 1995 audit policy offered major incentives for entities to
discover, disclose and correct environmental violations. On April 11, 2000, EPA issued a revised final Audit Policy
that replaces the 1995 Audit Policy (65 FR 19,617). The April 11, 2000 revision maintains the basic structure and
terms of the 1995 Audit Policy while lengthening the prompt disclosure period to 21 days, clarifying some of its
language (including the applicability of the Policy in the acquisitions context), and conforming its provisions to
actual EPA practices. The revised audit policy continues the Agency's general practice of waiving or substantially
mitigating gravity-based civil penalties for violations discovered through an environmental audit or through a
compliance management system, provided the violations are promptly disclosed and corrected and that all of the
Policy conditions are met. On the criminal side, the revised policy continues the Agency's general practice of not
recommending that criminal charges be brought against entities that disclose violations that are potentially criminal
in nature, provided the entity meets all of the policy's conditions. The policy safeguards human health and the
environment by precluding relief for violations that cause serious environmental harm or may have presented an
imminent and substantial endangerment. The audit policy is available on the Internet at www.epa.gov/auditpol.html.
In 1996, EPA issued its "Policy on Compliance Incentives for Small Businesses" which is commonly called the
"Small Business Policy" (see 61 FR 27984 June 3, 1996). The Small Business Policy was intended to promote
environmental compliance among small businesses by providing them with special incentives to participate in
government sponsored on-site compliance assistance programs or conduct environmental audits. EPA will eliminate
or reduce penalties for small businesses that voluntarily discover, promptly disclose, and correct violations in a
timely manner.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
On April 11, 2000, EPA issued its revised final Small Business Policy (see 65 FR 19630) to expand the options
allowed under the 1996 policy for discovering violations and to establish a time period for disclosure. The major
changes contained in the April 11, 2000 Small Business Policy revision include lengthening the prompt disclosure
period from 10 to 21 calendar days and broadening the applicability of the Policy to violations uncovered by small
businesses through any means of voluntary discovery. This broadening of the Policy takes advantage of the wide
range of training, checklists, mentoring, and other activities now available to small businesses through regulatory
agencies, private organizations, and the Internet.
More information on EPA's Small Business and Audit/Self-Disclosure Policies are available by contacting
EPA's Enforcement and Compliance Docket and Information Center at (202) 564-2614 or visiting the EPA
web site at: http://www.epa.gov/oeca/ccsmd/profile.html.
How to Use The Protocols
Each protocol provides guidance on key requirements, defines regulatory terms, and gives an overview of the federal
laws affecting a particular environmental management area. They also include a checklist containing detailed
procedures for conducting a review of facility conditions. The audit protocols are designed to support a wide range
of environmental auditing needs; therefore several of the protocols in this set or sections of an individual protocol
may not be applicable to a particular facility. To provide greater flexibility, each audit protocol can be obtained
electronically from the U.S. EPA Website (www.EPA.gov/oeca/ccsmd/profile.html). The U.S. EPA Website offers
the protocols in a word processing format which allows the user to custom-tailor the checklists to more specific
environmental aspects associated with the facility to be audited.
The protocols are not intended to be an exhaustive set of procedures; rather they are meant to inform the auditor,
about the degree and quality of evaluation essential to a thorough environmental audit. U.S. EPA is aware that other
audit approaches may also provide an effective means of identifying and assessing facility environmental status and
in developing corrective actions.
It is important to understand that there can be significant overlap within the realm of the federal regulations. For
example, the Department of Transportation (DOT) has established regulations governing the transportation of
hazardous materials. Similarly, the Occupational Safety and Health Administration (OSHA) under the U.S.
Department of Labor has promulgated regulations governing the protection of workers who are exposed to hazardous
chemicals. There can also be significant overlap between federal and state environmental regulations. In fact, state
programs that implement federally mandated programs may contain more stringent requirements that are not
included in these protocols. There can also be multiple state agencies regulating the areas covered in these
protocols. The auditor also should determine which regulatory agency has authority for implementing an
environmental program so that the proper set of regulations is consulted. Prior to conducting the audit, the auditor
should review federal, state and local environmental requirements and expand the protocol, as required, to include
other applicable requirements not included in these documents.
Review of Federal Legislation and Key Compliance Requirements:
These sections are intended to provide only supplementary information or a "thumbnail sketch" of the regulations
and statutes. These sections are not intended to function as the main tool of the protocol (this is the purpose of the
checklist). Instead, they serve to remind the auditor of the general thrust of the regulation and to scope out facility
requirements covered by that particular regulation. For example, a brief paragraph describing record keeping and
reporting requirements and the associated subpart citations will identify and remind the auditor of a specific area of
focus at the facility. This allows the auditor to plan the audit properly and to identify key areas and documents
requiring review and analysis.
This document is intended solely for guidance. No statutory or regulatory jv
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
State and Local Regulations:
Each U.S. EPA Audit Protocol contains a section alerting the auditor to typical issues addressed in state and local
regulations concerning a given topic area (e.g., RCRA and used oil). From a practical standpoint, U.S. EPA cannot
present individual state and local requirements in the protocols. However, this section does provide general
guidance to the auditor regarding the division of statutory authority between U.S. EPA and the states over a specific
media. This section also describes circumstances where states and local governments may enact more stringent
requirements that go beyond the federal requirements.
U.S. EPA cannot overemphasize how important it is for the auditor to take under consideration the impact of state
and local regulations on facility compliance. U.S. EPA has delegated various levels of authority to a majority of the
states for most of the federal regulatory programs including enforcement. For example, most facilities regulated
under RCRA, and/or CWA have been issued permits written by the states to ensure compliance with federal and state
regulations. In turn, many states may have delegated various levels of authority to local jurisdictions. Similarly,
local governments (e.g., counties, townships) may issue permits for air emissions from the facility. Therefore,
auditors are advised to review local and state regulations in addition to the federal regulations in order to perform a
comprehensive audit.
Key Terms and Definitions:
This section of the protocol identifies terms of art used in the regulations and the checklists that are listed in the
"Definitions" sections of the Code of Federal Regulations (CFR). It is important to note that not alldefinitions from
the CFR may be contained in this section, however; those definitions, which are commonly repeated in the checklists
or are otherwise critical to an audit process are included. Wherever possible, we have attempted to list these
definitions as they are written in the CFR and not to interpret their meaning outside of the regulations.
The Checklists:
The checklists delineate what should be evaluated during an audit. The left column states either a requirement
mandated by regulation or a good management practice that exceeds the requirements of the federal regulations.
The right column gives instructions to help conduct the evaluation. These instructions are performance objectives
that should be accomplished by the auditor. Some of the performance objectives may be simple documentation
checks that take only a few minutes; others may require a time-intensive physical inspection of a facility. The
checklists contained in these protocols are (and must be) sufficiently detailed to identify any area of the company or
organization that would potentially receive a notice of violation if compliance is not achieved. For this reason, the
checklists often get to a level of detail such that a specific paragraph of the subpart (e.g., 40 CFR262.34(a)(l)(i))
contained in the CFR is identified for verification by the auditor. The checklists contain the following components:
"Regulatory Requirement or Management Practice Column"
The "Regulatory Requirement or Management Practice Column" states either a requirement mandated by
regulation or a good management practice that exceeds the requirements of the federal regulations. The
regulatory citation is given in parentheses after the stated requirement. Good management practices are
distinguished from regulatory requirements in the checklist by the acronym (MP) and are printed in italics.
"Reviewer Checks" Column:
The items under the "Reviewer Checks:" column identify requirements that must be verified to accomplish
the auditor's performance objectives. (The key to successful compliance auditing is to verify and document
site observations and other data.) The checklists follow very closely with the text in the CFR in order to
provide the service they are intended to fulfill (i.e., to be used for compliance auditing). However, they are
not a direct recitation of the CFR. Instead they are organized into more of a functional arrangement (e.g.,
record keeping and reporting requirements vs. technical controls) to accommodate an auditor's likely
sequence of review during the site visit. Wherever possible, the statements or items under the "Reviewer
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Checks" column, will follow the same sequence or order of the citations listed at the end of the statement in
the "Regulatory Requirement" column.
"NOTE:" Statements
"Note:" statements contained in the checklists serve several purposes. They usually are distinguished from
"Verify" statements to alert the auditor to exceptions or conditions that may affect requirements or to
referenced standards that are not part of Title 40 (e.g., American Society for Testing and Materials (ASTM)
standards). They also may be used to identify options that the regulatory agency may choose in interacting
with the facility (e.g., permit reviews) or options the facility may employ to comply with a given
requirement.
Checklist Numbering System:
The checklists also have a unique numbering system that allows the protocols to be more easily updated by
topic area (e.g., RCRA Small Quantity Generator). Each topic area in turn is divided into control breaks to
allow the protocol to be divided and assigned to different teams during the audit. This is why blank pages
may appear in the middle of the checklists. Because of these control breaks, there is intentional repetition
of text (particularly "Note" Statements) under the "Reviewer Checks" column to prevent oversight of key
items by the audit team members who may be using only a portion of the checklist for their assigned area.
Environmental regulations are continually changing both at the federal and state level. For this reason, it is
important for environmental auditors to determine if any new regulations have been issued since the publication of
each protocol document and, if so, amend the checklists to reflect the new regulations. Auditors may become aware
of new federal regulations through periodic review of Federal Register notices as well as public information bulletins
from trade associations and other compliance assistance providers. In addition, U.S. EPA offers information on new
regulations, policies and compliance incentives through several Agency Websites. Each protocol provides specific
information regarding U.S. EPA program office websites and hotlines that can be accessed for regulatory and policy
updates.
U.S. EPA will periodically update these audit protocols to ensure their accuracy and quality. Future updates of the
protocols will reflect not only the changes in federal regulations but also public opinion regarding the usefulness of
these documents. Accordingly, the Agency would like to obtain feedback from the public regarding the format, style
and general approach used for the audit protocols. The last appendix in each protocol document contains a user
satisfaction survey and comment form. This form is to be used by U.S. EPA to measure the success of this tool and
future needs for regulatory checklists and auditing materials.
The Relationship of Auditing to Environmental Management Systems
An environmental auditing program is an integral part of any organization's environmental management system
(EMS). Audit findings generated from the use of these protocols can be used as a basis to implement, upgrade, or
benchmark environmental management systems. Regular environmental auditing can be the key element to a high
quality environmental management program and will function best when an organization identifies the "root causes"
of each audit finding. Root causes are the primary factors that lead to noncompliance events. For example a
violation of a facility's wastewater discharge permit may be traced back to breakdowns in management oversight,
information exchange, or inadequate evaluations by untrained facility personnel.
As shown in Figure 1, a typical approach to auditing involves three basic steps: conducting the audit, identifying
problems (audit findings), and fixing identified deficiencies. When the audit process is expanded, to identify and
correct root causes to noncompliance, the organization's corrective action part of its EMS becomes more effective.
In the expanded model, audit findings (exceptions) undergo a root cause analysis to identify underlying causes to
noncompliance events. Management actions are then taken to correct the underlying causes behind the audit findings
and improvements are made to the organizations overall EMS before another audit is conducted on the facility.
This document is intended solely for guidance. No statutory or regulatory vj
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Expanding the audit process allows the organization to successfully correct problems, sustain compliance, and
prevent discovery of the same findings again during subsequent audits. Furthermore, identifying the root cause of an
audit finding can mean identifying not only the failures that require correction but also successful practices that
promote compliance and prevent violations. In each case a root cause analysis should uncover the failures while
promoting the successes so that an organization can make continual progress toward environmental excellence.
Figure 1 - Expanded Corrective Action Model
Improve
Environmental
Mgmt. System
Effectiveness
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
VII
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This document is intended solely for guidance. No statutory or regulatory vjjj
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Section II
Audit Protocol
Applicability
This audit protocol addresses facilities that manufacture, process, store, or otherwise use hazardous substances defined in 40
CFR Part 302, extremely hazardous substances (EHSs) defined in 40 CFR Part 355, and toxic chemicals defined in 40 CFR
Part 372. This document is an update to the previous U.S. EPA document titled Protocol for Conducting Environmental
Compliance Audits under the Emergency Planning and Community Right-to-Know Act (EPA Document No. 305-B-98-007)
that was published by EPA in December 1998. This updated version clarifies and refines sections of the first version of the
audit protocol and incorporates changes in the federal regulations that have occurred since December 1998.
There are numerous environmental regulatory requirements administered by federal, state, and local governments. Each level
of government may have a major impact on areas at the facility that are subject to the audit. Therefore, auditors are advised to
review federal, state, and local regulations in order to perform a comprehensive assessment.
Review of Federal Legislation
The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA)
CERCLA, known commonly as Superfund, became law in 1980 and authorizes U.S. EPA to respond to releases or threatened
releases of hazardous substances that may endanger public health, welfare, or the environment. The basic purpose of
CERCLA is to provide funding and enforcement authority to U.S. EPA for overseeing the clean up of environmental
contamination caused by responsible parties. The Superfund Amendments and Reauthorization Act (SARA) of 1986 revised
various sections of CERCLA, and created a free-standing law, SARA Title III, also known as the Emergency Planning and
Community Right-to-Know Act (EPCRA). The CERCLA hazardous substance release reporting regulations (Section 103; 40
CFR Part 302) direct the person in charge of a facility to report to the National Response Center any environmental release of
a listed hazardous substance that equals or exceeds a reportable quantity. Reportable quantities are listed in 40 CFR Section
302.4. A release report may trigger a response by U.S. EPA or by one or more federal or state emergency response
authorities.
Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA)
This act, also known as SARA Title III, was designed to promote emergency planning and preparedness at both the state and
local level. It provides citizens, local governments, and local response authorities with information regarding the potential
hazards in their community. EPCRA requires the use of emergency planning and designates state and local governments as
recipients of information regarding certain chemicals used in the community. EPCRA has four major components:
Emergency planning (Sections 301-303)
Emergency release notification (Section 304)
Community right-to-know reporting (Sections 311-312)
Toxic chemical release reporting (Section 313)
Pollution Prevention Act of 1990 (PPA)
The goals of PPA were the following: preventing or reducing pollution at the source whenever feasible; pollution that cannot
be prevented should be recycled in an environmentally safe manner whenever feasible; pollution that cannot be prevented or
recycled should be treated in an environmentally safe manner whenever feasible; and disposal or other release into the
environment should be employed only as a last resort and conducted in an environmentally safe manner. Section 6607 of the
PPA requires owners or operators of facilities who have to file an annual toxic chemical release form (Form R) under EPCRA
Section 313 to include a toxic chemical source reduction and recycling report for the preceding calendar year that has been
incorporated into the Form R.
State/Local Regulations
State and local emergency response agencies may establish additional and/or more stringent reporting requirements under
Section 312 of EPCRA and may require the use of state-specific reporting forms.
This document is intended solely for guidance. No statutory or regulatory \
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Key Compliance Requirements
Emergency Planning (40 CFR 355.30) (EPCRA Section 302)
A facility with quantities of extremely hazardous substances equal to or greater than the limits found in 40 CFR Part 355,
Appendix A is required to notify the state emergency response commission within 60 days that the facility is subject to
emergency planning requirements. The facility must designate a representative to participate in local emergency planning as a
facility emergency response coordinator. The facility must also submit additional information to the local emergency planning
committee upon request and notify them of any changes at the facility which might be relevant to emergency planning (i.e.,
designation of the emergency response coordinator, material changes in inventory) (40 CFR 355.10 through 355.30 and 40
CFR 355 Appendices A and B).
Emergency Release Notification (40 CFR 355.40) (EPCRA Section 304)
Under Section 304 of EPCRA, a facility that produces, uses, or stores a hazardous chemical must immediately notify the
designated state and local emergency response authorities if there is a release of a listed EHS or a hazardous substance that
equals or exceeds the reportable quantity for that substance. Refer to 40 CFR 355, Appendices A and B for the EHSs. The
hazardous substances are designated under CERCLA (see 40 CFR 302.4). If the release is a CERCLA-listed hazardous
substance, the National Response Center (NRC) in Washington, DC, must also be notified (1-800-424-8802). If the release is
transportation-related, a 911 call will meet the requirement of notification to the state and local authorities. The NRC must
always be contacted for reportable transportation-related releases.
The initial notice should give as much information as possible about the release as long as notification is not delayed. The
initial notification of a release can be made by telephone, radio, or in person, but must be followed by a written notice to the
state and local emergency response authorities as soon as practicable (40 CFR 355.40(b)(3)).
Community Right-to-Know Requirements
MSDS Reporting (40 CFR 370.21)
Under Section 311 of EPCRA, those facilities which are required under OSHA's Hazard Communication Standard
regulations to prepare or have Material Safety Data Sheets (MSDSs) available are also required to submit copies of the
MSDSs (or corresponding lists as described below) to the state emergency response commission (SERC), local
emergency planning committee (LEPC), and the fire department with jurisdiction over the facility. MSDSs (or
corresponding lists) must be submitted for each hazardous chemical present at the facility according to the following
thresholds:
All hazardous chemicals present at the facility at any one time in amounts equal to or greater than 10,000 Ib. (4540
kg) (Note: Hazardous chemicals requiring an MSDS are chemicals designated by OSHA under 29 CFR 1910.1200),
and
All extremely hazardous substances present at the facility in amounts equal to or greater than 500 Ib. (227 kg -
approximately 55 gal) or the threshold planning quantity, whichever is lower.
If a hazardous chemical is present in a mixture, the facility can either provide information on the mixture or on each
hazardous chemical component of the mixture.
Instead of submitting the MSDSs, the facility can submit a list of hazardous chemicals for which MSDSs are required,
grouped by hazard category (e.g., immediate health hazard, delayed health hazard, fire hazard, sudden release of pressure
hazard, and reactive hazard). The list must include the chemical or common name of each substance. If the facility
provides a list, it must provide a copy of the MSDS for any chemical on the list within 30 days of a request from the local
emergency planning committee.
If a new hazardous chemical exceeds the threshold limit or significant new information is discovered, the facility has 3
months to submit the revised list of chemicals or new MSDS.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Inventory Reporting (40 CFR 370.25, 370.40, 370.41)
Under Section 312 of EPCRA, those facilities that are required under OSHA's Hazard Communication Standard
regulations to prepare or have MSDSs available are also required to submit annual emergency and hazardous chemical
inventory forms to the state emergency response commission, the local emergency planning committee, and the fire
department that has jurisdiction over the facility. The Tier I form includes chemical categories, quantities, and locations
of hazardous chemicals on-site. More detailed information may be requested by emergency response organizations, in
which case facilities must submit a Tier II form within 30 days. Facilities also can choose to submit the Tier II form
instead of a Tier I report. Either report must be submitted on or before March 1 of each year.
The information in these reports does not include accidental releases or permitted discharges and is specifically targeted
toward hazardous chemicals requiring MSDSs that are present on-site above the following threshold levels:
All hazardous chemicals present at the facility at any one time in amounts equal to or greater than 10,000 Ib. (4540
kg), and
All extremely hazardous substances present at the facility in amounts equal to or greater than 500 Ib. (227 kg -
approximately 55 gal) or the threshold planning quantity, whichever is lower.
Facilities who submit inventory forms must allow the fire department to inspect the site upon request and must provide
specific location information about hazardous chemicals at the facility.
Toxic Chemical Release Reporting (40 CFR 372)
Section 313 of EPCRA and Section 6607 of the PPA require certain facilities to report to the federal and state governments
the annual quantity of toxic chemicals (listed in 40 CFR 372.65) entering each environmental medium, either through normal
operations or as the result of an accident, quantities transferred offsite in waste, as well as other information. Facilities
subject to this requirement must submit to EPA and state officials a toxic chemical release form (Form R) for each toxic
chemical manufactured, processed, or otherwise used in quantities exceeding minimum threshold values during the preceding
calendar year. Facilities that have a "reportable waste quantity" of 500 Ib of a listed toxic chemical may take advantage of an
alternate threshold of one million pounds. If the facility does not manufacture, process or otherwise use more than one million
pounds, it may certify by filing a Form A certification statement rather than a Form R. Releases that must be reported include
those to air, water, and land (including land disposal and underground injection). In addition, discharges to a POTW and
transfers to off-site locations for treatment, disposal, energy recovery, and recycling must also be reported. Facilities must also
report on the quantities of the chemicals treated, recycled, or combusted for energy recovery on-site.
Form R/Form A reports must be submitted to both the EPA and the state on or before July 1. Copies of Form R/Form A
reports and related documentation must be kept at the facility for three years after the report is submitted.
The Pollution Prevention Act requires facilities subject to Form R/Form A reporting to also submit information on
source reduction.
For further information regarding the EPCRA regulations, contact U.S. EPA's EPCRA, RCRA/UST, and Superfund Hotline
at 800-424-9346 (or 703-412-9810 in the D.C. area) from 9 a.m. to 6 p.m., Monday through Friday.
This U.S. EPA hotline provides up-to-date information on regulations developed under EPCRA, as well as RCRA, CERCLA
(Superfund), and the Oil Pollution Act. The hotline can assist with Section 112(r) of the Clean Air Act (CAA) and Spill
Prevention, Control and Countermeasures (SPCC) regulations. The hotline also responds to requests for relevant documents
and can direct the caller to additional tools that provide a more detailed discussion of specific regulatory requirements.
In addition, the U.S. EPA, as the chair of the National Response Team (NRT), has developed the NRT's Integrated
Contingency Plan Guidance ("one plan"). This guidance is intended to be used by facilities to prepare emergency response
plans. The guidance provides a mechanism for consolidating multiple plans that facilities may have prepared to comply with
various regulations into one functional emergency response plan or integrated contingency plan (ICP). Copies of the
guidance can be obtained by calling the Superfund Hotline number listed above. In addition, this guidance is available
electronically at the home page of U.S. EPA's Chemical Emergency Preparedness and Prevention Office
(www.epa.gov/swercepp/)
This document is intended solely for guidance. No statutory or regulatory 3
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Key Terms and Definitions
Act
The Superfund Amendments and Reauthorization Act of 1986 (40 CFR 355.20).
Acts
Title III (40 CFR 372.3).
Article
A manufactured item which (40 CFR 372.3):
1. is formed to a specific shape or design during manufacture;
2. has end use functions dependent in whole or in part upon its shape or design during end use;
3. does not release a toxic chemical under normal conditions of processing or use of that item at the facility or
establishments.
Beneficiation
The preparation of ores to regulate the size (including crushing and grinding) of the product, to remove unwanted
constituents, or to improve the quality, purity, or grade of a desired product (40 CFR 372.3).
Boiler
An enclosed device using controlled flame combustion and having the following characteristics (40 CFR 372.3):
1. all of the following:
a) the unit must have physical provisions for recovering and exporting thermal energy in the form of steam, heated
fluids, or heated gases; and
b) the unit's combustion chamber and primary energy recovery section(s) must be of integral design. To be of integral
design, the chamber and the primary energy recovery section(s) (such as waterwalls and superheaters) must be
physically formed into one manufactured or assembled unit. A unit in which the combustion chamber and the
primary energy recovery section(s) are joined only by ducts or connections carrying flue gas is not integrally
designed; however, secondary energy recovery equipment (such as economizers or air preheaters) need not be
physically formed into the same unit as the combustion chamber and the primary energy recovery section. The
following units are not precluded from being boilers solely because they are not of integral design: process heaters
(units that transfer energy directly to a process stream), and fluidized bed combustion units; and
c) while in operation, the unit must maintain a thermal energy recovery efficiency of at least 60 percent, calculated in
terms of the recovered energy compared with the thermal value of the fuel; and
d) the unit must export and utilize at least 75 percent of the recovered energy, calculated on an annual basis. In this
calculation, no credit shall be given for recovered heat used internally in the same unit. (Examples of internal use are
the preheating of fuel or combustion air, and the driving of induced or forced draft fans or feedwater pumps); or
2. the unit is one which the Regional Administrator has determined, on a case-by-case basis, to be a boiler, after considering
the standards in 40 CFR 260.32.
CERCLA
The Comprehensive Environmental Response, Compensation and Liability Act of 1980, as amended (40 CFR 355.20).
CERCLA Hazardous Substance
A substance on the list defined in section 101(14) of CERCLA. (NOTE: Listed CERCLA hazardous substances appear in
table 302.4 of 40 CFR Part 302) (40 CFR 355.20).
Chief Executive Officer of the Tribe
The person who is recognized by the Bureau of Indian Affairs as the chief elected administrative officer of the tribe (40 CFR
355.20, 370.2, and 372.3).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Coal Extraction
The physical removal or exposure of ore, coal, minerals, waste rock, or overburden prior to beneficiation, and encompasses
all extraction-related activities prior to beneficiation. Extraction does not include beneficiation (including coal preparation),
mineral processing, in situ leaching or any further activities (40 CFR 372.3).
Commission
The emergency response commission for the State in which the facility is located except where the facility is located in Indian
Country, in which case, commission means the emergency response commission for the tribe under whose jurisdiction the
facility is located. In absence of an emergency response commission, the Governor and the chief executive officer,
respectively, shall be the commission. Where there is a cooperative agreement between a State and a Tribe, the commission
shall be the entity identified in the agreement (40 CFR 355.20 and 370.2)
Committee or Local Emergency Planning Committee (LEPC)
The local emergency planning committee appointed by the state emergency response commission (40 CFR 355.20 and 370.2).
Continuous
A continuous release is a release that occurs without interruption or abatement or that is routine, anticipated, and intermittent
and incidental to normal operations or treatment processes (40 CFR 302.8(b))
Customs Territory of the United States
The 50 states, the District of Columbia, and Puerto Rico (40 CFR 372.3).
Disposal
Any underground injection, placement in landfills/surface impoundments, land treatment, or other intentional land disposal
(40 CFR 372.3).
Environment
Water, air, and land and the interrelationship which exists among and between water, air, and land and all living things (40
CFR 355.20 and 370.2).
EPA
The United States Environmental Protection Agency (40 CFR 372.3).
Establishment
An economic unit, generally at a single physical location, where business is conducted or where services or industrial
operations are performed (40 CFR 372.3).
Extremely Hazardous Substance
A substance listed in Appendices A and B of 40 CFR 355 (40 CFR 355.20).
Extremely Hazardous Substance
A substance listed in the appendices to 40 CFR Part 355, Emergency Planning and Notification (40 CFR 370.2).
Facility
All buildings, equipment, structures, and other stationary items that are located on a single site or on contiguous or adjacent
sites and which are owned or operated by the same person (or by any person which controls, is controlled by, or under
common control with, such person). A facility may contain more than one establishment. Facility shall include manmade
structures as well as all natural structures in which chemicals are purposefully placed or removed through human means such
that it functions as a containment structure for human use. For purposes of emergency release notification, the term includes
motor vehicles, rolling stock, and aircraft (40 CFR 355.20 and 370.2).
Facility
All buildings, equipment, structures, and other stationary items which are located on a single site or on contiguous or adjacent
sites and which are owned or operated by the same person (or by any person which controls, is controlled by, or under
common control with such person). A facility may contain more than one establishment (40 CFR 372.3).
This document is intended solely for guidance. No statutory or regulatory 5
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Full-time Employee
2000 hours per year of full-time equivalent employment. To calculate the number of full-time employees, total the hours
worked during the calendar year by all employees, including contract employees, and divide the total by 2000 hours (40 CFR
372.3).
Hazard Category
Any of the following (40 CFR 370.2):
1. immediate (acute) health hazard, including highly toxic, toxic, irritant, sensitizer, corrosive, (as defined under Sec.
1910.1200 of Title 29 of the Code of Federal Regulations) and other hazardous chemicals that cause an adverse effect to
a target organ and which effect usually occurs rapidly as a result of short term exposure and is of short duration;
2. delayed (chronic) health hazard, including carcinogens (as defined under Sec. 1910.1200 of Title 29 of the Code of
Federal Regulations) and other hazardous chemicals that cause an adverse effect to a target organ and which effect
generally occurs as a result of long term exposure and is of long duration;
3. fire hazard, including flammable, combustible liquid, pyrophoric, and oxidizer (as defined under Sec. 1910.1200 of Title
29 of the Code of Federal Regulations);
4. sudden release of pressure, including explosive and compressed gas (as defined under Sec. 1910.1200 of Title 29 of the
Code of Federal Regulations); and
5. reactive, including unstable reactive, organic peroxide, and water reactive (as defined under Sec. 1910.1200 of Title 29
of the Code of Federal Regulations).
Hazardous Chemical
Any hazardous chemical as defined under Sec. 1910.1200(c) of Title 29 of the Code of Federal Regulations, except for the
following substances (40 CFR 355.20 and 370.2):
1. any food, food additive, color additive, drug, or cosmetic regulated by the Food and Drug Administration.
2. any substance present as a solid in any manufactured item to the extent that exposure to the substance does not occur
under normal conditions of use.
3. any substance to the extent it is used for personal, family, or household purposes, or is present in the same form and
concentration as a product packaged for distribution and use by the general public.
4. any substance to the extent it is used in a research laboratory or a hospital or other medical facility under the direct
supervision of a technically qualified individual.
5. any substance to the extent it is used in routine agricultural operations or is fertilizer held for sale by a retailer to the
ultimate customer.
Hazardous Substance
Any substance designated pursuant to 40 CFR 302 (40 CFR 302.3).
Import
To intend a chemical to be imported into the customs territory of the United States and to control the identity of the imported
chemical and the amount to be imported (40 CFR 372.3).
Indian Country
Indian country as defined in 18 U.S.C. 1151 (40 CFR 355.20, 370.2 and 372.3):
1. 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;
2. 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;
3. all Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the
same.
Indian Tribe
Those tribes federally recognized by the Secretary of the Interior (40 CFR 355.20, 370.2 and 372.3).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Industrial Furnace
Any of the following enclosed devices that are integral components of manufacturing processes and that use thermal treatment
to accomplish recovery of materials or energy (40 CFR 372.3):
1. cement kilns
2. lime kilns
3. aggregate kilns
4. phosphate kilns
5. coke ovens
6. blast furnaces
7. smelting, melting and refining furnaces (including pyrometallurgical devices such as cupolas, reverberator furnaces,
sintering machines, roasters, and foundry furnaces)
8. titanium dioxide chloride process oxidation reactors
9. methane reforming furnaces
10. pulping liquor recovery furnaces
11. combustion devices used in the recovery of sulfur values from spent sulfuric acid
12. halogen acid furnaces (HAFs) for the production of acid from halogenated hazardous waste generated by chemical
production facilities where the furnace is located on the site of a chemical production facility, the acid product has a
halogen acid content of at least 3%, the acid product is used in a manufacturing process, and, except for hazardous waste
burned as fuel, hazardous waste fed to the furnace has a minimum halogen content of 20% as-generated
13. such other devices as the Administrator may, after notice and comment, add to this list on the basis of one or more of the
following factors:
a) the design and use of the device primarily to accomplish recovery of material products;
b) the use of the device to burn or reduce raw materials to make a material product;
c) the use of the device to burn or reduce secondary materials as effective substitutes for raw materials, in processes
using raw materials as principal feedstocks;
d) the use of the device to burn or reduce secondary materials as ingredients in an industrial process to make a material
product;
e) the use of the device in common industrial practice to produce a material product; and
f) other factors, as appropriate.
Inventory Form
The Tier I and Tier II emergency and hazardous chemical inventory forms set forth in Subpart D of 40 CFR 370 (40 CFR
370.2).
Land Disturbance Incidental to Extraction
This includes: land clearing; overburden removal and stockpiling; excavating, handling, transporting, and storing ores and
other raw materials; and replacing materials in mined-out areas as long as such materials have not been beneficiated or
processed and do not contain elevated radionuclide concentrations (greater than 7.6 picocuries per gram or pCi/g of Uranium-
238, 6.8 pCi/g of Thorium-232, or 8.4 pCi/g of Radium-226) (40 CFR 355.40)
Material Safety Data Sheet or MSDS
The sheet required to be developed under 29 CFR 1910.1200(g) (40 CFR 370.2).
Manufacture
To produce, prepare, import, or compound a toxic chemical. Manufacture also includes coincidental production of a toxic
chemical during the manufacture, processing, use, or treatment of another chemical or mixture of chemicals, including a toxic
chemical that is separated from that other chemical or mixture of chemicals as a byproduct, and a toxic chemical that remains
in that other chemical or mixture as an impurity (>0.1% for carcinogens; otherwise >1%) (40 CFR 372.3).
Management Practice
Practice that, although not mandated by law, is encouraged to promote safe operating procedures.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Mixture (EPCRA 311, 312, and 313)
Any combination of two or more chemicals, if the combination is not, in whole or in part, the result of a chemical reaction.
However, if the combination was produced by a chemical reaction but could have been produced without a chemical reaction,
it is also treated as a mixture. A mixture also includes any combination that consists of a chemical and associated impurities
(40 CFR 372.3).
Mixture (EPCRA 304)
A heterogeneous association of substances where the various individual substances retain their identities and can usually be
separated by mechanical means. Includes solutions or compounds but does not include alloys or amalgams (40 CFR 355.20).
Normal Range
The normal range of a release is all releases (in pounds or kilograms) of a hazardous substance reported or occurring over any
24-hour period under normal operating conditions during the preceding year. Only releases that are both continuous and
stable in quantity and rate may be included in the normal range (40 CFR 302.8(b)).
Otherwise Use
Any use of a toxic chemical that is not covered by the terms "manufacture" or "process" and includes use of a toxic chemical
contained in a mixture, trade name product or waste. Otherwise use of a toxic chemical does not include disposal,
stabilization (without subsequent distribution in commerce), or treatment for destruction unless (40 CFR 372.3):
1. the toxic chemical that was disposed, stabilized, or treated for destruction was received from off-site for the purposes of
further waste management; or
2. the toxic chemical that was disposed, stabilized, or treated for destruction was manufactured as a result of waste
management activities on materials received from off-site for the purposes of further waste management activities.
Relabeling or redistributing of the toxic chemical where no repackaging of the toxic chemical occurs does not constitute
otherwise use or processing of the toxic chemical.
Overburden
The unconsolidated material that overlies a deposit of useful materials or ores. It does not include any portion of ore or waste
rock (40 CFR 372.3).
Person
Any individual, trust, firm, joint stock company, corporation (including a government corporation), partnership, association,
state, municipality, commission, political subdivision of a state, or interstate body (40 CFR 355.20 and 370.2).
Present in the Same Form and Concentration as a Product Packaged for Distribution and Use by the General Public
A substance packaged in a similar manner and present in the same concentration as the substance when packaged for use by
the general public, whether or not it is intended for distribution to the general public or used for the same purpose as when it
is packaged for use by the general public (40 CFR 370.2).
Process
The preparation of a listed toxic chemical, after its manufacture, for distribution in commerce (40 CFR 372.3):
1. in the same or different form or physical state from which it was received by the person preparing such substance, or
2. as part of an article containing the toxic chemical. Process also applies to the processing of a toxic chemical contained in
a mixture or trade name product.
RCRA Approved Test Method
Includes Test Method 9095 (Paint Filter Liquids Test) in "Test Methods for Evaluating Solid Waste, Physical/Chemical
Methods," EPA Publication No. SW-846, Third Edition, September 1986, as amended by Update I, November 15, 1992 (40
CFR 372.3).
Release
Any spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting, escaping, leaching, dumping, or disposing
into the environment (including the abandonment or discarding of barrels, containers, and other closed receptacles) of any
hazardous chemical, extremely hazardous substance, or CERCLA hazardous substance (40 CFR 355.20).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Release
Any spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting, escaping, leaching, dumping, or disposing
into the environment (including the abandonment or discarding of barrels, containers, and other closed receptacles) of any
toxic chemical (40 CFR 372.3).
Reportable Quantity
For a CERCLA hazardous substance, the reportable quantity is the amount established in 40 CFR 302 Table 302.4. For an
extremely hazardous substance, the reportable quantity is the amount established in 40 CFR 355, Appendices A and B (40
CFR 355.20).
Routine
Routine release is a release that occurs during normal operating procedures or processes (40 CFR 302.8(b))
Senior Management Official
An official with management responsibility for the person or persons completing the report, or the manager of environmental
programs for the facility or establishments, or for the corporation owning or operating the facility or establishment responsible
for certifying similar reports under other environmental regulatory requirements (40 CFR 372.3).
Stable In Quantity and Rate
A release that is stable in quantity and rate is a release that is predictable and regular in amount and rate of emission (40 CFR
302.8(b)) [Added April 1999].
State
Any state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the
United States Virgin Islands, the Northern Mariana Islands, any other territory or possession over which the United States has
jurisdictions and Indian Country (40 CFR 355.20, 370.2 and 372.3).
Statistically Significant Increase
A statistically significant increase in a release is an increase in the quantity of the hazardous substance released above the
upper bound of the reported normal range of the release (40 CFR 302.8(b))
Threshold Planning Quantity
The threshold planning quantity for an extremely hazardous substance as listed in 40 CFR 355, Appendices A and B (40 CFR
355.20 and 370.2).
Title III
Title III of the Superfund Amendments and Reauthorization Act of 1986, also titled the Emergency Planning and Community
Right-to-Know Act of 1986 (40 CFR 372.3).
Toxic Chemical
A chemical or chemical category listed in 40 CFR 372.65 (40 CFR 372.3).
Trade Name Product
A chemical or mixture of chemicals that is distributed to other persons and that incorporates a toxic chemical component that
is not identified by the applicable chemical name or Chemical Abstracts Service Registry number listed in 40 CFR 372.65.
Treatment for Destruction
The destruction of a toxic chemical in waste such that the substance is no longer the toxic chemical subject to reporting under
EPCRA section 313. Treatment for destruction does not include the destruction of a toxic chemical in waste where the toxic
chemical has a heat value greater than 5,000 Btu and is combusted in any device that is an industrial furnace or boiler (40
CFR 372.3).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Unlisted Hazardous Substances
A solid waste, as defined in 40 CFR 261.2, which is not excluded from regulation as a hazardous waste under 40 CFR
261.4(b), is a hazardous substance under section 101(14) of CERCLA if it exhibits any of the characteristics identified in 40
CFR 261.20 through 261.24 (40 CFR 302.4(b))
Waste Stabilization
Any physical or chemical process used to either reduce the mobility of hazardous constituents in a hazardous waste or
eliminate free liquid as determined by a RCRA approved test method for evaluating solid waste as defined in 40 CFR 372.3.
A waste stabilization process includes mixing the hazardous waste with binders or other materials, and curing the resulting
hazardous waste and binder mixture. Other synonymous terms used to refer to this process are "stabilization," "waste
fixation," or "waste solidification" (40 CFR 372.3).
Typical Records to Review
Emergency response plan(s)
Emergency Release Notification Reports
Chemical inventory forms
MSDSs
Pollution prevention plan (optional)
Tier I/Tier II reports
Toxic chemical source reduction and recycling reports (for facilities subject to Form R reporting)
Toxic release inventory (TRI) reports (Form R/Form A) and related documentation
Hazardous communication plan
Contingency plan.
Typical Physical Features to Inspect
Chemical storage areas
Chemical manufacturing or processing areas (generation sites)
Recordkeeping system
Shop activities
Hazardous material/waste transfer areas
Treatment units
Recycling sites
Disposal sites
Surface impoundments
List of Acronyms and Abbreviations
Btu British Thermal Units
CAA Clean Air Act
CAS Chemical Abstract Service
CERCLA Comprehensive Environmental Response, Compensation, and Liability Act (or Superfund)
CFR Code of Federal Regulations
CWA Clean Water Act
CY Calendar Year
EHS Extremely hazardous substance
EPA Environmental Protection Agency
EPCRA Emergency Planning and Community Right-to-Know Act of 1986
FR Federal Register
gal. Gallon
h Hour
kg Kilogram
This document is intended solely for guidance. No statutory or regulatory 19
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Ib. Pound
Ib/yr Pounds per year
LEPC Local Emergency Planning Committee
Mi Mile
MP Management practice
MSDS Material Data Safety Sheet
NOV Notice of violation
NRC National Response Center
OSHA Occupational Health and Safety Act
PAC Polycyclic aromatic compound
PBT Persistent bioaccumulative toxic
POTW Publicly owned treatment works
PPA Pollution Prevention Act of 1990
RCRA Resource Conservation and Recovery Act
RQ Reportable quantity
SARA Superfund Amendments and Reauthorization Act of 1986
SERC State Emergency Response Commission
SIC Standard Industrial Classification
SPCC Spill Prevention, Control and Countermeasures
TPQ Threshold planning quantity
TRI Toxic release inventory
U.S.C. United States Code
yr Year
=/> Equal to or greater than
=/< Equal to or less than
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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This document is intended solely for guidance. No statutory or regulatory 12
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Index for Checklist Users
Compliance Category Index
Category
General
Planning
Release Notification/Reporting
Recordkeeping
Refer To:
Checklist Items:
EP.1.1 through EP.l. 3
EP. 10.1 and EP. 10.2
EP.20.1 through EP.20.6
EP.30.1
Page Numbers:
15
17
19
33
Statute Index
Statute or Statute Section
EPCRA Section 302
EPCRA Section 304
CERCLA Section 103
CERCLA Section 103(f)(2)
EPCRA Section 3 1 1
EPCRA Section 3 12
EPCRA Section 3 13
Refer To:
Checklist Items:
EP.10.1
EP.20.1
EP.20.5
EP.20.6
EP.20.2
EP.20.3
EP.20.4 and EP.30.1
Page Numbers:
17
19
27
28
20
22
26 and 33
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
13
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This document is intended solely for guidance. No statutory or regulatory 14
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Checklist
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
GENERAL
EP.l
EP.1.1. The current status of
any ongoing or unresolved
Consent Orders, Compliance
Agreements, Notices of
Violation (NOVs), or
equivalent state enforcement
actions should be examined.
Determine if noncompliance issues have been resolved by reviewing a copy of the
previous audit report, Consent Orders, Compliance Agreements, NOVs, or
equivalent state enforcement actions.
Determine and indicate, for open items, what corrective action is planned and
milestones established to correct problems.
EP.1.2. Facilities are
required to comply with all
applicable federal regulatory
requirements not contained in
this checklist.
Determine if any new regulations have been issued since the finalization of this
guide. If so, annotate checklist to include new standards.
Determine if the facility has activities or facilities that are federally regulated, but
not addressed in this checklist.
Verify that the facility is in compliance with all applicable and newly issued
regulations.
EP.1.3. Facilities are
required to abide by state and
local regulations concerning
hazardous materials.
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:
- notification requirements
- response plan requirements
- spill response requirements.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
15
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This document is intended solely for guidance. No statutory or regulatory 15
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
PLANNING
EP.10
EP.10.1. Facilities with
quantities of extremely
hazardous substances equal to
or greater than the threshold
limitations are required to
follow specific emergency
planning procedures (40 CFR
355.30 and 355 Appendix A).
(NOTE: For purposes of this checklist item, an amount of any extremely
hazardous substance means the total amount of an extremely hazardous substance
present at any one time at a facility at concentrations greater than one percent by
weight, regardless of location, number of containers, or method of storage.)
Verify that the facility has notified the Commission (see definitions) that it is
subject to the emergency planning requirements within 60 days after the facility
first becomes subject to these requirements.
Verify that the facility has a designated representative who participates in the local
emergency planning process as a facility emergency response coordinator.
Verify that the facility has notified the local emergency planning committee, or
governor if there is no committee, of the facility representative within 30 days
after establishment of a local emergency planning committee.
Verify that the local emergency planning committee is informed of any changes
occurring at the facility that may be relevant to emergency planning.
Verify that, upon request of the local emergency planning committee, the facility
promptly provides to the committee any information necessary for development or
implementation of the local emergency plan.
(NOTE: If a container or storage vessel holds a mixture or solution of an
extremely hazardous substance, then the concentration of extremely hazardous
substance, in weight percent (greater than 1 percent sign), shall be multiplied by
the mass (in pounds) in the vessel to determine the actual quantity of extremely
hazardous substance therein. Extremely hazardous substances that are solids are
subject to either of two threshold planning quantities (i.e., 500/10,000 Ib). The
lower quantity applies only if the solid exists in powdered form and has a particle
size less than 100 microns; or is handled in solution or in molten form; or meets
the criteria for a NFPA rating of 2, 3, or 4 for reactivity. If the solid does not meet
any of these criteria, it is subject to the upper (10,000 Ib) TPQ. The 100-micron
level may be determined by multiplying the weight percent of solid with a particle
size less than 100 microns in a particular container by the quantity of solid in the
container. The amount of solid in solution may be determined by multiplying the
weight percent of solid in the solution in a particular container by the quantity of
solution in the container. The amount of solid in molten form must be multiplied
by 0.3 to determine whether the lower threshold planning quantity is met.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
EP.10.2. The contingency
plan developed for the facility
should be compared to the
local emergency contingency
plan (MP).
Verify that the facility contingency plan is compatible with the contingency plan
developed by the local emergency planning committee.
Verify that the facility contingency plan considers how local emergency response
officials will likely respond to a chemical release.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
RELEASE,
NOTIFICATION,
REPORTING
EP.20
(NOTE: Emergency release notification requirements do not apply to:
- any release that results in exposure to persons solely within the boundaries of
the facility
- any release that is a federally permitted release as defined in section 101 (10)
of CERCLA
-any release that is continuous and stable in quantity and rate under the
definitions in 40 CFR 302.8(b)
-any release of a pesticide product exempt from CERCLA section 103(a)
reporting under section 103(e) of CERCLA
-any release not meeting the definition of release under Section 101(22) of
CERCLA, and therefore exempt from Section 103(a) reporting
- any radionuclide release which occurs:
- naturally in soil from land holdings such as parks, golf courses, or other
large tracts of land
-naturally from land disturbance activities, including farming,
construction, and land disturbance incidental to extraction during
mining activities, except that which occurs at uranium, phosphate, tin,
zircon, hafnium, vanadium, monazite, and rare earth mines
- from the dumping and transportation of coal and coal ash (including fly
ash, bottom ash, and boiler slags), including the dumping and land
spreading operations that occur during coal ash uses
-from piles of coal and coal ash, including fly ash, bottom ash, and
boiler slags.)
(NOTE: Exemption from these emergency release notification requirements for
continuous releases does not include exemption from requirements for:
- initial notifications as defined in 40 CFR 302.8(d) and (e)
- notification of a "statistically significant increase"
- notification of a "new release"
- notification of a change in the normal range of the release as required under
40 CFR 302.8(g)(2).)
When there is a
of a reportable
(RQ) of any
hazardous
or CERCLA
substance
release
is required (40
355
EP.20.1
release
quantity
extremely
substance
hazardous
emergency
notification
CFR 355.40 and
Appendices A and B)
Determine if there has been a release of an extremely hazardous substance or
CERCLA hazardous substance in excess of the RQ.
Verify that, if a release has occurred in excess of the reportable quantity, the
following are immediately notified:
-community emergency coordinator for the local emergency planning
committee of any area likely to be affected by the release
- state emergency response commission of any state likely to be affected by
the release
- local emergency response personnel if there is no local emergency planning
committee.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
Verify that the notice contains the following, to the extent known at the time of
notice, so long as no delay in notice or emergency response results:
- the chemical name or identity of any substance involved in the release
- an indication of whether the substance is an extremely hazardous substance
- an estimate of the quantity of any such substance that was released into the
environment
-the time and duration of the release
- the medium or media into which the release occurred
- any known or anticipated acute or chronic health risks associated with the
emergency, and, where appropriate, advice regarding medial attention
necessary for exposed individuals
- proper precautions to take as a result of the release, including evacuation
(unless such information is readily available to the community emergency
coordination because of the local emergency plan)
- the names and telephone numbers of the person or persons to be contacted
for further information.
Verify that, after the immediate verbal notification, a written follow-up emergency
notification is produced which contains the same information detailed in the
verbal notice (outlined above), plus:
- actions taken to respond to and contain the release
- any known or anticipated acute or chronic health risks associated with the
release
- advice regarding medical attention necessary for exposed individuals.
EP.20.2. Releases in excess
of or equal to the RQ of listed
and unlisted hazardous
substances shall be reported to
the NRC immediately (40
CFR 302.5 through 302.6)
Verify that a release (other than a federally permitted release or application of a
pesticide) of a hazardous substance from a vessel, an offshore facility, or an
onshore facility is reported to the NRC immediately after the release is identified.
(NOTE: 40 CFR 302.4 lists hazardous substances (see definitions section of this
document) and RQs subject to the notification requirements outlined in 40 CFR
302.6. These hazardous substances contained in the tables and Appendix B of 40
CFR 302.4 are referred to in these regulations as "listed hazardous substances".
See 40 CFR 302.5(a).)
(NOTE: The RQ of an unlisted hazardous substance (see definitions) is 100 Ib,
except for those unlisted hazardous wastes that exhibit extraction procedure (EP)
toxicity identified in 40 CFR 261.24. Unlisted hazardous wastes that exhibit EP
toxicity have the RQs listed in the table in 40 CFR 302.4 for the contaminant on
which the characteristic of EP toxicity is based. The RQ applies to the waste itself,
not merely to the toxic contaminant. If an unlisted hazardous waste exhibits EP
toxicity on the basis of more than one contaminant, the RQ for that waste shall be
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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the lowest of the RQs listed in the table in 40 CFR 302.4 for those contaminants. If
an unlisted hazardous waste exhibits the characteristic of EP toxicity and one or
more of the other characteristics referenced in 40 CFR 302.4(b), the RQ for that
waste is the lowest of the applicable reportable quantities.)
Verify that, if mixtures or solutions (including hazardous waste streams) of
hazardous substances are released, except for radionuclides, the release is reported
when either of the following occur:
- the quantity of all hazardous constituents of the mixture or solution is known
and a reportable quantity or more of any hazardous constituent is released
- the quantity of one or more of the hazardous constituents of the mixture or
solution is unknown and the total amount of the mixture or solution released
equals or exceeds the reportable quantity for the hazardous constituent with
the lowest reportable quantity.
(NOTE: Radionuclides are subject to these notification requirements only in the
following circumstances:
- if the identity and quantity (in curies) of each radionuclide in a released
mixture or solution is known, the ratio between the quantity released (in
curies) and the RQ for the radionuclide must be determined for each
radionuclide. The only such releases notification requirements are those in
which the sum of the ratios for the radionuclides in the mixture or solution
released is =/> 1
- if the identity of each radionuclide in a released mixture or solution is known
but the quantity released (in curies) of one or more of the radionuclides is
unknown, the only such releases subject to notification requirements are
those in which the total quantity (in curies) of the mixture or solution
released is =/> the lowest RQ of any individual radionuclide in the mixture or
solution
- if the identity of one or more radionuclides in a released mixture or solution
is unknown (or if the identity of a radionuclide released by itself is
unknown), the only such releases subject to notification requirements are
those in which the total quantity (in curies) released is equal to or greater
than either one curie or the lowest RQ of any known individual radionuclide
in the mixture or solution, whichever is lower.)
(NOTE: The following categories of releases are exempt from the notification
requirements:
-releases of those radionuclides that occur naturally in the soil from land
holdings such as parks, golf courses, or other large tracts of land
- releases of naturally occurring radionuclides from land disturbance activities,
including farming, construction, and land disturbance incidental to extraction
during mining activities, except that which occurs at uranium, phosphate, tin,
zircon, hafnium, vanadium, monazite, and rare earth mines. Land disturbance
incidental to extraction includes: land clearing; overburden removal and
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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stockpiling; excavating, handling, transporting, and storing ores and other
raw materials; and replacing materials in mined-out areas as long as such
materials have not been beneficiated or processed and do not contain
elevated radionuclide concentrations (greater than 7.6 pCi/g of Uranium-238,
6.8 pCi/g of Thorium-232, or 8.4 pCi/g of Radium-226)
- releases of radionuclides from the dumping and transportation of coal and
coal ash (including fly ash, bottom ash, and boiler slags), including the
dumping and land spreading operations that occur during coal ash uses
- releases of radionuclides from piles of coal and coal ash, including fly ash,
bottom ash, and boiler slags.)
(NOTE: Except for releases of radionuclides, notification of the release of an RQ
of solid particles of antimony, arsenic, beryllium, cadmium, chromium, copper,
lead, nickel, selenium, silver, thallium, or zinc is not required if the mean diameter
of the particles released is larger than 100 micrometers (0.004 in.).
EP.20.3. Specific
notifications are required for
releases of hazardous
substances that qualify for
reduced reporting options (40
CFR 302.8)
Determine if there are any releases that are continuous and stable in quantity and
rate.
Verify that the following notifications have been given:
- initial telephone notification
- initial written notification within 30 days of the initial telephone notification
-follow-up notification within 30 days of the first anniversary date of the
initial written notification
- notification of changes in:
-the composition or source of the release
- information submitted in the initial written notification
- information submitted in the follow-up notification when there is an increase
in the quantity of the hazardous substances in any 24-h period that represents
a statistically significant increase.
Verify that, prior to making an initial telephone notification of a continuous
release, the person in charge of a facility or vessel establishes a sound basis for
qualifying the release for reporting by one of the following:
-using release data, engineering estimates, knowledge of operating
procedures, or best professional judgment to establish the continuity and
stability of the release
-reporting the release to the NRC for a period sufficient to establish the
continuity and stability of the release or when a basis has been established to
qualify the release for reduced reporting, initial notification to the NRC is
made by telephone.
Verify that the notification is identified as an initial continuous release notification
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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report and includes the following information:
-the name(s) and location(s) of the facility or vessel
-the name(s) and identity(ies) of the hazardous substances being released.
Verify that initial written notification of a continuous release is made to the
appropriate U.S. EPA Regional Office for the geographical area where the
releasing facility or vessel is located and occurs within 30 days of the initial
telephone notification to the NRC.
Verify that the initial written notification includes, for each release for which
reduced reporting as a continuous release is claimed, the following information:
- the name of the facility or vessel; the location, including the latitude and
longitude; the case number assigned by the NRC or the U.S. EPA; the Dun
and Bradstreet number of the facility, if available; the port of registration of
the vessel; the name and telephone number of the person in charge of the
facility or vessel
-the population density within a one-mi radius of the facility or vessel,
described in terms of the following ranges: 0-50 persons, 51-100 persons,
101-500 persons, 501-1,000 persons, more than 1,000 persons
-the identity and location of sensitive populations and ecosystems within a
one-mi radius of the facility or vessel (e.g., elementary schools, hospitals,
retirement communities, or wetlands)
- for each hazardous substance release claimed to qualify for reporting under
CERCLA section 103(f)(2), the following information:
-the name/identity of the hazardous substance; the CAS Registry
Number for the substance (if available); and, if the substance being
released is a mixture, the components of the mixture and their
approximate concentrations and quantities, by weight
-the upper and lower bounds of the normal range of the release (in
pounds or kilograms) over the previous year
-the source(s) of the release (e.g., valves, pump seals, storage tank vents,
stacks). If the release is from a stack, the stack height (in feet or meters)
- the frequency of the release and the fraction of the release from each
release source and the specific period over which it occurs
-a brief statement describing the basis for stating that the release is
continuous and stable in quantity and rate
- an estimate of the total annual amount that was released in the previous
year (in pounds or kilograms)
- the environmental medium affected by the release, such as the name of
the surface water body; the stream order or average flowrate (in cubic
feet/second) and designated use; the surface area (in acres) and average
depth (in feet or meters) of the lake; the location of public water supply
wells within two mi if on or underground
-a signed statement that the hazardous substance release described is
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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continuous and stable in quantity and rate and that all reported information is
accurate and current to the best knowledge of the person in charge.
Verify that, within 30 days of the first anniversary date of the initial written
notification (see above), each hazardous substance release reported is evaluated to
verify and update the information submitted in the initial written notification.
Verify that the follow-up notification contains all the information required in the
initial notification, plus notification of changes in the release not otherwise
reported
(NOTE: Instead of the initial written report or follow-up report, a copy of the
Toxic Release Inventory (TRI) form submitted under SARA Title III section 313
to U.S. EPA for the previous July 1 may be used if the following information is
added:
-the population density within a one mile radius of the facility or vessel
described in terms of the following ranges:
- 0 to 50 persons
-51 to 100 persons
-101 to 500 persons
-501 to 1000 persons
- more than 1000 persons
-the identify and location of sensitive populations and ecosystems within a
one mile radius of the facility or vessel (e.g., elementary schools, hospitals,
retirement communities, or wetlands)
- the following information for each hazardous substance release that qualifies
for reporting under CERCLA section 103(f)(2):
-the upper and lower bounds of the normal range of the release (in
pounds or kilograms) over the previous year
- the frequency of the release and the fraction of the release from each
release source and the specific period over which it occurs
-a brief statement describing the basis for stating that the release is
continuous and stable in quantity and rate
- a signed statement that the release is continuous and stable in quantity
and rate and that all reported information is accurate and current to the
best knowledge of the person in charge.)
(NOTE: If there is a change in any information submitted in the initial written
notification or the follow-up notification other than a change in the source,
composition, or quantity of the release, the person in charge of the facility or
vessel shall provide written notification of the change to the U.S. EPA Region for
the geographical area where the facility or vessel is located, within 30 days of
determining that the information submitted previously is no longer valid.
Notification shall include the reason for the change, and the basis for stating that
the release is continuous and stable under the changed conditions. Notification of
changes shall include the case number assigned by the NRC or the U.S. EPA and
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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also the signed certification statement.)
Verify that notification of a statistically significant increase in a release is made to
the NRC as soon as there is knowledge of the release.
(NOTE: A determination of whether an increase is a "statistically significant
increase" shall be made based upon calculations or estimation procedures that will
identify releases that exceed the upper bound of the reported normal range.)
Verify that each hazardous substance release is evaluated annually to determine if
changes have occurred in the information submitted in the initial written
notification, the follow-up notification, and/or in a previous change notification.
(NOTE: Where necessary to satisfy the requirements of 40 CFR 302.8, the person
in charge may rely on recent release data, engineering estimates, the operating
history of the facility or vessel, or other relevant information to support
notification. All supporting documents, materials, and other information shall be
kept on file at the facility, or in the case of a vessel, at an office within the United
States in either a port of call, a place of regular berthing, or the headquarters of the
business operating the vessel.)
Verify that supporting materials are kept on file for a period of one yr and that
they substantiate the reported normal range of releases, the basis for stating that
the release is continuous and stable in quantity and rate, and the other information
in the initial written report, the follow-up report, and the annual evaluations.
(NOTE: The supporting materials must be made available to U.S. EPA upon
request.)
(NOTE: Multiple concurrent releases of the same substance occurring at various
locations with respect to contiguous plants or installations upon contiguous
grounds that are under common ownership or control may be considered
separately or added together in determining whether such releases constitute a
continuous release or a statistical increase in the release; whichever approach is
elected for purposes of determining whether a release is continuous also must be
used to determine a statistically significant increase in the release.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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EP.20.4. Facilities which are
required to prepare or have
available a MSDS for a
hazardous chemical under
OSHA are required to meet
specific MSDS reporting
requirements for planning
purposes (40 CFR 370.20(a)
through 370.21(a), 370.20(c),
and 370.28).
(NOTE: The emergency response commission consists of the State Emergency
Response Commission and the local Emergency Planning Committee. Some
states have only one of these.)
Verify that MSDSs (or a list as described below) are submitted to the emergency
response commission, the local emergency planning committee, and the fire
department with jurisdiction over the facility for each hazardous chemical present
according to the following thresholds:
-for all extremely hazardous substances present in amounts greater than or
equal to 500 Ib (227 kg, approximately 55 gal) or the threshold planning
quantity, whichever is lower
- for gasoline (all grades combined) in amounts greater than or equal to 75,000
gal (or approximately 283,900 L) when the gasoline is in tanks entirely
underground at a retail gas station that was in compliance during the
preceding calendar year with all applicable UST regulations (40 CFR Part
280 or requirements of the state UST program approved by U.S. EPA under
40 CFR Part 281)
-for diesel fuel (all grades combined) in amounts greater than or equal to
100,000 gal (or approximately 378,500 L) when the diesel is in tanks entirely
underground at a retail gas station that was in compliance during the
preceding calendar year with all applicable UST regulations (40 CFR Part
280 or requirements of the state UST program approved by U.S. EPA under
40 CFR Part 281)
- for all other hazardous chemicals present at any one time in amounts equal to
or greater than 10,000 Ib (4540 kg).
(NOTE: For the purposes of these threshold values, a retail gas station is a retail
facility engaged in selling gasoline and/or diesel fuel principally to the public, for
motor vehicle use on land.)
(NOTE: Commonly overlooked substances requiring an MSDS are propane and
petroleum based fuels. For diesel and unleaded gasoline, 10,000 Ib equals
approximately 1379 gal using the weight of 7.25 Ib/gal.)
Verify that if the facility has not submitted MSDSs, the following have been
submitted:
-a list of hazardous chemicals for which the MSDS is required, grouped by
hazard category (see Key Terms and Definitions section of this document for
a definition of Hazard Category)
- the chemical or common name of each hazardous chemical as provided on
the MSDS
- any hazardous component of each hazardous chemical as provided on the
MSDS unless reported as a mixture (see 40 CFR 370.28(a)(2).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Verify that revised MSDSs are provided to the local emergency planning
committee, emergency response commission, and fire department within 3 mo
after the discovery of significant new information concerning the hazardous
chemical for which the MSDSs were submitted.
(NOTE: When MSDSs for hazardous chemicals present at the facility have not
been submitted to the local emergency planning committee, the facility owner or
operator must submit the MSDSs within 30 days of the receipt of such a request.)
(NOTE: These reporting requirements for a hazardous chemical that is a mixture
of hazardous chemicals can be fulfilled by doing one of the following:
- providing the required information on each component in the mixture that is
a hazardous chemical
-providing the required information on the mixture itself so long as the
reporting of a mixture by a facility is in the same manner as required by 40
CFR 370.21 where practicable.)
EP.20.5. Facilities which are
required to prepare or have
available a MSDS for a
hazardous chemical under
OSHA are required to meet
specific inventory reporting
requirements for planning
purposes (40 CFR 370.20(a),
370.20(b), 370.20(d), 370.25,
and 370.28(a)).
Verify that the Tier I (or Tier II) Hazardous Chemical Inventory forms are
submitted annually to the local emergency planning committee, the emergency
response commission, and the fire department with jurisdiction over the facility.
(NOTE: Hazardous chemicals and substances that must be included Hazardous
Chemical Inventory forms are:
- all extremely hazardous substances present in amounts greater than or equal
to 500 Ib (227 kg, approximately 55 gal) or the threshold planning quantity,
whichever is lower
-gasoline (all grades combined) in amounts greater than or equal to 75,000
gal (or approximately 283,900 L) when the gasoline is in tanks entirely
underground at a retail gas station that was in compliance during the
preceding calendar year with all applicable UST regulations (40 CFR Part
280 or requirements of the state UST program approved by U.S. EPA under
40 CFR Part 281)
- diesel fuel (all grades combined) in amounts greater than or equal to 100,000
gal (or approximately 378,500 L) when the diesel is in tanks entirely
underground at a retail gas station that was in compliance during the
preceding calendar year with all applicable UST regulations (40 CFR Part
280 or requirements of the state UST program approved by U.S. EPA under
40 CFR Part 281)
- all other hazardous chemicals present at any one time in amounts equal to or
greater than 10,000 Ib (4540 kg).)
Verify that Tier I or Tier II forms are submitted on or before March 1 of the first
year after the facility becomes subject to 40 CFR 370.20 through 370.28.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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(NOTE: For the purposes of these threshold values, a retail gas station is a retail
facility engaged in selling gasoline and/or diesel fuel principally to the public, for
motor vehicle use on land.)
(NOTE: Commonly overlooked substances requiring an MSDS are propane and
petroleum based fuels.)
(NOTE: A Tier II form may be submitted in lieu of the Tier I information with
respect to any hazardous chemical at the facility. If requested, all Tier II forms
must be submitted to the local emergency planning committee, the emergency
response commission and the fire department with jurisdiction over the facility.
Tier II forms must be submitted within 30 days of the receipt of each request.)
(NOTE: The owner or operator of a facility that has submitted a Tier I or Tier II
inventory form must allow on-site inspection by the fire department having
jurisdiction over the facility upon request of the department and provide to the
department specific location information on hazardous chemicals at the facility.)
(NOTE: These reporting requirements for a hazardous chemical that is a mixture
of hazardous chemicals may be fulfilled by doing one of the following:
- providing the required information on each component in the mixture that is
a hazardous chemical
-providing the required information on the mixture itself so long as the
reporting of mixtures by a facility is in the same manner as required by 40
CFR 370.21 where practicable.)
EP.20.6. Facilities that
manufacture, process, or
otherwise use a listed toxic
chemical in excess of
applicable threshold quantities
and that have 10 or more
employees are subject to
certain reporting requirements
(40 CFR 372.22 through
372.38 and 372.95(b)).
(NOTE: These reporting requirements apply to facilities that meet all of the
following criteria for a calendar year:
-the facility has 10 or more full-time employees
-the facility is in Standard Industrial Classification (SIC) (as in effect on
January 1, 1987) major group codes 10 (except 1011, 1081, and 1094), 12
(except 1241), or 20 through 39; industry codes 4911, 4931, or 4939 (limited
to facilities that combust coal and/or oil for the purpose of generating power
for distribution in commerce); or 4953 (limited to facilities regulated under
the RCRA, subtitle C, 42 U.S.C. section 6921 et seq.), or 5169, or 5171, or
7389 (limited to facilities primarily engaged in solvent recovery services on a
contract or fee basis) by virtue of the fact that it meets one of the following
criteria:
-the facility is an establishment with a primary SIC major group or
industry code in the above list
-the facility is a multi-establishment complex where all establishments
have primary SIC major group or industry codes in the above list
-the facility is a multi-establishment complex in which one of the
folio wing is true:
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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- the sum of the value of services provided and/or products shipped
and/or produced from those establishments that have primary SIC
major group or industry codes in the above list is greater than 50
percent of the total value of all services provided and/or products
shipped from and/or produced by all establishments at the facility
-one establishment having a primary SIC major group or industry
code in the above list contributes more in terms of value of
services provided and/or products shipped from and/or produced
at the facility than any other establishment within the facility.
- the facility manufactured (including imported), processed, or otherwise used
a listed toxic chemical in excess of an applicable threshold quantity of that
chemical.)
(NOTE: The following are the threshold levels for a facility that is manufacturing
(including importing), processing, or otherwise using a toxic chemical:
-has manufactured or processed over 25,000 Ib/yr of toxic chemicals, except
for persistent bioaccumulative toxic (PBT) chemicals
- has otherwise used over 10,000 Ib of toxic chemicals during the year, except
for PBT chemicals
-for the chemicals listed in Appendix A of this document, the amounts
indicated in the appendix.
(NOTE: The reporting requirement thresholds for PBY chemicals are listed in
Table 2 of Appendix A of this document.)
Verify that a completed U.S. EPA Form R (U.S. EPA Form 9350-1) is submitted
annually, for each toxic chemical known by the facility owner or operator to be
manufactured (including imported) or otherwise used and exceeding threshold
levels in one calendar year to the U.S. EPA and state on or before July 1 of the
next year.
(NOTE: Articles containing toxic chemicals are not included in calculations of
total toxic chemical present. See 40 CFR 372.38(b) for procedure to determine
whether an excess has occurred.)
(NOTE: The owner or operator of a facility regulated under 40 CFR Part 372 is
required to complete and submit U.S. EPA Form R, as described above, for a toxic
chemical that is present as a component of a mixture or trade name product which
the owner or operator receives from another person, if that chemical is imported,
processed, or otherwise used by the owner or operator in excess of an applicable
threshold quantity at the facility as part of that mixture or trade name product.)
(NOTE: The owner or operator or a facility at which a toxic chemical was
manufactured (including imported), processed or otherwise used in excess of an
applicable threshold quantity may submit a separate Form R for each
establishment or for each group of establishments within the facility to report the
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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activities involving the toxic chemical at each establishment or group of
establishments, provided that activities involving the toxic chemical at all the
establishments within the covered facility are reported. See 40 CFR 372.30(c) for
instruction and procedures regarding alternatives for reporting when the facility
consists of more than one establishment.
(NOTE: A facility may apply an alternate threshold of one million Ib/yr to a
chemical if it is calculated that the facility would have an annual reportable
amount of that toxic chemical not exceeding 500 Ib for the combined total
quantities released at the facility, disposed within the facility, treated at the facility
(as represented by amounts destroyed or converted by treatment processes),
recovered at the facility as a result of recycle operations, combusted for the
purpose of energy recovery at the facility, and amounts transferred from the
facility to offsite locations for the purpose of recycle, energy recovery, treatment,
and/or disposal. The alternate threshold provisions do not apply to the chemicals
listed in Appendix A of this document.)
Verify that, if a facility uses the alternate reporting threshold, the facility owner or
operator submits the required certification statement that contains the following
information instead of the U.S. EPA Form R:
- reporting year
- an indication of whether the chemical identified is being claimed as trade
secret
-chemical name and CAS number (if applicable) of the chemical, or the
category name
- signature of a senior management official certifying the following: pursuant
to 40 CFR 372.27, "I hereby certify that to the best of my knowledge and
belief for the toxic chemical listed in this statement, the annual reportable
amount, as defined in 40 CFR 372.27(a), did not exceed 500 Ib for this
reporting year and that the chemical was manufactured, or processed, or
otherwise used in an amount not exceeding 1 million pounds during this
reporting year"
- date signed
- facility name and address
- mailing address of the facility if different than the above
- toxic chemical release inventory facility identification number if known
- name and telephone number of a technical contact
- the four-digit SIC codes for the facility or establishments in the facility
- latitude and longitude coordinates for the facility
- Dun and Bradstreet number of the facility
-U.S. EPA identification number(s) (RCRA) ID. Number(s) of the facility
- facility NPDES permit number(s)
-underground Injection Well Code (UIC) ID. Number(s) of the facility
- name of the facility's parent company
- parent company's Dun and Bradstreet Number.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Verify that, when more than one threshold applies to facility activities, the facility
owner or operator reports if it exceeds any applicable threshold and reports on all
activities at the facility involving the chemical unless otherwise exempted (see
below).
Verify that, when a facility manufactures, processes, or otherwise uses more than
one member of a chemical category listed in 40 CFR 372.65(c), the facility owner
or operator reports if it exceeds any applicable threshold for the total volume of all
the members of the category involved in the applicable activity and the report
covers all activities at the facility involving members of the category.
(NOTE: A facility may process or otherwise use a toxic chemical in a
recycle/reuse operation. To determine whether the facility has processed or used
more than an applicable threshold of the chemical, the owner or operator of the
facility counts the amount of the chemical added to the recycle/reuse operation
during the calendar year. In particular, if the facility starts up such an operation
during a calendar year, or in the event that the contents of the whole recycle/reuse
operation are replaced in a calendar year, the facility owner or operator also counts
the amount of the chemical placed into the system at these times.)
(NOTE: Certain toxic chemicals, manufacturing methods used to produce these
chemicals and/or the physical forms or colors of these chemical may limit
reporting requirements under 40 CFR Part 372. These specific circumstances and
conditions and reporting requirements are outlined in 40 CFR 372.25(f) through
(h).)
(NOTE: The following exemptions apply:
- if a toxic chemical is present in a mixture of chemicals at a covered facility
and the toxic chemical is in a concentration in the mixture which is below
one percent of the mixture, or 0.1 percent of the mixture in the case of a toxic
chemical which is a carcinogen as defined in 29 CFR 1910.1200(d)(4), the
quantity of the toxic chemical present in such mixture does not have to be
considered when determining whether an applicable threshold has been met
or determining the amount of release to be reported under 40 CFR 372.30.
This exemption applies whether the person received the mixture from another
person or the person produced the mixture, either by mixing the chemicals
involved or by causing a chemical reaction that resulted in the creation of the
toxic chemical in the mixture. However, this exemption applies only to the
quantity of the toxic chemical present in the mixture. If the toxic chemical is
also manufactured (including imported), processed, or otherwise used at the
covered facility other than as part of the mixture or in a mixture at higher
concentrations, in excess of an applicable threshold quantity, the facility is
required to report. This exemption does not apply to the chemicals listed in
Appendix A of this document
- if a toxic chemical is present in an article at a covered facility, the quantity of
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
the toxic chemical present in such article does not have to be considered
when determining whether an applicable threshold has been met or
determining the amount of release to be reported. This exemption applies
whether the person received the article from another person or produced the
article. However, this exemption applies only to the quantity of the toxic
chemical present in the article. If the toxic chemical is manufactured
(including imported), processed, or otherwise used at the covered facility
other than as part of the article, in excess of an applicable threshold quantity,
reporting is required. If a release of a toxic chemical occurs as a result of the
processing or use of an item at the facility, that item does not meet the
definition of article.
- if a toxic chemical is used at a covered facility for one of the following
purposes, it is not required to consider the quantity of the toxic chemical used
for such purpose when determining whether an applicable threshold has been
met under 40 CFR 372.25 or determining the amount of releases to be
reported. However, this exemption only applies to the quantity of the toxic
chemical used for the purpose described in the following list. If the toxic
chemical is also manufactured (including imported), processed, or otherwise
used at the covered facility other than as listed below, in excess of an
applicable threshold quantity, reporting is required. The list includes:
-use as a structural component of the facility
-use of products for routine janitorial or facility grounds maintenance
- personal use by employees or other persons at the facility of foods,
drugs, cosmetics, or other personal items containing toxic chemicals,
including supplies of such products within the facility such as in a
facility operated cafeteria, store, or infirmary
-use of products containing toxic chemicals for the purpose of
maintaining motor vehicles operated by the facility
- use of toxic chemicals present in process water and non-contact cooling
water as drawn from the environment or from municipal sources
- toxic chemicals present in air used either as compressed air or as part of
combustion.
- if a toxic chemical is manufactured, processed, or used in a laboratory at a
covered facility under the supervision of a technically qualified individual, it
is not required to consider the quantity so manufactured, processed, or used
when determining whether an applicable threshold has been met or
determining the amount of release to be reported (NOTE: This exemption
does not apply in the following cases: specialty chemical production;
manufacture, processing, or use of toxic chemicals in pilot plant scale
operations; activities conducted outside the laboratory).
(NOTE: Other exemptions may also apply to certain owners of leased property,
certain operators of establishments on leased property, and owners and operators
of facilities engaged in coal extraction activities, or metal mining overburden
activities. See 40 CFR 372.38(e) through (h) for further detail regarding these
types of exemptions.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
32
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
RECORDKEEPING
EP.30
EP.30.1. Facilities that
manufacture, process, or
otherwise use a listed toxic
chemical in excess of
applicable threshold
quantities and that have 10 or
more employees are subject to
certain recordkeeping
requirements (40 CFR
372.22(a), 372.22(b),
372.22(c, 372.25(a),
372.25(b), 372.10(a) through
372.10(d), and 372.38).
(NOTE: These recordkeeping requirements apply to facilities that meet all of the
following criteria for a calendar year:
-the facility has 10 or more full-time employees
-the facility is in Standard Industrial Classification (SIC) (as in effect on
January 1, 1987) major group codes 10 (except 1011, 1081, and 1094), 12
(except 1241), or 20 through 39; industry codes 4911, 4931, or 4939 (limited
to facilities that combust coal and/or oil for the purpose of generating power
for distribution in commerce); or 4953 (limited to facilities regulated under
the RCRA, subtitle C, 42 U.S.C. section 6921 et seq.), or 5169, or 5171, or
7389 (limited to facilities primarily engaged in solvent recovery services on
a contract or fee basis) by virtue of the fact that it meets one of the following
criteria:
-the facility is an establishment with a primary SIC major group or
industry code in the above list
- the facility is a multi-establishment complex where all establishments
have primary SIC major group or industry codes in the above list
-the facility is a multi-establishment complex in which one of the
following is true:
- the sum of the value of services provided and/or products shipped
and/or produced from those establishments that have primary SIC
major group or industry codes in the above list is greater than 50
percent of the total value of all services provided and/or products
shipped from and/or produced by all establishments at the facility
-one establishment having a primary SIC major group or industry
code in the above list contributes more in terms of value of
services provided and/or products shipped from and/or produced
at the facility than any other establishment within the facility.
- the facility manufactured (including imported), processed, or otherwise used
a toxic chemical in excess of an applicable threshold quantity of that
chemical.)
(NOTE: The following are the threshold levels for reporting purposes that apply
to a facility that is manufacturing (including importing), processing, or otherwise
using a toxic chemical:
- has manufactured or processed 25,000 Ib/yr of toxic chemicals
- has used 10,000 Ib of toxic chemicals in other ways during the year
-for the chemicals listed in Appendix A of this document, the amounts
indicated in the appendix.
(NOTE: Articles containing toxic chemicals are not included in calculations of
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
33
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
total toxic chemical present. See 40 CFR 372.30(b)(3) for procedure to determine
whether an excess has occurred.)
Verify that the following records are kept 3 yr from the date of the submission of
U.S. EPA Form R (U.S. EPA Form 9350-1):
- a copy of each Form R report submitted
- all supporting materials and documentation used by the person to make the
compliance determination that the facility or establishments is a covered
facility under 40 CFR 372.22 or 372.45
- documentation supporting the submitted report, including:
- documentation supporting any determination that a claimed allowable
exemption under 40 CFR 372.38 applies
-data supporting the determination of whether a reporting threshold
applies for each toxic chemical
- documentation supporting the calculations of the quantity of each toxic
chemical released to the environment or transferred to an off-site
location
-documentation supporting the use indications and quantity onsite
reporting for each toxic chemical, including dates of manufacturing,
processing, or use
- documentation supporting the basis of estimate used in developing any
release or off-site transfer estimates for each toxic chemical
- receipts or manifests associated with the transfer of each toxic chemical
in waste to off-site locations
- documentation supporting reported waste treatment methods, estimates
of treatment efficiencies, ranges of influent concentration to such
treatment, the sequential nature of treatment steps, if applicable, and the
actual operating data, if applicable, to support the waste treatment
efficiency estimate for each toxic chemical.
Verify that the following records are maintained for 3 yr at the facility to which
the report applies or from which supplier notification was provided:
-all supporting materials and documentation used to determine if supplier
notification is required
- all supporting materials and documentation used in developing each required
supplier notification and a copy of each notification.
(NOTE: Records retained under this section must be maintained at the facility to
which the report applies or from which a notification was provided. Such records
must be readily available for purposes of inspection by U.S. EPA.)
Verify that, if it has been determined the alternate threshold (see 40 CFR 372.27
may be applied, the following records are kept for 3 yr from the date of
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
34
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
submission of the required certification statement:
- a copy of each certification statement submitted
-all supporting materials and documentation used to make the compliance
determination that the facility or establishment is eligible to apply the
alternate threshold
- documentation supporting the certification statement submitted, including:
- data supporting the determination of whether the alternate threshold
applies for each toxic chemical
- documentation supporting the calculation of annual reportable amount
(see 40 CFR 372.37(a)), for each toxic chemical, including
documentation supporting the calculations and the calculations of each
data element combined for the annual reportable amount
- receipts or manifests associated with the transfer of each chemical in
waste to off-site locations.
(NOTE: The following exemptions apply:
- if a toxic chemical is present in a mixture of chemicals at a covered facility
and the toxic chemical is in a concentration in the mixture which is below 1
percent of the mixture, or 0.1 percent of the mixture in the case of a toxic
chemical which is a carcinogen as defined in 29 CFR 1910.1200(d)(4), the
quantity of the toxic chemical present in such mixture does not have to be
considered when determining whether an applicable threshold has been met
or determining the amount of release to be reported under 40 CFR 372.30.
This exemption applies whether the person received the mixture from
another person or the person produced the mixture, either by mixing the
chemicals involved or by causing a chemical reaction that resulted in the
creation of the toxic chemical in the mixture. However, this exemption
applies only to the quantity of the toxic chemical present in the mixture. If
the toxic chemical is also manufactured (including imported), processed, or
otherwise used at the covered facility other than as part of the mixture or in a
mixture at higher concentrations, in excess of an applicable threshold
quantity, the facility is required to report. This exemption does not apply to
the chemicals listed in Appendix A of this document
- if a toxic chemical is present in an article at a covered facility, the quantity of
the toxic chemical present in such article does not have to be considered
when determining whether an applicable threshold has been met or
determining the amount of release to be reported. This exemption applies
whether the person received the article from another person or produced the
article. However, this exemption applies only to the quantity of the toxic
chemical present in the article. If the toxic chemical is manufactured
(including imported), processed, or otherwise used at the covered facility
other than as part of the article, in excess of an applicable threshold quantity,
reporting is required. If a release of a toxic chemical occurs as a result of the
processing or use of an item at the facility, that item does not meet the
definition of article.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
35
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
COMPLIANCE CATEGORY:
EPCRA
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
- if a toxic chemical is used at a covered facility for one of the following
purposes, it is not required to consider the quantity of the toxic chemical
used for such purpose when determining whether an applicable threshold has
been met under 40 CFR 372.25 or determining the amount of releases to be
reported. However, this exemption only applies to the quantity of the toxic
chemical used for the purpose described in the following list. If the toxic
chemical is also manufactured (including imported), processed, or otherwise
used at the covered facility other than as listed below, in excess of an
applicable threshold quantity, reporting is required. The list includes:
-use as a structural component of the facility
-use of products for routine janitorial or facility grounds maintenance
- personal use by employees or other persons at the facility of foods,
drugs, cosmetics, or other personal items containing toxic chemicals,
including supplies of such products within the facility such as in a
facility operated cafeteria, store, or infirmary
-use of products containing toxic chemicals for the purpose of
maintaining motor vehicles operated by the facility
- use of toxic chemicals present in process water and non-contact cooling
water as drawn from the environment or from municipal sources
- toxic chemicals present in air used either as compressed air or as part of
combustion.
- if a toxic chemical is manufactured, processed, or used in a laboratory at a
covered facility under the supervision of a technically qualified individual, it
is not required to consider the quantity so manufactured, processed, or used
when determining whether an applicable threshold has been met or
determining the amount of release to be reported (NOTE: This exemption
does not apply in the following cases: specialty chemical production;
manufacture, processing, or use of toxic chemicals in pilot plant scale
operations; activities conducted outside the laboratory).
(NOTE: Other exemptions may also apply to certain owners of leased property,
certain operators of establishments on leased property, and owners and operators
of facilities engaged in coal extraction activities, or metal mining overburden
activities. See 40 CFR 372.38 (e) through (h) for further detail regarding these
types of exemptions.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
36
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Protocol for Conducting Environmental Compliance
Audits under EPCRA and CERCLA Section 103
Appendix A:
Lower Thresholds for Chemicals of Special Concern (40 CFR 372.28)
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Lower Thresholds for Chemicals of Special Concern
(40 CFR 372.28)
[Added January 2001]
Table 1
Chemical Listing in Alphabetic Order.
Chemical Name
Aldrin
Benzo(g,h,i)perylene
Chlordane
Heptachlor
Hexachlorobenzene
Isodrin
Lead (this lower threshold does not
apply to lead when contained in a
stainless steel, brass or bronze alloy)
Mercury
Methoxychlor
Octachlorostyrene
Pendimethalin
Pentachlorobenzene
Polychlorinated biphenyl (PCBs)
Tetrabromobisphenol A
Toxaphene
Trifluralin
CAS NO.
00309-00-2
00191-24-2
00057-74-9
00076-44-8
00118-74-1
00465-73-6
7439-92-1
07439-97-6
00072-43-5
29082-74-4
40487-42-1
00608-93-5
01336-36-3
00079-94-7
08001-35-2
01582-09-8
Reporting
Threshold
100
10
10
10
10
10
100
10
100
10
100
10
10
100
10
100
Table 2
Chemical Categories in Alphabetic Order
Category name
Reporting threshold
Dioxin and dioxin-like compounds (Manufacturing; and
the processing or otherwise use of dioxin and dioxin-like
compounds if the dioxin and dioxin-like compounds are
present as contaminants in a chemical and if they were
created during the manufacturing of that chemical) (This
category includes only those chemicals listed below).
- 1,2,3,4,6,7,8-Heptachlorodibenzofuran
-1,2,3,4,7,8,9-Heptachlorodibenzofuran
- 1,2,3,4,7,8-Hexachlorodibenzofuran
- 1,2,3,6,7,8-Hexachlorodibenzofuran
- 1,2,3,7,8,9-Hexachlorodibenzofuran
- 2,3,4,6,7,8-Hexachlorodibenzofuran
- 1,2,3,4,7,8-Hexachlorodibenzo-p-dioxin
- 1,2,3,6,7,8-Hexachlorodibenzo-p-dioxin
- 1,2,3,7,8,9-Hexachlorodibenzo-p-dioxin
- 1,2,3,4,6,7,8-Heptachlorodibenzo-p-dioxin
-1,2,3,4,6,7,8,9-Octachlorodibenzofuran
- 1,2,3,4,6,7,8,9-Octachlorodibenzo-p-dioxin
0.1 grams
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
Al
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Protocol for Conducting Environmental Compliance Audits under EPCRA and CERCLA Section 103
Category name
Reporting threshold
- 1,2,3,7,8-Pentachlorodibenzofuran
- 2,3,4,7,8-Pentachlorodibenzofuran
- 1,2,3,7,8-Pentachlorodibenzo-p-dioxin
- 2,3,7,8-Tetrachlorodibenzofuran
- 2,3,7,8 Tetrachlorodibenzo-p-dioxin
Lead Compounds
100
Mercury compounds
10
Poly cyclic aromatic compounds (PACs) (This 100
category includes only those chemicals listed below).
- Benz(a)anthracene
- Benzo(b)fluoranthene
- Benzo(j)fluoranthene
- Benzo(k)fluoranthene
- Benzo(j ,k)fluorene
- Benzo(r,s,t)pentaphene
- Benzo(a)phenanthrene
- Benzo(a)pyrene
- Dibenz(a,h)acridine
- Dibenz(a,j)acridine
- Dibenzo(a,h)anthracene
- 7H-Dibenzo(c,g)carbazole
- Dibenzo(a,e)fluoranthene
- Dibenzo(a,e)pyrene
- Dibenzo(a,h)pyrene
- Dibenzo(a,l)pyrene
- 7,12-Dimethylbenz(a)anthracene
- Indeno [ 1,2,3 -cd]pyrene
- 3-Methylcholanthrene
- 5-Methylchrysene
- 1-Nitropyrene
100
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
A2
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Protocol for Conducting Environmental Compliance
Audits under EPCRA and CERCLA Section 103
Appendix B:
User Satisfaction Questionnaire and Comment Form
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User Satisfaction Survey
(OMB Approval No. 1860.01)
Expires 9/30/2001
We would like to know if this Audit Protocol provides you with useful information. This information will
be used by EPA to measure the success of this tool in providing compliance assistance and to determine
future applications and needs for regulatory checklists and auditing materials.
1. Please indicate which Protocol(s) this survey applies to:
Title:
EPA Document Number:
2. Overall, did you find the Protocol helpful for conducting audits:
Yes No
If not, what areas of the document are difficult to understand?
3. How would you rate the usefulness of the Protocol(s) for conducting compliance audits on a scale of 1-
5?
1 = not useful or effective, 3 = somewhat useful/effective, 5 = very useful/effective
Low Medium High
12345 Introduction Section
12345 Key Compliance Requirements
12345 Key Terms and Definitions
12345 Checklist
4. What actions do you intend to take as a result of using the protocol and/or conducting the audit? Please
check all that apply.
Contact a regulatory agency
Contact a compliance assistance provider (e.g., trade association, state agency, EPA)
Contact a vendor
Disclose violations discovered during the audit under EPA's audit Policy
Disclose violations discovered under EPA's Small Business Policy
Obtain a permit or certification
Change the handling of a waste, emission or pollutant
Change a process or practice
Purchase new process equipment
Install emission control equipment (e.g., scrubbers, wastewater treatment)
Install waste treatment system (control technique)
Implement or improve pollution prevention practices (e.g., source reduction, recycling)
Improve organizational auditing program
Institute an Environmental Management System
Improve the existing Environmental Management System (e.g., improve training, clarify standard
operating procedures, etc.)
Other
-------
5. What, if any, environmental improvements will result from the actions to be taken (check all that
apply)?
reduced emissions
waste reduction
reduced risk to human health and the environment due to better management practices
reduced quantity and toxicity of raw materials
water conservation
energy conservation
conserved raw materials
conservation of habitat or other environmental stewardship practice:
other:
no environmental improvements are likely to result from the use of this document
6. How did you hear about this document?
trade association
state technical assistance provider
EPA internet homepage or website
document catalog
co-worker or business associate
EPA, state, or local regulator
other (please specify)
7. In order to understand your response, we would like to know what function you perform with respect to
environmental compliance and the size of your organization.
Company Personnel Trade Association Compliance Assistance
Environmental Auditor National Provider
Corporate Level Regional EPA
Plant-level Local State
Legal Manager State Small Business
Environmental Manager Information Specialist Assistance
Operator - (e.g., Local
Pollution Control Other
Equipment
Other:
Regulatory Personnel Vendor/Consultant
State Environmental Auditor
Local Environmental
EPA Engineer/Scientist
Attorney
How many employees are located at your facility (including full-time contractors?)
0-9 10-49 50-100 101-500 More than 500
-------
Optional (Please Print)
Name: Address:
Title: City: State:
Zip code:
Organization Name:
Phone: ( 1 E-mail:
Please return all pages (1 thru 3) of this survey by folding pages 1 and 2 into page 3 and using the
preprinted, pre-stamped address on the reverse side of page 3. If you have accessed this document
electronically from one of EPA's web sites, simply e-mail this questionnaire to:
satterfield.richard(@,epa.gov.
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United States
Environmental Protection
Agency
Office of Solid Waste
and Emergency Response
(5101)
EPA 550-F-00-004
March 2000
©EPA
The Emergency Planning and
Community Right-to-Know Act
The Emergency Planning and Community Right-to-Know Act of 1986
(EPCRA) establishes requirements for Federal, State and local govern-
ments, Indian Tribes, and industry regarding emergency planning and
"Community Right-to-Know" reporting on hazardous and toxic chemicals.
The Community Right-to-Know provisions help increase the public's
knowledge and access to information on chemicals at individual facilities,
their uses, and releases into the environment. States and communities,
working with facilities, can use the information to improve chemical safety
and protect public health and the environment.
What Does EPCRA Cover? section 303. The plans must
EPCRA has four major provisions:
Emergency planning (Section 301-303),
Emergency release notification (Section
304),
Hazardous chemical storage reporting
requirements (Sections 311-312), and
Toxic chemical release inventory
(Section 313).
Information gleaned from these four
requirements will help States and
communities develop a broad perspective of
chemical hazards for the entire community
as well as for individual facilities.
Regulations implementing EPCRA are
codified in Title 40 of the Code of Federal
Regulations, parts 350 to 372. The
chemicals covered by each of the sections
are different, as are the quantities that
trigger reporting. Table 1 on the next page
summarizes the chemicals and thresholds.
What Are Emergency
Response Plans
(Sections 301-303)?
Emergency Response plans contain
information that community officials can
use at the time of a chemical accident.
Community emergency response plans for
chemical accidents were developed under
Identify facilities and transportation
routes of extremely hazardous
substances;
Describe emergency response
procedures, on and off site;
Designate a community coordinator and
facility coordinators) to implement the plan;
Outline emergency notification
procedures;
Describe how to determine the probable
affected area and population by releases;
Describe local emergency equipment
and facilities and the persons responsible
for them;
Outline evacuation plans;
Provide a training program for
emergency responders (including
schedules); and,
Provide methods and schedules for
exercising emergency response plans.
Planning activities of LEPCs and facilities
initially focused on, but were not limited to,
the 356 extremely hazardous substances
listed by EPA. The list includes the
threshold planning quantities (minimum
limits) for each substance. Any facility
that has any of the listed chemicals at or
above its threshold planning quantity must
notify the SERC and LEPC within 60 days
after they first receive a shipment or
produce the substance on site.
Chemical Emergency Preparedness and Prevention Office
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What Are the Emergency Notification
Requirements
(Section 304)?
Facilities must immediately notify the LEPC and the SERC
if there is a release into the environment of a hazardous
substance that is equal to or exceeds the minimum
reportable quantity set in the regulations. This requirement
covers the 356 extremely hazardous substances as well as
the more than 700 hazardous substances subject to the
emergency notification requirements under CERCLA
Section 103(a)(40 CFR 302.4). Some chemicals are
common to both lists. Initial notification can be made by
telephone, radio, or in person. Emergency notification
requirements involving transportation incidents can be met
by dialing 911, or in the absence of a 911 emergency
number, calling the operator. This emergency notification
needs to include:
The chemical name;
An indication of whether the substance is extremely
hazardous;
An estimate of the quantity released into the
environment;
The time and duration of the release;
Whether the release occurred into air, water, and/or
land;
Any known or anticipated acute or chronic health risks
associated with the emergency, and where necessary,
advice regarding medical attention for exposed
individuals;
Proper precautions, such as evacuation or sheltering in
place; and,
What Are SERCs
and LEPCs?
The Governor of each state designated a State
Emergency Response Commission (SERC). The
SERCs, in turn, designated about 3,500 local
emergency planning districts and appointed Local
Emergency Planning Committees (LEPCs) for each
district. The SERC supervises and coordinates the
activities of the LEPC, establishes procedures for
receiving and processing public requests for
information collected under EPCRA, and reviews local
emergency response plans.
The LEPC membership must include, at a minimum, local
officials including police, fire, civil defense, public health,
transportation, and environmental professionals, as well
as representatives of facilities subject to the emergency
planning requirements, community groups, and the media.
The LEPCs must develop an emergency response plan,
review it at least annually, and provide information about
chemicals in the community to citizens.
Name and telephone number of contact person.
A written follow-up notice must be submitted to the SERC
and LEPC as soon as practicable after the release. The
follow-up notice must update information included in the
initial notice and provide information on actual response
actions taken and advice regarding medical attention
necessary for citizens exposed.
Table 1: EPCRA Chemicals and Reporting Thresholds
Chemicals
Covered
Thresholds
Section 302
356 extremely hazardous
substances
Threshold Planning
Quantity 1-10,000
pounds on site at any
one time
Section 304
>1,000 substances
Reportable quantity,
1-5,000 pounds, released
in a 24-hour period
Sections 311/312
500,000 products
TPQ or 500 pounds for
Section 302 chemicals;
10,000 pounds on site
at any one time for
other chemicals
Section 313
650 toxic chemicals and
categories
25,000 pounds peryear
manufactured or
processed; 10,000
pounds a year used;
certain persistent
bioaccumulative
toxics have lower
thresholds
Chemical Emergency Preparedness and Prevention Office
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What Are the Community
Right-to-know Requirements
(Sections 311/312)?
Under Occupational Safety and Health Administration
(OSHA) regulations, employers must maintain a material
safety data sheet (MSDS) for any hazardous chemicals
stored or used in the work place. Approximately 500,000
products have MSDSs.
Section 311 requires facilities that have MSDSs for
chemicals held above certain quantities to submit either
copies of their MSDSs or a list of MSDS chemicals to the
SERC, LEPC, and local fire department. If the facility
owner or operator chooses to submit a list of MSDS
chemicals, the list must include the chemical or common
name of each substance and must identify the applicable
hazard categories. These hazard categories are:
Immediate (acute) health hazard;
Delayed (chronic) health hazard;
Fire hazard;
Sudden release of pressure hazard; and
Reactive hazard.
If a list is submitted, the facility must submit a copy of the
MSDSs for any chemical on the list upon the request of the
LEPC or SERC.
Facilities that start using a chemical or increase the quantity
to exceed the thresholds must submit MSDSs or a list of
MSDSs chemicals within three months after they become
covered. Facilities must provide a revised MSDS to update
the original MSDS if significant new information is
discovered about the hazardous chemical.
Facilities covered by section 311 must, under section 312,
submit annually an emergency and hazardous chemical
inventory form to the LEPC, the SERC, and the local fire
department. Facilities provide either a Tier I or Tier II
form. Tier I forms include the following aggregate
information for each applicable hazard category:
An estimate (in ranges) of the maximum amount of
chemicals for each category present at the facility at any
time during the preceding calendar year;
An estimate (in ranges) of the average daily amount of
chemicals in each category; and,
The general location of hazardous chemicals in each
category.
The Tier II report contains basically the same information
as the Tier I, but it must name the specific chemicals.
Many states require Tier II information under state law.
Tier II forms provide the following information for each
substance:
The chemical name or the common name as indicated on
the MSDS;
An estimate (in ranges) of the maximum amount of the
chemical present at any time during the preceding
calendar year and the average daily amount;
A brief description of the manner of storage of the
chemical;
The location of the chemical at the facility; and
An indication of whether the owner elects to withhold
location information from disclosure to the public.
Because many SERCs have added requirements or
incorporated the Federal contents in their own forms, Tier
I/II forms should be obtained from the SERC. Section 312
information must be submitted on or before March 1 each
year. The information submitted under sections 311 and
312 is available to the public from LEPCs and SERCs.
In 1999, EPA excluded gasoline held at most retail gas
stations from EPCRA 311/312 reporting. EPA estimates
that about 550,000 facilities are now covered by EPCRA
311/312 requirements.
Reporting Schedules
Section
302 One time notification to SERC
304 Each time a release above a
reportable quantity occurs; to LEPC
and SERC
311 One time submission; update only for
new chemicals or information;
to SERC, LEPC, fire department
312 Annually, by March 1 to SERC,
LEPC, fire department
313 Annually, by July 1, to EPA and State
Chemical Emergency Preparedness and Prevention Office
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What is the Toxics Release Inventory
(Section 313)?
EPCRA section 313 (commonly referred to as the Toxics
Release Inventory or TRI) requires certain facilities (see
box) to complete a Toxic Chemical Release Inventory
Form annually for specified chemicals. The form must be
submitted to EPA and the State on July 1 and cover
releases and other waste management of toxic chemicals
that occurred during the preceding calendar year. One
purpose of this reporting requirement is to inform the public
and government officials about releases and other waste
management of toxic chemicals. The following information
is required on the form:
The name, location and type of business;
Whether the chemical is manufactured (including
importation), processed, or otherwise used and the
general categories of use of the chemical;
An estimate (in ranges) of the maximum amounts of the
toxic chemical present at the facility at any time during
the preceding year;
Quantity of the chemical entering the air, land, and water
annually;
Off-site locations to which the facility transfers toxic
chemicals in waste for recycling, energy recovery,
treatment or disposal; and
Waste treatment/disposal methods and efficiency of
methods for each waste stream;
In addition, the Pollution Prevention Act of 1990 requires
collection of information on source reduction, recycling, and
treatment. EPA maintains a national TRI database,
available on the Internet (see the Where Can I Find
EPCRA Information? section for further details).
What Else Does EPCRA Require?
Trade Secrets. EPCRA section 322 addresses trade
secrets as they apply EPCRA sections 303, 311, 312, and
313 reporting; a facility cannot claim trade secrets under
section 304 of the statute. Only chemical identity may be
claimed as a trade secret, though a generic class for the
chemical must be provided. The criteria a facility must
meet to claim a chemical identity as a trade secret are in 40
CFR part 350. In practice, less than one percent of
facilities have filed such claims.
Even if chemical identity information can be legally
withheld from the public, EPCRA section 323 allows the
Who's Covered by TRI?
The TRI reporting requirement applies to facilities that
have 10 or more full-time employees, that manufacture
(including importing), process, or otherwise use a listed
toxic chemical above threshold quantities, and that are
in one of the following sectors:
Manufacturing (Standard Industrial Classification
(SIC) codes 20 through 39)
Metal mining (SIC code 10, except for SIC codes
1011,1081,and 1094)
Coal mining (SIC code 12, except for 1241 and
extraction activities)
Electrical utilities that combust coal and/or oil (SIC
codes 4911,4931, and 4939)
Resource Conservation and Recovery Act (RCRA)
Subtitle C hazardous waste treatment and disposal
facilities (SIC code 4953)
Chemicals and allied products wholesale distributors
(SIC code 5169)
Petroleum bulk plants and terminals (SIC code 5171)
Solvent recovery services (SIC code 7389)
information to be disclosed to health professionals who
need the information for diagnostic and treatment purposes
or local health officials who need the information for
prevention and treatment activities. In non-emergency
cases, the health professional must sign a confidentiality
agreement with the facility and provide a written statement
of need. In medical emergencies, the health professional, if
requested by the facility, provides these documents as soon
as circumstances permit.
Any person may challenge trade secret claims by
petitioning EPA. The Agency must then review the claim
and rule on its validity.
EPCRA Penalties. EPCRA Section 325 allows civil and
administrative penalties ranging up to $ 10,000-$75,000 per
violation or per day per violation when facilities fail to
comply with the reporting requirements. Criminal penalties
up to $50,000 or five years in prison apply to any person
who knowingly and willfully fails to provide emergency
release notification. Penalties of not more than $20,000
and/or up to one year in prison apply to any person who
knowingly and willfully discloses any information entitled to
protection as a trade secret.
Chemical Emergency Preparedness and Prevention Office
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Citizens Suits. EPCRA section 326 allows citizens to
initiate civil actions against EPA, SERCs, and the owner or
operator of a facility for failure to meet the EPCRA
requirements. A SERC, LEPC, and State or local
government may institute actions against facility owner/
operators for failure to comply with EPCRA requirements.
In addition, States may sue EPA for failure to provide trade
secret information.
Where Can You Find EPCRA
Information?
MSDSs, hazardous chemical inventory forms, follow-up
emergency notices, and the emergency response plan are
available from the SERC and LEPC.
MSDSs on hazardous chemicals are maintained by a
number of universities and can be accessed through
www .hazard. com.
EPA also provides fact sheets and other information on
chemical properties through its website: www.epa.gov.
EPA has compiled a list of all chemicals covered by name
under these regulations into a single list and published them
as The Title III List of Lists available at www.epa.gov/
swercepp/ds-epds.htm#title3.
Profiles of extremely hazardous substances are available at
www.epa.gov/ceppo/ep_chda.htm#ehs
Each year, EPA publishes a report summarizing the TRI
information that was submitted to EPA and States during
the previous year. In addition, TRI data are available
through EPA's Envirofacts database at www.epa.gov/
enviro. TRI data are also available at www.epa.gov/tri,
www.rtk.net, and www.scorecard.org.
All of these sites can be searched by facility, city, county,
and state and provide access to basic TRI emissions data.
The RTK-Net site, maintained by the public advocacy
group OMB Watch, provides copies of the full TRI form
for each facility. The Scorecard site, maintained by the
Environmental Defense public advocacy group, ranks
facilities, States, and counties on a number of parameters
(e.g., total quantities of carcinogens released) as well as
maps that show the locations of facilities in a county or city.
Initial emergency release notifications made to the National
Response Center or EPA are available on line at
www.epa.gov/ernsacct/pdf/index.html.
A list of LEPCs and SERCs is available at http://
www.RTK.NET: 80/lepc/.
Many of these sites can also be accessed through
www.epa.gov/ceppo/.
Are There Other Laws That Provide
Similar Information?
The Oil Pollution Act (OPA) of 1990 includes national
planning and preparedness provisions for oil spills that are
similar to EPCRA provisions for extremely hazardous
substances. Plans are developed at the local, State and
Federal levels. The OPA plans offer an opportunity for
LEPCs to coordinate their plans with area and facility oil
spill plans covering the same geographical area.
The 1990 Clean Air Act Amendments require the EPA and
OSHA to issue regulations for chemical accident
prevention. Facilities that have certain chemical above
specified threshold quantities are required to develop a risk
management program to identify and evaluate hazards and
manage those hazards safely. Facilities subject to EPA's
risk management program rules must submit a risk
management plan (RMP) summarizing its program. Most
RMP information is available through RMP*Info, which
can be accessed through www.epa.gov/enviro.
For More Information
Contact the EPCRA Hotline at:
(800)424-9346 or(703)412-9810
TDD (800)553-7672
Monday -Friday, 9 AM to 6 PM, EST
Visitthe CEPPO Home Page at:
WWW.EPA.GOV/CEPPO/
For EPA EPCRA contacts, check the CEPPO home page.
For TRI program officials and EPA TRI regional contacts,
checkwww.epa.gov/tri/statecon.htm.
Chemical Emergency Preparedness and Prevention Office
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Department of Veterans Affairs VA Directive 0057
Washington, DC 20420 Transmittal Sheet
September 14, 2004
VA ENVIRONMENTAL MANAGEMENT SYSTEM AND
GOVERNING ENVIRONMENTAL POLICY
1. REASON FOR ISSUE
a. This directive establishes Department policy to ensure that VA Administrations and staff
offices take necessary actions to become good stewards of the environment by integrating
environmental accountability into day-to-day decision-making and long-term planning
processes.
b. This directive also establishes policy and assigns responsibilities for developing and
implementing environmental management systems at all appropriate VA facilities by
December 31, 2005.
2. SUMMARY OF CONTENTS/MAJOR CHANGES. This directive sets forth Department-
level policy and responsibilities related to the management of environmental programs. It
contains information on the following:
a. Policy statements regarding VA's commitment to protecting the environment while
carrying out its mission to serve our Nation's veterans.
b. Development and implementation of environmental management systems.
c. Responsibilities of VA Administrations and staff offices to develop guidance and policy
to implement the requirements of this directive.
3. RESPONSIBLE OFFICE. Office of the Associate Deputy Assistant Secretary for Program
Management and Operations (049M).
4. RELATED HANDBOOK. None.
5. RESCISSIONS. None.
CERTIFIED BY: BY DIRECTION OF THE SECRETARY
OF VETERANS AFFAIRS:
Isl Is/
Robert N. McFarland William A. Moorman
Assistant Secretary for Acting Assistant Secretary for Management
Information and Technology
Distribution: Electronic Only
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SEPTEMBER 14, 2004 VA DIRECTIVE 0057
VA ENVIRONMENTAL MANAGEMENT SYSTEM AND
GOVERNING ENVIRONMENTAL POLICY
1. PURPOSE AND SCOPE
a. The Department of Veterans Affairs' (VA) mission is to deliver quality health care to our
Nation's veterans, provide benefits and services to veterans and their families, and honor
veterans with final resting places and lasting memorials that commemorate their service to our
Nation. In accomplishing this mission, VA is committed to preventing pollution, reducing
waste, and conserving natural and cultural resources. The purpose of this directive is to
establish VA policy to ensure that all necessary actions are taken to integrate environmental
accountability into day-to-day decision-making and long-term planning processes across VA
activities, functions, and services.
b. This directive also establishes policy and assigns responsibilities for developing and
implementing an environmental management system (EMS) at all appropriate VA facilities by
December 31, 2005, pursuant to Executive Order (EO) 13148, Greening the Government
Through Leadership in Environmental Management. An EMS provides a systematic
framework to identify and address the environmental aspects and impacts of an organization's
work, ensure compliance with applicable environmental requirements, and determine
opportunities for continual improvement.
2. POLICY. In conducting its mission to serve our Nation's veterans, it is VA's environmental
policy to:
a. Encourage VA employees at all levels to be good stewards of the environment by
complying with all applicable environmental requirements; preventing pollution; reducing
waste; conserving energy, water, and other natural and cultural resources; and continually
reviewing and improving VA environmental programs.
b. Ensure top management commitment and accountability through the incorporation of
position description elements and performance standards/measures related to pollution
prevention and environmental management for appropriate senior level managers and other
employees who have responsibilities related to the management of environmental programs.
c. Have top managers provide necessary support, including funds and other resources, to
ensure compliance by VA facilities with Federal, state, and local environmental requirements,
including development and implementation of an EMS.
d. Utilize sustainable practices to eliminate, minimize, or mitigate adverse environmental
impacts.
e. Evaluate and monitor the operation of VA facilities and incorporate policies and
procedures necessary to reduce environmental vulnerabilities and ensure environmental
compliance.
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VA DIRECTIVE 0057 SEPTEMBER 14, 2004
f. Integrate pollution prevention, waste reduction, natural and cultural resource
conservation, affirmative procurement/green purchasing, life cycle costing, and environmental
compliance into planning, purchasing, and operating decisions, wherever practicable.
g. Implement source reduction as the pollution prevention method of choice, or alternative
methods of reuse, recycling, treatment of wastes, or proper disposal.
h. Use natural resources efficiently and maintain and protect plant and wildlife habitat,
consistent with VA's mission.
i. Recognize that the development and construction of VA facilities must consider the
unique conditions of the environment of which the facility is a part.
j. Train all appropriate VA staff, as needed, to satisfactorily carry out the environmental
responsibilities of their positions.
k. Solicit input regarding environmental matters affecting the operation of VA facilities, as
appropriate, from stakeholders including, but not limited to, staff, veterans, and the community.
I. Develop and implement an EMS at all appropriate VA facilities by December 31, 2005.
(1) The environmental responsibilities of VA Administrations and staff offices differ in both
scope and complexity. As such, Administrations and staff offices shall develop an EMS best
suited to its needs and based on the International Organization for Standardization (ISO)
14001 or equivalent standard.
(2) For assistance, the Administrations and staff offices may use the Green Environmental
Management System (GEMS) Guidebook developed by the Veterans Health Administration,
Office of the Deputy Under Secretary for Health for Operations and Management (1 ON). The
GEMS Guidebook presents a nine-step process based on the ISO 14001 Standard.
3. RESPONSIBILITIES
a. The Assistant Secretary for Management (004) is the VA Environmental Executive
and will be responsible for environmental policy and oversight to coordinate implementation of
the requirements of this directive at the Department level.
b. The Office of Acquisition and Materiel Management (OA&MM), Office of the
Associate Deputy Assistant Secretary for Program Management and Operations (049M),
will be responsible for providing program leadership, guidance, and coordination at the
Department level to ensure that the requirements of this directive are appropriately
implemented.
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SEPTEMBER 14, 2004 VA DIRECTIVE 0057
c. VA Administrations and Staff Offices will be responsible for the development,
implementation, and management of an EMS and other environmental programs. Each VA
Administration and staff office shall:
(1) Develop guidance and policy, as needed, to implement and manage environmental
programs, including the requirements of this directive.
(a) Environmental policy is to be developed that specifically addresses the requirements
contained in paragraph 2. Policy in this directive.
(b) Internally developed guidance and policy shall be consistent with applicable Federal,
state, and local environmental requirements.
(2) Define "appropriate" facilities in accordance with EO 13148 and direct these facilities to
develop and implement an EMS. The designation of "appropriate" facilities is to be based on
facility size, complexity, and the environmental aspects of an individual facility's operations.
Appropriate facilities would generally include those that are either subject to registration or
permitting by the U.S. Environmental Protection Agency (EPA) or state/local environmental
regulators or otherwise could have a significant impact on the environment.
(3) Staff offices that operate VA facilities in VA-owned or -leased space are responsible
for determining which of their facilities are "appropriate" in accordance with the criteria stated in
paragraph 3 (c) (2) (i.e., size, complexity, and environmental aspects) and for directing these
facilities to develop and implement an EMS. Such an EMS shall address functions under the
control of the staff office and be coordinated to the extent practicable with the owner of the
space in which VA is a tenant.
(4) Develop a facility self-declaration protocol by December 31, 2004, that provides
credible verification of the status of an EMS in accordance with guidance provided by the EPA,
the Council on Environmental Quality, or other national standard recognized by EPA.
(5) Ensure that the requirements of this directive are implemented at the facilities for
which they are responsible.
4. REPORTING. Each VA Administration and staff office shall report on the status of
implementation of an EMS, including providing a list of "appropriate" facilities. Reports are due
annually to OA&MM (049M) by January 31, or alternative date provided to meet EO 13148
reporting requirements.
5. REFERENCES
a. Executive Order 13148, Greening the Government Through Leadership in
Environmental Management (April 21, 2000).
b. Green Enviromental Management System (GEMS) Guidebook (March 2004).
http://vaww.ceosh.med.va.qov
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