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Unted Slates
Environmental Protection
Healthcare Environmental Assistance Resources
Pollution Prevention and Compliance Assistance
for Healthcare Facilities
-------
PLAN - DO - CHECK - ACT
for Operational Controls
PLAN
Identify Significant Aspects
(Procedure for Environmental Aspects)
ACT
Establish & Track Corrective Actions
For Non-Compliance/Non-Conformance
Discovered During Monitoring &
Measuring and Verify Effectiveness
(Procedure for Corrective Actions')
DO
Establish Operational Controls for
Significant Aspects
(Procedure for Establishing Operational
Controls for Significant Aspects)
CHECK
Monitor & Measure Activities for
Consistency with Operational Controls
(Procedure for Monitoring & Measuring)
-------
PLAN-DO-CHECK-ACT
for Compliance Assurance
PLAN
Identify Environmental Requirements
(Procedure for Legal & Other
Requirements)
ACT
Establish & Track Corrective Actions for
Non-Compliance/Non-Conformance
Discovered During Monitoring &
Measuring, Gap Analysis, &
Multi-Media Compliance Audit
(Procedure for Corrective Actions)
DO
Establish Operational Controls for
Regulated Activities/Materials
(Procedure for Establishing
Operational Controls for Significant
Aspects)
CHECK
Monitor & Measure Consistency with
Operational Controls
(Procedure for Monitoring & Measuring)
Conduct GEMS Gap Analysis
Annually
(Procedure for Gap Analysis)
Conduct Baseline Multi-Media
Compliance Audit at Least Every
3 Years
(Measuring and Monitoring Procedures)
-------
PLAN - DO - CHECK - ACT
For Objectives and Targets
PLAN
Select Objectives & Targets
(Procedure for Objectives &
Targets)
ACT
Implement & Evaluate Corrective
Actions Discovered During
Monitoring & Measuring
(Procedure for Corrective Actions)
DO
Establish Operational Controls and
Measuring & Monitoring for
Objectives & Targets
(Procedure for Establishing Operational
Controls for Significant Aspects)
CHECK
Monitor & Measure Consistency with
Objectives & Targets
(Procedure for Monitoring & Measuring)
-------
Nine Steps to Establish a Successful
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-------
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-------
Sample GEMS Documents Department of Veterans Affairs
Document 5B2-8
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Hazardous Material and Waste
1. Purpose. To provide for the safest methods to minimize or eliminate the potential for
hazardous material incidents.
2. Policy. This Medical Center will establish, maintain and coordinate a hazardous material and
waste management plan.
3. Responsibilities.
a. Director will support training, and require compliance with policy and all applicable
laws.
b. Industrial Hygienist will coordinate program activities, provide information, training and
other support to services, verify that manifests are properly filled out, monitor contractors
as applicable, report to Environmental Protection Agency (EPA) or State as required,
control and inspect waste storage facilities, oversee service waste handling, report to
Director or designee, verify compliance with all applicable laws, maintain all records
related to hazardous waste, and coordinate shipments of hazardous waste. He/she will
receive training in chemical hazards, maintain records that may be required in case of a
spill, inform the Fire Department or other designated responder in case of a spill, and
coordinate spill response.
c. Services will identify and classify all regularly produced wastes; train all employees
producing or handling wastes on the requirements of the policy, the hazards associated
with the waste, safe handling and storage techniques, proper labeling and spill response;
and place all generated waste in specified storage facility in proper containers with proper
labels.
4. Identification/Classification of Waste.
a. Regularly Produced Waste. The Service should characterize this waste as soon as
practicable after acceptance of the policy. The characterization should include the rate of
waste production, storage requirements for the waste, hazards associated with the waste,
applicable EPA waste codes, proper labeling for waste, storage area designated for the
waste and person responsible for the waste.
b. Unusual Wastes. These materials should be characterized by their components by the
producer. They should be evaluated by a designated person in the service (with the
assistance of the Industrial Hygienist) for proper labeling and storage requirements.
5. Record Keeping Requirements. Services should identify all materials put into the hazardous
waste area storage to the person in charge of that storage area. A log should be kept in each
storage area identifying each waste by container and source and the dates that wastes are put
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
into these containers. This log should be maintained as a source of information for the
hazardous waste manifests and as information for emergency response in case of a spill.
6. Hazardous Waste Storage.
a. Centralized Storage Area. (Describe the location of storage area, procedure for adding
waste to storage, record keeping system and requirements, person in charge of storage
area, persons authorized to have access, and required inspections, spill or emergency
procedures.)
b. Satellite Storage Area. For each area, describe the same information as for central
storage area.
7. Training. All employees dealing with hazardous waste shall be trained on general chemical
hazards and the hazard communication standard, on the hazards of the chemicals and wastes
they are dealing with, on proper safety precautions including use of required personal
protective equipment, and on the requirements of the hazardous material policy and
hazardous waste policy.
8. Emergency Spill Procedures. Spills of hazardous waste, as with spills of other hazardous
materials, should be classified as either small spills of materials within the area where the
material is used, or other spills. Services should have a policy or Standard Operating
Procedure (SOP) for dealing with small spills of materials or wastes they normally use or
produce. Larger spills of hazardous waste or spills outside the area of normal use should be
treated as hazardous material spills and should be evaluated and dealt with by trained
personnel.
9. References. 40 CFR 260-265.
10. Rescission.
11. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document SB 1-10
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS)
Monitoring and Measuring Procedures
1. Purpose. To establish and maintain procedures to accomplish monitoring and measuring
activities on a regular basis as part of the Medical Center's Green Environmental
Management Systems (GEMS).
2. Policy. GEMS' monitoring and measuring focuses on the key characteristics of this Medical
Center's operations that have a significant impact on the environment. Through monitoring
and measuring, it demonstrates:
• Compliance with environmental regulations and other requirements.
• Operational control of significant aspects.
• Conformance with environmental objectives and targets.
• Continual improvement.
3. Responsibilities.
a. The Medical Center Director shall ensure that adequate resources are provided to
maintain effective monitoring and measuring and shall approve GEMS monitoring and
measuring procedures.
b. The GEMS Committee is responsible for:
• Monitoring environmental objectives and targets.
• Reviewing and approving monitoring and measuring for significant aspects.
• Tracking and reporting GEMS monitoring and measuring.
• Ensuring that the appropriate actions are taken on the results of monitoring and
measuring activities to ensure an effective program that is continually improving.
c. The GEMS Coordinator is responsible for coordinating the various monitoring and
measuring activities and the calibration of environmental monitoring equipment, as well
as periodic environmental compliance audits.
4. Procedures.
a. The GEMS Committee documents the status of objectives and targets at least quarterly in
its minutes.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
b. Calibration of environmental monitoring equipment will be conducted in accordance with
manufacturer's recommendations, and records will be maintained in accordance with the
GEMS Records Procedures.
c. As significant aspects are identified, the GEMS Committee reviews and approves
monitoring and measuring activities submitted by the Operating Units.
d. Monitoring and measuring activities are those included in the "Check" part of Plan-Do-
Check-Act (see Attachments A and B). These activities include:
1) Monitoring and measuring operational controls for significant aspects and objectives
and targets. Operational controls and monitoring procedures (including frequency)
for each significant aspect are identified by the Operating Unit and are reported to the
GEMS Committee. The GEMS Committee approves or revises the procedures.
Operational control monitoring reports are submitted by the Operating Units, along
with any corrective actions resulting from the discrepancies discovered during the
monitoring. These reports are reviewed and approved by the GEMS Committee.
Objectives and targets are monitored in the same way.
2) Conducting a baseline multi-media environmental compliance audit as well as follow-
up audits at least every three years, using an external audit team. The compliance
audit covers federal, state and local environmental regulations and Executive Orders,
as well as VA policy and other requirements determined by the GEMS Committee.
The GEMS Committee approves the audit tool prior to proceeding with the audit.
5. References. The Green Environmental Management Systems (GEMS) Guidebook, (Book
6A); and the Environmental Compliance Guidebook, (Book 6B).
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Attachments:
A. Plan-Do-Check-Act Process for Operational Controls
B. Plan-Do-Check-Act Process for Environmental Compliance
Distribution:
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Sample GEMS Documents
Department of Veterans Affairs
Attachment A to Document SB 1-10
PLAN - DO - CHECK - ACT
Operational Controls for Significant Environmental Aspects
PLAN
Identify Significant Aspects
(Procedure for Environmental Aspects)
ACT
Establish and Track Corrective
Actions For Non-Compliance/Non-
Conformance Discovered During
Monitoring and Measuring and
Verify Effectiveness
(Procedure for Corrective Actions)
DO
Establish Operational Controls for
Significant Aspects
(Procedure for Establishing Operational Controls
for Significant Aspects)
CHECK
Monitor and Measure Activities for
Consistency with Operational Controls
(Procedure for Monitoring and Measuring)
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Sample GEMS Documents
Department of Veterans Affairs
Attachment B to Document SB 1-10
PLAN - DO - CHECK - ACT
Environmental Compliance Assurance under GEMS
PLAN
Identify Environmental
Requirements
(Procedure for Legal and Other Requirements)
ACT
Establish and Track Corrective
Actions for Non-Compliance /Non-
Conformance Discovered During
Monitoring and Measuring, Gap
Analysis, and Multi-Media
Compliance Audit
(Procedure for Corrective Actions)
DO
Establish Operational Controls for
Regulated Activities/Materials
(Procedure for Establishing Operational Controls
for Significant Aspects)
CHECK
Monitor and Measure Consistency with
Operational Controls
(Procedure for Monitoring & Measuring)
Conduct GEMS Gap Analysis Annually
(Procedure for Gap Analysis)
Conduct Multi-Media Compliance Audit
Baseline and at Least Every 3 Years
(Measuring and Monitoring Procedure)
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Sample GEMS Documents Department of Veterans Affairs
Document SB 1-11
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS)
Nonconformance and Corrective and Preventive Action
1. Purpose. This policy defines the processes that will be implemented for noncompliance,
nonconformance, preventive and corrective actions.
2. Policy. It is the policy of this (Insert Medical Center Name) that nonconformance issues
identified from GEMS audits, monitoring, measuring and other reviews will necessitate
remedial action. Once remedial action is implemented, additional monitoring protocols shall
be established to assure effectiveness.
3. Responsibilities.
a. The GEMS Coordinator, in association with the GEMS Committee, will monitor and
review all processes related to GEMS activities to ensure corrective actions are
implemented.
b. The GEMS Committee shall assign responsibilities to abate nonconformance items.
4. Procedures.
a. Identifying and Reporting. Any individual who identifies a potential nonconformance
will report the issue to the GEMS Coordinator. The GEMS Coordinator will then process
the information through the GEMS Committee for review and action.
b. Investigation and Analysis.
1) Once a nonconformance is identified and submitted to the GEMS Committee, the
GEMS Coordinator will assign an individual or team to review the issue.
2) The individual or team will perform an investigation into the nonconformance,
referencing all applicable standards.
3) A causal analysis will be performed to determine the methods of corrective action:
a) The magnitude of the causal analysis will be determined by the GEMS
Coordinator or GEMS Committee.
b) The objective of performing the causal analysis is to determine the root cause of
the process or system failure, not to impose blame or enforce disciplinary action
on a person.
c. Mitigation of Impacts. Once the team has completed the investigation, the report will be
delivered to the GEMS Coordinator for review and will then be forwarded to the
applicable Service Line Manager for his/her concurrence prior to implementation.
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d. Corrective or Preventive Actions.
1) The GEMS Coordinator will assign responsibilities to abate nonconformance items.
2) The investigation report shall address continuous improvement and monitoring
processes that will be implemented to assure conformance.
3) Determine the root cause.
4) Develop appropriate corrective and preventive action.
5) Document the corrective and preventive action.
6) Forward the corrective and preventive action to the GEMS Coordinator for
implementation and have the Safety Officer concur.
7) The GEMS Coordinator will provide oversight of the implementation of the
corrective action and establish realistic deadlines for implementation.
8) The GEMS Committee will track and verify the effectiveness of the corrective or
preventive actions. Frequency of reporting shall be identified within the analysis;
however, the results of the analysis and the success of the corrective or preventive
actions shall be included in the annual report.
5. References.
6. Rescission.
7. Review Date.
(Name)
Medical Center Director
Distribution:
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Document 5B1-12
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS)
Gap Analysis Program Review
1. Purpose. To produce a gap analysis to help understand what is already in conformance with
the programmatic requirements of GEMS and to evaluate ways to build on existing programs
and activities. Determining what GEMS activities are already in place will result in only
having to "fill in the gaps" between what is already being done and what needs to be done for
the Medical Center GEMS. The primary purpose of GEMS is to bind together existing
environmental programs and activities so that efficiency, effectiveness, performance and
cost-effectiveness for the entire facility can be achieved.
2. Policy. A review process of the GEMS program will be in place at this Medical Center as
part of a continual improvement program.
3. Responsibilities. The GEMS Coordinator will coordinate the initial and periodic gap
analyses of the GEMS program using criteria consistent with the VHA GEMS Guidebook
and the ISO 14001 model. The GEMS Committee will review the completed gap analysis
and develop an implementation plan to address the program gaps.
4. Procedures. The GEMS Coordinator will designate the team that will conduct the annual
GEMS program review. The review team will use the attached GEMS initial review and gap
analysis audit tool to conduct these reviews. The completed reviews should identify any
"gaps" that are found and make recommendations to address areas not in conformance. The
completed review and recommendations should then be forwarded to the GEMS Committee
for further review and development of an implementation plan.
5. References. VHA Green Environmental Management Systems (GEMS) Guidebook, (Book
6A); International Organization of Standards (ISO) 14001 Standards.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Attachment:
GEMS Gap Analysis Tool
Distribution:
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Attachment to Document 5B1-12
GEMS Gap Analysis Tool
Note: The following Criteria Statements were updated April 1, 2004;
therefore, this Tool will vary from the printed version of the Guidebook.
1. Category 1 - Environmental Policy. (ISO 14001, Section 4.2; VHA GEMS Guidebook,
Sections 2.1 and 5.1, Tabs A and B).
a. Policy. Is there an environmental policy in place that supports pollution prevention,
regulatory compliance and continuous environmental improvement?
b. Policy. Is the policy documented, implemented, maintained and communicated to the
employees?
2. Category 2 - Planning.
a Environmental Aspects and Impacts. (ISO 14001, Section 431; VHA GEMS
Guidebook, Sections 2.2, 3.2 and 4.2 and Document 5B1-1).
1) Aspects and Impacts. Has the facility established a procedure to identify the
environmental aspects of the activity, products and services over which it has control
and influence?
2) Aspects and Impacts. Have significant impacts been determined and considered in
setting environmental objectives and targets?
b. Legal Requirements. (ISO 14001, Section 4.2; VHA GEMS Guidebook, Sections 2.3
and 5.1 and Document 5B1-2).
Legal. Is there a procedure to identify, access and evaluate federal, state and local legal
requirements?
c. Objectives and Targets. (ISO 14001, Section 4.3.3; VHA GEMS Guidebook,
Sections 2.4, 2.5 and 3.2 Step 6 and Document 5B1-3).
1) Setting Objectives and Targets. Has a procedure been developed to identify and
document environmental objectives and targets for each relevant function and level?
2) Setting Objectives and Targets. Does the procedure consider legal requirements,
significant aspects and other operational requirements?
d. Plan For Achieving Objectives and Targets. (Environmental Programs) (ISO 14001,
Section 4.3.4; VHA GEMS Guidebook, Sections 2.4 and 2.5 and Documents 5B1-3 and
5B1-4).
1) Plan for Objectives and Targets. Is there a procedure to achieve objectives and
targets and identify the means and acceptable timeframes for accomplishment?
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2) Plan for Objectives and Targets. Does the procedure include a designation of
responsibility at each relevant function and level?
Category 3 - Implementation and Operation,
a Accountability (Structure and Responsibility). (ISO 14001, Section 4.4.1; VHA
GEMS Guidebook, Sections 2.6, 3.1 and 3.2 Steps 1-2 and Document 5B1-4).
1) Accountability. Has top management provided adequate resources? Has top
management appointed a GEMS Coordinator and a GEMS Committee to oversee,
track and report GEMS status and performance?
2) Accountability. Have roles, responsibilities and authorities been defined,
documented and communicated to facility staff to ensure effective environmental
management?
b. Training. (ISO 14001, Section 4.4.2; VHA GEMS Guidebook, Sections 2.7 and 3.2
Steps 2 and 7 and Document 5B1-5).
1) Training. Has the organization identified training needs for those workers who may
create a significant impact on the environment?
2) Training. Does the training include significant environmental impacts, emergency
response procedures and nonconformance with standard operating procedures?
c. Communications. (ISO 14001, Section 4.4.3; VHA GEMS Guidebook, Section 2.8 and
Document 5B1-6).
1) Communications. Is there a procedure for internal communication between the
various levels/functions of the facility, the GEMS Coordinator and the GEMS
Committee?
2) Communications. Is there a procedure in place to coordinate and document inquiries
from external public, private and regulatory organizations?
d GEMS Documentation and Record Keeping. (ISO 14001, Section 444, 453; VHA
GEMS Guidebook, Sections 2.9, 2.10 and 2.15 and Documents 5Bl-5and 5B1-7).
1) GEMS Documentation. Is there a procedure requiring the documenting of the core
elements of the GEMS and explaining their interaction with other facility-related
documents?
2) Record Keeping. Is there a procedure to identify, maintain and dispose of
environmental, training and audit records?
3) Record Keeping. Are environmental records identifiable, legible, readily retrievable
and traceable to activity, product and service?
e. Operational Control. (ISO 14001, Section 4.4.6; VHA GEMS Guidebook, Sections
2.11 and 3.2 Step 5 and Documents 5B1-7 and 5B1-8).
1) Operational Control. Are the operations aligned with significant environmental
aspects and objectives?
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2) Operational Control. Are procedures in place to communicate the GEMS
requirements to suppliers and contractors?
f. Emergency Response. (ISO 14001, Section 4.4.7; VHA GEMS Guidebook, Section
2.12 and Document 5B1-9).
Emergency Response. Is there an emergency preparedness and response procedure to
recognize and mitigate potential environmental impact?
4. Category 4 - Checking and Corrective Action.
a. Monitoring and Measurement. (ISO 14001, Section 4.2; VHA GEMS Guidebook,
Sections 2.13 and 3.2 Steps 8 and 9 and Document 5B1-10).
1) Monitoring and Measurement. Is there a documented monitoring and measuring
procedure for operations and activities related to significant aspects?
2) Monitoring and Measurement. Does the procedure include requirements for
calibration and recording of information to track performance, operational controls
and conformance objectives and targets?
3) Monitoring and Measurement. Has a periodic (every 3 years) and/or baseline
environmental compliance audit been conducted?
b. Corrective and Preventive Action. (ISO 14001, Section 4.5.2; VHA GEMS
Guidebook, Sections 2.14 and 3.2 Step 9 and Document 5B1-11).
1) Action Plans. Is there a procedure covering the definition of roles and
responsibilities for investigating and determining a cause of nonconformance?
2) Action Plans. Does the procedure include action needed to mitigate impact and
necessary preventive action?
3) Action Plans. Do corrective and preventive action plans address the causes of the
deficiency?
4) Action Plans. Is the effectiveness of corrective and preventive actions verified
before considered completed?
5) Action Plans. Are resources assigned to corrective and preventive actions in order to
complete them in a reasonable timeframe?
6) Action Plans. Are corrective and preventive actions tracked to completion in the
GEMS committee?
d. Gap Analysis. (ISO 14001, Section 4.5.4; VHA GEMS Guidebook, Sections 2.16 and
3.2 Step 8 and Document 5B1-12).
1) Gap Analysis. Does the program have procedures for conducting annual gap
analyses of GEMS?
2) Gap Analysis. Is the scope based on the environmental importance of the activity
and the results of the previous audit?
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3) Gap Analysis. Are the results reviewed by the GEMS Committee and the
recommendations forwarded to top management for review?
5. Category 5 - Management Review. (ISO 14001, Section 4.2; VHA GEMS Guidebook,
Sections 2.17 and 3.2 Step 9 and Document 5B1-13).
a. Annual Review. Is the management review conducted and documented on an annual
basis and reported in the GEMS Committee?
b. Annual Review. Does the GEMS Committee use the gap analysis results to address the
need for changes to policy, objectives and other GEMS elements?
c. Annual Review. Is there evidence that the facility director (top management)
participates in the annual review (for instance, by signing annual review report)?
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Document 5B1-13
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS)
Procedure for Annual Effectiveness Review and Report
1. Purpose. This procedure guides the GEMS Committee in evaluating the effectiveness of the
GEMS, evaluating performance with respect to the past year's environmental objectives and
targets, selecting new objectives and targets for the upcoming year, presenting the draft
report and recommendations to the Medical Center Director and publishing the final report
via the GEMS Committee minutes.
2. Policy. The policy of this Medical Center is to conduct an annual evaluation of the
effectiveness of the GEMS in order to maintain an effective program that supports continual
improvement.
3. Responsibilities. The GEMS Committee evaluates the effectiveness of the GEMS using
primarily the following three methods and tools.
a. GEMS Gap Analysis, with the desirable outcome demonstrating a trend over two or more
years toward fewer and less significant gaps.
b. Environmental Compliance Audit/Inspections, with the desirable outcome demonstrating
a trend toward fewer and less significant findings of non-compliance and rapid and
effective corrective actions.
c. GEMS Targets and Objectives, with the desirable outcome demonstrating meaningful
objectives with realistic targets being met.
4. Procedures.
a. At the beginning of each fiscal year, the GEMS Committee ensures that evaluation
methods and tools are established/maintained to support the end-of-year GEMS
effectiveness evaluation. These will include:
1) GEMS Gap Analysis.
2) Environmental Compliance Audits/Inspections.
3) GEMS Targets and Objectives.
4) Methods for tracking preventive and corrective actions from GEMS Gap Analysis,
Environmental Compliance Audit and other inspections.
b. The effectiveness of the GEMS is monitored (by methods identified in paragraph 4a
above) throughout the year, and corrective and preventive actions are taken to improve its
effectiveness as the need is identified.
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c. At the end of the fiscal year the GEMS Coordinator drafts an annual report of the
effectiveness of the GEMS based on the criteria identified in paragraph 4a above. The
evaluation includes thoughtful analyses of successes and opportunities for improvement.
The draft is submitted to the GEMS Committee for approval or modification.
d. The GEMS Committee selects meaningful objectives and targets recommended for the
upcoming year.
e. The GEMS Committee presents items (identified in paragraphs 4c and 4d above) to the
Medical Center Director for modification and/or approval.
f. The Medical Center Director approves the effectiveness report for the past year and the
objectives and targets for the upcoming year.
5. References. GEMS Guidebook (Book 6A); Environmental Compliance Guidebook
(Book 6B).
6. Rescission. None.
7. Review Date.
(Name)
Medical Center Director
Attachment:
Sample GEMS Committee Report of Annual Effectiveness Review
Distribution:
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Sample Documents
Attachment to Document 5B1-13
SAMPLE
GEMS Committee Report of Annual Effectiveness Review
Excerpt From the Minutes of the GEMS Committee, November 4, 2004
Approved and Signed by the Medical Center Director
1. The Committee found the GEMS effective in its first year, as indicated by:
• Completion of 60 % of the corrective actions for the GEMS Gap Analysis conducted
June 2003
• Completion of 25% of the corrective actions for the baseline Environmental Compliance
Audit, conducted August 2003
• Achievement of the objectives and targets (as modified at the Jan 14 GEMS Committee
Meeting)
2. The Committee recommends the following new objectives and targets for FY 2005:
• 5 % reduction in lawn management chemical usage in FY 2005 compared with FY 2004
(see attached plan for monitoring and accomplishment)
• 10 % reduction in hazardous waste generation in the Research Lab (see attached plan for
monitoring and accomplishment)
3. The following GEMS dashboard summarizes the status of effectiveness evaluations:
GEMS Gap Analysis
Performance
Objectives
Appoint a GEMS
Coordinator and a GEMS
Committee
Conduct a Gap Analysis
to Determine Disparity in
our Present Program
Develop and Implement a
GEMS Program
Environmental Rounds
are Conducted Quarterly
in all Areas (Patient and
Non-Patient) of the
Medical Center to
Demonstrate Compliance
with GEMS.
Performance Target
Coordinator and Committee
will be appointed no later
that the end of the first
quarter.
Gap analysis will be
completed by the end of the
second quarter.
The program will be
published and in effect by
the end of FY 04.
Surveys conducted 90% of
the time and deficiencies
are corrected within 30
days.
Status
Mr/Ms, was appointed the GEMS Coordinator
with participants from all organizational units.
Mr/Ms., Associate Director, was appointed
committee chairman.
The gap analysis was completed February 2004,
with new policies developed as needed and
routed for comments.
The newly established written GEMS program
was established September 1, 2004.
This performance standard was significantly
met during FY 2004. All surveys were
performed as scheduled in MCM 00-46,
Environmental Rounds and in accordance with
the Environment of Care Standards (JCAHO).
However, not all deficiencies were abated
within 30 days. Although 89% (1030/1154) of
the items noted were abated within 30 days, the
percentage fell below the stated goal of 100%.
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Sample GEMS Documents
GEMS Gap Analysis
Performance
Objectives
Performance Target
Status
It should be noted that there was no duplication
of deficiencies when making rounds the second
time in FY 1999.
Environmental Compliance Audits/Inspections
Compliance
Standard
Safe Drinking Water
(SOW)
Resource Conservation
and Recovery Act
(RCRA)
Air Emissions
Compliance Problem
The well exceeds safe
drinking water standards.
Inspection log not up-to-
date.
Boiler exceeds air emission
standards in permit.
Status
Standards met as evidenced by
Standards met as evidenced by
Standards met as evidenced by
GEMS Targets and Objectives
Performance
Objectives
Red Bag Waste
Pesticide Use
Performance Target
Reduce red-bag waste by
3% by weight by end of
fiscal year.
Change practice of
scheduled pesticide
application to apply when
determined necessary by
sampling through fiscal
year.
Status
Standards met as evidenced by
Standards met as evidenced by
Submitted by:
Date:
Approved by:
Date:
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Date:
Activity or Service
Aspect
Impact
Compliance
Risk
Frequency
of Activity
VAMC
Control
TOTAL
SCORE
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Sample GEMS Documents Department of Veterans Affairs
Document 5B1-1
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Procedure for Determining Significant Green Environmental
Management Systems (GEMS) Environmental Aspects and Impacts
1. Purpose. The purpose of this policy is to provide a system to consistently identify
environmental aspects of Medical Center activities, products and services in order to
determine those that may have a significant impact on the environment.
2. Policy. This Medical Center shall ensure that the aspects with significant impacts are
considered in setting environmental targets and objectives for environmental performance
improvement activities.
3. Responsibility.
a. The GEMS Coordinator is responsible for the centralized collection of environmental
aspects and impacts from the Service Line Managers.
b. The GEMS Committee is responsible for:
1) Analyzing significant aspects and impacts that the Medical Center has control over.
2) Establishing Medical Center targets and objectives, operational and document
controls.
3) Determining which environmental aspects are significant.
4) Implementing appropriate control measures.
5) Controlling all related documents.
4. Procedures.
a. The GEMS Committee will establish an Environmental Aspect and Impact template to
systematically identify those environmental aspects that may have a significant impact on
the environment.
b. The scoring of impacts (Attachment A) will incorporate the following factors:
• The extent to which the aspect is regulated by law, regulation, Executive Order or
other requirements.
• The degree of risk to any exposed human population or exposed ecosystems.
• The frequency of the activity.
• The extent to which the aspect is under the control of the Medical Center.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
c. These scores are documented on the GEMS Aspect template (Attachment B), and it is
then submitted to the GEMS Committee.
d. The total of the scores will determine which environmental aspects are significant and,
therefore, require detailed operational controls. The GEMS Committee will establish the
significant aspect cut-off score after review of the templates from the Operating Units.
e. Environmental aspects and impacts will be re-evaluated whenever there are significant
changes in materials, activities, procedures or other legal requirements, but at least
annually.
5. Reference.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Attachments:
A. Explanation of Aspects and Impacts Template Scoring
B. GEMS Aspects Template (Blank)
Distribution:
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Sample GEMS Documents
Department of Veterans Affairs
Attachment A to Document 5B1-1
Explanation of Aspects and Impacts Template Scoring
Compliance
The extent to which the aspect is regulated by law, regulation,
Executive Order or other requirement
The aspect is not regulated or is in full compliance.
Compliance activity has been initiated.
Compliance activity has been scheduled.
There is an awareness of non-compliance status, considering
compliance options.
The aspect is out of compliance and has taken no compliance activity
to date.
Score Assigned
0
1
2
3
4
Risk
The degree of risk to any exposed human populations or exposed
ecosystems
Minor risk to human population and/or ecosystems.
Moderate risk to sensitive human populations and/or ecosystems.
Moderate risk to general human populations and/or ecosystems.
High risk to sensitive human populations and/or ecosystems.
High risk to the general human population and/or ecosystems.
Score Assigned
0
1
2
3
4
Frequency
Frequency that this activity occurs
< Once per calendar year
Biannually or less
Monthly
Weekly
Daily or more
Score Assigned
0
1
2
3
4
Control
The extent to which the aspect is under control of the Medical
Center
Medical Center has no control or influence.
Medical Center has some influence or control.
Medical Center has influence parity with other entities with some level
of control.
Medical Center has significant influence.
Medical Center has total control over this aspect.
Score Assigned
0
1
2
3
4
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Sample GEMS Documents Department of Veterans Affairs
Document SB 1-2
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management System (GEMS)
Procedure for Legal and Other Requirements
1. Purpose. To guide the staff in identifying and accessing the legal and other requirements to
which this Medical Center subscribes.
2. Policy. This Medical Center abides by the environmental regulations promulgated by
federal, state and local authorities, as well as the requirements of Executive Orders, VA
policy and the Joint Commission for Accreditation of Healthcare Organizations (JCAHO)
Standards, National Fire Protection Agency (NFPA) and other industry codes. All Medical
Center staff with environmental responsibilities will have access to these codes, standards
and regulations.
3. Responsibilities.
a. Information Resources Management (IRM) provides the means for access to electronic
databases for legal and other requirements to those staff having environmental
responsibilities.
b. Operating Units will identify applicable legal and other requirements for their activities,
identify staff having need to access these requirements due to their environmental
responsibilities and ensure the identified staff are given access to the regulations,
standards and policies.
c. GEMS Coordinator assists Operating Units in identifying and implementing the legal and
other requirements.
d. GEMS Committee reviews the effectiveness of this element of the GEMS and makes
improvements when warranted.
4. Procedures.
a. With the assistance of the GEMS Coordinator, Operating Units will track updates to legal
and other requirements and incorporate compliance with the new requirements into their
activities.
b. While most of the federal environmental regulations are accessed online, the state and
local regulations are accessed via hardcopy. The GEMS Coordinator attends periodic
meetings with local regulators to keep up-to-date on those requirements and will then
pass any information on new requirements on to affected Operating Units.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
c. The GEMS Coordinator attends basic training and update courses and participates in
VHA conference calls and Email groups to stay abreast of the current legal and other
requirements.
d. The Operating Units with the assistance of the GEMS Coordinator use the following list
to identify legal and other requirements affected by the activities of the Operating Unit.
1) Examples of applicable legal and other requirements and further information may be
accessed through:
a) US Environmental Protection Agency (EPA) - http://www.epa.gov.
b) Hospitals for a Healthy Environment - http://www.h2e-online.org.
c) (Enter your State) Department of Health and Environment.
d) Center for Disease Control (CDC) - http://www.cdc.gov.
e) City/County Ordinances.
f) Office of the Federal Environmental Executive - www.ofee.gov.
g) Occupational Safety and Health Administration (OSHA) - http://www.osha.gov.
h) VISN Safety/Industrial Hygiene Manager.
i) VHA Directives and Informational Letters (IL).
j) GEMS Guidebook (Book 6A).
k) Environmental Compliance Guidebook (Book 6B).
1) Emergency Management Program Guidebook (Book 8).
m) Executive Orders.
2) Applicable requirements may include, but are not limited to:
a) Water:
• Clean Water Act (33 USC 125 etseq.: 40 CFR 100-140).
• Wild and Scenic Rivers Act (16 USC 1271-1287).
• Safe Drinking Water Act (42 USC 300f etseq.).
• Rivers and Harbors Act, Section 10 (33 U.S.C. 403).
• Clean Water Act, Section 404.
b) Air:
• Federal Clean Air Act (42 USC 7401 et seq.).
• Local Air Pollution Control Agency Regulations.
• National Emissions Standards for Hazardous Air Pollutants (Asbestos)
(40 CFR Part 61).
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Sample GEMS Documents Department of Veterans Affairs
c) Solid Waste:
• Resource Conservation and Recovery Act (42 U.S.C 6901 et seq.).
d) Hazardous Materials and Waste:
• Comprehensive Environmental Response, Compensation and Liability Act
(CERCLA), as amended by the Superfund Amendments and Reauthorization
Act (SARA) (42 U.S.C. 9601 et. seq.).
• National Contingency Plan (40 CFR 300 et. seq.).
• Underground Storage Tanks Resource Conservation and Recovery Act (42
USC 6991 [Subchapter IX]).
• Federal Underground Storage Tank Regulations (40 CFR 280).
• Hazard Communication Standard (OSHA Regulations, 29 CFR 1910; General
Occupational Health Standards, WAC 296-24 and Hazardous Waste
Operations and Emergency Response 296-62, Part P).
• PCB Management (Toxic Substances Control Act, 15 USC 2605(e); PCB
Regulations, 40 CFR Part 761; Dangerous Waste Regulations, WAC CH 173-
303).
• Transportation of Hazardous Materials, CDL Requirements (Hazardous
Materials Transportation Act, 49 USC 5101 et seq.: DOT Regulations, 49
CFR Part 100 et seq., including 107, 171). Also overlaps with Hazardous
Waste Regulations.
• Federal Insecticide, Fungicide and Rodenticide Act (7 U.S.C. 135 et seq.).
• National Fire Code and other local jurisdiction Fire Codes.
• Emergency Planning and Community Right-To-Know Act (EPCRA) (SARA
Title III).
• Federal Power Act (16 USC 791a-828).
e) Environmental Review:
• National Environmental Policy Act (NEPA) (42 USC 4321 - 4370).
f) Historical and Archeological:
• National Historic Preservation Act (NHPA) (16 USC 470).
• Archeological and Historic Preservation Act (16 USC 469).
• Regulations Implementing the NHPA (36 CFR Part 800).
g) Other Federal Regulations:
• Endangered Species Act (16 USC 1531 et seq.).
• Executive Orders.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
h) Other State and Local Requirements:
• Coastal Zone Management Act (16 USC 1451 et seq.).
• Local Government Noise Ordinances.
• Local Government Land Use and Construction Codes.
• Local Sensitive Areas Ordinance.
• Uniform Fire Code.
i) Other Requirements as may be applicable.
5. References. GEMS Guidebook (Book 6A); Environmental Compliance Guidebook (Book
6B); Handbook for the Management of Hazardous Waste (Book 6C).
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents
Department of Veterans Affairs
Attachment B to Document 5B1-3
SAMPLE
Green Environmental Management System (GEMS)
Objective & Target Form
(Note: Use one form per objective)
Individual Responsible for Implementation:
Housekeeping Officer and Infection Control Practitioner
Date Oct. 5. 2004
Environmental Objective:
To reduce the generation ofbiohazardous waste.
Related Target(s):
3% reduction by weight ofbiohazardous waste.
Related Significant Environmental Aspect(s):
Air and land pollution due to disposal ofbiohazardous waste.
Service Specific Function and/or Department:
Primary Care, Behavior Health, Surgery, Specialty & Diagnostics, Housekeeping
Target Date (Month/Year): End of Calendar Year
Frequency of Monitoring:
(Check one)
Weekly
Monthly
X
Quarterly
Annually
Action Plan:
Implement biohazard segregation program, implement staff education program, identify areas for
biohazard containers, continuous monitoring during environmental rounds.
How will this objective be met? (Attach additional pages as necessary)
1. Housekeeping will survey all areas of the health care system to determine appropriate placement
of biohazard receptacles.
2. Infection Control will develop training curriculum and deliver staff education.
3. Monitoring will be performed by housekeeping staff during trash removal and surveyed during
environmental rounds.
What operational controls shall be incorporated to achieve this objective?
Strategic placement of waste containers.
How will this objective be tracked? (Attach additional pages as necessary)
All biohazard waste will be weighed prior to transport off-site.
What resources will be required to achieve this objective? (Attach additional pages as
necessary)
Purchase of additional municipal and biohazardous waste containers.
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Document 5B1-3
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Establishing Objectives and Targets for the Green Environmental
Management Systems (GEMS) Program
1. Purpose. To ensure that the organization establishes and maintains documented
environmental objectives and targets and has a process to implement the steps necessary to
achieve the objective and targets.
2. Scope. This procedure applies to environmental objectives and targets set at all relevant
levels within the organization.
3. Definitions.
a. Environmental Objective - A goal that is consistent with the environmental policies and
considers significant environmental impacts and applicable laws and regulations.
Objectives are quantified wherever practicable.
b. Environmental Target - A detailed performance requirement (quantified wherever
practical) based on an environmental objective. A target should be met in order for the
underlying objective to be achieved.
4. General. The organization establishes environmental objectives and targets in order to
implement environmental policies. Objectives and targets also provide a means for the
organization to measure the effectiveness of its environmental efforts and to improve the
performance of the environmental management system. In establishing environmental
objectives, the organization considers:
a. Applicable laws and regulations (and requirement of other programs, such as ...).
b. Environmental aspects of the organization's activities and products.
c. Technological, financial, operational and other organizational requirements.
d. The views of employees and other interested parties.
Based on the organization's environmental objectives, targets are established for different
functions within the organization and for different areas of the facility. For example, the
organization may establish an environmental objective to "reduce waste generation by 10%
per year." Based on this objective, different areas of the facility might set targets for
reducing individual waste streams in order to ensure that the organization's objective might
also be translated into individual projects (such as changes in production processes, materials
or pollution control equipment) in different facility areas.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
5. Procedures.
a. The GEMS Committee is responsible for establishing environmental objectives on an
annual basis. To initiate the process, the GEMS Coordinator or designee holds a meeting
of all staff members to discuss the development of environmental objectives. Objectives
are action and prevention-oriented and are intended to result in meaningful improvements
in the organization's environmental performance.
b. Each Service Line Manager is responsible for providing input from his or her own
function (Fiscal, Engineering, etc.) or shop area (fabrication, assembly,
shipping/receiving, etc.). The GEMS Committee is responsible for providing input on
applicable laws and regulations, significant site environmental impacts and the views of
interested parties.
c. As a starting point, the GEMS Committee evaluates performance against environmental
objectives for the current year. As part of this effort, the GEMS Committee examines the
results of its environmental performance evaluations.
d. Preliminary environmental objectives are developed for further discussion and
evaluation. Each Service Line Manager is responsible for evaluating the potential
impacts of the proposed environmental objectives within their Service Line or
department. The organization's GEMS Committee reviews proposed objectives to ensure
consistency with the overall environmental policy.
e. Environmental objectives are finalized, based on review comments from the Service Line
Managers and employees. Each Service Line Manager identifies the impacts of the
objectives of their function or shop, establishes targets to achieve the objectives and
develops appropriate measures to track progress towards meeting the objectives and
targets.
f Each Service Line Manager is responsible for communicating objectives and targets and
the means for achieving them to others in Service Line/Program/department. They will
also designate roles and responsibilities of department personnel and provide appropriate
training necessary to meet the objectives and targets.
g. Progress towards the objectives and targets is reviewed on a regular basis at management
meetings. The progress is also communicated to employees via bulletin boards and other
similar means.
h. At the end of each calendar year, the organization's management reviews its performance
with regard to achieving the objectives and targets. This information is used as input in
determining the objectives and targets for the succeeding year.
6. Steps for Establishing Objectives and Targets.
Step 1 The development of objectives and targets result from a comprehensive evaluation of
all processes in every department. Collect as much information as possible prior to
surveying the area.
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Sample GEMS Documents
Department of Veterans Affairs
Information Sources
Process maps
Waste and emission data
Site maps
Compliance audit reports
List of identified environmental
aspects and impacts
Communications from interested
parties
Others??
How They Will Help?
Identify process steps with environmental
aspects
Determine current wastes and sources, etc.
Determine if there are any processes that
may be seasonal and should be reviewed
at a different time of the year.
_2_ Look at processes and activities associated with significant environmental aspects.
Are there any other issues the GEMS Committee should consider, in addition to
those listed above as significant impacts?
Process or Activity
Issues
Possible Objectives & Targets
Step 3 List any new regulatory requirements that affect the healthcare environment (or
other regulations for which the need for additional actions has been identified).
Regulations; Other Requirements
Possible Objectives & Targets
Step 4 Consider inputs from interested parties. Any need for additional objectives related
to views of neighbors, community groups or other parties?
Inputs from Interested Parties
Possible Objectives & Targets
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Step 5 Evaluate the lists of possible objectives developed in Steps 4-7. GEMS Committee
determines if these objectives are:
• Reasonable.
• Technologically feasible.
• Consistent with other organizational plans/goals.
• Affordable.
List preliminary objectives and targets based on this exercise:
Selected Preliminary Objectives
Step 6 Determine how you will measure each of the selected preliminary objectives. If you
cannot establish an effective way to measure it, put that objective "on-hold" for later
consideration. If applicable, evaluate those issues placed "on-hold" in the annual
evaluation and determine if it is feasible for implementation in the next year.
Selected Objectives
Performance Indicators )
Step 7 For each objective that you selected, determine who is going to develop the action
plan (who, what, when, where, how). List these names below:
Selected Objectives
Responsibility for Action Plan
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Sample GEMS Documents Department of Veterans Affairs
1. Reference.
8. Rescission.
9. Review Date.
(Name)
Medical Center Director
Attachments:
A. Environmental Objectives and Targets Process Chart
B. Objective and Target Form
Distribution:
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Attachment A to Document 5B1-3
PLAN - DO - CHECK - ACT
Environmental Objectives and Targets
PLAN
Select Objectives & Targets
(Procedure for Objectives & Targets)
ACT
Implement & Evaluate
Corrective Actions Discovered
During Monitoring & Measuring
(Procedure for Corrective Actions)
DO
Establish Operational Controls and
Measuring & Monitoring for
Objectives & Targets
(Procedure for Establishing Operational
Controls for Significant Aspects)
CHECK
Monitor & Measure Consistency
with Objectives & Targets
(Procedure for Monitoring & Measuring)
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Sample GEMS Documents
Department of Veterans Affairs
Document 5B1-4
SAMPLE
Green Environmental Management Systems (GEMS)
Responsibility Matrix
Communicate the
importance of
environmental
management
Coordinate auditing
efforts
Track/analyze new
regulations (and
maintain library)
Obtain permits and
develop compliance
plans
Prepare reports required
by regulations
Coordinate
communications
with interested
parties
Train employees
Integrate environmental
management into
recruiting practices
Integrate environmental
management into
performance
appraisal process
Communicate with
contractors on
environmental
expectations
Comply with applicable
regulatory
requirements
Conform with
organization's
environmental
management system
requirements
Medical
Center
Director
L
L
L
L
GEMS
Coordinator
S
L
L
L
L
L
S
L
L
Business
Service
Line
L
L
S
L
S
S
Facility
Mgmt.
Service
S
S
L
L
S
S
S
S
Other
Service
Chief
S
S
S
L
L
S
S
S
Operating
Section
S
L
S
S
S
Employees
S
S
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Sample GEMS Documents
Maintain equipment/
tools to control
environmental
impact
Monitor key processes
Coordinate emergency
response efforts
Identify environmental
aspects of products,
activities, or
services
Establish environmental
objectives and
targets
Develop budget for
environmental
management
Maintain environmental
management
records (training,
etc.)
Coordinate
environmental
management
document control
efforts
Medical
Center
Director
L
S
L
GEMS
Coordinator
S
S
S
S
S
L
Business
Service
Line
S
L
S
Facility
Mgmt.
Service
S
S
Other
Service
Chief
L
S
S
Operating
Section
S
S
S
L
Employees
S
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VHA Environmental Training Program Plan
Training
Agenda
Audience
Forum
Resources
Regulatory Compliance Training
National
Environmental VA
Meeting Kick-off
Environmental
Compliance 101
RCRA Hazardous
Waste Mgmt
Training and Annual
Refresher
Identification of
Hazardous Waste for
Healthcare
Required
Certification
Training
Laboratory-Specific
Environmental
Training
Intro by top VA Management to show
environmental commitment; Overview of
major statutes and GEMS.
Overview of major statutes (i.e.,
RCRA/UST, CAA, CWA, SPCC, [storm
water, wetlands] EPCRA, TSCA [Lead,
PCBs], SDWA, FIFRA).
Compliance with other requirements such
as Executive Orders and VA Policy, etc.
Required EPA hazardous waste
management training.
Detailed discussion on waste
characterization.
Necessary training to be certified to
perform task.
Describes the environmental requirements
and best management practices that relate
to laboratories such as RCRA, CWA and
CAA. At a minimum, it will satisfy the
training requirements of RCRA 265. 16.
Also, covers auditing questions.
Environmental Coordinators,
HQs and VISN
Safety /Health, Medical
Center Directors/ Associate
Directors
Environmental Coordinators,
HQs, VISN Safety/Health,
Program/Service Managers,
Director/ Associate Directors
Environmental Coordinators,
VISN Safety/Health
Environmental Coordinators,
HQs, VISN Safety/Health
Employees such as HVAC,
wastewater treatment,
pesticides applicators, boiler
plant operators
Environmental Coordinator,
VISN Safety/Health,
Laboratory employees,
including the Laboratory
Program Manager
4 day (2 day compliance, 2
day GEMS) conference
face-to-face in Spring
2004. Taped for future use
by VA.
1-1 !/2 day face-to-face in
each EPA Region during
FY2004 that will be taped
for future use by VA.
Distance Learning by VA.
1 day - could be broadcast
or videotaped.
As required.
CD-ROM or interactive
video developed by VA.
With EPA HQs and
Regional help (suggestion
to make it a civilian-wide
conference and add RCRA
training).
EPA Regions FFPMs -
Region 1 will hold in
October 2003.
Numerous contractors give
course. NETI RCRA
Inspector Training CD-
ROM.
EPA Region 2 has
developed - to be given
November 12th.
Many contractors give
course.
GEMS guide for small
laboratories. Lab 21
Website.
-------
Training
DOT training
UST Training
Module
SPCC Training
Module.
Clean Water Act
Training Module.
Toxic Substances
Training Module
Facilities
Maintenance Module
Clean Air Act
Training Module
Medical Waste
Training Module
EPCRA Training
Module
Agenda
Review of the underground storage tank
requirements. Includes auditing questions.
Review of the SPCC requirements at a
facility. Includes how to develop a SPCC
plan and auditing questions.
Review of the CWA requirements at a
facility such as NPDES, pre -treatment,
wetlands and storm water. Includes
auditing questions. May want to include
security issues as relates to wastewater
plants.
Describes requirements and best
management practices related to Asbestos,
Lead-Paint, PCBs and Mercury. Includes
auditing questions.
Environmental Requirements and best
management practices that apply to the
facilities maintenance operations such as
CAA, CWA, SDWA (UIC), FIFRA,
RCRA, Universal Waste, TSCA, beneficial
landscaping, etc. It must meet the RCRA
260. 16 training requirements. Includes
auditing questions.
Review of Clean Air Act requirements that
apply to healthcare facilities. Includes
auditing questions.
Review of requirements related to medical
waste. Includes auditing questions.
Review of EPCRA requirements. Includes
auditing questions.
Audience
Environmental Coordinators,
Warehouse shippers
Environmental Coordinators,
VISN Safety/Health, Facility
Engineer
Environmental Coordinators,
VISN Safety/Health, Facility
Engineer
Environmental Coordinators,
VISN Safety/Health,
Wastewater Plant Operators,
COTR if construction project
Environmental Coordinators,
VISN Safety/Health, COTR
if demolition/renovation
project
Environmental Coordinators,
VISN Safety/Health,
Facilities maintenance
personnel (e.g., motor pool,
paint shop, grounds keeping,
HVAC, plumbing,
electricians, carpentry, etc.)
Environmental Coordinators,
VISN Safety/ Health, Boiler
personnel
Environmental Coordinators,
VISN Safety/ Health,
Housekeeping
Environmental Coordinators,
VISN Safety/ Health
Forum
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
Resources
UST guidebooks and
website. EPA UST
presentations. UST
auditing protocol.
SPCC website. EPA
SPCC presentations.
SPCC booklets.
EPA NPDES website.
EPA presentations.
Construction Compliance
Assistance Center.
EPA Asbestos webpage.
Numerous Mercury
elimination documents.
Auditing Protocol for
TSCA.
EPA's national CA
centers.
EPA Websites. CFC
checklists.
State Agencies.
EPA Websites. EPATRI
courses.
-------
Training
Agenda
Audience
Forum
Resources
SDWA Training
Module
Review of SDWA requirements. May
want to include security issues as related to
drinking water plants. Includes auditing
questions.
Environmental Coordinators,
VISN Safety/Health,
Drinking Water Treatment
Plant Operators
CD-ROM or interactive
video developed by VA.
EPA Websites.
Dental
Environmental
Compliance Module
Review of requirements and best
management practices related to dental
facilities, such as RCRA. Including
auditing questions.
Environmental Coordinators,
VISN Safety/ Health, Dental
personnel
CD-ROM or interactive
video developed by VA.
Vermont's Dental Guide.
Pharmacy
Environmental
Compliance Module
Review of requirements and best
management practices related to
pharmacies, such as RCRA. Includes
auditing questions.
Environmental Coordinators,
VISN Safety/Health,
Pharmacy personnel
CD-ROM or interactive
video developed by VA.
Pharmacology Website.
Environmental
Compliance for
Lawyers
Review major environmental laws
applicable to VAMCs, state and federal
regulator's procedures for inspections,
violations, fines and VAMC legal defense
strategies.
District Counsel
Green Environmental Management System Training
GEMS Training For
Top Management
Designing Your
GEMS - Federal
Facility Workshop
GEMS Element-By-
Element Hands-On
Training
GEMS Committee
Overview of GEMS Elements.
More detailed discussion of
GEMS elements and hands-on
workshop with VA examples.
Detailed discussion of
elements - one element at a
time with facility -specific
help.
Training on the
implementation of the GEMS
Directors and Associate Directors at
VAMC, HQs and VISN level
GEMS Coordinators & Auditors
GEMS Coordinators and Auditors
GEMS Coordinators,
Program/Service Managers (or
designated person)
GEMS Committee
2 Hour broadcast by VA.
2-day conference. Same as
what is offered in Kick-off.
V-TELbyVISN. Done once
a month until GEMS
complete.
All GEMS Committee
members are required to
attend the 4-hour course on
the implementation of the
GEMS Program.
Diane Thiel, EPA Region 8 &
Gary Chiles.
Gary Chiles & Carol Bell
(Contractors). May be offered
by EPA Regions in near
future.
See metal finishing GEMS
workshops - Linda Darveau -
EPA Region 1.
Power Point presentation
located in the GEMS
Guidebook.
-------
Training
Facility-Specific
GEMS Training
ISO 14001 Lead
Auditor Course
Agenda
Training on facility-specific
policies and procedures related
to GEMS.
Training on how to conduct a
GEMS audit.
Audience
All Employees
VISN GEMS Auditor
Forum
A minimum of annually.
Classroom for 5 days.
Resources
GEMS Booklet, Self-learning
module, Safety Blitz, etc.
Offered by many contractors.
Pollution Prevention/Environmental Stewardship
Environmental
Preferable
Purchasing/ RCRA
60027 Executive
Orders
Waste
Minimization/
Product Substitution
Green Cleaning
Green Building
Indoor Air Quality
P2 Training for
Auto Repair Shops
Best Management
Practices for
Outdoor Shooting
Ranges
Training on buying
environmentally preferable
products and complying with
RCRA 6002 and Executive
Orders.
Training on waste
minimization at healthcare
facilities.
Awareness of more
environmentally and safer
cleaning products.
Awareness of building and
renovating in a greener
manner.
Training on indoor air quality.
Training on pollution
prevention techniques
available to auto repair
shops/fleet maintenance.
Best management practices for
outdoor shooting ranges.
Environmental Coordinators, VISN
Safety/Health, COTRs, COs, Credit
Card Holders, Chief, Acquisition &
Materiel Management
Environmental Coordinators, VISN
Safety/ Health, Program/Service
Managers, Credit Card Holders,
COTRs, COs
Environmental Coordinators, VISN
Safety/Health,
Housekeeping/Laundry
Environmental Coordinators, VISN
Safety/Health, COTRs
Environmental Coordinators, VISN
Safety/Health, COTRs
Motor Pool, Environmental
Coordinators, VISN Safety/ Health
Outdoor shooting ranges if built.
CD-ROMs, interactive
videos, PowerPoint
presentations.
CD-ROMs, videos
CD-ROMs, videos.
CD-ROMs, videos.
CD-ROM by VA.
Video and workbooks.
Guidance Document.
H2E, EPA EPP Program,
OFEE. Lyons VA.
H2E, EPA Wastewise.
Diane Thiel Region 8, EPA
EPP Program, Greening Govt
CD EPA Regions 1-3.
EPA, LEEDS.
Completed.
EPA Region 9 has completed.
EPA Region 2 Guide.
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Sample GEMS Documents
Department of Veterans Affairs
Attachment B to Document 5B1-5
SAMPLE
Green Environmental Management System (GEMS) Training Log
Training Topic
GEMS
Awareness
Supervisor
GEMS Training
Hazardous
Waste
Management
Hazardous
Waste
Operations
Spill Prevention
and Response
Chemical
Management
Emergency
Response
Accident
Investigation
Hazardous
Materials
Transport
Hazard
Communication
Personal
Protective
Equipment
Fire Safety
Electrical Safety
Hearing
Conservation
Confined Space
Entry
Lock-out/Tag-
Out
Attendees*
Frequency
Course
Length
Course
Method
Comments
Date
Completed
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Training Topic
Blood borne
Pathogens
Job-Specific
Training (list)
Attendees*
Frequency
Course
Length
Course
Method
Comments
Date
Completed
*Attendees Code
1 All Employees
2 Supervisors/Managers
3 Operators
4 Maintenance
5 Laboratory
6 Clinical
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Sample GEMS Documents Department of Veterans Affairs
Document 5B1-5
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS) Training Program
1. Purpose. (Insert Medical Center Name) will provide the necessary educational opportunities
to assure that all employees are knowledgeable of the Green Environmental Management
Systems (GEMS) program and the identified aspects related to his/her specific job tasks.
2. Policy. It is the policy of this Medical Center to provide effective training to all employees
on the implementation and processes associated with GEMS and to monitor staff knowledge
to assure an effective program.
3. Responsibilities.
a. The GEMS Coordinator is responsible for the overall development and implementation
of the GEMS training program.
b. The Education and Training Department will monitor employee compliance and enforce
attendance at required training sessions for all employees in environmental positions as
relates to their specific roles in the GEMS program. Employee compliance will be
monitored using TEMPO.
c. Supervisors are to ensure that all employees receive appropriate training in GEMS.
4. Procedures.
a. The GEMS Coordinator, in association with the Education and Training Department,
shall develop a training program reflective of the design and implementation of the
GEMS program. Training will include emphasis on the following:
1) The importance of conformance to the policy.
2) Recognition of significant aspects identified by the GEMS Committee.
3) Individual roles and responsibilities regarding GEMS implementation and operation.
4) Results of nonconformance.
5) Environmental Awareness Training to all employees, including implementation in the
New Employee Orientation program.
6) Annual Reporting Requirements.
b. All employees shall possess the knowledge and skills required to effectively implement
the GEMS. Competency shall be monitored by the employee's ability to demonstrate
through the implementation process that sufficient education and training has been
provided. Monitoring will be performed by annual audits, questionnaires and trending of
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staff knowledge. Information pertaining to monitoring of staff knowledge will be
processed and reviewed by the GEMS Committee and forwarded to the Environment of
Care Committee for review.
c. The GEMS brochure, Green Environmental Management Systems (GEMS), will be made
available to all employees, in addition to the basic awareness training that will be
provided.
5. References.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Attachments:
A. VHA Environmental Training Program Plan
B. GEMS Training Log
Distribution:
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Document 5B1-6
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management System (GEMS)
Communication to External and Internal Parties
1. Purpose. This procedure establishes a process for outreach and communication with
external/internal parties regarding the organization's Green Environmental Management
Systems (GEMS).
2. Policy. It is the policy of this VA Medical Center to ensure that the environmental
management policy is well documented, implemented and communicated to all employees
and is available to the interested public.
3. Scope. This procedure describes how the VA Medical Center receives, documents and
responds to communications from external/internal parties. It also describes proactive steps
that the organization takes to maintain a meaningful dialogue with external/internal parties on
environmental matters.
4. Definition.
Interested Parties - Individuals or groups with an interest in the environmental impacts of the
organization's products, activities or services. These parties include regulators, local
residents, employees, customers, environmental groups and the general public.
5. Procedures.
a. The organization uses a number of mechanisms to ensure effective communication with
interested parties. These mechanisms include regulatory filings (such as permit
applications and reports), posting of policies and procedures on the VA intranet site,
open houses and informal discussions with regulators, community representatives and
local business leaders.
b. To solicit the views of interested parties, the Medical Center may use additional
techniques, including (but not limited to) surveys, community advisory panels,
newsletters or informal meetings with representatives of external/internal groups.
c. General rules for external/internal communications require that the information provided
by the organization:
• Be understandable and adequately explained to the recipient(s).
• Present an accurate and verifiable picture of the organization and its environmental
management system, its environmental performance or other related matters.
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d. Management of Communications from External/Internal Parties.
1) Inquiries and other communications (received by mail, fax, E-mail, telephone or in
person) from external/internal parties concerning the organization's GEMS or
environmental performance may be directed to a number of the organization's
representatives, including the Facilities Manager, the GEMS Coordinator and the
Human Resources Manager. All such communications are reviewed by the GEMS
Coordinator or his/her designee to determine the appropriate response.
2) Communication with representatives of regulatory agencies is delegated to the
organization's GEMS Coordinator, who maintains records of all such
communications (both incoming and outgoing). In the absence of the GEMS
Coordinator, communications with regulatory officials are delegated to the Chief,
Facilities Management.
3) Copies of all other written communications on environmental matters are maintained
by the GEMS Coordinator. All non-written communications from external/internal
parties are documented using telephone logs or similar means. All records of
external/internal communications are maintained by the GEMS Coordinated.
4) A record of the responses to all communications from external/internal parties is
maintained by the GEMS Coordinator in files designated for that purpose.
e. Outreach to Interested Parties.
1) The organization solicits the views of interested parties on its GEMS, its
environmental performance and other related matters. In particular, such outreach is
conducted when significant changes at the facility are being considered, such as
facility expansion or other actions that might affect the actual or potential
environmental impacts of the organization's products, activities or services.
2) As part of the Management Review process, the team designated to conduct the
review evaluates proactive efforts to communicate with external/internal parties.
Based on this evaluation and other factors, the organization's management determines
the need for outreach with external/internal parties in the coming year and how such
communications can be carried out most effectively.
f. External Hazard and Emergency Communications. (Note: All external/internal
communications regarding emergency response are addressed in the Emergency
Management Plan.)
6. Reference.
1. Rescission.
8. Review Date.
(Name)
Medical Center Director
Distribution:
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Worksheet: Document Control
Document
Who Will Use It
Contact Person:
Permanent Location
Periodic Review
Schedule/ Who
/
/
/
/
/
/
/
/
/
When Can Be
Destroyed
Date Completed:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B1-7
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS)
Document and Record Control
1. Purpose. To develop written procedures to ensure proper management of Green
Environmental Management Systems (GEMS) documentation and records.
2. Policy. The (specify VAMC) will maintain documents and records as recommended in the
VHA Green Environmental Management Program guidelines. Documents are policies and
procedures that are subject to change and update on a regular basis. Records are documents
that record tests, inspections, maintenance, etc., which will not change and will serve to
demonstrate past performance.
3. Responsibility. The GEMS Coordinator is responsible to maintain facility level documents
and records per requirements of this Medical Center Memorandum. Program Managers/
Service Chiefs are responsible for maintaining documents and records in a similar manner for
their respective area.
4. Procedures.
a. GEMS Documents.
1) The GEMS Coordinator shall maintain and control the GEMS Manual and all other
documents associated with it, such as the environmental objectives and targets and
management plans to achieve them.
2) In maintaining and controlling the GEMS Manual, the GEMS Coordinator shall
ensure that the GEMS Manual and its associated documents are publicly available
and that updates adding new information and/or removing obsolete information are
made to the GEMS Manual immediately following any agreed changes to documents.
3) The GEMS Coordinator shall preserve an original of all documents and changes,
establish and maintain a record of all document changes, and ensure that all
documents are numbered, dated with dates of origination or revision and, where
necessary, signed and approved.
b. Required Records.
1) Audits. Copies of all audits (Baseline, Medical Center Self-Audits, Annual and
Incident) are kept on file at the GEMS Coordinator's office.
2) Manifests. Copies of all manifests and bills of lading related to hazardous waste or
recycled materials, such as batteries and used oil, shall be kept at the GEMS
Coordinator's office.
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3) Manuals for all equipment with environmental impacts must be acquired and kept
within each using Service.
4) Training.
a) Copies of records of all environmental training shall be kept with the
environmental records and/or in the employee's official electronic training record
(TEMPO).
b) Additional copies shall be kept in accordance with other VA requirements.
5) Annual Reports.
a) Copies of the GEMS Annual Report shall be kept in the GEMS Coordinator's
Office.
b) Additional copies shall be kept in accordance with other VA requirements.
c. Location.
1) The environmental files at the Medical Center should be kept in 3-inch binders for
ready access or, if possible, electronically on shared drives.
2) Manifests may be kept in filing cabinets within a drawer specifically designated for
environmental records.
3) Manuals shall be kept in a protected location in the work areas or on shared drives
accessible to all persons who work in areas of significant environmental impacts.
d. Revision.
1) Dated Materials.
a) Materials that are date-sensitive will be date stamped.
b) VA Central Office controlled documents shall be kept in accordance with their
expiration dates.
2) Annual review: Dated materials are to be reviewed annually, based on the original
date stamping, to determine if the document is current.
3) New requirements revise current documents as necessary.
4) Documentation will be updated as outlined in Medical Center Memorandum 00-
XXX.
Note: VAMCs that do not have a facility policy on document control will need to
create such a policy that addresses the following:
• Document Approval and Issue - Authorized personnel, including the
VA Medical Center GEMS Coordinator and others appointed by the
VA Medical Center Director, shall review VA Medical Center
specific environmental documents for adequacy and approve them
prior to issuance. Authorized personnel will ensure that
environmental documents are made available to appropriate staff.
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Sample GEMS Documents Department of Veterans Affairs
Periodic Review of Environmental Documents - The VA
Medical Center GEMS Coordinator shall review all
environmental documents on an annual basis and update
documents, as necessary. Upon issuance of updated
documents by VA, VHA and federal, state and local
regulators, the VA Medical Center GEMS Coordinator
shall replace the outdated documents as soon as feasible
and inform appropriate VA Medical Center staff of the
availability of the updated documents. Authorized
personnel shall review updated documents promptly,
remove obsolete environmental documents and archive
them in accordance with VA and VA Medical Center
procedures.
Document Changes/Modifications - Changes to
documents shall be reviewed and approved by the same
functions or organizations that performed the original
review and approval, unless specifically designated
otherwise. Review and approval of changes to documents
shall follow normal VA Medical Center procedures related
to document approval.
Distribution of Copies of Documents - The VA Medical Center
GEMS Coordinator is responsible for the distribution of copies of
environmental documents via standard VA Medical Center
channels. The VA Medical Center GEMS Coordinator shall
maintain a distribution list in order to ascertain that staff with
environmental responsibilities have been duly informed of the
information contained in the document and to ensure that the same
staff is advised of changes to any/all documents.
Legibility - Environmental documents shall be produced and
maintained so that they are legible.
Document Dates - Environmental documents that are part of the
VA Medical Center GEMS shall be dated. When documents are
revised, the date of revision shall be included on the document.
Document Maintenance - Environmental documents that are part
of the VA Medical Center GEMS shall be maintained in a central
location under the control of the VA Medical Center GEMS
Coordinator. Environmental documents germane to the operation
of VA Medical Center organizations shall also be maintained by the
organization under the control of the organization's manager.
Environmental documents may also be maintained electronically in
accordance with VA Medical Center policy and procedures.
Retaining Documents - Environmental documents that are part of
the VA Medical Center GEMS shall be retained at least for the
length of time required by law and/or VA and VA Medical Center
Policy. In general environmental documents shall be maintained as
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
long as they are current and/or represent applicable VA and VHA
policy or guidance that remains in force.
e. Retention.
1) VA record retention policies are to be followed.
2) Regulatory: Environmental records shall be retained in accordance with regulatory
requirements, but for a minimum of five years.
3) The following documents shall not be disposed of:
a) Manifests for the disposal of hazardous and non-hazardous waste.
b) Records pertaining to the VA Medical Center's involvement in Superfund
projects or other projects that involve remediation or removal actions related to
environmental contamination and environmental releases.
4) Records related to the environmental investigation conducted in conjunction with real
property transactions including, but not limited to, sale and lease.
5. Reference.
6. Rescission.
7. Review Date.
(Name)
Medical Center Director
Attachments:
A. Explanation to Policy Writer
B. Document Control Worksheet
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Attachment A to Document 5B1-7
Explanation to Policy Writer
I. Purpose
Design a standardized framework your installation will use to develop and organize the
various types of documentation required by ISO 14001.
II. Importance
Complete, well-organized documentation is essential for describing, managing, evaluating
and improving the Green Environmental Management Systems (GEMS). GEMS
documentation provides a written description of your installation's GEMS and directions for
how things should be done. Developing GEMS 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 develop. The following subsections describe the types of GEMS
documentation required.
A. Documentation Hierarchy
Think of GEMS documentation as a tiered system. Four types of GEMS documentation
typically constitute the hierarchy. (Records are not considered part of documentation.)
As you move down the pyramid, the amount of information, the degree of specificity and
the number of pages generally increase.
B. Step-by-Step Guidance
Documentation and records assist employees to perform their jobs in ways consistent
with the installation's environmental policy and the goals and objectives of the GEMS.
The Standard Operating Procedures (SOPs) should incorporate significant environmental
aspects, objectives and targets, and monitoring and measurement procedures into the
daily activities or job practices of facility personnel. Environmental personnel should
work with unit leaders and supervisors to produce SOPs that support the GEMS. These
SOPs give specific, detailed instructions that describe the methods for attaining
environmental goals and, hence, complying with environmental policy. 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 at your facility and maintain steady progress toward
revising the SOPs.
C. GEMS Records
GEMS records are considered part of GEMS documentation. Documentation describes
policies, procedures and other directive information, while records provide a written
history of GEMS performance and actions completed (such as training).
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
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Sample GEMS Documents Department of Veterans Affairs
Document 5B1-8
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Procedures for Green Environmental Management Systems (GEMS)
Operational Controls
1. Purpose. To ensure that operational controls are established so all activities conform to the
Green Environmental Management Systems (GEMS) policies, objectives and targets.
Note: Operational controls include those policies, procedures and
instructions in place to minimize the potential environmental impact of
the VA Medical Center's activities and processes. Operational
controls generally apply directly to the VA Medical Center's processes
and activities (e.g., segregation of medical waste, maintenance work,
boiler plant operations, etc.). A procedure is a prescribed, sequential
series of activities often performed by several individuals or a team
(i.e., boiler startup procedures, disposal of contaminated sharps).
2. Policy. It is the policy of this VA Medical Center to establish operational controls for
significant environmental aspects.
3. Responsibilities.
a. The GEMS Committee is responsible for ensuring that operational controls are in place
for all significant environmental aspects. It also much ensure that the operational
controls reflect the actual practice of Operating Units and meet environmental regulations
and other requirements. When environmental aspects impact more than one Service
Line/Department, the GEMS Committee ensures that operational controls are both
consistent and coordinated. The GEMS Committee directs VA Medical Center
organizations to change operational controls to better meet environmental compliance
requirements and the requirements of the VA Medical Center GEMS.
b. All Medical Center Service Chiefs/Service Line Directors ensure that the Operating Units
under their control develop operational controls and that these controls are consistent
across the Service Line with the VA Medical Center GEMS and the direction of the
GEMS Committee
c. Operating Units develop operational controls for significant aspects to ensure
conformance with the GEMS policies, objectives and targets.
4. Procedures.
a. The GEMS Committee identifies significant environmental aspects.
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b. Operating Units develop and/or review existing operational controls to ensure that they
meet GEMS requirements. These are usually contained in written Standard Operating
Procedures (SOPs).
c. Operating Units provide operational controls to the GEMS Committee for review and
approval.
d. A review of the effectiveness of operational controls is evaluated in the following ways:
• During GEMS gap analysis.
• As a result of an Environmental Compliance Audit.
• By monitoring and measuring the objectives and targets.
• As may occur during facility operation.
e. Corrective actions regarding operational controls are implemented as soon as practical
after being identified (see GEMS Procedure for Corrective/Preventive Actions,
Document 5B1-11 in this Guidebook).
5. Reference.
6. Rescission.
7. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B1-9
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS)
Emergency Planning and Response
1. Purpose. To establish and maintain procedures to recognize and mitigate the potential
environmental impact associated with emergency response operations.
2. Policy. It is the policy of this Medical Center to consider the environmental impacts
associated with emergency response operations.
3. Responsibilities.
a. The GEMS Coordinator will collaborate with the Emergency Management Committee
for all procedures related to the environmental impact associated with emergency
response operations, including pollution prevention and mitigation.
b. All other responsibilities related to emergency management are outlined in the Medical
Center Emergency Management Plan.
4. Procedures. This document references the Medical Center Emergency Management Plan for
all procedures associated with emergency response operations. The Emergency Management
Plan is an "all-hazards" approach to emergency management. The plan includes a Hazard
Vulnerability Analysis accounting for the environmental impact associated with emergency
response operations.
5. References. Emergency Management Program Guidebook, (Book 8).
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-1
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Biohazardous Waste Management
1. Purpose. To establish the policy and procedures for identification, handling, storage and
disposal of biohazardous waste at this Medical Center.
2. Policy.
a. Biohazardous waste will be managed to protect people and the environment while
complying with federal, state and local regulations.
b. Procedures, such as segregation of waste, will be employed to reduce the generation of
biohazardous waste. All employees who handle biohazardous waste will practice proper
waste segregation procedures as directed in training and by their supervisors.
c. Individuals required to handle biohazardous waste will receive the appropriate job
training and will wear personal protective clothing/equipment as directed in training and
by their supervisors.
3. Waste Segregation Definitions.
a. Biohazardous waste is a category of waste separate from hazardous waste and includes
the following:
1) Microbiology Laboratory Waste - cultures that come in contact with infectious
agents.
2) Pathology Waste - body parts, morgue waste and tissue specimens.
3) Blood and Body Fluids - any body fluid, secretion, or excretion.
4) Bulk Blood and Body Fluids - bulk quantities, dripping or pourable, or items
saturated with blood or body fluids.
5) Infectious Waste - any item contaminated with blood or body fluids that could be
released in liquid or semi-liquid form if compressed.
b. The term "sharps" means medical or laboratory articles, including those that are
potentially infectious and may cause punctures or cuts.
c. The following are not included in the definition of infectious waste and should be placed
in containers for unregulated (ordinary) waste:
• Items soiled (but not saturated) with body fluids.
• Intravenous tubing without needles (needles detached).
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• Urinary catheter tubing and bags that have been emptied of liquid.
4. Responsibilities:
a. Program Managers/Supervisors:
1) Will ensure and document that all employees are receiving appropriate job training
related to biohazardous waste procedures for which they are responsible.
2) Will identify biohazards their employees come in contact with, select appropriate
personal protective equipment (PPE) and clothing, and conduct training on the proper
use and purpose of the PPE, in accordance with the Occupational Safety and Health
Administration (OSHA) PPE Standard and the OSHA Blood borne Pathogen
Standard.
b. Safety Committee will review this Medical Center Memorandum annually to ensure
compliance with policies, procedures and laws relating to chemical, physical and
radioactive hazardous waste.
c. Infection Control Committee will review all Service and VAMC policies and procedures
relating to biohazardous waste when initiated and annually thereafter.
d. Conclusions, actions and recommendations will be reported to the Safety, Occupational
Health and Fire Protection Committee.
e. Safety Office:
1) Maintains the temporary storage facilities to ensure that time constraints,
accumulation requirements and proper storage techniques are followed for
chemotherapy waste stored in Hazardous Waste Storage.
2) Participates in monthly Hazard Surveillance Rounds that includes monitoring proper
segregation, handling, storage and disposal of biohazardous and hazardous wastes.
f. Chief, Facilities Management Service:
1) Oversees the shipping and disposal of biohazardous waste.
2) Leads the monthly inspection team on Hazard Surveillance Rounds that includes the
monitoring of proper segregation, handling, storage and disposal of biohazardous and
hazardous wastes.
3) Directs Housekeeping supervisors to conduct periodic surveillance of compliance
with biohazardous waste policy and procedures, including PPE and segregation and
disposal of waste.
g. Infection Control Practitioner:
1) Trains staff on infection control procedures including recognition, handling and
disposal of biohazardous waste (See Attachment A, Training Topics and Schedule.)
2) Participates in Hazard Surveillance Rounds.
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h. Radiation Safety Officer: Oversees the handling and disposal of radiological wastes that
are also contaminated with infectious wastes.
5. Procedures.
a. Biohazardous waste will be collected in red plastic bags and placed in collection
containers or areas with biohazardous waste labels. All red-bagged waste will be stored
and transported separately from other refuse. When red-bagged waste comes in contact
with other waste, all the waste will be considered infectious. All infectious waste will be
placed in impervious containers at the collection point for pick-up by the contractor for
disposal.
b. Clinical staff will place all biohazardous waste in biohazard containers lined with red
bags and marked with the biohazard label. Waste that is not biohazardous will not be
placed in biohazard containers. Biohazard containers will be kept closed. When
containers approach % full, they will be closed and replaced with empty containers by
Housekeeping staff.
c. Housekeeping staff will collect biohazardous waste according to the attached schedule
(Attachment B) and when notified that a container is approaching 3/4 full. During
collection and transport to the storage facility, waste containers will be closed. Staff
handling the containers will wear disposable gloves. Spills will be cleaned up
immediately, and the surfaces decontaminated. Storage areas will be secured from access
by unauthorized persons.
d. Before suction canisters and containers of bulk liquid are sent to the collection point,
clinical staff will add the isolyzer agent to the container prior to disposal to solidify the
liquid and prevent leaking.
e. Biohazardous waste that is also contaminated with more than 3% (by volume) of anti-
neoplastic waste will be placed in a covered container, labeled with the yellow
"Chemotherapy" sticker, and picked up by Facilities Management drivers and transported
to the hazardous waste storage shed. The Facilities Management driver will notify the
Supervisor Utility Systems Operator of the delivery of this waste. Facilities Management
employees will wear latex or vinyl gloves while handling the sealed containers. If
somehow contaminated, these gloves will be disposed of with the waste. In the event of a
leak, the employee will notify his/her supervisor, the Safety Office for Incident Analysis,
and also the Pharmacy, which will perform proper clean-up procedures. If the person
handling the waste material comes in contact with it, the affected area will be flushed
with water and the person will report to the Employee Health Unit as soon as possible.
See Hazardous Waste Management, Medical Center Memorandum #XX.
f. Biohazardous waste contaminated with radiological waste will be handled and disposed
of in accordance with Medical Center Memorandum #XX, Radiological Waste
Management.
6. References. OSHA Blood borne Pathogen Standard, 29 CFR 1910.1030; OSHA PPE
Standard, 29 CFR 1910.138; Joint Commission for Accreditation of Healthcare
Organizations (JCAHO) Manual for Hospitals; Medical Center Memorandum XX,
5-75
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
Hazardous Waste Management; and Medical Center Memorandum XX, Radiological Waste
Management.
7. Follow-up Action: Chief, Facilities Management Service, and Infection Control
8. Rescission.
9. Review Date.
(Name)
Medical Center Director
Attachments: (Note: Attachments are to be created by individual facilities according to each
one's needs.)
A. Training Topics and Schedule for Biohazardous Waste
B. Schedule for Replacement of Biohazardous Containers
Distribution:
5-76
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-10
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Mercury Pollution Prevention Program
1. Purpose. The goal of a mercury pollution prevention program is to reduce or eliminate
identifiable sources of mercury being discharged to the environment.
2. Policy. It is the policy of this Medical Center to comply with current regulatory requirements
concerning the reduction of mercury discharges and its impact on the natural environment.
3. Responsibility. Pollution prevention and the reduction of mercury discharged to the
environment are job responsibilities of all employees.
a. Medical Center Director is committed to the reduction of mercury-containing discharges.
b. Safety Manager/Industrial Hygienist is responsible for the development and
implementation of the mercury reduction plan.
c. Service Managers shall:
1) Identify and inventory possible sources of mercury in their service.
2) Educate their employees on source reduction possibilities.
3) Find alternatives to mercury-containing products.
d. Chief, Acquisition and Material Management shall:
1) Purchase environmentally preferred and recoverable products in accordance with the
Federal Pollution Prevention Act.
2) Work with suppliers to obtain copies of heavy metals analysis reports on products
potentially containing mercury.
e. Chief, Facilities Management shall:
1) Conduct effluent, sludge application site soils and sludge testing requirements as
established by Department of Environmental Protection (DEP) rules and permits.
2) Minimize the release of mercury through the wastewater treatment plant.
4. Procedures.
a. The most significant opportunity for reduction or prevention of mercury containing
discharges is through changes in procurement, operations and/or raw material usage of
mercury-containing compounds or products. Substitution of mercury containing
materials, changes in work practices, recycling and treatment alternatives should be
investigated before relying on the proper disposal option.
b. Current law prohibits the discharge of mercury into the water in any concentration that
increases the natural concentration of mercury in the receiving waters. A mercury
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
pollution prevention plan that includes source reduction, treatment, monitoring and
discharge limitations is required by the (State) DEP.
c. Mercury is monitored in the wastewater effluent, sludge and sludge application site soils
in accordance with EPA method 1669 and other approved methods. The wastewater
treatment plant operators conduct monitoring and results are maintained and provided to
the (State) Department of Environmental Protection.
d. A baseline effluent level has been established by the DEP.
e. Mercury-containing products are prevalent in the hospital. Blood pressure monitors,
dental amalgam, thermometers, thermostats, esophageal dilators, Cantor tubes, Miller
Abbott tubes, and histology fixatives and stains all may contain mercury. Cleaners,
degreasers, ph buffers, vaccines, test kit reagents, fluorescent light bulbs, batteries and
other items may also contain mercury. Mercury-free alternatives are available for all of
these items.
f. Mercury-containing medical products such as sphygmomanometers, thermometers,
esophageal dilators, Cantor Tubes and Miller Abott tubes, and mercury-containing
chemicals will be phased out as they are replaced. Acquisition and Material Management
will assist Service Managers with information on substitutes.
g. Service Managers will investigate all hazardous materials purchased that may contain
mercury. Since the Material Safety Data Sheet only requires mercury to be listed as a
component if it is found in concentrations of 1% or more, all materials that are used in
quantities of 55 gallons or greater will be investigated with the manufacturer for trace
mercury concentrations.
h. Facilities Management Service will ensure that magnetic switches, optic sensors or
mechanical switches are used instead of mercury tilt switches, if available, for
thermostats, sump pumps or other electrical lighting, power supply switching or
resistance heating applications.
i. Low-mercury fluorescent light bulbs will be used in lieu of mercury-containing bulbs.
New manometers will be replaced with non-mercury alternatives.
j. Acquisition and Material Management Service will consider disposal costs when
evaluating a product.
k. Batteries, fluorescent lamps and other mercury-containing materials will be recycled
and/or disposed of in accordance with the Hazardous Waste Management Program.
1. All Service Managers must ensure that their employees are competent in their ability to
properly manage, purchase, handle and dispose of mercury-containing materials and the
practices outlined in this policy.
m. Annually, Acquisition & Material Management will develop a list of products that
contain mercury along with a list of possible substitutes. This substitution list will be
provided to all potential purchasers of these materials.
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Sample GEMS Documents Department of Veterans Affairs
5. Training.
a. The Safety Manager will train all Service Managers in the requirements for mercury
reduction.
b. A&MMwi\\ train all Service Managers in proper procurement of mercury-free materials.
c. Service Managers will train their employees, at the desired level of competency, in the
Mercury Pollution Prevention Program.
6. Spills.
a. All spills involving mercury-containing products will be handled in accordance with
EPA-established clean up guidelines and the state DEP mercury-containing lamp policy.
For broken light bulbs, sweep up and place in a closed plastic container with tight fitting
lid. For liquid mercury, call the Facility Management Service or local emergency
response, as appropriate. They will use mercury-absorbent spill pads or the mercury
vacuum based upon the amount spilled.
b. All mercury spill debris will be collected in tight fitting plastic containers, labeled
appropriately and sent to an approved hazardous waste disposal site. Use the Hazardous
Waste Management Program for guidance.
7. Reference.
8. Rescission.
9. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-11
SAMPLE
VA Medical Center Medical Center Memorandum ()
(Location) (Date)
Mercury Reduction Program
1. Purpose. To establish medical center policy for the reduction (virtual elimination) of any
metal mercury in the Medical Center.
2. Policy. It shall be the policy of this Medical Center that mercury-containing material
procurement shall be reduced as much as possible.
3. Background. Mercury (Hg) is a toxic metal and a natural element commonly seen as a
shiny, silver, white, odorless, liquid metal. It is persistent, bio-accumulative and a toxic
pollutant that affects the nervous system. All forms of Hg are toxic to humans, but the
various forms of organic and inorganic mercury have different toxicity. The organic forms
are much more toxic than the inorganic forms. The organic forms are primarily neurotoxins;
therefore, exposure can damage the brain and nervous system. Potential exposure to Hg is
via inhalation, ingestion and absorption. The most likely routes of exposure are due to
inhalation of inorganic Hg after a spill or refilling, exposure or ingestion of methyl mercury.
4. Responsibilities.
a. Logistics Program Manager is responsible for:
• Conducting a thorough inventory and documenting the number and type of medical
and non-medical devices containing mercury within the facility.
• Replacing mercury sphygmomanometers (blood pressure monitors) with aneroid
sphygmomanometers.
• Replacing Hg thermometers with non-Hg thermometers.
• Replacing mercury intestinal and esophageal dilators and feeding tubes with
alternatives using water, saline or tungsten.
b. Engineering Program Manager is responsible for:
• Procuring low-mercury fluorescent lights and development of a recycling program for
all fluorescent lights.
• Replacing batteries containing mercury with mercury-free alternatives and/or
rechargeable products.
• Replacing mercury thermostats, pressure gauges, barometers, switches and other
building facility equipment with mercury-free alternatives.
c. Dental Program Manager is responsible for:
• Replacing mercury-containing fixatives and preservatives with mercury-free
alternatives.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
• Setting up a program for appropriate collection of used amalgam and installation of
amalgam separators in sinks and drains in the Dental Clinic.
d. Housekeeping Officer is responsible for:
• Replacing bleach and cleaning chemicals containing traces of mercury with mercury-
free alternatives.
• Training of housekeeping employees on how to handle a mercury spill at the Medical
Center.
e. Safety Manager/Industrial Hygienist is responsible for:
• Collecting and storing waste mercury for disposal.
• Providing training and spill equipment for the housekeepers.
• Training employees (as appropriate) in proper handling of mercury-containing
equipment.
• Coordinating, as appropriate, testing/analyzation of mercury-containing fluorescent
lights.
5. Procedures.
a. All mercury-containing equipment shall not be procured for the Medical Center unless
there is no alternative available.
b. Engineering will collect and recycle all mercury-containing fluorescent lights in a barrel
for shipment to recycling sites.
c. Dental Assistant will collect and separate waste amalgam before disposal.
d. Waste mercury will be collected by the Industrial Hygienist and disposed of in
accordance with federal, state and local regulations.
6. References. VHA Directive 2002-018, April 1, 2002.
7. Rescission.
8. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-12
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Notification of Environmental Incidents
(Spills/Releases/Discharges)
1. Purpose. To ensure that prompt and effective actions are taken to minimize risk to persons,
property and the environment in the event of an accidental release, spill or leak of hazardous
substances. Also, to identify the persons responsible for preparing a written and telephonic
notification to the federal or state Environmental Protection Agency (EPA), Department of
Transportation (DOT), and National Response Center (NRC) for spills during transportation
of chemical hazards, or the Centers for Disease Control (CDC) for spills during the
transportation of biologic hazards.
2. Policy. It is the policy of this Medical Center to notify the appropriate officials and agencies
in case of emergency spills, releases and discharges as required by the Hazardous Materials
Transportation Act (HMTA), Comprehensive Environmental Response, Compensation and
Liability Act (CERCLA) and SARA (Superfund Amendments and Reauthorization Act).
Also, to ensure correct transportation procedures are issued and followed as indicated below.
3. Responsibilities. The Safety and Occupational Health Specialist., as our facility
Environmental Compliance Coordinator (ECC), upon notification from any and all contract
hazardous chemical or waste transporters used by our facility, will ensure proper notification
to the required agencies as outlined in the matrix in the following paragraphs (4d through
4g).
4. Procedures.
a. Manifests. Our facility (generator) will ensure that Hazardous Waste Manifests are
properly filled out and completed. This will be certified by the ECC and includes:
1) State-generated manifests obtained from the receiving State and the originating State,
if these states have manifests different from the Federal Uniform Hazardous Waste
Manifest.
2) The facility EPA identification (ID) number recorded on the manifest and a manifest
document number (a serially increasing number of five digits) is assigned by the
facility (by the generator), if the State or receiving facility does not provide a
manifest document number.
3) The facility site location and emergency contract telephone number provided on all
manifests.
4) At least one certified transporter and a permitted Treatment, Storage or Disposal
(TSD) receiving facility for waste is designated on the manifest. The receiving site
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
address of the TSD facility is recorded on the manifest (not the corporate
headquarters or other addresses).
5) Waste descriptions follow Department of Transportation package marking
requirements by using the same shipping name, hazard class, identification number,
with the word "Waste" appearing before each shipping name. Waste description
should also include the EPA designation for the type of waste. The type of container
and units of quantity (abbreviated symbols) are designated on the form and if a
reportable quantity (RQ) has been established for the waste material, the letters RQ
must appear in parentheses before the shipping name.
6) A facility official (generator) signs and dates all manifests, certifying that the
shipment has been properly classified, packed, marked and labeled.
b. Placarding. The ECC ensures placarding meets DOT requirements for the transportation
of chemical or biological hazardous wastes. This includes:
1) The transporter of hazardous waste from the facility has an EPA ID number and a
State permit, if that state has enacted a Waste Material Transporter Permit Program.
2) The transporter displays the proper color-coded, diamond-shaped placards for
transport, specific to the hazardous characteristics of the shipment (placards may not
be required on the vehicles carrying only etiologic agents, materials classified ORM-
A, B, C, D, or E, or limited quantities of hazardous materials).
3) The facility Safety Office ensures proper placarding for the transportation of
hazardous materials. If the transporter does not have proper placards, the facility
either provides proper placards or does not allow the waste to leave the facility
(placarding is a joint responsibility of the shipper and transporter).
c. Training. The ECC will assure training is provided and documented for contractor
employees involved in transportation of chemical or biological hazardous materials as
described in the DOT regulation.
d. Internal Emergency Telephone Numbers.
Medical Center Spill Response Coordinators (when notification is to be provided):
Name Work No. Home No.
e. Outside Emergency Telephone Numbers - State. *
1) (State) Underground Storage Tank (UST) Act:
Subject Ref. Std. Office/Contact Phone
USTs10 CSR 20-10.010 *National Response Center 1-800-424-8802
Leaking USTs *National Response Center 1-800-424-8802
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Sample GEMS Documents
Department of Veterans Affairs
2) (State) Hazardous Waste Management:
Subject Ref. Std.
Office/Contact
Phone
Emergency
Notification
Community Right-
To-Know (federal
agencies exempt)
Waste Oil
10 CSR 24
10 CSR 25-11.010
Envir. Emergency Nat.
Resp. Center
Haz. Waste Program
f. Outside Emergency Telephone Numbers - Federal. *
**1) Comprehensive Environmental Response, Compensation and Liability Act
(CERCLA) (Superfund):
Subject Ref. Std. Office/Contact Phone
Haz. Waste Site
Cleanup
40 CFR 302
Superfund Program
**2) Superfund Amendments and Re-authorization Act (SARA); Title III, Emergency
Planning and Community Right-To-Know Act (EPCRA):
Subject
Ref. Std.
Office/Contact
Phone
Sec. 302
Extremely Haz.
Sub. (EHS)
Sec. 304
Reportable
Quantity for EHS
Sec. 313
Emissions or
Release
RCRA Wastes and
Codes
40 CFR 355
40 CFR 302
40 CFR 372
40 CFR 261
Emergency Response
Program
Emergency Response
Program
Emergency Response
Program
Emergency Response
Program
*National Response
Center
1-800-424-8802
RCRA/CERCLA
TSCA Hotline
1-800-424-9346
1-800-424-9065
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
*EPA National Response Center (NRC) is the primary federal point of contact for
reporting ALL oil, chemical, biological and etiological discharges into the
environment anywhere in the United States.
"Releases covering the items marked as such are also associated with a transportation
event.
g. If the Spill Response Coordinator determines that the facility has had an outside chemical
release in reportable quantity (see Attachment) that could threaten human health or the
environment, the Spill Response Coordinator shall notify the EPA National Response
Center at 1-800-424-8802.
5. References. US EPA Title 401 Subpart K, Toxic Substance Control Act; 40 CFR 261, 302,
355, and 372; JCAHO, PTSM Series, Managing Hazardous Materials and Wastes; OSHA
1910.120, Hazardous Waste Operations; and 49 CFR Part 171.15-16, Hazardous Materials
Transportation Act.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Attachment:
Index of Chemical Classifications
Distribution:
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Sample GEMS Documents
Department of Veterans Affairs
Attachment to Document 5B2-12
Index of Chemical Classifications
The following index identifies 38 common chemicals (in alphabetical order) found in healthcare
facilities. The reader may utilize this index to identify the chemical classification and
Reportable Quantity (RQ) for each chemical listed. Chemicals not found on the list can be
found in 40 CFR Part 302 or on the Material Safety Data Sheet (MSDS).
Chemical Reportable Name Chemical Classification Reportable Quantity (RQ)
Acetic Acid
Acetone
Acetylene
Alcohol(s)
Ammonium Hydroxide
Ammonium Thiosulfate
Butane
Carbon Dioxide
Chemotherapeutic Drugs
Chlorine (Gas)
Cyanide
Ether
*Ethylene Oxide
Freon
* Formaldehyde
Hydrochloric Acid
Mercury
Methylene Chloride
Methyl-Ethyl-Ketone
Mineral Spirits
Acid
Flammable Liquid 10 Ibs
Flammable Gas
Flammable Liquid
Caustic 1,000 Ibs
Caustic 1,000 Ibs
Flammable Gas
Nonflammable/Asphyxiant
Carcinogen/Chemo Drugs 1 Ib
Nonflammable/Asphyxiant 10 Ibs
Poisons 10 Ibs
Explosive 100 Ibs
Flammable Gas/Carcinogen 10 Ibs
Nonflammable/Asphyxiant
Flammable 1,000 Ibs
Liquid/Carcinogen
Acid 5,000 Ibs
Toxic-Metal 1 Ib
Flammable Liquid 1 Ib
Flammable Liquid 5,000 Ibs
Flammable Liquid
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Methyl Methacrylate
Muriatic Acid
Naphtha
Nitric Acid
Nitrous Oxide
Perchloric Acid
Phenol
Phosphoric Acid
Picric Acid
Potassium Hydroxide
Propane
Sodium Hydroxide
Sulfuric Acid
Toluene
Trichlorotriflouromethane
Tetra Hydrofuran
Trichloracetic Acid
Xylene
Flammable Liquid
Acid
Flammable Liquid 1,000 Ibs
Oxidizer/Asphyxiant 100 Ibs
Nonflammable Gas
Oxidizer/Acid
Poison
Acid 1 Ib
Explosive/Oxidizer/Acid 1,000 Ibs
Caustic
Flammable Gas
Caustic 1,000 Ibs
Oxidizer/Acid 1,000 Ibs
Flammable Liquid 100 Ibs
Nonflammable Asphyxiant 1,000 Ibs
Flammable Liquid
Acid
Flammable Liquid 1,000 Ibs
*Note: Ethylene Oxide and Formaldehyde are fully regulated chemicals and are, therefore,
addressed with separate Spill Response Guides.
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-13
SAMPLE
Oil Spill Prevention Control and Countermeasure Plan
1. General Information.
a. Name of Facility/Owner: Department of Veterans Affairs
b. Site Description: The Department of Veterans Affairs Medical Center is a XXX bed
medical, surgical and mental health care hospital with a XXX bed Nursing Home facility,
outpatient support services and regional office center. Facilities include a boiler plant,
maintenance garage, wastewater treatment plant, hospital building, fire station, shops,
offices and housing units. The medical center is located on approximately XXX acres.
c. Key Contacts:
d. Name of Professional Engineer:
Date of Certification:
License Number:
State of Certification:
e. Management Approval of the Plan: Approved Disapproved_
Date:
f. Review Date: December 12, 2004
g. Amendments: Date:
Purpose. The purpose of this contingency plan is to minimize hazards to human health and
the environment and to familiarize personnel with the proper procedures should an
emergency with oil or other hazardous materials occur. All oil spills shall be reported as
required by state and federal agencies.
a. The Oil Spill Prevention and Countermeasure Plan will establish policy, outline
procedures and assign responsibility for the prevention, mitigation and contingency
planning for any potential chemical and/or oil material spills on the Medical Center
facility that may enter into the environment. This policy incorporates by reference the
Hazardous Materials Spill Response Policy for spills that occur within buildings. This
policy applies to all Services and to all VA personnel, including employees of the
satellite facilities under the control of this Medical Center.
b. This contingency plan describes the preventive measures taken and the facility's response in
the event of the release of oil or hazardous materials. This contingency plan is available for
inspection by any local, state or federal representative, employee representatives and
supervisory personnel and must be kept in the Environment of Care Manual.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
c. This plan should be reviewed annually or upon failure of adequate response in the event
of a spill or other incident and shall be amended whenever the list of emergency
coordinators and/or the list of emergency equipment change.
3. Policy. It is the policy of this Medical Center to identify and respond to spills of hazardous
materials, oils and/or infectious materials in a rapid and effective manner. Potential exposure
to patients, employees, volunteers, visitors, environment and the community are to be
minimized by proper clean up and disposal of any accidental spills of oil, hazardous
chemicals and/or infectious material. Spillage wastes are to be disposed in accordance with
applicable local, state and federal requirements.
4. Responsibilities.
a. Service Chiefs who handle, store or use oil or hazardous/infectious materials within their
respective Services must have spill prevention and response policies available.
b. VA Police will ensure that the affected spill areas are secure from unauthorized entry.
Without entering the immediate hazard area, VA Police will isolate the area to ensure the
safety of people and the environment in the vicinity of the incident, and will keep people
away from the scene and the perimeter, allowing enough room to move and remove
equipment that may be necessary to respond to the emergency.
c. VA Police and the Business Service Line will coordinate communication assistance
through the telephone operators and the Medical Administrative Assistant (MAA).
d. Urgent Care will provide technical and emergency medical assistance.
e. Facilities Management Service will provide Engineering representatives to the area
involved in the spill/release.
f. The Chief or Captain of the Fire Department will be authorized as the Incident
Commander. It is the responsibility of the Incident Commander to determine if the spill
or release is reportable to government authorities. A release is defined in 40 CFR 355 as
any spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting,
escaping, leaching, dumping or disposing into the environment of any hazardous
chemical, extremely hazardous substance or Comprehensive Environmental Response,
Compensation and Liability Act (CERCLA) hazardous substance. The environment is
defined in 40 CFR 355 as water, air and land and the interrelationship that exists among
and between water, air and land and all living things. To determine if a release is
reportable to the National Response Center or the Department of Environmental
Protection, the Incident Commander will need to determine if the discharge is in a
quantity that may be harmful to public health or the environment.
g. All firefighters or individuals who respond to releases or potential releases for the
purpose of stopping the release, will be trained at the Hazardous Materials Technician
level. They assume a more aggressive role than a first responder at the operations level
in that they will approach the point of release in order to plug, patch, or otherwise stop
the release of a hazardous substance. Hazardous Materials Technicians shall receive at
least 24 hours of training equal to the first responder operations level and in addition the
VA will certify competency in the following areas:
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Sample GEMS Documents Department of Veterans Affairs
1) Knowledge of the emergency response plan.
2) Knowledge or the classification, identification and verification of known and
unknown materials by using field survey instruments and equipment.
3) Knowledge of their assigned roles in the Incident Command System.
4) Knowledge of the selection and use of chemical personal protective equipment.
5) Understanding of hazard assessment and risk management techniques.
6) Knowledge of advanced control, containment, and/or confinement operations within
the capabilities of the resources and personal protective equipment available with the
unit.
7) Knowledge of proper decontamination procedures.
8) Knowledge of proper termination procedures.
9) Knowledge of basic chemical and toxicological terminology and behavior.
5. Initial Response Procedures Upon Discovery. The exact procedure followed and the
personnel involved in spill clean up will depend on the severity of the situation. The
employee first observing the spill will follow their Service spill response policy procedures.
This employee is responsible for notifying his/her supervisor who, in turn, will assure that the
proper procedures are followed. If a chemical spill is such that it is immediately hazardous
and cannot be handled by on-site personnel or if it has entered the environment, the
emergency line (911) shall be called and all pertinent information, such as location, type of
material, amount spilled, etc., should be provided.
a. Internal notification. The telephone operators will notify the following services or
sections when requested by a service that is seeking chemical spill or release assistance.
1) Fire Department.
2) Safety Office.
3) Police Section.
b. The individual who discovers the spill is to:
1) Cordon off the area to prevent facility personnel unaware of the situation from
wandering into the spill area.
2) Arrange to have utilities and ventilation systems shut down if necessary.
3) Stand by to provide assistance to the Fire Department and to act as a Coordinator
until relieved by someone with more technical experience such as the Safety
Manager, the Chief of the Fire Department or Spill Response Agency.
c. External notification: The Incident Commander will notify the National Response Center
and the Department of Environmental Protection for all discharges to the environment if
it has been determined that the discharge is in a quantity that will:
1) Violate applicable water quality standards.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
2) Cause a film or "sheen" upon discoloration on the surface of the water or adjoining
shorelines.
3) Cause a sludge or emulsion to be deposited beneath the surface of the water or upon
adjoining shorelines.
4) The rule of thumb is if the spill requires a spill pad or pillow, it is reportable to the
State Department of Environmental Protection (DEP) and the National Response
Center.
6. Response Management System Command Responsibilities.
a. The Fire Chief or Captain of the Fire Department will function as Incident Commander
unless or until a response agency arrives. The Incident Commander will coordinate all
emergency actions:
1) Notify facility employees of emergency situations caused by a release, fire or
explosion of oil materials.
2) Take appropriate measures to cope with the emergency.
3) Order evacuation, if necessary.
4) Initiate notification of response agencies according to the nature of the emergency.
5) Arrange for the proper disposal of any recovered materials.
b. The Medical Center Director or Medical Administrative Assistant on duty will assume
the Emergency Operations Center's responsibilities.
c. The Medical Administrative Assistant (MAA) will assume the Emergency Operations
Center's responsibilities if the Medical Center Director is not present.
d. The duties of the VA Police shall include securing the scene of the incident and directing
traffic from the scene.
e. The Chief, Facilities Management is responsible for:
1) Supplying all maintenance equipment and personnel required to perform such
emergency actions, such as powering down any utilities, turning on/off water mains,
providing backhoe operations, etc.
2) Becoming familiar with this Plan as well as the Health and Safety and Emergency
Evacuation Plans.
3) Acting as an Incident Commander if the event requires Facilities Management
leadership.
7. Procedures for the Establishment of Objectives and Priorities for Response to the Incident.
a. The immediate goals/tactical planning is for fire and explosion prevention control. The
oil materials used at this facility can be highly flammable or toxic. Extreme caution must
be exercised to prevent an incident from occurring during the transfer, usage or storage of
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Sample GEMS Documents Department of Veterans Affairs
these materials. Each employee must be familiar with the following preventive
measures:
1) Storage and Handling of Flammable Liquids:
a) No smoking or intense heat sources will be allowed.
b) Caution must be used to prevent sparking from metal parts.
c) Waste and virgin material must be properly stored and disposed of.
d) Containers must be closed except when taking/putting in material.
e) Metal containers must be grounded when transferring liquids.
2) Fire Fighting Procedures:
a) Any Medical Center employee may extinguish small fires involving such items as
paper, cardboard, etc., that can be extinguished with an ABC fire extinguisher.
Anything beyond that, including all fires involving flammable liquids, must be
extinguished by the Fire Department. All fires are to be reported to the Fire
Department regardless of size, source or type. The Fire Department is responsible
for notifying the Safety Office of any fires on the next regular business day.
b) If evacuation is required, personnel leaving the building will assemble and leave
according to the VA Medical Center Emergency Evacuation Plan.
c) Evacuation must be ordered, if necessary, by the Incident Commander.
b. Mitigating actions: Diking and spill control equipment are located on Unit X of the Fire
Department's emergency response vehicles. Additional materials are located in the
basement of the Maintenance Garage. All spill residues must be stored in the Hazardous
Waste Storage Building X until final disposal. Spill debris must be segregated by type of
material, must be contained in leak-tight barrels located on appropriate spill protective
devices, and must be logged on the Daily Inspection Sheet found in Building X by the
Officer bringing the material to the building.
c. Identification of resources required for response: The Incident Commander will
determine the resources necessary to mitigate the spill and is authorized to recommend
implementation of the Medical Center's Emergency Preparedness Plan as necessary, or to
call in Mutual Aid.
d. Implementation procedures:
1) Safety Equipment - Spill kits are located in the Maintenance Building, Unit X of the
Fire Department, and the Hazardous Waste Storage Building. Spill kits contain the
following materials:
a) Speed-dry, spill pillows and spill pads.
b) Non-sparking plastic shovel.
c) Drain cover.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
2) Personal protective equipment (Small spill clean up only):
a) Non-vented chemical splash goggles.
b) Nitrile gloves.
c) Tyvek coveralls.
d) Neoprene overboots.
e) Self Contained Breathing Apparatus (SCB A).
3) Other equipment:
a) Caterpillar Backhoe, Maintenance Building X.
b) Dump trucks, Maintenance Building X.
c) Front End Loader, Maintenance Building X.
8. Sustained Actions. For extended clean up or spill response operations, the Emergency
Preparedness Plan will be implemented.
9. Response Critique and Plan Review Modification Procedures. All spills and their
responses will be critiqued during the next business day. During the critique of a spill
incident, any recommendations will be sent to the Medical Center Director for approval. The
Integrated Contingency Plan will be reviewed on a triennial basis. All documentation
concerning incidents involving spills of hazardous materials will be documented (using a
Reporting an Oil Spill form [Attachment A] and a VA Form 2162) and will be forwarded to
the Safety Office.
10. Facility and Locality Information.
a. Above Ground Storage Tank (AST) System.
1) The AST system consists of four storage tanks that provide fuel for heating
equipment, motor vehicles and maintenance equipment. The tanks are XXX gallon
tanks with associated diking used for #2 and #6 fuel oil for the boilers, and XXX
gallon tanks used for gasoline and diesel fuel for motor vehicles and maintenance.
There are also XXX gallon tanks used for the emergency generators located in the
generator buildings, XXX gallon tanks used for generators, XXX gallon diesel tank
for generators and XX high voltage oil filled transformers. The XXX gallon tanks are
located in structures called dike tanks that act as secondary containment should the
primary tank develop a leak. The volume of a dike tank is equal to 110% of the
volume of the primary tank. The dike tanks drain into oil water separators. The XXX
gallon tanks are fire rated gasoline tanks of double wall construction. All of the tanks
are constructed of steel. There is no underground piping associated with the gasoline
or diesel tanks; all piping is above ground.
2) Leak detection: All tanks are readily visible.
3) Spill prevention: The tanks are filled by a commercial carrier. They connect the fill
hose from a pump truck to a fill pipe located at each tank. The fill pipes for tanks 1,
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Sample GEMS Documents Department of Veterans Affairs
2, 3 and 4 are located in remote spill boxes directly adjacent to the tank. Tanks 3 and
4 are equipped with overfill protection around each fill pipe on the top of the tank.
This system ensures that any product spilled during the connection and disconnection
of the fill hose will be contained within the spill box. In addition, the piping to the
remote spill boxes have shut-off valves and check valves to prohibit product flowing
back to the spill boxes after disconnection of the fill hose.
4) Overfill protection: Tanks X-X are equipped with an OPW61FSTOP-1000 AST
overfill valve and a Morrison 918 clock gauge with alarm. As an additional overfill
safety precaution, the tank vents contain a manifold that will return product to the
dike tank in the unlikely event of an overfill situation.
5) Fuel dispenser: The fuel dispenser is located on an island behind Building X and is
located on the concrete pad for tanks X and X. The dual product dispenser is
supplied by tank X (gasoline) and tank X (diesel). The island is equipped with an
automatic fire suppression system with manual deployment capabilities. A remote
emergency shut-off switch is located at Building X. The piping to the dispenser
contains special valves that will shut off the fuel supply in the event of fire or if the
dispenser is knocked over by a vehicle. The dispenser hoses are equipped with
breakaway connectors.
b. Emergency Generator Fuel Tanks. Emergency generator fuel tanks are all located inside
secondary spill containment greater than 110% of the fuel tank.
c. Quarters Fuel Tanks. All fuel tanks in the quarters utilize secondary spill containment
and the basement for tertiary containment.
d. Hazardous Waste Storage Areas. All liquid hazardous waste storage are placed on the
spill control diking pallets of at least 110% of the capacity of the drums and kept inside
of Building X to prevent accumulation of rainwater. The Hazardous Waste Storage
Building has its own spill containment built into the structure.
e. Transformers. All transformers are protected by placement on concrete pads and firmly
planted bollards.
f Miscellaneous storage of containers of 55-gallon drums. All oil, flammable liquids or
other hazardous chemicals found in drums of 55 gallons or more are to be placed on spill
control pallets of a size equal to 110% of the storage capacity of the drums and stored
inside of a building. Spill control devices are to be used for all other smaller containers
as appropriate.
11. Notification Arrangements with Authorities. The Medical Center and the Incident
Commander will notify, cooperate and coordinate with local, state and federal authorities or a
spill response agency in the event of an incident that could possibly pose a threat to human
health or the environment. The Medical Center may need to call on these authorities for
assistance in mitigating a fire, explosion or release of oil materials and to keep them
informed and up-to-date with regard to any of the hazardous substances or wastes used and
stored at the facility. A copy of this plan has been given to the local Fire Department and the
local Emergency Planning Committee.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
12. Incident Documentation. All documentation concerning incidents involving spills of
hazardous materials will be documented using a VAF 2162, Report of Accident, and the
"Reporting an Oil Spill" form (Attachment A), and will be forwarded to the Safety Office.
13. Training and Exercises/Drills.
a. Training will be given to each supervisor and employee involved in the receipt,
possession, use, storage, transfer or disposal of oil materials and waste. A copy of this
Plan will be provided and reviewed.
b. Initial training will be done immediately after hiring and upon assignment to a job
involved with oil materials or waste.
c. Training will be classroom and on-the-job and will be conducted by the Safety Manager
or supervisor.
d. Records of training will be kept until closure of the facility.
14. Prevention. Inspection schedules:
a. Daily Inspection.
1) The Boiler Operator will make a general inspection of the main oil storage area (by
Building X) as often as possible but not less than once per day. A log will be kept of
all inspections.
2) Any problems or deficiencies must be brought to the immediate attention of the Plant
Operations Supervisor and the Fire Chief/Captain, if necessary.
b. Weekly Inspection. All oil storage tanks greater than 275 gallons are to be inspected
weekly by the Plant Operations Supervisor. Copies of all inspection forms are to be
maintained for three years from the date of the inspection and are to be kept in the office
of the Plant Operations Supervisor. All other tanks will be inspected annually.
Attachments:
A. Reporting an Oil Spill Form
B. Oil Spill Report Form
C. Oil Storage Information Sheet
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Sample GEMS Documents Department of Veterans Affairs
Attachment A to Document 5B2-13
Reporting an Oil Spill at
(Facility Name) VA Medical Center
1. In Event of an Oil Spill, call:
TELEPHONE OPERATOR 911
2. Provide the Following Information:
• Material Spilled
• Location of Spill
• Estimated Quantity Entering Sewer, Manhole, etc.
3. Telephone Operators to Inform the Following Personnel:
Work Home Pager
FIRE CHIEF
CHIEF ENGINEER
SAFETY MANAGER
SPILL RESPONSE CONTRACTORS (For external notification)
4. Chief, Facility Management, or Safety Manager will notify:
National Response Center 1-(800) 424-8802
(State) Emergency Management Agency
(State) Department for Air
Water
Waste
FOR SPILLS OF OIL OF ANY SIZE, REPORT TO: 800 482-0777
FOR SPILLS OF HAZARDOUS MATERIALS: 800 452-4664
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
Attachment B to Document 5B2-13
OIL SPILL REPORT
Veterans Affairs Medical Center
(Location)
Operation: Location:
Date: Time of Spill:
Type of Oil Spilled: Amount of Spill:
Did any oil reach a catch basin or sewer? Yes No
Did any oil leave our property? Yes No
Who was contacted: Time:
Description of Spill:
Did the weather affect the spill?_
What actions were taken?
Actions taken to prevent a recurrence:.
How was clean-up material disposed of?_
In-house personnel or contractor who performed clean up:
Name: Signature:
Address: Title:
Phone: EPA #:
Signature of person filing report:
Title of person filing report: Date:
Reviewed by: Title:
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Sample GEMS Documents Department of Veterans Affairs
Attachment C to Document 5B2-13
SAMPLE
OIL STORAGE INFORMATION SHEET
Veterans Affairs Medical Center
(Location)
(Complete one for each tank)
SERVICE: Engineering
CONTACTS: Chief, Engineering Service
Engineer
Manager, Safety
TYPE OF FACILITY: Aboveground Fuel Oil Tanks
TANK DESIGNATION: AST Number X
LOCATION: Building X
TOTAL CAPACITY: XX,000 Gallons
TYPE OF OIL: No. X Fuel Oil
POTENTIAL FOR EQUIPMENT FAILURE: Overflow During Filling, Transfer Pump and
Piping
CONTAINMENT: XX,000 Gallon Steel Dike Tank
INSPECTION AND TESTING: Measures for water contamination. Daily manual check for
level of tank, and results are recorded into boiler log. Any irregularities are reported
immediately to emergency contacts listed in this plan.
SPILL HISTORY: None
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-14
SAMPLE
Pollution Prevention Plan
A. Pollution Prevention Overview.
1. The purpose of this Pollution Prevention Plan is to develop a coordinated management
strategy to minimize the amount of pollution generated as a result of healthcare delivery
and services for the Department of Veterans Affairs (DVA), VA Medical Centers
(VAMCs) and Community Based Outpatient Clinics (CBOCs). The plan shall serve to:
• Establish the current status of waste management at the facility.
• Set both short and long term goals.
• Establish a clear policy commitment.
• Review and document current pollution prevention initiatives in place.
• Create specific objectives for the coming year.
A team of designated staff members participate in the Pollution Prevention (P2) effort by
overseeing P2 efforts in their respective departments. This team is designated as the
Pollution Prevention Team for the VA Medical Center.
The Safety Manager/Industrial Hygienist has been designated as the P2 Team
Coordinator and shall serve as the overall coordinator for pollution prevention efforts; as
such he/she will document pollution prevention efforts, data collection and progress
measurement.
The P2 Team Coordinator reports to the Green Environmental Management Systems
(GEMS) Committee and presents, at least annually, the hospital's P2 progress and
program status.
The P2 program is linked to other important efforts within the organization, including:
• The JCAHO Standards for the Environment of Care.
• The Environment of Care Committee and Environment of Care Rounds.
• Patient Safety and Risk Management.
• Performance Improvement teams at the Service or Care Line.
2. Mission and Environmental Management Principles.
a. The VA's mission is "To care for him who shall have borne the battle, for his widow
and his orphan" in an environmentally responsible manner by meeting or exceeding
all applicable environmental laws and regulations.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
b. VA Environmental Management Principles.
1) Top management is committed to improving environmental performance by
establishing policies to emphasize pollution prevention and compliance with
environmental requirements.
2) The VA implements proactive programs that assures compliance and pollution
prevention.
3) The VA develops and implements programs to enable personnel to perform their
functions consistent with the agency mission and their environmental
responsibilities.
4) Environmental performance measures are developed and employees held
accountable.
5) A program for continuous improvement in environmental performance measures
is developed and implemented.
This program sets forth the strategic plan for the management of hazardous
materials and wastes that pose a significant risk to human health and the
environment to assure that they are appropriately handled. In so doing, this
program will comply with the regulatory requirements set forth by the
Environmental Protection Agency (EPA) under it's Resource Conservation and
Recovery Act (RCRA) 40 CFR, Clean Air Act (CAA), Clean Water Act(CWA),
and the Department of Transportation (DOT) and other relevant regulations,
including the State Hazardous Waste Regulations.
B. Organizational Policy Statement.
1. The Medical and Regional Office Center is committed to improving environmental
performance by establishing policies that will emphasize pollution prevention and will
ensure compliance with environmental regulations.
2. It is the policy of the VA to implement proactive programs that will identify and address
potential compliance problem areas and will utilize pollution prevention approaches to
correct deficiencies and improve environmental performance.
C. Pollution Prevention Program,
1. The pollution prevention program is important to:
• Comply with GEMS requirements for environmental compliance and continuous
improvement.
• Comply with Joint Commission standards for the environment of care that requires
our organization to have a documented management plan that considers hazardous
materials and hazardous wastes.
• Reduce the pollution created by hospital activities.
• Improve hospital's community relations.
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Sample GEMS Documents
Department of Veterans Affairs
• Protect the safety and health of employees.
2. Scope of P2 Program: This program applies to the following facilities and entities:
Facility Name
xxxx
Location
XXXX
This program will apply to:
• The handling of all hazardous wastes as defined by 40 CFR part 261.
• The handling of infectious, non-hazardous and radioactive wastes.
• A comprehensive plan to ensure that the VA is fully cognizant of and has procedures
for all waste products generated in the process of healthcare delivery.
• The need to evaluate products as they are purchased to ensure that such products do
not create sources of environmental harm.
D. Key Contacts for Service Hazardous Waste Management and Pollution Prevention.
Area
Laboratory
Pharmacy
Radiology
Facilities
Clinical Engineering
Information Management
Dental
Housekeeping: Chemicals
Acquisition and Material
Management
Central Sterile
Reprocessing
Contact
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
P2 Initiatives/ Coordination
Ethanol and Clearite reduction
Formaldehyde recovery
Lab Packs and Laboratory Chemicals
Mercury prevention
Silver
RCRA Hazardous Pharmaceuticals Management
Reverse Distribution Program
Other
Coordination of recovery of Lead aprons, silver from x-ray film,
silver from fixer/developer solutions
Track data
Champion digital imaging systems
Proper management of cutting oils, freon, solvents, compressed
gases, used batteries, waste oil, greasy rags, paints, boiler
chemicals, pest management, florescent lamps, mercury
switches, paints, etc.
Recycling program
Battery Recycling
Mercury Reduction
Cathode Ray Tubes
Silver photo processing
Mercury amalgam
Lead foil
Coordinate product substitution
Medical Waste Management and Reduction
Coordinate laundry program
Affirmative procurement program
Coordinate phase out/minimization of Ethylene Oxide
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
E. Related Policies. The Pollution Prevention Team will coordinate the development of
organizational policies that support and improve pollution prevention activities within the
institution. These policies will support the elimination of hazardous substances wherever
possible, the minimization of use of substances containing persistent bioaccumulative toxic
substances, resource conservation, waste minimization, and a collaborative approach to
problem solving with vendors, staff and the community at large.
1. Hazardous Materials Management:
a. Hazardous Materials Management Program.
b. Hazard Communication.
c. Respiratory Protection Program.
d. Asbestos Management.
e. Industrial Hygiene Survey Program.
f. Oxygen and Compressed Gas Policy.
g. Ethylene Oxide Program.
h. Radiation Safety Committee.
i. Lead Hazard Control Program.
j. Waste Anesthetic Gases and Vapors Hazard Control Program.
k. Formaldehyde Exposure Control Program.
1. Pesticide Management Program.
m. Antineoplastic Agents.
n. Chemical Hygiene Plan.
2. Environmental Management Program:
a. Environmental Management Program.
b. Hazardous Waste Management Program.
c. Hazardous Waste Reduction Program.
d. Hazardous Materials Spill Response Policy.
e. Spill Prevention and Control Countermeasure Plan (SPCC).
f. Management of Universal Hazardous Waste.
g. Mercury Reduction.
h. Residential Lead Disclosure.
i. Pollution Prevention Program.
j. Waste Characterization Sampling and Analytical Work Plan.
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Sample GEMS Documents Department of Veterans Affairs
F. Staff Education and Training for Pollution Prevention.
1. This VA Medical Center recognizes that for the P2 program to achieve success, staff
members need to be educated on how they can participate. Hospital-wide and
department-specific inservice presentations will be supported and delivered on a regular
basis to ensure that staff members are active participants in meeting pollution prevention
goals. Environmental education has been added to the annual mandatory inservice
programs that every staff member receives.
2. Service specific programs for staff education on waste management and pollution
prevention shall include, but shall not be limited to the following, where appropriate:
a. New Employee Orientation shall provide an overview of environmentally preferable
purchasing, waste management and waste segregation for the service, including
recycling.
b. Mandatory annual inservices shall review waste management programs with all
employees.
c. Special training for employees with specific environmental responsibilities including
managing waste, detecting and solving problems and regulatory compliance.
d. Emergency response training for chemical and blood spill clean up and hazard
identification.
e. Specific certifications for Department of Transportation, Occupational Safety and
Health Administration, Hazard Communication and Hazardous Material training
when appropriate.
G. Summary of the VAMC Pollution Prevention Goals and Initiative.
1. Reduction in the generation of wet chemistry X-ray films developed by 90% by the year
XXXX. Waste photo processing liquids from the development of X-rays comprises the
largest hazardous waste stream generated at our Medical Center. Liquids with a
concentration of greater than 5 parts per million of silver are considered a hazardous
waste and must be treated in accordance with Resource Conservation and Recovery Act
regulations. The VAMC has a license by rule with the Department of Environmental
Protection to recover the silver from these photo-processing fluids before we discharge to
our sludge holding tank for land disposal. The wastewater treatment plant has very
stringent limitations on the amount of silver we may discharge to VAMC stream, so
every effort must be made to keep silver out of our wastewater. Because of the increased
amounts of patients that we serve and the increase in X-ray films processed, the total
amounts of processing fluids has been steadily increasing the last several years.
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Silver Photoprocessing Fluids
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Radiology and Clinical Engineering have developed a plan for replacing and eliminating
the wet film processors in use in the hospital with the new Digital Radiography
equipment. The schedule for replacement and estimates of the effects on photo
processing fluids reduction is as follows:
Initiative
Digital Radiography for chest room.
Prints exclusively to dry printer.
New Ultrasound.
Nuclear Medicine (3 units) and CT
DICOM printers.
Operating Room Cysto (Urology)
System.
Portable C-Arm.
CR (Computed Radiography) Systems
(2).
R/F (Radiographic/Fluoroscopic) Systems
(2).
Dental Upgrade for Dental Processor.
Date
Effects
95% reduction in chest wet films
produced.
95% reduction in ultrasound wet
films.
40% reduction in total wet films
produced.
80% reduction in OR wet
processing.
90% reduction in C-arm wet films
produced.
95% reduction CR wet films.
95% reduction in fluoroscopic wet
films.
90% reduction in Dental
generation.
2. Reduction of Mercury-Containing Devices by 90% by FY XXXX Initiative. Mercury is
a persistent, bioaccumulative and toxic pollutant that affects the nervous system and is
found in many medical and other devices such as sphygmomanometers, thermometers,
barometers, switches, electrical components, laboratory chemicals, dental amalgam and
fluorescent lamps. Eliminating the purchase of these devices and substitution for
mercury-free devices will reduce the release of mercury to the environment.
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Sample GEMS Documents
Department of Veterans Affairs
Identified mercury-containing devices:
Building
Building X
Building X
Building X
Building X
XCBOC
XCBOC
XCBOC
XCBOC
Total
Building
Building X Laboratory
Building
Building X
Number of Sphygmomanometers
209
5
5
5
5
5
5
2
241
Identified Mercury Thermometers
10
Mercury Switches
60
Problem
Accurate chemical
inventory
Identify mercury
containing compounds
Substitution of mercury
compounds
Eliminate mercury
thermometers
Switch to low mercury
fluorescent Lamps
Stop purchase of
mercury containing
switches, thermostats
etc.
Phase out mercury
Sphygmomanometers
Action
Memo to all Service Chiefs.
Request suppliers to provide Certificates of
Analysis for large quantity chemicals.
Service Chiefs to investigate and substitute
products.
Procurement to stop purchase of mercury
thermometers.
Purchase only low mercury lamps.
Change procurement practices.
Establish timeframe for phase out, use a take back
program.
Completion
Date
Mercury Amalgam Separators: Dental Offices typically contribute significantly to
mercury levels in wastewater treatment plants. The limit at the VAMC wastewater
treatment plant is very low—35 parts per trillion. The Dental Suite was built with a chair
side trap system to collect mercury amalgam and wastes from the dental chairs and
operations. Newer systems provide much more effective means for the collection of
these mercury wastes. A major goal to reduce mercury from our wastewater is to replace
the amalgam separators with state of the art equipment to reduce the release of mercury
to the environment.
Reduce the Generation of Miscellaneous Hazardous Waste by 50%. The generation of
miscellaneous hazardous waste generally has been a result of poor practices in the
acquisition and management of hazardous materials. Service Chiefs will purchase
hazardous materials versus non-hazardous materials, purchase quantities that will never
be used, improperly store these materials or allow materials to become out of date before
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
use. As a result of better procurement activities, hazardous wastes in these categories has
declined in the last several years. Major cleanout efforts in the paint shop in Facilities
Management Service, Laboratory Service and Medical Media have reduced significantly
the amounts that will be stored and potentially become waste in the future.
Hazardous Waste Shipped
•o
O
Q.
4. Recycle 90% of Universal Wastes. Items such as fluorescent light bulbs containing
mercury, batteries containing mercury, lead acid, nickel cadmium or lithium and
computer display terminals would normally considered hazardous wastes because of the
heavy metals found within. New regulations allow these items to be treated as universal
wastes that are exempted from the full scope of the hazardous waste regulations if the
generator manages the waste in accordance with the Universal Hazardous Waste
regulations. The focus on universal wastes is to recycle more of the wastes under the
universal waste regulations rather than simply disposing of it. Initiatives in FY XX
include a recycling program with ABC Recycling. Rechargeable batteries are sent to
ABC for recycling rather than disposing of them as a hazardous waste. Boxes are
strategically placed to allow segregation of different battery types, ease of packaging and
ease of shipment. Over 200 pounds were managed this way in XXXX. In FY XX, a
substantial collection of Computer Display Terminals that were retired were recycled
under the universal waste program.
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Sample GEMS Documents
Department of Veterans Affairs
Recycling of Universal Wastes
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
DBatteries QMercuryContaining Bulbs
5. Biohazardous Waste Minimization by 10%. Ongoing education and training on
segregation of red bag versus other solid wastes by Environmental Management should
decrease the amounts of waste treated as bio-hazardous waste.
6. Increase the Amount of Procurement of Recycled Products and Recycling by 10%.
During FY XX, the VA purchased the following recycled materials:
Material
Structural fiberboard and laminated paperboard
Recycled content plastic desktop accessories
Recycled toner cartridges
Recycled content chipboard and plastic covered binders
Environmentally preferable plastic trash bags
Cost
The following materials were recycled:
Material
Pallets
Ferrous (steel, cast iron, tin, no-ferrous, aluminum, brass,
copper, lead and appliances)
Silver
Paper and corrugated cardboard
Pounds Recycled
20,160
10,000
40.4
226,000
Specific Programs are currently established for the following items:
a. Corrugated Cardboard.
b. Mixed Paper.
c. Toner Cartridges.
d. X-ray and Silver Recovery from Radiology.
e. Sludge from the Wastewater Treatment Plant.
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
f. Lead Acid Rechargeable Batteries.
g. Ni-Cad Rechargeable Batteries.
h. Lithium Batteries.
i. Computer Display Terminals.
j. Metals.
k. Pallets.
Energy Conservation. Air emissions as a result of burning fuel have continued an overall
decline despite increased outpatient visits and additional square footage served. Energy
saving projects in the last several years included window maintenance, variable
frequency drives, green lights program, energy management systems and soft start
motors. Pollution prevention efforts for air emissions include low nitrous oxide burners
in the boiler plant and use of low sulfur fuels.
200000n
180000-
160000-
140000-
120000-
100000-
80000-
60000-
40000-
20000-
Air Emissions: 1992 to Present
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Water Conservation. Water conservation efforts have included several major projects
that have resulted in reduced water usage. The amount of water treated at the wastewater
treatment plant has declined from approximately 130,000 gallons per day to around
83,000 gallons per day.
Project
Laundry Project
Water-Cooled Condensers
Water Savings in Gallons
15,000
30,000
Purchasing Initiatives for Pollution Prevention. Products purchased by the VAMC
eventually become wastes. Acquisition and Material Management is involved with
pollution prevention through product selection. This includes evaluating products for
their environmental impact, packaging, type of waste they will become and exploring any
vendor information on product disposal. Purchasing will communicate the intent and
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Sample GEMS Documents
Department of Veterans Affairs
10.
need for support in achieving pollution prevention and waste reduction goals to affiliated
Group Purchasing Organizations and Vendors on at least an annual basis.
Specific Goals:
• Language will be inserted into our purchasing contracts specifying that mercury
containing products and devices will not be acquired.
• The product standards committee will include environmental criteria in their
assessment of new products.
• Actively research alternatives to products now being used in the hospital that have
been identified as producing Persistent Bioaccumulative Toxins (PBTs) in their
manufacture or disposal; products that in their manufacture or disposal may create
and release dioxins (e.g., chlorine containing products and PVC containing products
and packaging).
• Review the use of chemicals in clinical, diagnostic, facilities, environmental services
and other departments to evaluate whether less hazardous materials may be available.
Copper Reduction in Wastewater Treatment Plant Effluent. The effluent that the VAMC
discharges to VAMC Stream, after extended aeration treatment, solids removal, and
disinfection, has historically been an issue with license conditions compliance. Toxic
reduction evaluation efforts have included the following initiatives to no avail:
Increased testing of incoming water, stream and effluent
PAC precipitation
Increase food to mass ratios
Decreasing sludge age
Copper pipe removals
Alkalinity adjustments in incoming water
Replacement of copper coiled water cooled condensers
Analysis of chemicals used for copper, below 1%
Water conservation
A trial has been conducted during the latter part of XXXX and the first part of XXXX
that has, for the first time, resulted in copper levels in compliance with our license. A
major reconfiguration of the wastewater treatment plant will be necessary to achieve
sustainable compliance. A project has been designed and will be awarded this year to
reduce the size of the oxidation ditch by 50%. Analysis on further improvements will
also be undertaken this fiscal year.
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-15
SAMPLE
Pollution Prevention And Waste Minimization Plan
1. Section 1 - Introduction and Regulatory Requirements.
a. Introduction.
1) Preventing pollution is this VA Medical Center's top environmental priority. The
current emphasis on pollution prevention is necessary to meet state and national
pollution prevention policy goals, reduce long-term liabilities of waste disposal, save
money by reducing the installation's raw material purchases and waste treatment and
disposal costs, and protect public health and the environment.
2) Pollution prevention is a cost-effective means of meeting environmental objectives in
an era when hospitals and government agencies are simultaneously subject to stricter
standards for pollution control, public criticism of their environmental records and
declining budgets. The costs of failing to prevent pollution are dramatically evident
when cleanup costs for improper waste disposal practices or material handling can
reach hundreds of millions of dollars.
3) Environmental liabilities increase directly with the volume of hazardous substances
and materials in use and increase to a lesser extent as a result of other materials used
and the solid waste generated. Reducing these long-term liabilities requires a positive
commitment, a sound plan and an aggressive program for modifying past attitudes
toward the conservation of all materials. Reducing liabilities also requires actively
searching for opportunities to reduce the amount of waste generated and the use of
toxic materials, fuels and chemicals while still accomplishing the mission of the VA
Medical Center (VAMC).
b. Regulatory and Policy Requirements. The Federal Pollution Prevention Act of 1990 was
enacted on November 5, 1990. Its purposes are as follows:
• Prevent or reduce pollution at the source whenever feasible.
• Promote recycling if pollution cannot be prevented.
• Permit treatment if pollution cannot be prevented or recycling cannot be
implemented.
• Discourage disposal or other releases into the environment.
This P2 plan is based on current U.S. Environmental Protection Agency (EPA) guidance
and is the foundation for complying with:
• The Federal Pollution Prevention Act of 1990.
• The Superfund Amendments and Reauthorization Act of 1986 (SARA).
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
• The Toxic Substances Control Act (TSCA).
• The Clean Air Act Amendments of 1990 (CAAA).
• The Clean Water Act of 1987 (CWA).
• The Montreal Protocol on Substances that Deplete the Ozone Layer.
• Executive Order 12856.
c. Definitions of Pollution Prevention Terms.
1) Under Executive Order 12856, pollution prevention means source reduction and other
practices that reduce or eliminate the creation of pollutants through:
• Increased efficiency in the use of raw materials, energy, water, or other resources.
• Protection of natural resources by conservation.
2) The Federal Pollution Prevention Act of 1990 defines "source reduction" to mean any
practice that:
• Reduces the amount of any hazardous substance, pollutant or contaminant
entering any waste stream or otherwise released into the environment (including
fugitive emissions) before recycling, treatment or disposal.
• Reduces the hazards to public health and the environment associated with the
release of such substances, pollutants or contaminants.
The term includes equipment or technology modifications, process or procedure
modifications, reformulation or redesign of products, substitution of raw materials,
and improvements in housekeeping, maintenance, training and inventory control.
3) Under the Act, recycling, treatment and disposal are not included in the definition of
pollution prevention. However, some practices commonly described as "in-process
recycling" may qualify as pollution prevention. Examples include solvent recycling
using an integral still, continuous filtering of a plating bath and recovery of volatile
organic compounds (VOCs) from degreasing vents. Recycling that is conducted in an
environmentally sound manner share many of the advantages of prevention: It can
reduce the need for treatment or disposal and conserve energy and natural resources.
d. Techniques for pollution prevention fall into six categories:
1) Source reduction.
2) In-process recycling.
3) Process modification.
4) Improved plant operations.
5) Input substitutions.
6) Changes in end product.
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Sample GEMS Documents Department of Veterans Affairs
Before pollution prevention techniques can be used, a waste assessment must be
conducted to show where reduction methods implemented by a facility can be most
effective.
2. Section 2 - Commitment Goals and Program Implementation.
a. This VA Medical Center is committed to reducing the environmental effects of its
activities through an active pollution prevention program. In support of this commitment,
the installation's pollution prevention policy statement has been prepared:
Pollution Prevention Policy Statement
This VAMC is committed to an active policy of protecting the environment in all of our
activities. This pollution prevention policy statement is based on our commitment to the
following:
• Providing a clean and safe environment in our community.
• Ensuring a safe and healthy workplace for our staff.
• Complying with all applicable laws and regulations.
• Efficiently accomplishing our mission.
• Reducing future liability for waste disposal.
• Reducing waste management costs.
To accomplish these objectives, we will implement programs for reducing or eliminating
generation of waste through source reduction and other pollution prevention
methodologies. This policy extends to air, wastewater and solid and hazardous wastes.
In addition to meeting the objectives, there are other important benefits related to
pollution prevention.
The VAMC is committed to reducing the weight and toxicity of generated wastes. As
part of this commitment, the Medical Center gives priority to source reduction. Where
source reduction is infeasible, other pollution prevention methods, such as recycling, will
be implemented where feasible. The wastes that cannot be prevented will be converted to
useful products or used beneficially, where feasible. Remaining wastes for which no
pollution prevention option is warranted will be effectively treated (to decrease volume or
toxicity) and responsibly managed. The Medical Center will select waste management
methods that minimize present and future effects on human health and the environment.
Pollution prevention is the responsibility of all of our staff. This Medical Center is
committed to identifying and implementing pollution prevention opportunities through
solicitation, encouragement and involvement of all employees.
b. Pollution Prevention Goals. The long-term goal of the VAMC is to eliminate the use of
hazardous materials, eliminate the generation of wastes and eliminate emissions of
pollutants to the environment (zero discharge). Achieving the goal of complete
elimination is recognized as not being technically or economically feasible. Thus, goals
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
have been adopted as interim measures with the ultimate goal of achieving zero discharge
(Table 2-1).
Table 2-1
VAMC Prevention Goals
Waste Category
Hazardous
Water
Ozone- Depleting
TRI
Material
Mercury
Silver
CFC Group III
Ethylene Oxide1
Reduction Goal
(%)
100%
100%
100%
100%
Base
Year
2001
2001
1999
1999
Target
Year
2005
2006
2006
2006
1. The Toxic Release Inventory process through the EPCRA program does not apply to hospitals, laboratories, and research facilities; however, the chemicals included
in this program are tracked for pollution prevention initiatives.
c. Identification and Evaluation of Pollution Prevention Opportunities. A range of pollution
prevention alternatives will be developed and screened for each of the major waste
streams and for waste management practices included in the inventory as a whole.
Technological, operational and managerial pollution prevention alternatives will be
identified.
Pollution prevention alternatives that pass preliminary screening will be evaluated further
for technical and economic feasibility. Economic analyses will be performed by
comparing potential reductions in treatment and disposal costs with the estimated costs of
implementing the change. Improvements in working conditions and worker safety also
should be considered.
d. Annual Pollution Prevention Reporting. An annual summary report of the Pollution
Prevention Program will be prepared and presented for review to the Environment of
Care Committee. The following reporting requirements that relate to pollution
prevention may be utilized in lieu of or to supplement pollution prevention activities for
data gathering:
• Hazardous Waste Annual Report.
• Annual Workplace Evaluation SAFE data.
• Annual Federal Facilities Compliance Report.
3. Section 3 - Survey.
Service
Facility Wide
Facility Wide
Facility Wide
Facility Wide
Facility Wide
Waste Stream
Cardboard
Oil
Co-mingled Paper
Excess/Surplus
Wood Pallets
Types
All
All
All
All
All
Disposal Methods
Recycle
Recycle
Recycle
Resell/recycle/donation
Donate for reuse
Party
CWT
Crystal Clean
CWT
Lot
Sales/Logistics
CWT
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Sample GEMS Documents
Department of Veterans Affairs
Facility Wide
Facilities
Management
X-Ray
Dental/X-Ray
Dental
Laboratory
Dietetics
Canteen/Dietetics
SPD
IRM
Clinical Support
Batteries
Aerosol Cans
Fluorescent/HID lamps
Medical Waste
CFC/HCFC
Air emissions
Asbestos
Film developer
Film developer
Amalgam
Xylene
Organic chemicals
Inorganic chemicals
Acids
Bases
Organic chemicals
Cooking Grease/Oil
Cooking Grease/Oil
Ethylene Oxide
Toner cartridges
CD ROM's
Oil
Lead
NiCAD, NiMH
Lithium
Carbon/Zinc
Alkaline
Mercury
All
All
Infectious
R11,R12,R22, 502,
113, 123,404A,
409A, 134A
Boilers
Emerg. generators
All
Digital
Silver
Mercury
All
All
All
Lapidary Clinic
Recycle
Recycle
Recycle
Haz. Waste
Haz. Waste
Haz. Waste
Haz. Waste
Recycle
Contract
Segregation
Waste Minimization
Recycle/Reclaim
Air
Air
Landfill
None
Silver Recovery - recycle
Haz Waste
Xylene recycler - still
Haz Waste/donation
Haz Waste/donation
Haz Waste/donation
Haz Waste/donation
Haz Waste/donation
Recycle
Recycle
None
Recycle
Currently storing/stock
piling
Non-Regulated Waste
Crystal Clean
Crystal Clean
Crystal Clean
Crystal Clean
Crystal Clean
Crystal Clean
Crystal Clean
Crystal Clean
BFI
On site
training
On site/HVAC
Waste
Management
On site
On site
Crystal Clean
On site
Crystal Clean
Crystal Clean
Crystal Clean
Crystal Clean
Crystal Clean
Bio-De-Grease
Bio-De-Grease
AMSCO
Contract
Store
Crystal Clean
4. Section 4 - Waste Minimization Opportunities.
Service
Waste Stream
Waste Minimization Opportunities
Facility Wide
Cardboard/Paper
Batteries
Shredded Paper
Peanuts
Minimize extraneous packaging. Recycle.
1. Increase training.
2. Trade in.
Worm digestion to compost.
Recycle.
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Green Environmental Management Systems (GEMS) Guidebook
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Facilities
Management
Dental
IRM
Laboratory
Canteen
Dietetics
Voluntary
Oil
Lighting
Leaves/Limbs
Construction
Film development
Lead film
Computer equipment
Chemicals
Cooking Grease/Oil
Cooking Grease/Oil
Aluminum cans
Utilize recycled oils.
Switch to low mercury T-8 lamps.
Compost.
1. Specify & insist on recycling of debris.
2. Purchase recycled materials for renovation/construction
projects.
Convert to Digital technology.
Digital will eliminate this waste stream.
1. Purchase software to swipe hard drives on CPUs turned in.
2. Participate in Federal Prison exchange.
3. Initiate recycling of software CDs.
4. D/C practice of destroying hard drives.
1. Order only required amounts for specific projects.
2. Substitute less hazardous substances where acceptable.
Installation of
grease traps.
Installation of
grease traps.
Recycle
5. Section 5 - Pollution Prevention Implementation Plan.
Program Implementation. This plan and the policies and procedures established to
implement the plan are developed and approved by the Environment of Care Committee and
approved by the Medical Center Director. The Pollution Prevention Program will be
supervised by the Safety Section of Facilities Management, in cooperation with applicable
Service Lines as needed to develop, evaluate and implement specific pollution prevention
projects.
6. Section 6 - Annual Pollution Prevention Reporting. Reports on the activities of the pollution
prevention and waste minimization program will be accomplished using the following
reporting methods and procedures:
Annually
VHA Waste Minimization Report:
VAMC Environmental Officials to VHA Office of Environmental Management
Hazardous Materials and Waste Program, Annual Evaluation of Effectiveness:
Safety Officer
Hazardous Materials Inventory:
Safety Section of Facilities Management
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-16
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Precautions in Handling Carcinogenic Chemicals and/or Cytoxic Agents
1. Purpose. To establish policies and procedures to assure appropriate steps are taken while
handling carcinogenic chemicals or cytoxic agents.
2. Policy. It is the policy of this medical center to assure that patients and staff are not
harmfully exposed to hazardous products and that adequate precautions are taken by
Logistics employees to protect patients as well as themselves while handling these products.
3. Responsibility. It is the responsibility of each employee to be familiar with and follow
regulations and policies to prevent accidental exposure to the products outlined in Safety
Management Plan and Environment of Care Committee/Program, Medical Center
Memorandum XXX.
4. Procedures.
a. Receipt Process:
1) Upon receipt of any chemical product where there has been obvious breakage or
leakage, the employee must, prior to handling:
a) Put on protective gloves.
b) Put on protective mask to inhibit inhalation of powders or aerosols.
c) Place spilled, broken, or leaking materials in a double red plastic bag and secure.
d) Identify the type of substance by purchase order (PO) number, etc., to determine
appropriate spill response actions. Reference Medical Center Memorandum
XXX, Hazardous Material and Waste Spill Response Procedures.
e) Take appropriate clean-up action.
2) Do not open any containers without adequate protection if breakage or a spill is
suspected. Identify the contents before further handling. If unprotected contact is
made, follow procedures listed on the Material Safety Data Sheet (MSDS).
b. Delivery: Logistics personnel must take precautions when delivering or picking up
flammable, hazardous, or toxic chemicals or agents. This will be accomplished by
assuring the items are well placed in/on carts, trucks, etc., to prevent them from falling or
breaking during transport.
c. Storage:
1) Occupational Safety and Health Administration's (OSHA's) Hazard Communication
Standard 1910.1200 requires vendors to label containers with:
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
a) Identification of the chemical.
b) Hazard warnings.
Permanent or temporary storage of these items will be in accordance with these
manufacturers' labels.
2) Logistics-stocked items falling into this category will be identified by placing an
appropriate color-coded label on the shelf where the item is stored. The master index
for these color codes will be posted for easy reference:
a) At the dock door in warehouse.
b) Shipping and Receiving area of Material Distribution Center.
d. Disposal: Disposals will be made in accordance with Medical Center Memorandum
XXX, Disposal of Hazardous Chemical Waste, and the appropriate Material Safety Data
Sheets (MSDS).
e. Spills: Spills will be handled in accordance with Medical Center Memorandum,
Hazardous Material and Waste Spill Response Procedures, and the appropriate MSDS.
f Shipping: Shipping will be accomplished in accordance with Medical Center
Memorandum XXX, Shipping of Hazardous Waste.
5. Rescission.
6. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-17
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Reclamation of Salvageable Material
1. Purpose. To provide policies and procedures for the reclamation of precious metals.
2. Policy. It is the policy of this Medical Center to salvage precious metals whenever
economically possible. Due to the cost of reclamation, there are some items that contain
precious metals that are not cost effective to recycle; some of which include silver paper and
EEG electrodes. If you have a question as to whether or not to submit a turn-in for
reclamation, contact the Logistics Manager at (insert telephone extension).
3. Delegation of Authority.
a. The Logistics Manage is responsible for disposition of all precious metals turned in to
Logistics as required.
b. Service Line Directors are responsible for notifying Logistics, through the turn-in
process, of all excess or salvageable precious metals. These items include: scrap dental
gold and amalgam, silver solution from x-ray processors, exposed and "green" x-ray film,
hearing aids, laryngectomy and tracheotomy tubes, etc.
4. Procedures.
a. As items are identified as excess, the using service will prepare an electronic IFCAP
VAF 2237 in accordance with procedures outlined in Medical Center Memorandum
XXX, to turn in the material and forward to Logistics. This request must contain:
1) Nomenclature.
2) Quantity.
3) Location for pick-up.
4) Contact person and telephone number.
5) Ownership of property and who arranged the loan.
6) Signature of approving official.
b. This request will be processed by the Supply Technician in Logistics, and Warehouse
personnel will pick up the material upon receipt of the paperwork from the Supply
Technician.
c. Warehouse personnel will act on the requisition appropriately and provide a copy to the
Service that initiated the turn-in.
d. The material will be safeguarded in the warehouse until final disposition.
e. Special handling requirements:
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
1) X-Ray Film: The used film will be removed from envelopes and packaged in special
boxes by Radiology Service. Total weight of these boxes is not to exceed 65 pounds.
Each box must be marked with the station name and number: i.e., VA Medical
Center, (Location), (Station #), prior to pick-up by warehouse personnel.
2) Silver Recovery from X-Ray Solutions: Logistics is responsible for the collection
and processing of these solutions.
3) Scrap Dental Gold and Amalgam:
a) Turn-ins for these materials should be submitted at least annually, and more often
if needed, but not more than quarterly.
b) The scrap should be weighed on an accurate scale and the weight annotated on the
IFCAP 2237. If scrap is not "clean" (teeth, porcelain, etc., attached), this
information should also be included and by annotating the IFCAP 2237 that the
identified weight includes teeth, etc.
c) When the warehouse picks up the material, it will be weighed again prior to
acceptance jointly by the service that generated the turn-in and warehouse
personnel. The weight will be annotated on the requisition as the action and a
copy of the requisition given back to the service.
d) The warehouse will ship out the substances in accordance with Logistics policy.
5. Reference. VA Directive and Handbook 7345.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-18
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Reporting Of Environmental Incidents
1. Purpose. To ensure that prompt and effective actions are taken to report environmental
incidents and to identify the persons responsible for notification of such incidents to
appropriate officials and agencies.
2. Policy. It is the policy of this Medical Center to report environmental incidents to the
appropriate officials and agencies within the required timeframes.
3. Responsibilities.
a. IndustrialHygienist is the Environmental Coordinator for the Medical Center.
b. Safety Manager/Industrial Hygienist is responsible for notifying the appropriate agency
of any reportable incident.
c. Supervisory personnel are responsible for notifying the Industrial Hygienist when an
incident occurs.
4. Procedure. The following procedure will be followed:
a. Underground Storage Tank Release - Contact the (insert State) Department of Natural
Resources (DNR) at (phone) within 24 hours of a confirmed release.
b. Air Emissions, Boilers, Incinerator and Ethylene Oxide.
1) The (insert State) DNR shall be contacted before 9:00 a.m. of the next working day at
(insert telephone numbers for State, City and County offices as appropriate).
2) A written report of the incident shall be submitted to the state DNR within 10 days.
c. Spills into Navigable Waters.
1) Oil or hazardous material that is discharged greater than the reportable quantity shall
be reported to the U.S. Coast Guard (Marine Safety) at (insert telephone number) and
(insert State) DNR at (insert telephone number).
2) Comprehensive Emergency Response Compensation Liability Act (CERCLA)
Section 103 and Superfund Amendments and Reauthorization Act (SARA) Title III
304 requires the (insert State) DNR be contacted at (insert telephone number).
5. References. Reporting Releases of Hazardous Substances under the CERCLA, Section 103;
and SARA, Title III Section 304.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-19
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Silver Recovery Program
1. Purpose. To update policy for the recovery of silver from x-ray film fixing solution.
2. Policy. This Medical Center has determined it is in the best interests of the Government to
recover precious metals from waste and excess personal property. This program provides for
financial compensation for silver recovered, conservation of a valuable natural resource and
protection of the environment from a potentially dangerous contaminant.
3. Procedure.
a. The Bio-Medical Technician will operate the unit in accordance with VA Supply Depot
instructions. He/she will initiate a work order for any maintenance or repair problems.
Silver-laden rotors will be promptly picked up by Material Management Section (MMS)
and sent to VA Supply Depot for reclamation.
b. The Bio-Medical Technician will advise MMS of the corrective action necessary for
maintenance and repair problems. Facilities Management Service can make adjustments
to the equipment but replacement parts will be requested through Material Management
Section to the Supply Depot at the Depot's expense.
c. Material Management Section will forward the silver-laden rotors to the Supply Depot in
accordance with published guidelines.
4. Responsibilities.
a. The Chief, Facilities Management Service, is responsible for the overall administration of
the program and will ensure all Services involved in the program are performing their
assigned functions.
b. The Bio-Medical Technician is responsible for the proper operation of the silver recovery
unit in accordance with instructions published by the VA Supply Depot.
c. The Chief, Facilities Management Service, is responsible for maintenance and repair of
the silver recovery equipment.
d. The VA Supply Depot is responsible for any costs incurred in the maintenance and repair
of the silver recovery unit.
5. Reference. VA Handbook 7345.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-2
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Affirmative Procurement Program for Recycled-Content Products
1. Purpose. This medical center is committed to developing an Affirmative Procurement
Program to increase the purchase of recycled-content products.
2. Policy. It is the policy of this medical center to implement a proactive program for
procurement of recycled-content products.
3. Responsibilities. In establishing the Affirmative Procurement Program, contracting officers
must require that vendors:
• Certify that the percentage of recovered materials to be used in the performance of the
contract will be at least the amount required by applicable specifications or other
contractual requirements, and
• Estimate the percentage of total material utilized for the performance of the contract that
contains recovered materials.
4. Requirements. Affirmative Procurement (AP) refers to the purchase and use of materials
containing recycled or recovered content in the greatest amounts practical, given resource
and performance constraints. Executive Order 12873 and The Resource Conservation and
Recovery Act (RCRA) Section 6002 requires procuring agencies to review specifications for
designated items and revise them to allow procurement of products containing recovered
material. RCRA Section 6002 also requires procuring agencies to establish an affirmative
procurement program. The Environmental Protection Agency (EPA) has established
Comprehensive Procurement Guidelines that identify categories of items to be purchased
with recycled content and specify the minimum acceptable recycled content level for items in
each category. EPA guideline items include paper and paper products, retread tires, re-
refined lubricating oil, building insulation, cement and concrete containing fly ash, engine
coolants, structural fiberboard, laminated paperboard, carpet and floor tile, patio blocks,
cement and concrete containing granulated blast furnace slag, traffic cones and barricades,
playground surfaces and running tracks, hydraulic mulch, yard trimmings compost, office
recycling containers and office waste receptacles, plastic desktop accessories, toner
cartridges, binders and plastic trash bags.
5. Resources. Affirmative Procurement requirements should be included in future construction
agreements, so contractors will have to use recycled materials in the beginning phase of
building. EPA has developed lists of manufacturers and vendors of the items designated in
published Comprehensive Procurement Guidelines. These lists will be updated periodically
as new sources are identified and EPA becomes aware of changes in product availability. To
assist procuring agencies, the lists will be made available at no charge by calling EPA's
RCRA Hotline at (800) 424-9346. A publication produced by the Northeast Waste Disposal
Authority, EPA Region 9 Offices, and the General Services Administration (GSA) entitled,
Greening the Government: A Guide to Implementing Executive Order 12873 - Closing the
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
Circle, outlines acquisition planning and affirmative procurement; standards, specifications
and designation of items; agency goals and reporting requirements; and, awareness. The
publication also contains information about on-line resources and recycled products markets.
For more information, or to get on the mailing list, contact the Office of the Federal
Environmental Executive, Mail Code 1600, 401 M Street SW, Washington, DC 20460, (202)
260-1297.
The GSA publishes an Environmental Products Guide, which lists items available through its
Federal Supply Service. This Guide is updated periodically as new items become available.
Copies of the GSA Environmental Products Guide can be obtained by contacting GSA's
Centralized Mailing List Service in Fort Worth, Texas, or at (817) 334-5215. In addition to
the information provided by EPA and GSA, there are other publicly available sources of
information about products containing recovered materials. For example, the Official
Recycled Products Guide (RPG) was established in March 1989 to provide a broad range of
information on recycled content products. Listings include product, company name, address,
contact, telephone, fax, type of company (manufacturer or distributor) and minimum recycled
content. Pricing information is not included. The RPG is available on a subscription basis
from American Recycling Market, Inc., (800) 267-0707.
Purchasing products with recycled content "closes the recycling loop" by stimulating demand
for recovered materials. This helps to ensure that there will be a viable market for
recyclables collected from the facility, and other facilities and organizations. Facilities will
meet the requirements of Executive Order 12873 and Section 6002 of RCRA by establishing
an Affirmative Procurement Program.
6. Procedures. Establishment of an Affirmative Procurement Program should include the
following action plan:
• Obtain EPA's Comprehensive Procurement Guidelines from the RCRA hotline at (800)
424-9346.
• Distribute a list of Affirmative Procurement items to purchasing staff.
• Train purchasing staff on Affirmative Procurement.
• Identify items to be procured with various levels of recycled content.
• Develop and implement a tracking program to monitor compliance and progress.
7. References.
8. Rescission.
9. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-20
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Storm Water Pollution Prevention Plan
1. Purpose.
a. The Storm Water Pollution Prevention Plan (SWPPP) describes this Medical Center's
storm water management program and indicates procedures to eliminate or reduce
pollution related to storm water runoff. Storm water accumulated from the hospital's
buildings or processes are collected in catch basins/storm sewers that are connected to
on-site storm drain systems. These on-site systems are connected to municipal storm
drain systems that discharge into the nearby (insert waterway). The (insert waterway)
discharges into the (insert river or waterway discharge).
b. The Federal Clean Water Act (CWA) authorizes the U.S. Environmental Protection
Agency (EPA) to regulate discharges to surface waters of the United States. The EPA
promulgated the National Pollution Discharge Elimination System (NPDES) Regulations,
40 CFR Part 122, to regulate surface water discharges.
c. This policy delineates the procedural guidelines for implementation of this Medical
Center's Storm Water Pollution Prevention Plan, identifying the specific measures
required for the elimination and reduction of pollution associated with storm water
discharge.
d. Definition: "Storm water" means any precipitation or discharge that comes into contact
with the facility and its surrounding grounds, equipment and vehicles, and drains from
the site, flowing into any nearby water body.
2. Policy. It is the policy at this Medical Center to maintain full compliance with the EPA
requirements specifically associated with the NPDES permitting regulations.
3. Procedures.
a. This Medical Center is comprised of the following industries or programs that may
impact the storm water requirements. Those industries include:
• 000 total acres.
• 000 square feet of parking space.
• (Insert Number) Health Care Buildings.
• (Insert Number) Business Occupancy Buildings.
• (Insert Number) Domiciliary.
• Aquatic Therapy.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
• Water Cooled Condensing Units.
• Heating Plant/Boiler Blow-Downs.
• Laundry Discharge.
• Paint Shop/Spray Paint Booth.
• Grounds Shops (Application of herbicides, snow removal chemicals, pesticides,
fertilizers, weed control).
• Maintenance Shops.
• Horticultural Therapy (Application of herbicides, pesticides, fertilizers, weed
control).
b. All storm water associated with industrial activity, currently discharges to the (insert
discharge route) and then to the (insert waterway) via the municipal storm drain system.
All roof leaders and catch basins lead to an on-site storm drain system connected to the
municipal storm drain system. Facilities Management will maintain specific site plan
information that identifies the following:
1) Site latitude and longitude coordinates.
2) The location of each storm water collection catch basin.
3) The location of each storm water drain access.
4) The location of existing structural control measures that reduce pollutants in storm
water runoff.
5) The location of receiving surface water bodies (the storm water collection system).
6) Locations where materials with potential to pollute are exposed to precipitation.
7) Locations where significant spills have occurred.
8) Locations where significant operations are exposed to precipitation or discharge
including:
• Parking areas.
• Vehicle fueling areas.
• Vehicle and equipment maintenance and/or cleaning areas.
• Material loading/unloading areas.
• Locations used for the storage of wastes and routes from the point of generation to
the storage areas.
• Storage tanks.
• Storage areas (including damaged vehicle storage areas and recycling areas).
• Direction of flow of storm water runoff.
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Sample GEMS Documents Department of Veterans Affairs
c. The following routine operations and activities have been identified as potential release
of contaminates to storm water runoff. These include:
1) The delivery of fuel to above/below ground storage tanks.
2) The delivery of heating oil to above/below ground storage tanks.
3) The removal of used oil from storage tanks.
4) The practice of parking service trucks and vehicles in open areas of a parking lot
where leaking fuels and oil are not contained.
5) The procedure of transferring bulk hazardous materials and hazardous wastes.
6) Cooling tower discharge to roof drains.
7) Draining or discharge of the therapeutic aquatic pool to the storm sewer.
d. The following routine operations and activities have been identified as potential to pollute
storm water run-off:
1) Parking.
2) Tank Truck Unloading.
3) Tank truck delivery of fuel oil poses the risk of a spill and also of operational release
of oil. Each tank, its containment conditions and location, is specified on the Oil Spill
Prevention Control and Countermeasure Plan.
4) Used Oil Tank Unloading.
5) Good handling practices are followed during tank emptying transfers.
6) Landscaping (Maintenance of Turf and Trees).
7) Outside Storage of Vehicles.
8) This Medical Center's vehicles (including transportation buses, service vehicles and
employee vehicles) outside. The potential exists for oil or hazardous materials,
leaking from the vehicles, to come into contact with storm water.
9) Leaks/Spills of Hazardous Materials or regulated medical waste during Transfer and
Storage.
10) The majority of hazardous and biological materials are stored inside facilities. All
containers storing hazardous materials located in rooms with floor drains or near
exterior doorways should be provided with secondary containment to minimize the
migration of leaks and spills into the sanitary sewer or storm water.
e. Compliance Inspections. An annual inspection should be performed to determine if
maintenance schedules and checklists have been performed. This inspection should be
done during a rainfall, if possible. The inspections shall include:
1) Material handling areas and other areas noted as potential sources of pollution, to see
evidence of or potential for, pollutants entering the storm water drain system. Storm
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
water run-off conveyances, erosion control measures and other pollution prevention
measures detailed in this plan, to ensure they are adequate, properly implemented,
and operating correctly.
2) Equipment needed to implement the plan (e.g. spill response equipment).
3) The results of the inspection and action taken to correct any deficiencies should be
filed and reviewed. This form should include:
• Who made the inspection.
• When the inspection was made.
• Observations.
• Corrective actions required.
• Corrective actions taken.
• Date completed.
f. Storm water Maintenance. A visual examination of the storm water discharge should be
conducted and documented quarterly. Examinations should be conducted during normal
duty hours in the daylight hours, during a rainfall or snowmelt runoff event in each of the
following periods:
• October through December
• January through March
• April through June
• July through September
g. Visual examinations will be made of water samples collected within the first 30 minutes
of when the runoff or snowmelt begins discharging. The examinations must be
documented and maintained on-site in the Storm Water Pollution Prevention Plan. The
reports will include:
1) Observations of color, odor, clarity, floating solids, settled solids, suspended solids,
foam, oil sheen and other obvious indicators of storm water pollution.
2) Probable sources of any observed storm water pollution.
3) Examination date and time.
4) Examination personnel.
5) The nature of the discharge, rainfall or snowmelt.
h. In our continuing efforts to maintain compliance with the regulations set forth by the
Storm water Pollution Prevention Plan, the following areas shall be incorporated for the
prevention or reduction of storm water pollution:
1) Good Housekeeping.
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Sample GEMS Documents Department of Veterans Affairs
2) Solid Waste Container Management.
3) Pesticide Application Methods.
4) Preventative Maintenance of Oil Water Separators.
5) Spill Prevention and Response Procedures incorporated into each utility management
plan.
6) Inspections of oil containing devices.
7) Employee Training.
8) Sediment and Erosion Control.
4. Responsibilities.
a. Medical Center Director: The Medical Center Director has overall responsibility for
compliance with the storm water regulations and the implementation of this policy.
b. Facilities Management:
1) Maintaining drawings of the locations of catch basins and storm sewer routes.
2) Maintaining historical data related to previous spills.
c. Safety Management Office: Responsible for the sampling of storm water and performing
analytical analysis to determine compliance with all applicable regulations.
5. References. 60 Federal Register 50804, Final National Pollutant Discharge Elimination
System Storm Water Multi-Sector General Permit for Industrial Activities; Notice,
September 29, 1995.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-21
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Underground Storage Tanks (USTs)
1. Purpose. To prevent, detect and correct leaks and spills due to underground storage of
petroleum based products as required by the U.S. Environmental Protection Agency (EPA)
and (insert State) Department of Natural Resources.
2. Policy. This Medical Center will adhere to all the requirements established in this policy.
Accomplishment and documentation of inspections and tests are essential in keeping our
environment free of contamination.
3. Procedures.
a. Registration. All underground storage tanks that contain petroleum-based products
(diesel fuel) are registered with the State Department of Natural Resources (DNR),
Division of Water Pollution Control.
b. Tightness Testing. All our facility's petroleum based underground storage tanks will be
tested for tightness as follows:
1) Upon request from the State DNR or other governmental agencies.
2) Initially, when the tank is ten years old for tanks containing more than 1,100 gallons,
and every five years thereafter until permanently closed.
This will be initiated in (year) and will again need to be done in (list years).
c. Leaks. All detected leaks will be handled in the following manner:
1) All underground storage tanks will, at a minimum, be monitored monthly by the use
of a dipstick and results entered in on a permanent log. Recorded usage from meters
(where installed) will also be entered, and running totals will be maintained.
2) In the event that a suspected shortage of fuel is noted, daily monitoring will be
required until such time that it is determined the recorded shortage is due to either use
or loss of fuel. At any time there is a suspected shortage, the Chief Engineer will be
notified by the Maintenance and Repair Foreman and/or the Utility System Foreman.
3) In the event that a shortage is determined to be an underground loss, immediate action
will be taken to transfer the fuel to other tanks or have the tank pumped out into tank
trucks. Arrangements for tankers will be the responsibility of the Chief Engineer. If
it is suspected or there is any indication that fuel is getting into the sewer system, the
local (insert city or municipality) Fire Department will be notified immediately by the
supervisor on site.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
4) The Safety and Occupational Health Specialist will notify the appropriate agencies,
i.e., the local Department of Natural Resources at and the
(insert State) Department of Natural Resources, Division of Water Pollution Control,
at .
5) Following the removal of fuel from a leaking tank, testing of the tank and associated
piping will be scheduled. This will be accomplished by pressure testing and/or soil
sampling by qualified personnel under contract. Following review of the test results,
repair or removal of the defective tank or piping will be scheduled.
d. Spills. The following action will be taken in the event of a spill over 25 gallons:
1) Take immediate action to stop and contain the spill.
2) Notify the local DNR at .
3) Remove any explosive vapors and all fire hazards in the immediate area.
4) Recover the spilled petroleum.
5) Report the progress to the local and state DNR no later than 20 days after the spill has
occurred.
6) Develop and submit a Corrective Action Plan within 45 days of the spill of more than
25 gallons. The plan must identify what damage was done to the environment and if
ground water was contaminated (additional studies may be required).
e. Closure. The following procedures will apply when storage tanks are closed for more
than twelve months:
1) Notify the state and local DNR 30 days before closure.
2) Determine if leaks have damaged the surrounding environment by means of a
tightness test.
3) If no problems are found, the tank can either be removed or abandoned in the ground.
In both cases, the tank must be emptied thoroughly. If abandoned, the tank must be
filled with sand.
4. Responsibilities.
a. The Safety and Occupational Health Specialist, as the Environmental Compliance
Officer, will be responsible for implementing this policy in conjunction with the Chief,
Engineering Service. He/She will also make the proper notifications as outlined in the
above paragraphs.
b. The Chief, Engineering Service will be responsible for providing the necessary equipment
and manpower needed for tank drainage and recovery of spill products, etc., when
possible.
5. References. U.S. EPA Pamphlet, "Musts for USTs;" VA Circular 00-91-5; "Underground
Storage Tanks," U.S. EPA; and 40 CFR, Part 280 and 281.
6. Rescission. None.
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Sample GEMS Documents Department of Veterans Affairs
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-22
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Date) (Location)
Waste Characterization Sampling and Analytical Work Plan
1. Purpose. All residuals from the Wastewater Treatment Plant or special wastes that are
stored, processed, beneficially used, used agronomically or disposed of in (insert State) must
be characterized in accordance with Department of Environmental Regulations, Chapter
405.6.B.
2. Policy. This Medical Center is responsible for developing a solid waste characterization
program to beneficially use sludge from the Wastewater Treatment Plant; however, this
program must receive approval from the Department of Environmental Protection (DEP)
prior to handling of wastes. This program will determine the chemical and physical
characteristics of the wastes and monitor the characteristics on a regular basis.
3. Responsibilities.
a. The Chief of Facilities Management Service is responsible for ensuring that the program
elements are implemented.
b. The Safety Manager/Industrial Hygienist will provide consultation and oversight for the
implementation of the Waste Characterization Sampling and Analytical Work Plan.
4. Procedures.
a. All sludge from the Wastewater Treatment Plant will be characterized in accordance with
DEP rules. Any statistical analysis performed will be done in accordance with U.S.
Environmental Protection Agency (EPA) SW-846, Test Methods for Evaluating Solid
Waste, Fourth Edition, Volume II, Chapter 9. If any tests fail the Toxicity Characteristic
Leachate Procedure analysis, the biosolids will be handled as a Resource Conservation
and Recovery Act (RCRA) waste.
b. Only laboratories certified for the specific test by the Health and Environmental Testing
Laboratory, Department of Human Services, will analyze sludge samples.
c. Chapter 405 details testing requirements for sewage sludge for land application.
Analyses are dependent on factors such as volume of sludge produced, concentrations of
pollutants and the type of wastes the plant processes.
d. Soil Nutrient Analysis: Soil nutrient analysis is required for sludge application areas.
Methods for nutrient analysis have been developed for (insert State) in order to best
evaluate soils for this region. Analytical methods for soil nutrients are listed in Table 1.
Laboratories using these methods should participate in the National Proficiency Testing
Program. Interpretive methods used for the initial solid nutrient analysis are equivalent to
those used at the (State) Soil Testing Service.
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Green Environmental Management Systems (GEMS) Guidebooks
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Table 1
Soil Nutrient Analysis
Parameter
Ph, soil pH
Lime Index
Available
phosphorous
Available potassium
Available calcium
Available
magnesium
Cation exchange
capacity (C.E.C)
Percent (C.E.C)
with potassium
Percent (C.E.C)
with calcium
Percent (C.E.C)
with magnesium
Acidity
% Organic matter
Optimum Range
5.5-6.5 (Forestry)
6.5-7.0 (Grass)
No optimum range
9-13 forest
10-40 grass
See % saturation
levels
>5
2.1-3.0 F
2.8-4.0 G
60-80
10-25
<10
5-8
Units
Lbs/acre
Lbs/acre
Lbs/acre
Lbs/acre
Me/100 gm
%
%
%
%
%
Method
Ref.
Selection Rationale
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
Baseline nutrient
1) Initial Soils Analysis: The parameters listed in Table 1 are analyzed prior to using
biosolids on the site.
2) On-going analysis: A minimum of one composite topsoil sample per utilization area
is collected at the site prior to utilization each year that a residual will be land applied.
Results of the analyses must be received and interpreted by the treatment plant and
safety office prior to utilization. These results must be used as a factor in determining
the amount of residual to be land applied.
e. Sludge Analysis: Recommendations and requirements for the semiannual residual
analysis are listed in Table 2. The land spreading parameters are found in (insert State)
regulations. The parameters to be analyzed, their detection limit, units of measure,
method number, reference and selection rationale are found in Table 2:
Table 2
Biosolids Analysis
Parameter
Arsenic, total
Cadmium, total
Calcium, total
Chromium, total
Copper, total
Iron, total
Lead, total
Magnesium, total
Mercury, total
Molybdenum, total
Detection
Limit
Minimum
detection
levels are
attached
Units
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Method
7062/3050B
7130/3050B
7140/3050B
7190/3050B
7210/3050B
7380/3050B
7420/3050B
7450/3050B
7471 A
7481/3050B
Ref.
SW8
SW8
SW8
SW8
SW8
SW8
SW8
SW8
SW8
SW8
Selection Rationale
Sewage sludge metal
Sewage sludge metal
Baseline Nutrient
Sewage sludge metal
Sewage sludge metal
Baseline Nutrient
Sewage sludge metal
Baseline Nutrient
Total inorganic
compound
Sewage sludge metal
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Sample GEMS Documents
Department of Veterans Affairs
Table 2 (Continued)
Biosolids Analysis
Parameter
Nickel, total
Potassium, total
Selenium, total
Silver, total
Sodium, total
Zinc, total
CaCO3 Equivalence
Chloride
PH
Phosphorous
Total Solids
TVS
Ammonia-N(NH4)
Nitrate/Nitrite-N
(NO3 & NO2)
Total Carbon
TKN
Detection
Limit
Units
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
Mg/kg
%
Mg/kg
su
Mg/kg
%
%
Mg/kg
Mg/kg
%
Mg/kg
Method
7520/3050B
7610/3050B
7741A/3050B
7760A/3050B
7770/3050B
7950/3050B
1.006
9056
9040B
4500P
CLP4F
160.4
4500NH3B/E
9056/4500N)2B
Calculation
4500NorgB/NH
3E
Ref.
SW8
SW8
SW8
SW8
SW8
SW8
ADA
SW8
SW8
STM
CLP
EPA
STM
SW8
STM
Selection Rationale
Sewage sludge metal
Baseline Nutrient
Sewage sludge metal
Precious metal recovery
Baseline Nutrient
Sewage sludge metal
Calcium Carbonate
Equivalent
Baseline Nutrient
Baseline Nutrient
Baseline Nutrient
Baseline Nutrient
Baseline Nutrient
Nitrogen
Nitrogen
Baseline Nutrient
Nitrogen
f. The frequency of sampling is outlined in Chapter 405 and in Table 3:
Table 3
Tons of Sludge Produced
Sampling and Analysis
Frequency
Analysis Results-Reports Due
on the 15th of the Month
Biosolids
<200 dry tons
Twice per year
July, January
Soil Analysis
Before utilization
* April or May
* Results are not required to be reported, but must be kept on file and produce if requested by DEP.
g. Near the end of each land spreading season, a composite soil sample from the same site
each year is collected in November and analyzed at the XXXX for the following heavy
metals and C.E.C. The results of this analysis are sent to the DEP upon receipt.
Table 4
Parameter
Ag
Cd
Cr
Cu
Hg
Ni
Pb
Zn
C.E.C.
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h. In determining whether a sample should be collected using a single grab or composite
sampling method, the following factors may be evaluated:
1) How well the sewage sludge is mixed.
2) Whether the sample is collected from a single batch of sewage sludge or from a
stockpile made up of several batches.
3) Whether the composition and concentration of the sewage sludge varies over time.
The samples will be collected as shown in Table 5.
i. The procedures for decontamination of sampling equipment prior to sampling and
between the collection of successive samples are outlined in Table 5 for the sludge and
residuals:
Table 5
Sludge Residual Sampling
Parameter
Arsenic, total
Cadmium, total
Calcium, total
Chromium, total
Copper, total
Iron, total
Lead, total
Magnesium, total
Mercury, total
Molybdenum,
total
Nickel, total
Potassium, total
Selenium, total
Silver, total
Sodium, total
Zinc, total
CaCO3
Equivalence
Chloride
PH
Phosphorous
Total Solids
TVS
Ammonia-
N(NH4)
Nitrate/Nitrite-N
(NO3 & NO2)
Total Caibon
TKN
Sample Point
Sludge
containment
vessel is well
mixed, and
sample taken
from 1-2 feet
from the top,
middle of the
tank
Sample
Size (ml)
600
500
500
500
500
500
500
500
400
500
500
500
500
500
500
500
500
500
500
500
500
500
500
500
500
500
Grab/
composite
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
Decon
procedure
Only new PVC
sample
containers are
use
Documentation
Chain of custody
and log book
And in Table 6 for soils:
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Sample GEMS Documents
Department of Veterans Affairs
Table 6
Soils Analysis
Ph
Available
phosphorous
Available
potassium
Available
calcium
Available
magnesium
Cation
exchange
capacity
(C.E.C)
Percent
(C.E.C) with
potassium
Percent
(C.E.C) with
calcium
Percent
(C.E.C) with
magnesium
Percent
(C.E.C) with
sodium
% Organic
matter
15 separate soil
samples are
taken from each
site and made
into one
composite
sample
Clean
cardboard
boxes
Chain of
custody and
logbook
j. The sample collection containers, preservation methods, and hold times are found in
Table 7: Soil sample containers are 25 cubic inch cardboard boxes supplied by the state
soil testing service or the Soils Cooperative Extension.
Table 7
Parameter
ammonia
arsenic
cadmium
calcium
Container
plastic or glass
plastic or glass
plastic or glass
plastic or glass
Preservation
Cool 4°C
H2SO4 pH <2 [aqueous]
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
Hold Time
28 days
6 months
6 months
6 months
calcium carbonate calculation based
equivalents
chloride
chromium
copper
iron
lead
magnesium
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
none
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
28 days
6 months
6 months
6 months
6 months
6 months
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Green Environmental Management Systems (GEMS) Guidebooks
Sample GEMS Documents
Table 7 (Continued)
Parameter
mercury
molybdenum
nickel
nitrate
nitrite
percent dry solids
PH
salt toxicity
selenium
silver
sodium
TCLP (Ml suite)
total carbon
total kjeldahl nitrogen
total phosphorus
total potassium
total volatile solids
zinc
Container
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
Plastic or glass
plastic or glass
glass, PFTE-lined cap
amber glass with TFE
lined caps
plastic or glass
plastic or glass
plastic or glass
plastic or glass
plastic or glass
Preservation
Cool 4°C
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
Cool 4°C
H2SO4 pH <2 [aqueous]
Cool 4°C
H2SO4 pH <2 [aqueous]
Cool 4°C
none
none
pH<2 HNO3 [aqueous]
PH < 2 HNO3 (aqueous)
pH<2 HNO3 [aqueous]
Cool 4°C (for VOC analysis)
Cool 4°C
H2SO4 pH <2 [aqueous]
Cool 4°C
pH<2 HNO3 [aqueous]
pH<2 HNO3 [aqueous]
Cool 4°C
pH<2 HNO3 [aqueous]
Hold Time
28 days
6 months
6 months
28 days
28 days
7 days
24 hours [liquids]
6 months
6 months
6 months
6 months
14 days (for VOC
analysis)
28 days
6 months
6 months
7 days
6 months
To obtain a representative sample of sewage sludge, the sample must be taken from the
correct locations and represent the entire amount of waste sludge undergoing aerobic
digestion and the lime stabilized batch process. In some situations, the sample point
location may have a dramatic effect on the monitoring results. It is important that
samples be collected from a location representative of the final sewage sludge that will be
land applied. Because the pollutant limits pertain to the quality of the final sewage
sludge applied to the land, sludge must be collected after lime stabilization. Samples
should be taken from the same point and in the same manner each time a sample
collection or monitoring is performed. The sampling location should be safe and
accessible.
Table 8
SLUDGE SAMPLING POINTS
Sludge Type
Aerobically Digested
Sampling Point
Sample from taps on discharge lines from pumps. If batch digestion is used,
sample directly from the digester.
Cautions are in order concerning this practice:
If aerated during sampling, air entrains in the sample.
Volatile organic compounds may purge with escaping air.
When aeration is shut off, solids separate rapidly in well-digested sludge.
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Sample GEMS Documents Department of Veterans Affairs
1. The sample handling, packaging, and transportation protocols must include the following
factors:
1) Sample containers must be packaged to reduce the risk of leakage.
2) They should be held upright and cushioned from shock.
3) Sufficient insulation/refrigerant should be added to maintain 4° C temperature for
shipment.
4) Unpreserved samples without heavy contamination are not regulated under DOT.
These samples may be shipped packaged as above using a commercial carrier.
Transit time should be held to <24 hours.
5) When environmental samples are preserved as recommended, they may be shipped as
non-hazardous samples.
m. Adequate documentation of sludge sampling activities is important for general program
quality assurance/quality control, and required by most monitoring regulations. Proper
sampling activity documentation includes proper sample labeling, chain-of-custody
procedures and a logbook of sampling activities. The number of people in the chain of
custody should be kept to a minimum to limit the possibility of contamination and to
increase accountability.
1) Sample Labeling: Labels and ink should be waterproof. Fix labels to containers with
clear waterproof tape. Tape completely around container and over label to prevent
accidental label loss or ink smear during shipping and handling. Sample labels
should include the following information at a minimum:
• Sample Number (specific to sampling event, i.e., location)
• Type of sample, i.e., grab, 24-hour composite, etc.
• Collector
• Additional information helpful for sample identification includes:
• Sampling Organization Name
• Facility Name (being sampled)
• Bottle Number (specific to container)
• Date, Time (24 hour time is preferable, i.e., 1600 vs. 4:00 p.m.)
• Sample Location
• Preservatives
• Analytical Parameter(s)
2) Chain-of-Custody: Each sample shipment requires a chain-of-custody record. A
chain-of-custody document provides a record of sample transfer from person to
person. This document helps protect the integrity of the sample by ensuring that only
authorized persons have custody of the sample. In addition, the chain-of-custody
procedure ensures an enforceable record of sample transfer, which is necessary, if the
sample results are to be used in a judicial proceeding alleging violations of sludge
standards. This document shall record each sample's collection and handling history
from time of collection until analysis, as well as the information listed on each sample
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Green Environmental Management Systems (GEMS) Guidebooks
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bottle. All personnel handling the sample shall sign, date and note the time of day on
the chain-of-custody document.
3) Sampling Log Book: All sampling activities shall be documented in a logbook. This
book duplicates all information recommended for the chain-of-custody document
above, and notes all relevant observations regarding sample stream conditions.
n. A quality assurance (QA) program consisting of the following elements will be initiated
at the wastewater treatment plant:
1) Proper collection procedures, equipment, preservation methods and chain of custody
procedures to ensure representative samples.
2) Proper sample preparation procedures, instruments, equipment and methodologies
used for the analysis of samples.
3) Proper procedures and schedules for calibration and maintenance of equipment and
instruments associated with the collection and analysis of samples.
4) Proper record keeping to produce accurate and complete records and reports, when
required.
5) Quality control for sample collection includes the use of spiked and split samples, use
of specific sampling protocol, proper decontamination of sampling equipment, and
the choice of appropriate analytical methods and procedures. Laboratory quality
assurance procedures should be available from the laboratory used for analysis.
o. All data reduction, validation and reporting methods including methods of statistical
interpretation of analytical results will be submitted to the Safety Office on a semiannual
basis. This will include:
1) Any statistical review of analytical results should be described, and all formulas
given.
2) Computer spreadsheets used to manipulate data received from a laboratory and a print
out of the spreadsheet showing calculation formulas.
Percentages of Organic Nitrogen Mineralized After
Sewage Sludge of Various Types Are Land Applied
Table 9
Years After
Sludge
Application
Type of Sewage Sludge
Primary and
Waste
Activated
0-1 40
1-2 20
2-3 10
3-4 5
Aerobically
Digested
30
15
8
4
Anaerobically
Digested
20
10
5
3
Composted
10
5
3
3
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Sample GEMS Documents Department of Veterans Affairs
5. References.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-23
SAMPLE
VA Medical Center Medical Center Memorandum ()
(Location) (Date)
Waste Minimization Program
1. Purpose.
a. The Department of Veterans Affairs Medical Center, by virtue of its diverse medical
activities and operational support functions, requires the use of materials that may pose a
chemical or biological hazard to employees. Use of these materials produce wastes that
still retain these hazards.
b. The Department of Veterans Affairs Medical Center has made a commitment to provide a
safe and healthful environment for its patients, visitors, staff and surrounding community.
This program is intended to be used for guidance in the management of hazardous and
solid wastes.
2. Policy. This Medical Center will adhere to proper management of waste materials from the
time of generation until such time as waste materials are treated or disposed of.
3. Responsibilities.
a. Industrial Hygienist shall be responsible for managing the hazardous waste program.
b. Environmental Management Service shall be responsible for managing the solid waste
program.
4. Objectives. This Medical Center is committed to the establishment of a safe and effective
waste minimization program. To achieve this goal, this program strives to meet the
following objectives:
a. Protect the health and well being of the patients, staff, visitors and the community
environment.
b. Develop a system that addresses the identification of hazardous waste and materials from
the point of entry into the facility to the point of final disposal.
c. Provide safe handling, storage, treatment and disposal of hazardous infectious and
chemical wastes generated at this facility.
d. Dispose of hazardous waste in an environmentally sound, responsible and cost-effective
manner that complies with federal, state and local requirements.
e. Comply with federal, state and local regulatory standards, guidelines and requirements.
f. Enhance coordination and communication among services/divisions and various
committees of the VA Medical Center.
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Green Environmental Management Systems (GEMS) Guidebook
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Procedures. Individual Services are strongly encouraged to consider ways of reducing the
volume of chemical waste generated through the redesign of procedures and recycling of
materials (see Table 1 for summary of these activities). The Industrial Hygienist will
administer a Waste Exchange Program. The program works on the theory that "one man's
trash is another man's treasure." Recycling or reusing chemicals instead of disposal will save
the Medical Center both the cost of disposal and the cost of new raw material. The Waste
Exchange Program contains the following elements:
a. A list of waste chemicals in the hazardous chemical waste storage area will be sent to all
Services approximately one week before the scheduled quarterly pickup.
b. Any Service or Laboratory that can make use of the waste chemical will be given that
chemical (at no charge).
c. Forming a liaison with state or regional Waste Exchange Programs that will identify
potential users or recyclers of the Medical Center's hazardous chemical waste will reduce
the quantity of these wastes scheduled for disposal by a Hazardous Chemical Waste
contractor.
Table 1
Examples of Waste Minimization Activities
Method
Acquisition
Process
Recycling
Waste
Exchange
Example
Require purchases to be in small quantities; constraints.
Substitute non-hazardous chemicals for hazardous ones.
Commercial recycling firms for waste mercury, solvents, batteries,
etc.
Identification of surplus or unwanted laboratory chemicals and
relocating them to laboratories that can use them.
6. References.
1. Rescission.
8. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-3
SAMPLE
VA Medical Center Meical Center Memorandum ( )
(Location) (Date)
Air Quality Management
1. Purpose. This memorandum establishes VA policy and responsibilities for compliance with
air quality and emissions requirements from stationary and mobile sources consistent with
the Clean Air Act (CAA) and local and state requirements.
2. Background. The CAA established National Ambient Air Quality Standards (NAAQS) to
protect the health and general welfare of the public. Each state must achieve these standards
and develop State Implementation Plans (SIP) that outline plans to achieve and maintain the
NAAQS for the Environmental Protection Agency (EPA). Air emission sources are required
to comply with the standards and other measures set forth in the individual SIPs. To improve
air quality nationwide, the CAA Amendments of 1990 mandated stringent pollution control
and prevention measures described within this document.
3. Federal Statutes.
a. CAA 0/1970, as Amended (42 USC 7401 et seq.)
1) SIPs implement pollution control programs such as New Source Performance
Standards (NSPS), New Source Review (NSR), and National Emission Standards for
Hazardous Air Pollutants (NESHAP) at the state and local levels. States may require
pollution control and prevention measures that are more stringent than those
mandated by the EPA, but they may not allow measures that are less stringent.
Federal agencies must comply with federal, state, and local air pollution control
regulations.
2) The 1990 Amendments to the CAA introduced sweeping changes to the legislation,
including:
• Reclassification of non-attainment areas.
• Regulation of mobile sources.
• Regulation of listed Hazardous Air Pollutants (HAP).
• Regulation of sulfur dioxide (SO2 ) and oxides of nitrogen (NOX) for acid
deposition control.
• Implementation of an extensive operating permit program.
• Strengthening EPA and state agency authority, allowing better enforcement of the
CAA provisions.
3) Section 118(a) of the CAA generally waives the Federal Government's sovereign
immunity with respect to federal, state and local air pollution control laws and
regulations. As a result of this waiver, VA activities are fully subject to the
requirements of federal, state and local air pollution control laws, including
permitting requirements, and must obey compliance orders issued through
administrative or judicial processes.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
b. EPCRA 0/1986 (42 USC 11001 et seq.). This Act, also known as Title III of the
Superfund Amendments and Reauthorization Act (SARA), in addition to the CAA,
addresses the release of hazardous substances into the environment and also requires the
release reporting of certain extremely hazardous substances to the environment. Certain
chemicals subject to the HAPs and risk management provisions of CAA Section 112 are
also subject to Title III.
c. The Alternative Motor Fuels Act (AMFA) of1988, as Amended (Public Law 100-494).
Congress passed AMFA in 1988 to achieve long-term energy security and to improve air
quality. Under AMFA, a portion of the new vehicles, which the federal Government
acquires each year, must be alternative fuel vehicles (AFV) in order to encourage the
production of these vehicles for consumer use.
d. The Energy Policy Act (EPACT) of 1992 (Public Law 102-486). EPACT seeks to
enhance the Nation's long-term energy security by reducing dependency on imported oil
and by improving energy efficiency. EPACT establishes a Federal leadership strategy
that encourages automobile manufacturers and fuel suppliers to expand the commercial
availability of alternative fuels and vehicles. Under EPACT, federal agencies must
acquire increasing numbers of AFVs.
e. Toxic Substances Control Act (TSCA) of 1976 (15 USC 2601 et seq.). In TSCA, the
section on Indoor Radon Abatement requires federal departments to conduct a study of
radon levels in federal buildings and to provide results of the study to the EPA. The EPA
has submitted to Congress a consolidated report on radon levels in federal buildings.
4. Requirements.
a. All VA Medical Centers must have certification that their vehicles have passed local
emission testing requirements.
b. Oil and gas-fired heating equipment shall be tuned up at the beginning of each heating
season.
c. Dust control methods shall be utilized at all cemeteries where fugitive dust is created.
This can be in the form of watering, soil amendments, covers or other suitable methods.
d. All vehicles and grounds maintenance must be tuned in accordance with manufacturer
recommendations.
e. All gasoline dispensed must be in conformance with local regulations.
5. References.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-4
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Construction Waste Management
1. Purpose. To outline the policy and procedures to ensure effective management/disposal of
any waste generated through approved construction projects at this Medical Center.
2. Policy. It is the policy of this Medical Center that construction projects shall generate the
least amount of waste possible.
3. Responsibilities. The Subcontractor shall employ processes that ensure the generation of as
little waste as possible and shall avoid the generation of waste due to the following:
a. Over-packaging.
b. Error.
c. Poor planning, layout.
d. Over ordering.
e. Breakage
f. Mishandling.
g. Contamination.
h. Damage from weather.
4. Procedures.
a. Of the inevitable waste that is generated, as many of the waste materials as economically
feasible shall be reused, salvaged or recycled.
b. Waste disposal in landfills shall be minimized to the greatest extent possible.
1) Waste Diversion Goals.
a) New Construction: Minimum of total project waste shall be diverted from
landfill.
b) Demolition, Major Remodeling: Minimum of total project waste shall be
diverted from landfill.
c) Interior Remodeling: Minimum of total project waste shall be diverted from
landfill.
2) The following waste categories, at a minimum, shall be diverted from landfill:
a) Green waste (biodegradable landscaping materials).
b) Soil.
c) Inerts (concrete, asphalt, masonry).
d) Clean dimensional wood, palette wood.
e) Engineered wood products: plywood, particle board, I-joists, etc.
f) Cardboard, paper, packaging.
g) Asphalt roofing materials.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
h) Insulation.
i) Gypsum board.
j) Carpet and pad.
k) Paint.
1) Plastics: ABS, PVC.
m) Beverage containers.
5. Description of Work.
a. Includes:
• Waste Management Plan development and implementation.
• Meetings to discuss goals, issues and training for the Waste Management Plan.
• Techniques to minimize waste generation.
• Sorting and separation of waste materials.
• Reuse of salvaged materials on site.
• Salvage of existing materials and items for reuse or resale.
• Recycling of materials that cannot be reused or sold.
• Record keeping of receipts and records of salvaged, recycled or land filled materials.
b. Related Elements:
• Alternates.
• Construction Waste Management.
• Site Demolition.
• Site Clearing.
• Slope Protect!on/Erosion Control.
• Asphalt Concrete.
• Crushed Stone Paving.
• Portland Cement Concrete Paving.
• Valve Boxes.
• Storm Sewers.
• Chain Link Fences and Gates.
• Walk, Road and Parking Appurtenances.
• Miscellaneous Landscaping Materials.
• Concrete, Concrete Formwork, and Concrete Reinforcement.
• Cast-in-Place Concrete.
• Unit Masonry.
• Structural Steel.
• Steel Roof Deck/Steel Floor Deck.
• Cold Formed Metal Framing.
• Metal Fabrications.
• Rough and Finish Carpentry.
• Engineered Structural Wood.
• Plastic Lumber.
• Building Insulation.
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Sample GEMS Documents Department of Veterans Affairs
• Modified Bitumen Roofing.
• Metal Doors.
• Wood and Plastic Doors and Frames.
• Metal Support Systems.
• Gypsum Wallboard.
• Acoustical Treatment.
• Resilient Flooring.
• Tile and Carpet.
• Painting.
• Toilet Compartments.
• Louvers and Vents.
• Signage and Graphics.
• Ductwork and Ductwork Accessories
6. Definitions.
a. Class III Landfill: A landfill that accepts non-hazardous resources such as household,
commercial and industrial waste resulting from construction, remodeling, repair and
demolition operations.
b. Clean: Untreated and unpainted; uncontaminated with adhesives, oils, solvents, mastics
and like products.
c. Construction and Demolition Waste: Includes all non-hazardous resources resulting from
construction, remodeling, alterations, repair and demolition operations.
d. Dismantle: The process of parting out a building in such a way as to preserve the
usefulness of its materials and components.
e. Disposal: Acceptance of solid wastes at a legally operating facility for the purpose of
land filling (includes Class III landfills and inert fills).
f. Inert Backfill Site: A location, other than inert fill or other disposal facility, to which
inert materials are taken for the purpose of filling an excavation, shoring or other soil
engineering operation.
g. Inert Fill: A facility that can legally accept inert waste, such as asphalt and concrete
exclusively for the purpose of disposal.
h. Inert Solids/Inert Waste: Non-liquid solid resources including, but not limited to, soil
and concrete that does not contain hazardous waste or soluble pollutants at concentrations
in excess of water-quality objectives established by a regional water board, and does not
contain significant quantities of decomposable solid resources.
i. Mixed Debris: Loads that include commingled recyclable and non-recyclable materials
generated at the construction site.
j. Mixed Debris Recycling Facility: A solid resource processing facility that accepts loads
of mixed construction and demolition debris for the purpose of recovering re-usable and
recyclable materials and disposing non-recyclable materials.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
k. Permitted Waste Hauler: A company that holds a valid permit to collect and transport
solid wastes from individuals or businesses for the purpose of recycling or disposal.
1. Recycling: The process of sorting, cleansing, treating, and reconstituting materials for the
purpose of using the altered form in the manufacture of a new product. Recycling does
not include burning, incinerating or thermally destroying solid waste.
1) On-site Recycling. Materials that are sorted and processed on site for use in an altered
state in the work, i.e. concrete crushed for use as a sub-base in paving.
2) Off-site Recycling. Materials hauled to a location and used in an altered form in the
manufacture of new products.
m. Recycling Facility: An operation that can legally accept materials for the purpose of
processing the materials into an altered form for the manufacture of new products.
Depending on the types of materials accepted and operating procedures, a recycling
facility may or may not be required to have a solid waste facilities permit or be regulated
by the local enforcement agency.
n. Re-Use: Materials that are recovered for use in the same form, on-site or off-site.
o. Return: To give back reusable items or unused products to vendors for credit.
p. Salvage: To remove waste materials from the site for resale or re-use by a third party.
q. Source-Separated Materials: Materials that are sorted by type at the site for the purpose
of reuse and recycling.
r. Solid Waste: Materials that have been designated as non-recyclable and are discarded for
the purposes of disposal.
s. Transfer Station: A facility that can legally accept solid waste for the purpose of
temporarily storing the materials for re-loading onto other trucks and transporting them to
a landfill for disposal, or recovering some materials for re-use or recycling.
7. References.
a. Guides. No preference is given to the recycles listed below; they are listed for the
convenience of the contractor.
• Dirt/clean fill.
• Green/landscaping waste.
• Concrete, asphaltic concrete.
• Cardboard, paper, packaging.
• Clean dimensional wood, palette wood.
• Usable palettes.
• Metals from banding, ductwork, piping, rebar, roofing, other trim, steel, iron,
galvanized sheet steel, stainless steel, aluminum, copper, zinc, lead, brass, and
bronze.
• Carpet and pad.
• Gypsum board.
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Sample GEMS Documents Department of Veterans Affairs
• Paint.
• Insulation.
• Asphalt shingles.
• Beverage containers.
8. Submittals.
a. Waste Management Plan. Prior to any waste removal, the Contractor shall submit their
Waste Management Plan to the Medical Center. The Plan shall contain the following:
1) Analysis of the estimated job site waste to be generated, including types and
quantities.
2) Proposed alternatives to land filling. Contractor shall prepare a list of each material
proposed to be salvaged, re-used, or recycled during the course of the project.
3) Methods handling of materials to be recycled.
i) On site:
• Materials separation
• Materials storage
• Materials protection, where applicable
ii) Off site: Provide name of mixed debris recycling facility; include list of materials
to be recycled.
4) Procedures. A description of the means to be employed in recycling the above
materials consistent with requirements for acceptance by designated facilities.
5) Landfill Options. The name of the landfill(s) where trash will be disposed of.
6) Meetings. Contractor shall conduct Construction Waste Management meetings.
Meetings shall include the Subcontractor, the Project Manager and representatives as
designated by the Chief Engineer. At a minimum, waste management goals and
issues shall be discussed at pre-bid meetings, pre-construction meetings and regular
job-site meetings.
7) Transportation. A description of the means of transportation of the recyclable
materials (whether materials will be site-separated and self-hauled to designated
centers, or whether mixed materials will be collected by a waste hauler and removed
from the site) and destination of materials.
8) Waste Management Plan Implementation.
a) Manager. The Subcontractor shall designate an on-site party (or parties)
responsible for instructing workers and subcontractors and overseeing and
documenting results of the Waste Management Plan for the project.
b) Distribution. The Subcontractor shall distribute copies of the Waste Management
Plan to the Medical Center Chief Engineer.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
c) Instruction. The Subcontractor shall provide on-site instruction of appropriate
separation, handling, recycling, salvage, reuse and return methods to be used by
all parties at appropriate stages of the project.
d) Separation Facilities. The Subcontractor shall lay out and label a specific area to
facilitate separation of materials for reuse, salvage, recycling, and return.
Recycling and waste bin areas are to be kept neat and clean and clearly marked in
order to avoid contamination or mixing of materials.
e) Hazardous Wastes. Hazardous wastes shall be separated, stored, and disposed of
according to local, state and federal regulations.
b. Reports.
1) The Contractor shall submit (monthly, quarterly, at end of job) a Waste Management
Progress Report. The report shall contain the amount (in tons or cubic yards) of
material land filled from the project, the identity of the landfill, the total amount of
tipping fees paid at the landfill and the total disposal cost. Include legible copies of
manifests, weight tickets, receipts and invoices. Manifests shall be from recycle
and/or disposal site operators that can legally accept the materials for the purpose of
reuse, recycling or disposal.
2) For each material recycled, reused or salvaged from the project, provide the
following:
• Amount (in tons or cubic yards).
• Date removed from the job site.
• Receiving party.
• Transportation cost.
• Amount of any money paid or received for the recycled or salvaged material. Net
total cost or savings of salvage or recycling each material. Attach manifests,
weight tickets, receipts, and/or invoices. Indicate the project information,
including project title, name of company completing form, and beginning and
ending dates of period covered by summary form.
9. Rescission.
10. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-5
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Disclosure of Known Lead-Based Paint in Residential Housing
1. Purpose. This Veterans Affairs Medical Center (VAMC) is committed to disclosing the
presence of any known lead-based paint and/or lead-based paint hazards before a lessee
occupies a Veterans Affairs (VA) Residential Housing Unit.
2. Policy. It is the policy of this Medical Center to notify all lessees via a lead hazard
information pamphlet and to educate them of potential hazards associated with lead-based
3.
paint.
Responsibilities. All employees must perform their functions consistent with regulatory
requirements, agency environmental policies and its overall mission:
a. The Safety Manager/Industrial Hygienist will provide information on the Toxic
Substance Control Act (TSCA) to managers with responsibility for the program, audit
records on a periodic basis and provide consultation in regards to lead-based paint
hazards.
b. Chief of Facilities Management will ensure that a process is in place to provide the
appropriate information to lessee, ensure the disclosure forms are appropriately
completed and ensure that re-disclosure is completed prior to any renovation work or
changes in the lease.
c. Lessees will follow the recommendations in the EPA brochure and will notify Chief,
Facilities Management, of any peeling or chipping paint and will maintain the apartments
in a clean condition.
Procedures. All residential dwellings at the VA Medical Center were built prior to (year)
and are considered to contain lead-based paint that may place young children at risk for
developing lead poisoning. Lead poisoning in young children may produce permanent
neurological damage including learning disabilities, reduced intelligence quotient, behavioral
problems and impaired memory. Lead poisoning may also pose a risk to pregnant women.
The following procedures will be followed in the disclosure of lead-based paint in residential
housing:
a. At the time the rental agreement is signed, the Chief of Facilities Management will
provide to the lessee a copy of the pamphlet "Protect Your Family from Lead in Your
Home," (EPA747-K-99-01). The Chief of Facilities Management will require the lessee
to sign the "Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint
Hazards" form (Attachment A).
b. The Chief of Facilities Management will maintain all records or reports on lead-based
paint and will provide the Safety Office a copy. The Safety Office will provide to the
Chief of Facilities Management a copy of all analyses for lead-based paint and
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
materials. The lessee will be provided access to all available records and reports
pertaining to lead-based paint in residential housing.
c. The Chief of Facilities Management will maintain a list of all documents pertaining to
lead-based paint in residential housing.
d. Prior to all renovation work in residential housing, the plans will be reviewed and
approved by the Safety Office for disruptions of lead-based paint hazards. For all
renovations involving greater than two (2) square feet of lead-based paint or other
materials, the residents will be re-notified and provided with another EPA pamphlet and a
"Lead-Based Paint Pre-Renovation Certification" form (Attachment B).
e. An additional pamphlet will be provided to the resident if there are any changes in the
lease or rental agreement. Changes would include rent increases, change in name on the
lease, payment method, etc.
f. The lessee will acknowledge the receipt of the pamphlet "Protect Your Family from Lead
in Your Home" by initialing the disclosure statement.
g. Facilities Management will maintain all disclosure statements for a period of thirty years.
5. Reference.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Attachments:
A. Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards
B. Lead-Based Paint Pre-Renovation Certification Form
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Attachment A to Document 5B2-5
Disclosure of Information on Lead-Based Paint and/or
Lead-Based Paint Hazards
Lead Warning Statement. Housing built before 1978 may contain lead-based paint. Lead from
paint, paint chips and dust can pose health hazards if not managed properly. Lead exposure
is especially harmful to young children and pregnant women. Before renting pre-1978
housing, lessors must disclose the presence of known lead-based paint and/or lead-based
paint hazards in the dwelling. Lessees must also receive a federally-approved pamphlet on
lead poisoning prevention.
Lessor's Disclosure. Presence of lead-based paint and/or lead-based paint hazards.
[Check (i) or (ii) below]:
(i) Known lead-based paint and/or lead-based paint hazards are present in the housing
(explain). It is presumed that lead-based paint exists in all residential quarters due to
the fact that all were constructed prior to 1978. No records exist or are available
pertaining to lead-based paint hazards in residential quarters.
(ii) Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the
housing.
Records and Reports Available to the Lessor. [Check (i) or (ii) below]:
(i) Lessor has provided the lessee with all available records and reports pertaining to
lead-based paint and/or lead-based paint hazards in the housing (list of documents
available are listed below).
(ii) Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint
hazards in the housing.
Lessee's Acknowledgment. (Initial):
Lessee has received copies of all information listed above.
Lessee has received the pamphlet "Protect Your Family from Lead in Your Home".
Agent's Acknowledgment. (Initial):
Agent has informed the lessor of the lessor's obligations under 42 U.S.C. 4852(d) and is
aware of his/her responsibility to ensure compliance.
Certification of Accuracy. The following parties have reviewed the information above and
certify to the best of their knowledge, that what they have provided is true and accurate.
Lessor Date
Lessee Date
Agent Date
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
Attachment B to Document 5B2-5
Lead-Based Paint Pre-Renovation Certification
Certification of Receipt of Lead Pamphlet:
I have received a copy of the pamphlet, "Protect Your Family from Lead in Your Home",
informing me of the potential risk of the lead hazard exposure from renovation activity to be
performed in my dwelling unit. I received this pamphlet before the work began.
Printed Name of Recipient Date
Signature of Recipient
Self-Certification Option (for tenant-occupied dwellings only). If the lead pamphlet was
delivered but a tenant signature was not obtainable, you may check the appropriate statement
below:
Refusal to Sign. I certify that I have made a good faith effort to deliver the pamphlet,
"Protect your Family from Lead in Your Home", to the rental dwelling unit listed
below at the date and time indicated, and that the occupant refused to sign the
confirmation of the receipt. I further certify that I have left a copy of the pamphlet at
the unit with the occupied.
Unavailable for Signature. I certify that I have made a good faith effort to deliver the
pamphlet, "Protect Your Family from Lead in Your Home", to the rental dwelling
unit listed below, and that the occupant was unavailable to sign the confirmation of
receipt. I further certify that I have left a copy of the pamphlet at the unit by sliding it
under the door.
Printed name of person certifying pamphlet delivery Attempted delivery date and time
Signature of person certifying lead pamphlet delivery
Unit address
Note Regarding Mailing Option: As an alternative to delivery in person, you may mail the lead
pamphlet to the tenant. Pamphlet must be mailed at least seven (7) days before renovation (document
with a certificate of mailing from the post office).
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-6
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Energy Management
1. Purpose. To outline a comprehensive Energy Management Program to ensure energy is
conserved and used efficiently, consistent with quality patient care, VHA energy
management goals, Executive Order 13123 and availability of resources.
2. Policy. The Energy Management Program consists of the following elements:
a. Energy conservation is to be emphasized in the architectural and engineering design of
VA facilities, including new construction and remodeling projects.
b. An Employee Awareness Education Program for energy conservation and to promote
energy-wise practices.
c. Control of all energy utilized for heating, cooling, ventilation, refrigeration, lighting,
operating equipment and office equipment.
d. A Motor Vehicle Management Program to reduce fuel consumption of government motor
vehicles.
e. Procurement and identification of Energy Star® and energy efficient products to ensure
we buy products that offer significant energy savings.
f. On-going technical surveys, audits and monitoring programs established to identify
energy efficient improvements by means of operations and maintenance actions and/or
energy conservation projects.
g. Development and maintenance of an up-to-date facility Energy Management Plan. This
five-year program forecasts all energy related operating and maintenance actions and
projects.
h. Energy utilization data collection and reporting, and maintenance of historical and
reference energy program files, literature and software.
3. Responsibilities.
a. The Associate Director is responsible for providing leadership and support for the Energy
Management Program, including overall program coordination, evaluation and
monitoring.
b. The Chief, Facilities Management is responsible for the Medical Center's Energy
Management Program. As the Facility Energy Supervisor, the Chief, Facility
Management, will delegate the everyday overview of the Energy Program to the Energy
Manager who is responsible for all energy management efforts.
c. Designated Energy Manager is responsible for:
1) Promulgating facility directives/controls.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
2) Reviewing/approving/disapproving actions that may have a detrimental effect on
patient care or essential Medical Center programs.
3) Implementation of feasible energy conservation measures by means of operating and
maintenance actions and/or projects; development and updating of the five-year
Facility Energy Management Plan; energy utilization data collection and reporting.
4) Maintaining an energy-efficient communications network.
5) Maintaining occupant comfort.
6) Keeping accurate historical data reference literature.
7) Updating/upgrading energy management software programs and files.
d. Service Chiefs and Supervisors are responsible for promoting and exercising leadership
in effective energy management within their areas of responsibility on a continuing basis.
Supervisors are also responsible for reviewing and forwarding to Facilities Management
all suggestions for energy conservation that are submitted by employees.
e. All Employees and Volunteers are responsible for practicing energy-wise conservation
practices. Employees are encouraged to use the incentive awards program for submitting
suggestions and proposals for improvement of our energy conservation program.
4. Procedures.
a. Employee Awareness Program:
1) Employees are encouraged to take an active role in conserving energy and in
identifying and submitting energy-saving ideas and suggestions for consideration.
2) Energy-wise practices and the Energy Management Program will be reviewed and
discussed periodically at service and section staff meetings to educate and provide
employees with specific knowledge and skills necessary for them to take action in
their everyday work that will conserve energy.
3) Educational and promotional articles and items will be published periodically in
medical center newsletters, weekly bulletins, etc.
4) Signs will be utilized to remind personnel to turn off lights and equipment, keep
doors closed, etc., as appropriate.
5) Helpful hints for all employees:
a) Turn off lights in all unoccupied rooms or spaces, including storerooms, closets
and restrooms. Computer systems and other non-essential electrical equipment
will be turned off at the close of the business day by using services. Notify
Engineering if you think an occupancy sensor would be appropriate to
automatically turn lights off during long periods of room inactivity.
b) Report excessively lighted spaces to Facilities Management. Identify light
fixtures that could be removed without sacrificing safety or productivity.
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Sample GEMS Documents Department of Veterans Affairs
c) Do not adjust thermostats or heating/cooling controls - contact the Work Order
desk to change room temperatures.
d) Keep windows and doors closed in air conditioned spaces. Disconnect window
air conditioning units during the heating season.
e) Dress appropriately for the season and daily weather.
b. Lighting Procedures:
1) Lighting will be turned off in unoccupied areas and controlled to meet only specific
needs in partially occupied areas.
2) Generally, non-patient area lighting levels will be maintained at approximately 50
foot-candles at workstations, 30 foot-candles in general areas and 10 foot-candles in
corridors. Prolonged office work with some visual difficulty may require 75 to 100
foot-candles. Anything over 75 foot-candles may be achieved with supplementary
task lighting.
3) Patient areas will be maintained at lighting levels appropriate to patient care as
determined by the clinical staff.
4) Lighting levels and control in animal care areas will be as recommended by research
staff.
5) Generally, interior finishes having good light reflectance will be utilized.
6) Energy-saving replacement lamps, tubes and ballasts will be utilized. Fluorescent
lamps used for general illumination will have color rending greater than 85, with
temperature between 3500° K and 5000° K. Services should request approval from
the Energy Manager for special lighting applications.
7) Lighting systems and other electrical equipment will be periodically cleaned and
appropriate preventive maintenance performed.
8) Preference will be given to the installation of more efficient lighting systems for new
construction and remodeled spaces to the extent that projected energy savings will
offset higher acquisition and maintenance costs.
9) The purchase of task lights must be approved by the Energy Manager prior to
purchase to ensure lights and ballasts are energy efficient.
c. Heating and Cooling Procedures:
1) Comfort shading control will be practiced.
2) Dress should be appropriate for the season and daily weather.
3) Convectors, diffusers, registers and grills will be kept clear of obstructions that
restrict air movement.
4) Generally, doors and windows will be kept closed when heating and cooling systems
are on, especially in air-conditioned areas.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
5) Systems and equipment will be shutdown or night-cycled when not needed and/or
demand/duty-cycled during periods of low demand.
6) Temperatures in non-patient areas will be maintained at not more than 70-74° F
during heating season and not less than 75-78° F during the cooling season. The use
of portable heater blowers, threshold heaters, and portable space heaters is prohibited
unless recommended and approved for a special medical reason. The requesting
Service will be required to obtain Space/Utility approval from the Energy Manager
prior to procurement and/or installation to avoid the possibility of overloading
electrical circuits.
7) Patient areas and animal care areas will be maintained at space temperatures specified
by the clinical or research staff.
8) Operations and Maintenance: Temperatures, pressures and flows will be maintained
at minimums necessary to meet operating needs. Exhaust air reduction and heat
recovery will be maximized. Insulation, caulking, shading control and weather-
stripping will be utilized to minimize building envelop transmission losses. Systems
and equipment will be periodically cleaned and appropriate preventive maintenance
performed. Cooling energy will not be used to achieve the temperature specified for
heating, e.g., a warm winter day.
d. Operating Equipment and Office Equipment Procedures:
1) Equipment will be turned off when not in use and warm-up time kept to the minimum
necessary.
2) Stairs should be used instead of elevators, especially when going down or up only one
level.
3) Generally lids will be used when cooking with pots and kettles.
4) Equipment will be periodically cleaned and appropriate maintenance performed.
5) Overall electrical system power factor will be maintained at a minimum of 0.90.
e. Motor Vehicle Management Program:
1) Vehicle use will be limited to necessary official business using the most direct
efficient routing.
2) Trips will be consolidated and vehicle use pooled whenever possible for most
efficient vehicle utilization.
3) Operators will observe posted speed limits in residential/city areas and highway/rural
areas. They will observe unposted speed limits as required by local laws.
4) Operators will ensure that vehicle tires are kept properly inflated.
5) Operators will take precautions to protect vehicle gasoline supplies and avoid waste
in dispensing fuel.
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Sample GEMS Documents Department of Veterans Affairs
f. Energy Efficient Project Design: Energy efficient designs and specifications will be used
for new construction and for construction alterations and retrofits.
g. Considerations/Procedures for Energy Star ® and Energy Efficient Equipment
Procurement:
1) Executive Order 13123, Greening the Government Through Energy Efficient
Management, requires the federal government to purchase energy-using equipment
which meets "EPA Energy Star" requirements for energy efficiency. These products
should be procured when available and practical.
2) If an Energy Star® product is not available, there is still the requirement to save.
Products that are in the upper 25% of energy efficiency for all similar products or
products that are at least 10% more efficient than the minimum level that meets
Federal Standards will be purchased whenever practical.
3) Items that consume power in a standby mode should meet Federal Energy
Management Program (FEMP) recommendations for standby power wattage. If
FEMP has listed a product without a corresponding wattage recommendation,
purchase items that use no more than one watt in their standby power consuming
mode. When it is impracticable to meet the one watt requirement, purchase items
with the lowest standby wattage practicable.
4) All employees are encouraged to procure products that are energy efficient or water
conserving.
h. Considerations/Procedures for Accelerated Retirement of Inefficient Equipment:
1) The early retirement of older, inefficient appliances and other energy and water-using
equipment is encouraged.
2) The requesting service and the Medical Center Equipment Committee will take into
account the availability of the many significant improvements in energy efficiency
and water conservation when reviewing the need to replace older, inefficient,
operating equipment.
3) The guidelines to determine the cost-effective early retirement of all older equipment
will include opportunities to downsize or otherwise optimize the replacement
equipment as a result of associated improvements in the building envelop, system or
process, efficiency and reductions in pollutant emissions, use of chlorofluorocarbons
and other environmental improvements.
4) All equipment requests, new or replacement, will be screened and reviewed by the
Energy Manager to ensure compliance with the intent of the Energy Act of 1992.
i. Operations and Maintenance Procedures:
1) Good operating and maintenance practices will be followed to:
a) Maintain/improve comfort, health, safety.
b) Extend equipment life.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
c) Keep energy consumption down.
d) Reduce repair and replacement costs.
2) Operations and maintenance practices as they relate to energy consumption will be
reviewed on an annual basis.
j. New Construction and Remodeling Project Procedures:
1) The Energy Manager will review all project documents to ensure new and remodeling
projects are designed and constructed to minimize the life cycle cost of the facility by
utilizing energy efficiency, water conservation, or solar or other renewable energy
technologies.
2) Monitoring and commissioning of newly installed or retrofit equipment will be
conducted by the Energy Manager and Project Manager to ensure the new
construction meets the requirements of the Energy Act of 1992.
k. General Conservation Methodology: The following conservation techniques or operating
procedures will be followed in addition to the above items:
1) Conservation of Heating Fuels. Insulation of all steam, hot water, condensate lines
and water heaters will be maintained in a maximum state of repair. Steam valves will
be maintained so that they are capable of shutting off the flow completely. Traps are
to be checked frequently and maintained to operate properly. Temperatures in hot
water storage tanks will be checked frequently and maintained at the minimum
allowable operating temperatures.
2) Conservation of Electricity. Electrical equipment, lighting, computer systems, etc.,
will be turned off at the close of the business day by using services, except in those
rooms that remain occupied. If absolutely necessary, computer equipment used to
receive information may be left on. Lighting levels will generally follow the foot-
candle guidelines listed in the Orange Book (Energy Conservation in the Veteran's
Administration, Table 4) and/or the recommended minimum lighting levels published
by the Illumination Engineers' Society. The use of electrically operated devices will
be kept to an absolute minimum consistent with proper and efficient operations.
3) Conservation of Water. All use of water will be kept at an absolute minimum,
consistent with proper operations; particularly, hot water, which requires energy to
heat. Attention is directed to leaking faucets and/or faucets not properly turned off.
Report all leaking faucets to Engineering for immediate repair.
4) Conservation of Ice. The use of ice will be kept to a minimum consistent with care of
patients and necessary for other operating purposes. Extreme care will be taken to
minimize the possibility of contamination of ice by foreign matter. Unnecessary
quantities of ice should not be allowed to melt in containers before being used.
5) Conservation of Air Conditioning. Where practical, air conditioning equipment will
be turned off when not in use. The use of heat-producing equipment in air-
conditioned areas will be kept to a minimum consistent with necessary operations.
Heat producing equipment should be turned off when not in use.
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Sample GEMS Documents Department of Veterans Affairs
6) Conservation of Refrigeration. Temperatures in deep freeze units (except for ultra-
low freezers) should be maintained between -8° and 0° F. Temperatures in coolers
should be maintained between 36° and 40° F.
5. References.
a. Energy Policy Act of 1992 (PL 102-486).
b. Executive Order 13123, Greening the Government Through Energy Efficient
Management, dated June 3, 1999.
c. Executive Order 13221, Energy Efficient Power Devices, dated July 31, 2001.
d. VA Directive 0055, VA Energy Conservation Program, dated July 28, 2003.
e. VA Handbook 0055, VA Energy Conservation Program Procedures, dated July 28, 2003.
f. VHA Supplement, MP-3, Chapter 2, paragraph 2.18 (Energy Conservation in Existing
Buildings), Department of Energy, dated July 15, 1988.
g. Total Energy Management for Hospitals; HHS.
h. Energy Management in Federal, State and Local Government Buildings, The Association
of Energy Engineers, dated October 24, 1992.
i. Energy Star®: http://www.energystar.gov.
j. Federal Energy Management Program, http://www.doe.gov
6. Concurrences.
Chief of Staff
Chief, Acquisition and Material Management
Chief, Facilities Management
Associate Director
7. Rescission.
8. Follow-Up Responsibility. Chief, Projects, Operations and Environmental Management
9. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-7
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Fuel Storage Tanks, Underground (USTs) and Above Ground (ASTs),
and Piping Management
1. Purpose. To establish a policy at this Medical Center for protection of human health and the
environment by safeguarding our natural resources and structures from fire, contamination or
explosions caused by fuel leaking from underground storage tanks (USTs) or above ground
storage tanks (ASTs).
2. Responsibility. The Engineering Program Manager, has the overall responsibility for
ensuring that all fuel storage tanks meet all current state and federal UST and AST
regulations. The Program Manager delegates the responsibility for compliance to
Maintenance and Operations Section, Project Section and Safety personnel.
a. Engineering Maintenance & Operations (M&O) personnel are responsible for the
compliance requirements for existing regulated USTs and ASTs:
• Tank Location(s) (List)
• Compliance Date (Identify)
Note: Tanks used for storage of heating oil are exempt from the laws but
shall meet the same criteria for leak protection and monitoring.
b. The Project Manager has the responsibility to develop and administer projects for
modification of existing tanks and piping, installation of replacement tanks and piping,
and installation of additional tanks and piping in accordance with state and federal UST
regulations. All tanks installed after December 22,1998, are new tanks and must meet all
requirements at time of installation.
c. The Safety Manager has the responsibility to record and report to the regulatory authority
at the beginning and end of a UST system's operating life. Also, all suspected or
confirmed leaks or spills will be reported.
3. Procedures.
a. General. All existing fuel storage tanks have been upgraded to comply with current state
and federal regulation as of December 22, 1998. All tanks are equipped with electronic
leak monitoring systems and are checked in accordance with a prescribed schedule for
any leaks.
b. The Project Manager shall develop and administer projects for replacement of existing
tanks or installation of additional tanks after December 1998 to meet the following
requirements:
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1) Certification that tank and piping are installed properly according to industry code,
EPA and (State) regulations.
2) Equip the UST with devices that prevent spills and overfills.
3) Protect AST tanks and piping from spills and overfills with dike enclosures sized to
fully contain the entire capacity of the tank.
4) Protect metal tanks and piping from corrosion or use all non-metallic materials for
tanks and piping.
5) Equip the tank and piping with leak detection and monitoring equipment.
c. The M&O Section Supervisors listed in Paragraph 2 will inventory monthly (minimum)
by use of a dipstick and enter in a permanent log. Recorded usage from meters will also
be entered and running totals will be maintained. Also, these supervisors will maintain
leak detection and monitoring systems in fully operational mode and will record
scheduled testing of such systems.
1) In the event that a suspected shortage of fuel is noted, daily monitoring will be
required until such time that it is determined that the recorded shortage is due to
either use or loss of fuel. At any time there is a suspected shortage, the Engineering
Program Manager will be notified through the appropriate chain of command of
supervisors.
2) In the event that a shortage is determined to be an underground loss, immediate action
will be taken to transfer the fuel to other tanks or have the tank pumped out into tank
trucks. Arrangements for tank trucks will be the responsibility of the General
Foreman of the responsible M&O Section. If it is suspected or there is any indication
that fuel is getting into the sewer systems, the local Fire Department and local Sewer
District will be notified by the supervisor on site immediately. The M&O General
Foreman will notify the Safety Manager immediately of a leak or spill.
3) Following the removal of fuel from a leaking tank, the M&O General Foreman will
arrange for testing of the tank and associated piping. This will be accomplished by
pressure testing and/or soil sampling by qualified personnel under contract.
Following a review of the test results, repair or removal of the defective tank or
piping will be accomplished.
d. The Safety Manager will maintain and file the following records to prove the facility's
recent compliance status:
1) Leak detection performance:
a) Last year's monitoring results.
b) Copies of performance claims provided by leak detection manufacturers.
c) Records of maintenance, repair and calibration of leak detection equipment.
2) Documents showing that a repaired or upgraded UST system was properly repaired or
upgraded per applicable codes and state and federal regulations.
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Sample GEMS Documents Department of Veterans Affairs
3) For three years after closing a UST, records of the site assessment results required for
permanent closure (these results must show what impact the UST has had on the
surrounding area).
a) The Safety Manager will report all suspected or confirmed leaks or spills to the
EPA and to the (State) Department of Natural Resources (DNR) Laboratory
Services Program within 24 hours.
Note: Petroleum spills and overfills of less than 25 gallons do not
have to be reported if immediate action to contain and clean up
is done.
b) Report clean up progress to DNR within 20 days after a leak or spill. Investigate
to determine extent of damage to the environment and report to DNR within 45
days after a leak or spill. Develop and submit a corrective action plan (if
required) that shows how requirements established by the DNR will be met.
4. References. Federal Register and EPA Regulations for USTs; U.S. Environmental
Protection Agency Booklet, "Musts for USTs," EPA 1530/UST/88/008, dated September
1988; State Department of Natural Resources, Division of Environmental Quality,
Underground Storage Tank Technical Regulations, dated December 22,1988.
5. Rescissions.
6. Review Date.
(Name)
Medical Center Director
Distribution:
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Sample GEMS Documents Department of Veterans Affairs
Document 5B2-9
SAMPLE
VA Medical Center Medical Center Memorandum ()
(Location) (Date)
Management of Universal Hazardous Wastes
1. Purpose. A number of devices used in our Medical Center contain mercury or other toxic
materials that may pose a hazard to human health or the environment when improperly
managed. These devices are universal hazardous wastes; they meet the definition of a
hazardous waste, but when disposed of may pose a relatively low risk during accumulation
and transport compared to other hazardous wastes. Alternative management practices for
universal hazardous wastes have been established by the U.S. Environmental Protection
Agency (EPA) and state Environmental Protection Agencies to promote recycling.
2. Policy. It is the policy of this Medical Center to reduce the amount of toxic substances used,
to reduce worker and environmental exposure to the release of toxic substances and to
manage universal hazardous waste in the most appropriate fashion.
3. Responsibilities. A facility-wide management policy involves all Services that use toxic
substances and generate universal hazardous wastes. Those responsible for ensuring that this
circular is enforced are:
a. The Safety Manager/Industrial Hygienist is responsible for the management of the
program, interpretation of regulations, training, management of manifests or bills of
lading and transportation.
b. Service Chiefs/Line Managers are responsible for the proper handling, labeling and
management of universal wastes until transported to the accumulation site.
c. Employees are responsible for following the contents of this policy.
4. Universal Hazardous Wastes. The following materials are considered universal hazardous
wastes:
• Mercury Thermostats/Thermometers/Devices
• Mercury containing lamps
• Batteries
• Cathode ray tubes
• Totally enclosed Polychlorinated Biphenyl (PCB) Ballasts
5. Procedures. It is extremely important to manage all universal hazardous wastes properly and
to prevent releases to the environment. The following procedures will be adhered to:
a. All employees handling universal hazardous wastes are prohibited from disposing,
diluting or treating universal hazardous wastes without proper authority from the Safety
Office.
b. All universal hazardous wastes must be stored in a closed container in good condition
that is compatible with the waste. Each container must have a Universal Hazardous
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Waste label marked with the date the accumulation started and the date when the
container became full.
c. Adequate aisle space must be provided to ensure visual inspection of the condition of all
containers.
d. All storage areas must be locked.
e. Each service responsible for generating the waste must inspect the storage area weekly
and document using the log in Attachment A. All items must be filled out on the log,
including the number and types of universal hazardous waste items.
f. The Safety Office must be notified the day the universal hazardous waste container
becomes full. Wastes must be shipped at least 90 days from the full date.
g. The best alternative for many universal hazardous wastes is to use a manufacturer who
will take back their product for recycling. This reduces the cost of universal hazardous
waste disposal.
h. All employees who handle universal hazardous wastes must be trained in proper
handling, storage, packaging and in the contents of this program.
i. The Safety Office will collect all inspection logs and retain all records pertaining to the
handling and disposal of universal hazardous wastes. Manifests, universal bills of lading,
and certificates of recycling will also be maintained in the Safety Office.
j. All spills of universal hazardous waste must be reported to the Safety Office.
6. References.
1. Rescission.
8. Review Date.
(Name)
Medical Center Director
Attachment:
Hazardous Waste Collection Form
Distribution:
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Department of Veterans Affairs
Attachment A to Document 5B2-9
Hazardous Waste Stored for Collection
Date to
Storage
Person
Responsible
Waste
Material
Waste
Phase
Waste
Amount
Container
Size/Type
Container
Number
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'ample GEMS Documents Department of Veterans Affairs
Attachment A to Biohazardous Waste Reduction Plan
Municipal and Biohazardous Waste Container Location List
Container # Container Location
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
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Attachment A to Report of Annual Effectiveness Review
SAMPLE
Biohazardous Waste Reduction Plan
1. Introduction and Scope.
a. Purpose. This plan sets forth the procedures for achieving the environmental objective of
biohazardous waste reduction. It adds to, without replacing, the local policy and
procedures for segregation and disposal of biohazardous waste at this Medical Center.
Because the disposal of biohazardous waste has a significant impact on the environment,
this GEMS Committee has selected the objective of reducing biohazardous waste by 10%
(by weight) this calendar year. Procedures for achieving this objective and target appear
below.
b. Causal Analysis of Improper Waste Segregation. The GEMS Committee conducted a
waste stream analysis of the waste disposed of in biohazardous waste containers and
determined that about 20% was not biohazardous waste. This means that it could have
been disposed of as municipal waste which would have saved this facility $18,000 last
year. When red-bagged waste comes in contact with non-biohazardous waste, all the
waste is considered biohazardous waste; therefore, the solution is proper segregation
before disposal. A causal analysis directed the GEMS Committee to the following
critical elements to proper waste segregation: Correctly identifying biohazardous waste
and properly disposing of biohazardous waste. The first element speaks to employee
education and behavior management, and the second element involves the availability of
the proper waste containers.
2. Implementation Procedures to Accomplish Goal. The procedures identified in the
Biohazardous Waste Management Medical Center Memorandum #XX remain in effect with
the following additions for this calendar year:
a. Forty-eight additional containers for municipal and biohazardous waste will be placed in
the identified locations to facilitate proper waste segregation. (See the Attachment A,
Municipal and Biohazardous Waste Container Location List.)
b. Monitoring the proper placement of waste containers and the proper segregation of waste
will be conducted monthly during regularly scheduled hazard surveillance rounds by the
hospital team and weekly by the Housekeeping supervisor. Segregation errors and
missing containers will be logged by both, and corrective actions will be instituted,
tracked and reported monthly to the GEMS Committee. (See Attachment B, Waste
Segregation and Waste Container Placement Log and Report Form.).
c. Hospital-wide trends in proper segregation (as determined by reduced error rates) and in
reduction of biohazardous waste will be charted quarterly. Progress in reduction of
biohazardous waste will be posted in the Canteen.
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d. All VAMC employees who come in contact with biohazardous waste will receive
refresher training on waste segregation and disposal from the Infection Control
Practitioner within 60 days of the date this plan is approved. Supervisors of employees
not meeting this requirement will meet with the Associate Director.
e. The Infection Control Practitioner will design, develop and present the refresher training
and will submit the list of topics covered to the GEMS Committee.
f. The Infection Control Practitioner will submit a list of employees requiring refresher
training and report the status of refresher training on a monthly basis until complete.
g. The GEMS Committee will consider a group award for special contribution to this
successful effort. Nominations for the award will be considered at the end of the year
when the annual program evaluation indicates the objective and target were exceeded.
Attachments:
A. Municipal and Biohazardous Waste Container Location List
B. Waste Segregation and Waste Container Placement Log and Report Form
Submitted by: Date:
Chairperson, GEMS Committee
Approved by: Date:
Medical Center Director
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Department of Veterans Affairs
Attachment B to Biohazardous Waste Reduction Plan
Waste Segregation and Waste Container Placement Log
and Report Form
Date
Problem
Location
Corrective Action
Date
Fixed
Date
Rechecked
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Department of Veterans Affairs
Attachment B to Report of Annual Effectiveness Review
SAMPLE
Green Environmental Management System (GEMS)
Objective & Target Form
(Note: Use one form per objective)
Individual Responsible for Implementation:
Housekeeping Officer and Infection Control Practitioner
Date October 5. 2004
Environmental Objective:
To reduce the generation ofbiohazardous waste.
Related Target(s):
3% reduction by weight ofbiohazardous waste.
Related Significant Environmental Aspect(s):
Air and land pollution due to disposal ofbiohazardous waste.
Service Specific Function and/or Department:
Primary Care, Behavior Health, Surgery, Specialty and Diagnostics, Housekeeping
Target Date (Month/Year): End of Calendar Year
Frequency of Monitoring:
(Check one)
Weekly
Monthly
X
Quarterly
Annually
Action Plan:
Implement biohazard segregation program, implement staff education program, identify areas for
biohazard containers, continuous monitoring during environmental rounds.
How will this objective be met? (Attach additional pages as necessary)
1. Housekeeping will survey all areas of the health care system to determine appropriate placement of
biohazard receptacles.
2. Infection Control will develop training curriculum and deliver staff education.
3. Monitoring will be performed by housekeeping staff during trash removal and surveyed during
environmental rounds.
What operational controls shall be incorporated to achieve this objective?
Strategic placement of waste containers.
How will this objective be tracked? (Attach additional pages as necessary)
All biohazard waste will be weighed prior to transport off-site.
What resources will be required to achieve this objective? (Attach additional pages as
necessary)
Purchase of additional municipal and biohazardous waste containers.
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5-
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Sample GEMS Documents
Department of Veterans Affairs
Document 5B3-1
SAMPLE
GEMS Committee Report of Annual Effectiveness Review
Excerpt From the Minutes of the GEMS Committee, (Insert date of meeting)
Approved and Signed by the Medical Center Director
1. The GEMS Committee found the GEMS program to be effective in its (first, second, etc.)
year, as indicated by:
• Completion of
(insert date).
• Completion of
_% of the corrective actions for the GEMS Gap Analysis conducted
% of the corrective actions for the baseline Environmental
Compliance Audit, conducted (insert date).
• Achievement of the objectives and targets set at GEMS Committee Meeting (insert date)
and as modified at the (insert date) GEMS Committee Meeting.
2. The GEMS Committee recommends the following new objectives and targets for FY (insert
upcoming FY): (Note: Attach objectives and targets form for each new objective identified.)
• % reduction in (insert area identified as a new objective) compared with FY (insert
previous FY). (See attached plan for monitoring and accomplishment.)
% reduction in (insert area identified as a new objective). (See attached plan for
monitoring and accomplishment.)
(List as many as identified by the GEMS Committee. Include a plan for monitoring and
accomplishing each item.)
3. The following dashboard summarizes the status of GEMS effectiveness evaluations:
GEMS Gap Analysis
Performance
Objectives
Appoint a GEMS
Coordinator and a
GEMS Committee
Performance Target
Coordinator and Committee
will be appointed no later that
the end of the first quarter.
Status
Mr./Ms. was appointed the GEMS
Coordinator with participants from
all organizational units. Mr./Ms.,
Associate Director, was appointed
committee chairman.
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Sample GEMS Documents
GEMS Gap Analysis
Performance
Objectives
Performance Target
Status
Conduct a Gap Analysis
to Determine Disparity
in our Present Program
Gap analysis will be
completed by the end of the
second quarter.
The gap analysis was completed
February 2004, with new policies
developed as needed and routed for
comments.
Develop and Implement
a GEMS Program
The program will be published
and in effect by the end of FY
04.
The newly established written
GEMS program was established
September 1, 2004.
Environmental Rounds
are Conducted Quarterly
in all Areas (Patient and
Non-Patient) of the
Medical Center to
Demonstrate
Compliance with
GEMS.
Surveys conducted 90% of the
time and deficiencies are
corrected within 30 days.
This performance standard was
significantly met during FY 2004.
All surveys were performed as
scheduled in MCM 00-46,
Environmental Rounds and in
accordance with the Environment
of Care Standards (JCAHO).
However, not all deficiencies were
abated within 30 days. Although
89% (1030/1154) of the items
noted were abated within 30 days,
the percentage fell below the stated
goal of 100%. It should be noted
that there was no duplication of
deficiencies when making rounds
the second time in FY 1999.
Environmental Compliance Audits/Inspections
Compliance
Standard
Safe Drinking Water
(SOW)
Resource Conservation
and Recovery Act
(RCRA)
Air Emissions
Compliance Problem
The well exceeds safe
drinking water standards.
Inspection log not up-to-date.
Boiler exceeds air emission
standards in permit.
Status
Standards met as evidenced by
Standards met as evidenced by
Standards met as evidenced by
GEMS Targets and Objectives
Performance
Objectives
Red Bag Waste
Pesticide Use
Performance Target
Reduce red-bag waste by 3%
by weight by end of fiscal
year.
Change practice of scheduled
Status
Standards met as evidenced by
Standards met as evidenced by
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Department of Veterans Affairs
GEMS Targets and Objectives
Performance
Objectives
Performance Target
pesticide application to be
applied when determined
necessary by sampling
through fiscal year.
Status
Attachments:
A. (Insert name(s) of plan(s) for monitoring and accomplishing objective(s) in paragraph 2.
Sample Biohazardous Waste Reduction Plan provided as a guide.)
B. GEMS Objective and Target Form(s) (one for each objective identified. Sample provided for
biohazardous waste.)
Submitted by:
Chairperson, GEMS Committee
Date
Approved by:
Medical Center Director
Date
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Department of Veterans Affairs
Document 5B3-2
SAMPLE
Green Environmental Management System (GEMS)
Objective & Target Form (Blank)
(Note: Use one form per objective)
Date
Individual Responsible for Implementation:
Environmental Objective:
Related Target(s):
Related Significant Environmental Aspect(s):
Service Specific Function and/or Department:
Target Date (Month/Year):
Frequency of Monitoring:
Action Plan:
How will this objective be met? (Attach additional pages as necessary)
What operational controls shall be incorporated to achieve this objective?
How will this objective be tracked? (Attach additional pages as necessary)
What resources will be required to achieve this objective? (Attach additional pages as
necessary)
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Department of Veterans Affairs
Document 5B3-2
SAMPLE
Green Environmental Management System (GEMS)
Objective & Target Form (Blank)
(Note: Use one form per objective)
Date
Individual Responsible for Implementation:
Environmental Objective:
Related Target(s):
Related Significant Environmental Aspect(s):
Service Specific Function and/or Department:
Target Date (Month/Year):
Frequency of Monitoring:
Action Plan:
How will this objective be met? (Attach additional pages as necessary)
What operational controls shall be incorporated to achieve this objective?
How will this objective be tracked? (Attach additional pages as necessary)
What resources will be required to achieve this objective? (Attach additional pages as
necessary)
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Document 5B
SAMPLE
VA Medical Center Medical Center Memorandum ( )
(Location) (Date)
Green Environmental Management Systems (GEMS) Policy
1. Purpose.
a. Executive Order 13148, Greening the Government Through Leadership in Environmental
Management, directs that federal agencies have a governing environmental policy in
place for the operation of its facilities. The Executive Order also requires that VHA
facilities develop and implement environmental management systems. The objectives of
an environmental management system are to ensure that facilities are in full compliance
with environmental regulations and are operated and managed in such a way as to result
in the continual improvement of the environmental program.
b. This VA Medical Center policy facilitates the use of its Green Environmental
Management Systems (GEMS) to attain continual improvement in environmental
programs.
2. Policy.
a. The mission of the VA Medical Center (insert medical center name) is to deliver quality
healthcare to our nation's veterans. In order to accomplish this mission, the VA Medical
Center recognizes that it must operate so as to protect both the environment and the
health and safety of patients, employees and visitors. This Memorandum establishes a
governing environmental policy to accomplish this mission.
b. In accomplishing its mission of providing quality healthcare to our nation's veterans it is
this VA Medical Center's policy to:
1) Develop and implement a VA Medical Center GEMS that will meet both the
requirements of EO 13148 and the guidance provided by Veterans Health
Administration.
2) Be a good steward of the environment by complying with federal, state and local
environmental laws and other requirements, preventing pollution, minimizing waste,
conserving cultural and natural resources and continually improving environmental
programs.
3) Utilize sustainable practices to eliminate, minimize or mitigate adverse environmental
impacts.
4) Evaluate the operation of the VA Medical Center to incorporate actions into facility
planning and procedures to reduce environmental vulnerabilities.
5-7
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
5) Integrate pollution prevention, waste minimization, resource conservation and
environmental compliance into VA Medical Center operations, purchasing, planning
and decision-making, wherever practical. Source reduction is the pollution
prevention method of choice, followed by recycling, treatment of wastes and proper
disposal.
6) Use natural resources efficiently, and maintain the protect plant and wildlife habitat
consistent with the VA Medical Center's mission.
7) Recognize that the development and construction at the VA Medical Center must
consider the unique conditions of the environment of which the facility is a part.
8) Train VA Medical Center staff as needed to carry out the environmental
responsibilities of their positions.
9) Solicit input, as appropriate, from stakeholders including staff, patients, visitors and
the local community regarding environmental matters affecting the operation of the
VHA facilities.
3. Responsibilities. All VA Medical Center employees must perform their functions consistent
with regulatory requirements, VA environmental and other policies and its overall mission.
a. Medical Center Director is responsible for implementation of the VA Medical Center
GEMS. The Medical Center Director appoints key personnel, including the GEMS
Coordinator and GEMS Committee members, to develop and implement the GEMS.
b. GEMS Coordinator:
1) Is the key member of the VA Medical Center GEMS Committee with technical
expertise in environmental management systems and environmental technology and
regulatory compliance.
2) Coordinates the development and implementation of the VA Medical Center GEMS
across organizational elements.
c. GEMS Committee:
1) Oversees development and implementation of the GEMS.
2) Identifies significant aspects.
3) Sets targets and objectives and approves the plan to achieve them.
4) Approves the corrective action plans.
5) Monitors progress on achieving targets and objectives, implementation of GEMS,
completion of corrective action plans and effectiveness of GEMS.
6) Submits an annual report on the effectiveness of the GEMS to the Medical Center
Director for approval.
7) Is responsible for ensuring that all aspects of this policy and implementation of the
GEMS program maintain full compliance with all environmental laws, regulations
and related statutes and other environmental requirements.
5-
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Sample GEMS Documents Department of Veterans Affairs
4. Procedures. Procedures to implement GEMS are published separately and include:
a. Procedure for Determining Significant GEMS Aspects and Impacts.
b. GEMS Legal and Other Requirements.
c. Establishing Objectives and Targets for GEMS Program.
d. GEMS Responsibility Matrix.
e. GEMS Training Program.
f. GEMS Communications to External and Internal Parties.
g. GEMS Document and Record Control.
h. Procedures for GEMS Operational Controls.
i. GEMS Emergency Planning and Response.
j. GEMS Monitoring and Measuring Procedure.
k. GEMS Nonconformance and Corrective and Preventive Action.
1. GEMS Gap Analysis Program Review.
m. GEMS Procedure for Annual Program Effectiveness Review and Report.
5. Reference. Executive Order 13158, Greening the Government Through Leadership in
Environmental Management.
6. Rescission.
1. Review Date.
(Name)
Medical Center Director
Distribution:
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
5- 10
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Acknowledgements
This Guidebook was possible because of the devoted attention of the personnel and
management of the
Center for Engineering & Occupational Safety and Health (CEOSH)
St. Louis, Missouri
We would like to thank the following individuals for their efforts in developing this
Guidebook and also for the support provided by their facility management:
* Arnold Bierenbaum, Director, Safety & Technical Services, VACO, Washington, DC
Tina Beckner, Technical Information Specialist, CEOSH, St. Louis, MO
Tom Boos, Safety Management Specialist, VAMC, Topeka, KS
Donald Campbell, Environmental Engineer, NCA, VACO, Washington, DC
Keith Davidson, Safety and Occupational Health Manager, VAMC, Sheridan, WY
Mary (Bernie) Foster, Technical Information Specialist, CEOSH, St. Louis, MO
Michael Frydach, Biomedical Engineer Trainee, CEOSH, St. Louis, MO
Jim Holland, VISN15 Network Safety Manager, St. Louis, MO
William Kulas, Safety Officer, VAMC, Togus, ME
Victoria Lay, Safety/Industrial Hygiene Trainee, CEOSH, St. Louis, MO
Becky Lemen, Adm. Officer, Facility Mgmt. Service Line, VAMC, St. Louis, MO
Diane Lynne, Attorney Advisor, U.S. EPA Headquarters, Washington, DC
Linda L. Martin, Director, OSH Program Support, CEOSH, St. Louis, MO
Freddie Martinez, Storage Specialist, VACO, Washington, DC
Barbara Matos, Environmental Program Specialist, VACO, Washington, DC
Ruben McCullers, Environmental Scientist, U.S. EPA Region 7, Kansas City, KS
Keith Repko, Engineering Program Manager, VAMC, St. Louis, MO
John (Jack) Staudt, VHA Environmental Engineer, VACO, Washington, DC
Vernon Wilkes, VHA Industrial Hygienist, VACO, Washington, DC
* Denotes Chairperson
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
In addition to the members of the GEMS Guidebook workgroup, we wish to acknowledge the
important contributions of the following dedicated environmental professionals who critiqued the
Guidebook manuscript and offered suggestions for improvement:
Edward Pinero, Deputy Federal Environmental Executive,
Office of Federal Environmental Executive-White House Task Force on
Waste Prevention and Recycling
Kathleen Malone, Federal Facility Program Manager, U.S. EPA Region 2
Anne Fenn, Federal Facility Program Manager, U.S. EPA Region 1
Gregory Winters, Industrial Hygienist, VA Central Office
We would like to thank Medical Center, VISN and VHA Central Office professional Safety and
Engineering individuals who made contributions to and reviewed this Guidebook.
We would like to thank Ms. Lesa Hall-Young, Medical Illustrator, VA Medical Center,
Durham, NC, for her graphic design work for the guidebook cover.
VI
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Administration
Date:
Activity or Service
Operation of Electrical
Equipment
Files and Records
Copying
Filing/Storage
Aspect
Energy Consumption
Paper Usage, Potential
Usage of Non-
Recycled Paper
Toner Usage
Cardboard Usage
Impact
Use of Natural
Resources
Use of Natural
Resources
Use of Natural
Resources
Use of Natural
Resources
Compliance
1
1
1
1
Risk
1
1
2
1
Frequency
Of Activity
4
4
2
3
VAMC
Control
2
2
2
2
TOTAL
SCORE
8
8
7
7
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Attachment A to Document 5B1-5
VHA Environmental Training Program Plan
Training
Agenda
Audience
Forum
Resources
Regulatory Compliance Training
National
Environmental VA
Meeting Kick-off
Environmental
Compliance 101
RCRA Hazardous
Waste Mgmt
Training and Annual
Refresher
Identification of
Hazardous Waste for
Healthcare
Required
Certification
Training
Laboratory-Specific
Environmental
Training
DOT training
Intro by top VA Management to show
environmental commitment; Overview of
major statutes and GEMS.
Overview of major statutes (i.e.,
RCRA/UST, CAA, CWA, SPCC, [storm
water, wetlands] EPCRA, TSCA [Lead,
PCBs], SDWA, FIFRA).
Compliance with other requirements such
as Executive Orders and VA Policy, etc.
Required EPA hazardous waste
management training.
Detailed discussion on waste
characterization.
Necessary training to be certified to
perform task.
Describes the environmental requirements
and best management practices that relate
to laboratories such as RCRA, CWA and
CAA. At a minimum, it will satisfy the
training requirements of RCRA 265. 16.
Also, covers auditing questions.
Environmental Coordinators,
HQs and VISN
Safety/Health, Medical
Center Directors/ Associate
Directors
Environmental Coordinators,
HQs, VISN Safety/Health,
Program/Service Managers,
Director/ Associate Directors
Environmental Coordinators,
VISN Safety/Health
Environmental Coordinators,
HQs, VISN Safety/Health
Employees such as HVAC,
wastewater treatment,
pesticides applicators, boiler
plant operators
Environmental Coordinator,
VISN Safety/Health,
Laboratory employees,
including the Laboratory
Program Manager
Environmental Coordinators,
Warehouse shippers
4 day (2 day compliance, 2
day GEMS) conference
face-to-face in Spring
2004. Taped for future use
by VA.
1-1 !/2 day face-to-face in
each EPA Region during
FY2004 that will be taped
for future use by VA.
Distance Learning by VA.
1 day - could be broadcast
or videotaped.
As required.
CD-ROM or interactive
video developed by VA.
With EPA HQs and
Regional help (suggestion
to make it a civilian-wide
conference and add RCRA
training).
EPA Regions FFPMs -
Region 1 will hold in
October 2003.
Numerous contractors give
course. NETI RCRA
Inspector Training CD-
ROM.
EPA Region 2 has
developed - to be given
November 12th.
Many contractors give
course.
GEMS guide for small
laboratories. Lab 21
Website.
-------
Training
UST Training
Module
SPCC Training
Module.
Clean Water Act
Training Module.
Toxic Substances
Training Module
Facilities
Maintenance Module
Clean Air Act
Training Module
Medical Waste
Training Module
EPCRA Training
Module
SDWA Training
Module
Agenda
Review of the underground storage tank
requirements. Includes auditing questions.
Review of the SPCC requirements at a
facility. Includes how to develop a SPCC
plan and auditing questions.
Review of the CWA requirements at a
facility such as NPDES, pre -treatment,
wetlands and storm water. Includes
auditing questions. May want to include
security issues as relates to wastewater
plants.
Describes requirements and best
management practices related to Asbestos,
Lead-Paint, PCBs and Mercury. Includes
auditing questions.
Environmental Requirements and best
management practices that apply to the
facilities maintenance operations such as
CAA, CWA, SDWA (UIC), FIFRA,
RCRA, Universal Waste, TSCA, beneficial
landscaping, etc. It must meet the RCRA
260. 16 training requirements. Includes
auditing questions.
Review of Clean Air Act requirements that
apply to healthcare facilities. Includes
auditing questions.
Review of requirements related to medical
waste. Includes auditing questions.
Review of EPCRA requirements. Includes
auditing questions.
Review of SDWA requirements. May
want to include security issues as related to
drinking water plants. Includes auditing
questions.
Audience
Environmental Coordinators,
VISN Safety/Health, Facility
Engineer
Environmental Coordinators,
VISN Safety/Health, Facility
Engineer
Environmental Coordinators,
VISN Safety/Health,
Wastewater Plant Operators,
COTR if construction project
Environmental Coordinators,
VISN Safety/Health, COTR
if demolition/renovation
project
Environmental Coordinators,
VISN Safety/Health,
Facilities maintenance
personnel (e.g., motor pool,
paint shop, grounds keeping,
HVAC, plumbing,
electricians, carpentry, etc.)
Environmental Coordinators,
VISN Safety/ Health, Boiler
personnel
Environmental Coordinators,
VISN Safety/ Health,
Housekeeping
Environmental Coordinators,
VISN Safety/ Health
Environmental Coordinators,
VISN Safety/ Health,
Drinking Water Treatment
Plant Operators
Forum
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
CD-ROM or interactive
video developed by VA.
Resources
UST guidebooks and
website. EPA UST
presentations. UST
auditing protocol.
SPCC website. EPA
SPCC presentations.
SPCC booklets.
EPA NPDES website.
EPA presentations.
Construction Compliance
Assistance Center.
EPA Asbestos webpage.
Numerous Mercury
elimination documents.
Auditing Protocol for
TSCA.
EPA's national CA
centers.
EPA Websites. CFC
checklists.
State Agencies.
EPA Websites. EPATRI
courses.
EPA Websites.
-------
Training
Agenda
Audience
Forum
Resources
Dental
Environmental
Compliance Module
Review of requirements and best
management practices related to dental
facilities, such as RCRA. Including
auditing questions.
Environmental Coordinators,
VISN Safety/ Health, Dental
personnel
CD-ROM or interactive
video developed by VA.
Vermont's Dental Guide.
Pharmacy
Environmental
Compliance Module
Review of requirements and best
management practices related to
pharmacies, such as RCRA. Includes
auditing questions.
Environmental Coordinators,
VISN Safety/Health,
Pharmacy personnel
CD-ROM or interactive
video developed by VA.
Pharmacology Website.
Environmental
Compliance for
Lawyers
Review major environmental laws
applicable to VAMCs, state and federal
regulator's procedures for inspections,
violations, fines and VAMC legal defense
strategies.
District Counsel
Green Environmental Management System Training
GEMS Training For
Top Management
Designing Your
GEMS - Federal
Facility Workshop
GEMS Element-By-
Element Hands-On
Training
GEMS Committee
Overview of GEMS Elements.
More detailed discussion of
GEMS elements and hands-on
workshop with VA examples.
Detailed discussion of
elements - one element at a
time with facility -specific
help.
Training on the
implementation of the GEMS
Directors and Associate Directors at
VAMC, HQs and VISN level
GEMS Coordinators & Auditors
GEMS Coordinators and Auditors
GEMS Coordinators,
Program/Service Managers (or
designated person)
GEMS Committee
2 Hour broadcast by VA.
2-day conference. Same as
what is offered in Kick-off.
V-TELbyVISN. Done once
a month until GEMS
complete.
All GEMS Committee
members are required to
attend the 4-hour course on
the implementation of the
GEMS Program.
Diane Thiel, EPA Region 8 &
Gary Chiles.
Gary Chiles & Carol Bell
(Contractors). May be offered
by EPA Regions in near
future.
See metal finishing GEMS
workshops - Linda Darveau -
EPA Region 1.
Power Point presentation
located in the GEMS
Guidebook.
-------
Training
Facility-Specific
GEMS Training
ISO 14001 Lead
Auditor Course
Agenda
Training on facility-specific
policies and procedures related
to GEMS.
Training on how to conduct a
GEMS audit.
Audience
All Employees
VISN GEMS Auditor
Forum
A minimum of annually.
Classroom for 5 days.
Resources
GEMS Booklet, Self-learning
module, Safety Blitz, etc.
Offered by many contractors.
Pollution Prevention/Environmental Stewardship
Environmental
Preferable
Purchasing/ RCRA
60027 Executive
Orders
Waste
Minimization/
Product Substitution
Green Cleaning
Green Building
Indoor Air Quality
P2 Training for
Auto Repair Shops
Best Management
Practices for
Outdoor Shooting
Ranges
Training on buying
environmentally preferable
products and complying with
RCRA 6002 and Executive
Orders.
Training on waste
minimization at healthcare
facilities.
Awareness of more
environmentally and safer
cleaning products.
Awareness of building and
renovating in a greener
manner.
Training on indoor air quality.
Training on pollution
prevention techniques
available to auto repair
shops/fleet maintenance.
Best management practices for
outdoor shooting ranges.
Environmental Coordinators, VISN
Safety/Health, COTRs, COs, Credit
Card Holders, Chief, Acquisition &
Materiel Management
Environmental Coordinators, VISN
Safety/ Health, Program/Service
Managers, Credit Card Holders,
COTRs, COs
Environmental Coordinators, VISN
Safety/Health,
Housekeeping/Laundry
Environmental Coordinators, VISN
Safety/Health, COTRs
Environmental Coordinators, VISN
Safety/Health, COTRs
Motor Pool, Environmental
Coordinators, VISN Safety/ Health
Outdoor shooting ranges if built.
CD-ROMs, interactive
videos, PowerPoint
presentations.
CD-ROMs, videos
CD-ROMs, videos.
CD-ROMs, videos.
CD-ROM by VA.
Video and workbooks.
Guidance Document.
H2E, EPA EPP Program,
OFEE. Lyons VA.
H2E, EPA Wastewise.
Diane Thiel Region 8, EPA
EPP Program, Greening Govt
CD EPA Regions 1-3.
EPA, LEEDS.
Completed.
EPA Region 9 has completed.
EPA Region 2 Guide.
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Date:
Activity or Service
Aspect
Impact
Compliance
Risk
Frequency
of Activity
VAMC
Control
TOTAL
SCORE
-------
Worksheet: Document Control
Document
Who Will Use It
Contact Person:
Permanent Location
Periodic Review
Schedule/ Who
/
/
/
/
/
/
/
/
/
When Can Be
Destroyed
Date Completed:
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Sample GEMS Documents
Department of Veterans Affairs
Attachment A to Document 5B1-1
Explanation of Aspects and Impacts Template Scoring
Compliance
The extent to which the aspect is regulated by law, regulation,
Executive Order or other requirement
The aspect is not regulated or is in full compliance.
Compliance activity has been initiated.
Compliance activity has been scheduled.
There is an awareness of non-compliance status, considering
compliance options.
The aspect is out of compliance and has taken no compliance activity
to date.
Score Assigned
0
1
2
3
4
Risk
The degree of risk to any exposed human populations or exposed
ecosystems
Minor risk to human population and/or ecosystems.
Moderate risk to sensitive human populations and/or ecosystems.
Moderate risk to general human populations and/or ecosystems.
High risk to sensitive human populations and/or ecosystems.
High risk to the general human population and/or ecosystems.
Score Assigned
0
1
2
3
4
Frequency
Frequency that this activity occurs
< Once per calendar year
Biannually or less
Monthly
Weekly
Daily or more
Score Assigned
0
1
2
3
4
Control
The extent to which the aspect is under control of the Medical
Center
Medical Center has no control or influence.
Medical Center has some influence or control.
Medical Center has influence parity with other entities with some level
of control.
Medical Center has significant influence.
Medical Center has total control over this aspect.
Score Assigned
0
1
2
3
4
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Sample GEMS Documents
Department of Veterans Affairs
Attachment A to Document SB 1-10
PLAN - DO - CHECK - ACT
Operational Controls for Significant Environmental Aspects
PLAN
Identify Significant Aspects
(Procedure for Environmental Aspects)
ACT
Establish and Track Corrective
Actions For Non-Compliance/Non-
Conformance Discovered During
Monitoring and Measuring and
Verify Effectiveness
(Procedure for Corrective Actions)
DO
Establish Operational Controls for
Significant Aspects
(Procedure for Establishing Operational Controls
for Significant Aspects)
CHECK
Monitor and Measure Activities for
Consistency with Operational Controls
(Procedure for Monitoring and Measuring)
5-57
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Attachment A to Document 5B1-3
PLAN - DO - CHECK - ACT
Environmental Objectives and Targets
PLAN
Select Objectives & Targets
(Procedure for Objectives & Targets)
ACT
Implement & Evaluate
Corrective Actions Discovered
During Monitoring & Measuring
(Procedure for Corrective Actions)
DO
Establish Operational Controls and
Measuring & Monitoring for
Objectives & Targets
(Procedure for Establishing Operational
Controls for Significant Aspects)
CHECK
Monitor & Measure Consistency
with Objectives & Targets
(Procedure for Monitoring & Measuring)
5- 1
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Sample GEMS Documents Department of Veterans Affairs
Attachment A to Document 5B1-7
Explanation to Policy Writer
I. Purpose
Design a standardized framework your installation will use to develop and organize the
various types of documentation required by ISO 14001.
II. Importance
Complete, well-organized documentation is essential for describing, managing, evaluating
and improving the Green Environmental Management Systems (GEMS). GEMS
documentation provides a written description of your installation's GEMS and directions for
how things should be done. Developing GEMS 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 develop. The following subsections describe the types of GEMS
documentation required.
A. Documentation Hierarchy
Think of GEMS documentation as a tiered system. Four types of GEMS documentation
typically constitute the hierarchy. (Records are not considered part of documentation.)
As you move down the pyramid, the amount of information, the degree of specificity and
the number of pages generally increase.
B. Step-by-Step Guidance
Documentation and records assist employees to perform their jobs in ways consistent
with the installation's environmental policy and the goals and objectives of the GEMS.
The Standard Operating Procedures (SOPs) should incorporate significant environmental
aspects, objectives and targets, and monitoring and measurement procedures into the
daily activities or job practices of facility personnel. Environmental personnel should
work with unit leaders and supervisors to produce SOPs that support the GEMS. These
SOPs give specific, detailed instructions that describe the methods for attaining
environmental goals and, hence, complying with environmental policy. 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 at your facility and maintain steady progress toward
revising the SOPs.
C. GEMS Records
GEMS records are considered part of GEMS documentation. Documentation describes
policies, procedures and other directive information, while records provide a written
history of GEMS performance and actions completed (such as training).
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
5-44
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Sample GEMS Documents Department of Veterans Affairs
Attachment A to Document 5B2-13
Reporting an Oil Spill at
(Facility Name) VA Medical Center
1. In Event of an Oil Spill, call:
TELEPHONE OPERATOR 911
2. Provide the Following Information:
• Material Spilled
• Location of Spill
• Estimated Quantity Entering Sewer, Manhole, etc.
3. Telephone Operators to Inform the Following Personnel:
Work Home Pager
FIRE CHIEF
CHIEF ENGINEER
SAFETY MANAGER
SPILL RESPONSE CONTRACTORS (For external notification)
4. Chief, Facility Management, or Safety Manager will notify:
National Response Center 1-(800) 424-8802
(State) Emergency Management Agency
(State) Department for Air
Water
Waste
FOR SPILLS OF OIL OF ANY SIZE, REPORT TO: 800 482-0777
FOR SPILLS OF HAZARDOUS MATERIALS: 800 452-4664
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Sample GEMS Documents Department of Veterans Affairs
Attachment A to Document 5B2-5
Disclosure of Information on Lead-Based Paint and/or
Lead-Based Paint Hazards
Lead Warning Statement. Housing built before 1978 may contain lead-based paint. Lead from
paint, paint chips and dust can pose health hazards if not managed properly. Lead exposure
is especially harmful to young children and pregnant women. Before renting pre-1978
housing, lessors must disclose the presence of known lead-based paint and/or lead-based
paint hazards in the dwelling. Lessees must also receive a federally-approved pamphlet on
lead poisoning prevention.
Lessor's Disclosure. Presence of lead-based paint and/or lead-based paint hazards.
[Check (i) or (ii) below]:
(i) Known lead-based paint and/or lead-based paint hazards are present in the housing
(explain). It is presumed that lead-based paint exists in all residential quarters due to
the fact that all were constructed prior to 1978. No records exist or are available
pertaining to lead-based paint hazards in residential quarters.
(ii) Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the
housing.
Records and Reports Available to the Lessor. [Check (i) or (ii) below]:
(i) Lessor has provided the lessee with all available records and reports pertaining to
lead-based paint and/or lead-based paint hazards in the housing (list of documents
available are listed below).
(ii) Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint
hazards in the housing.
Lessee's Acknowledgment. (Initial):
Lessee has received copies of all information listed above.
Lessee has received the pamphlet "Protect Your Family from Lead in Your Home".
Agent's Acknowledgment. (Initial):
Agent has informed the lessor of the lessor's obligations under 42 U.S.C. 4852(d) and is
aware of his/her responsibility to ensure compliance.
Certification of Accuracy. The following parties have reviewed the information above and
certify to the best of their knowledge, that what they have provided is true and accurate.
Lessor Date
Lessee Date
Agent Date
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Sample GEMS Documents Department of Veterans Affairs
Attachment A to Report of Annual Effectiveness Review
SAMPLE
Biohazardous Waste Reduction Plan
1. Introduction and Scope.
a. Purpose. This plan sets forth the procedures for achieving the environmental objective of
biohazardous waste reduction. It adds to, without replacing, the local policy and
procedures for segregation and disposal of biohazardous waste at this Medical Center.
Because the disposal of biohazardous waste has a significant impact on the environment,
this GEMS Committee has selected the objective of reducing biohazardous waste by 10%
(by weight) this calendar year. Procedures for achieving this objective and target appear
below.
b. Causal Analysis of Improper Waste Segregation. The GEMS Committee conducted a
waste stream analysis of the waste disposed of in biohazardous waste containers and
determined that about 20% was not biohazardous waste. This means that it could have
been disposed of as municipal waste which would have saved this facility $18,000 last
year. When red-bagged waste comes in contact with non-biohazardous waste, all the
waste is considered biohazardous waste; therefore, the solution is proper segregation
before disposal. A causal analysis directed the GEMS Committee to the following
critical elements to proper waste segregation: Correctly identifying biohazardous waste
and properly disposing of biohazardous waste. The first element speaks to employee
education and behavior management, and the second element involves the availability of
the proper waste containers.
2. Implementation Procedures to Accomplish Goal. The procedures identified in the
Biohazardous Waste Management Medical Center Memorandum #XX remain in effect with
the following additions for this calendar year:
a. Forty-eight additional containers for municipal and biohazardous waste will be placed in
the identified locations to facilitate proper waste segregation. (See the Attachment A,
Municipal and Biohazardous Waste Container Location List.)
b. Monitoring the proper placement of waste containers and the proper segregation of waste
will be conducted monthly during regularly scheduled hazard surveillance rounds by the
hospital team and weekly by the Housekeeping supervisor. Segregation errors and
missing containers will be logged by both, and corrective actions will be instituted,
tracked and reported monthly to the GEMS Committee. (See Attachment B, Waste
Segregation and Waste Container Placement Log and Report Form.).
c. Hospital-wide trends in proper segregation (as determined by reduced error rates) and in
reduction of biohazardous waste will be charted quarterly. Progress in reduction of
biohazardous waste will be posted in the Canteen.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
d. All VAMC employees who come in contact with biohazardous waste will receive
refresher training on waste segregation and disposal from the Infection Control
Practitioner within 60 days of the date this plan is approved. Supervisors of employees
not meeting this requirement will meet with the Associate Director.
e. The Infection Control Practitioner will design, develop and present the refresher training
and will submit the list of topics covered to the GEMS Committee.
f. The Infection Control Practitioner will submit a list of employees requiring refresher
training and report the status of refresher training on a monthly basis until complete.
g. The GEMS Committee will consider a group award for special contribution to this
successful effort. Nominations for the award will be considered at the end of the year
when the annual program evaluation indicates the objective and target were exceeded.
Attachments:
A. Municipal and Biohazardous Waste Container Location List
B. Waste Segregation and Waste Container Placement Log and Report Form
Submitted by: Date:
Chairperson, GEMS Committee
Approved by: Date:
Medical Center Director
5-82
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'ample GEMS Documents Department of Veterans Affairs
ttachmentA to Biohazardous Waste Reduction Plan
Municipal and Biohazardous Waste Container Location List
Container # Container Location
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
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Sample GEMS Documents
Department of Veterans Affairs
Attachment B to Document 5B1-10
PLAN - DO - CHECK - ACT
Environmental Compliance Assurance under GEMS
PLAN
Identify Environmental
Requirements
(Procedure for Legal and Other Requirements)
ACT
Establish and Track Corrective
Actions for Non-Compliance /Non-
Conformance Discovered During
Monitoring and Measuring, Gap
Analysis, and Multi-Media
Compliance Audit
(Procedure for Corrective Actions)
DO
Establish Operational Controls for
Regulated Activities/Materials
(Procedure for Establishing Operational Controls
for Significant Aspects)
CHECK
Monitor and Measure Consistency with
Operational Controls
(Procedure for Monitoring & Measuring)
Conduct GEMS Gap Analysis Annually
(Procedure for Gap Analysis)
Conduct Multi-Media Compliance Audit
Baseline and at Least Every 3 Years
(Measuring and Monitoring Procedure)
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Attachment B to Document SB 1-3
SAMPLE
Green Environmental Management System (GEMS)
Objective & Target Form
(Note: Use one form per objective)
Individual Responsible for Implementation:
Housekeeping Officer and Infection Control Practitioner
Date Oct. 5. 2004
Environmental Objective:
To reduce the generation ofbiohazardous waste.
Related Target(s):
3% reduction by weight ofbiohazardous waste.
Related Significant Environmental Aspect(s):
Air and land pollution due to disposal ofbiohazardous waste.
Service Specific Function and/or Department:
Primary Care, Behavior Health, Surgery, Specialty & Diagnostics, Housekeeping
Target Date (Month/Year): End of Calendar Year
Frequency of Monitoring:
(Check one)
Weekly
Monthly
X
Quarterly
Annually
Action Plan:
Implement biohazard segregation program, implement staff education program, identify areas for
biohazard containers, continuous monitoring during environmental rounds.
How will this objective be met? (Attach additional pages as necessary)
1. Housekeeping will survey all areas of the health care system to determine appropriate placement
of biohazard receptacles.
2. Infection Control will develop training curriculum and deliver staff education.
3. Monitoring will be performed by housekeeping staff during trash removal and surveyed during
environmental rounds.
What operational controls shall be incorporated to achieve this objective?
Strategic placement of waste containers.
How will this objective be tracked? (Attach additional pages as necessary)
All biohazard waste will be weighed prior to transport off-site.
What resources will be required to achieve this objective? (Attach additional pages as
necessary)
Purchase of additional municipal and biohazardous waste containers.
5- 1
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Sample GEMS Documents
Department of Veterans Affairs
Attachment B to Document SB 1-5
SAMPLE
Green Environmental Management System (GEMS) Training Log
Training Topic
GEMS
Awareness
Supervisor
GEMS Training
Hazardous
Waste
Management
Hazardous
Waste
Operations
Spill Prevention
and Response
Chemical
Management
Emergency
Response
Accident
Investigation
Hazardous
Materials
Transport
Hazard
Communication
Personal
Protective
Equipment
Fire Safety
Electrical Safety
Hearing
Conservation
Confined Space
Entry
Lock-out/Tag-
Out
Blood borne
Pathogens
Attendees*
Frequency
Course
Length
Course
Method
Comments
Date
Completed
5-39
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Job-Specific
Training (list)
*Attendees Code
1 All Employees
2 Supervisors/Managers
3 Operators
4 Maintenance
5 Laboratory
6 Clinical
5-40
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Sample GEMS Documents Department of Veterans Affairs
Attachment B to Document 5B2-13
OIL SPILL REPORT
Veterans Affairs Medical Center
(Location)
Operation: Location:
Date: Time of Spill:
Type of Oil Spilled: Amount of Spill:
Did any oil reach a catch basin or sewer? Yes No
Did any oil leave our property? Yes No
Who was contacted: Time:
Description of Spill:
Did the weather affect the spill?_
What actions were taken?
Actions taken to prevent a recurrence:.
How was clean-up material disposed of?_
In-house personnel or contractor who performed clean up:
Name: Signature:
Address: Title:
Phone: EPA #:
Signature of person filing report:
Title of person filing report: Date:
Reviewed by: Title:
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Attachment B to Report of Annual Effectiveness Review
SAMPLE
Green Environmental Management System (GEMS)
Objective & Target Form
(Note: Use one form per objective)
Individual Responsible for Implementation:
Housekeeping Officer and Infection Control Practitioner
Date October 5. 2004
Environmental Objective:
To reduce the generation ofbiohazardous waste.
Related Target(s):
3% reduction by weight ofbiohazardous waste.
Related Significant Environmental Aspect(s):
Air and land pollution due to disposal ofbiohazardous waste.
Service Specific Function and/or Department:
Primary Care, Behavior Health, Surgery, Specialty and Diagnostics, Housekeeping
Target Date (Month/Year): End of Calendar Year
Frequency of Monitoring:
(Check one)
Weekly
Monthly
X
Quarterly
Annually
Action Plan:
Implement biohazard segregation program, implement staff education program, identify areas for
biohazard containers, continuous monitoring during environmental rounds.
How will this objective be met? (Attach additional pages as necessary)
1. Housekeeping will survey all areas of the health care system to determine appropriate placement of
biohazard receptacles.
2. Infection Control will develop training curriculum and deliver staff education.
3. Monitoring will be performed by housekeeping staff during trash removal and surveyed during
environmental rounds.
What operational controls shall be incorporated to achieve this objective?
Strategic placement of waste containers.
How will this objective be tracked? (Attach additional pages as necessary)
All biohazard waste will be weighed prior to transport off-site.
What resources will be required to achieve this objective? (Attach additional pages as
necessary)
Purchase of additional municipal and biohazardous waste containers.
5-
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Sample GEMS Documents
Department of Veterans Affairs
Attachment B to Biohazardous Waste Reduction Plan
Waste Segregation and Waste Container Placement Log
and Report Form
Date
Problem
Location
Corrective Action
Date
Fixed
Date
Rechecked
5-85
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Sample GEMS Documents Department of Veterans Affairs
AttachmentB to Document 5B2-5
Lead-Based Paint Pre-Renovation Certification
Certification of Receipt of Lead Pamphlet:
I have received a copy of the pamphlet, "Protect Your Family from Lead in Your Home",
informing me of the potential risk of the lead hazard exposure from renovation activity to be
performed in my dwelling unit. I received this pamphlet before the work began.
Printed Name of Recipient Date
Signature of Recipient
Self-Certification Option (for tenant-occupied dwellings only). If the lead pamphlet was
delivered but a tenant signature was not obtainable, you may check the appropriate statement
below:
Refusal to Sign. I certify that I have made a good faith effort to deliver the pamphlet,
"Protect your Family from Lead in Your Home", to the rental dwelling unit listed
below at the date and time indicated, and that the occupant refused to sign the
confirmation of the receipt. I further certify that I have left a copy of the pamphlet at
the unit with the occupied.
Unavailable for Signature. I certify that I have made a good faith effort to deliver the
pamphlet, "Protect Your Family from Lead in Your Home", to the rental dwelling
unit listed below, and that the occupant was unavailable to sign the confirmation of
receipt. I further certify that I have left a copy of the pamphlet at the unit by sliding it
under the door.
Printed name of person certifying pamphlet delivery Attempted delivery date and time
Signature of person certifying lead pamphlet delivery
Unit address
Note Regarding Mailing Option: As an alternative to delivery in person, you may mail the lead
pamphlet to the tenant. Pamphlet must be mailed at least seven (7) days before renovation (document
with a certificate of mailing from the post office).
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Sample GEMS Documents
Department of Veterans Affairs
Attachment C to Document 5B2-13
SAMPLE
OIL STORAGE INFORMATION SHEET
Veterans Affairs Medical Center
(Location)
(Complete one for each tank)
SERVICE: Engineering
CONTACTS: Chief, Engineering Service
Engineer
Manager, Safety
TYPE OF FACILITY: Aboveground Fuel Oil Tanks
TANK DESIGNATION: AST Number X
LOCATION: Building X
TOTAL CAPACITY: XX,000 Gallons
TYPE OF OIL: No. X Fuel Oil
POTENTIAL FOR EQUIPMENT FAILURE: Overflow During Filling, Transfer Pump and
Piping
CONTAINMENT: XX,000 Gallon Steel Dike Tank
INSPECTION AND TESTING: Measures for water contamination. Daily manual check for
level of tank, and results are recorded into boiler log. Any irregularities are reported
immediately to emergency contacts listed in this plan.
SPILL HISTORY: None
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Sample GEMS Documents Department of Veterans Affairs
Attachment to Document 5B1-12
GEMS Gap Analysis Tool
Note: The following Criteria Statements were updated April 1, 2004;
therefore, this Tool will vary from the printed version of the Guidebook.
1. Category 1 - Environmental Policy. (ISO 14001, Section 4.2; VHA GEMS Guidebook,
Sections 2.1 and 5.1, Tabs A and B).
a. Policy. Is there an environmental policy in place that supports pollution prevention,
regulatory compliance and continuous environmental improvement?
b. Policy. Is the policy documented, implemented, maintained and communicated to the
employees?
2. Category 2 - Planning.
a Environmental Aspects and Impacts. (ISO 14001, Section 431; VHA GEMS
Guidebook, Sections 2.2, 3.2 and 4.2 and Document 5B1-1).
1) Aspects and Impacts. Has the facility established a procedure to identify the
environmental aspects of the activity, products and services over which it has control
and influence?
2) Aspects and Impacts. Have significant impacts been determined and considered in
setting environmental objectives and targets?
b. Legal Requirements. (ISO 14001, Section 4.2; VHA GEMS Guidebook, Sections 2.3
and 5.1 and Document 5B1-2).
Legal. Is there a procedure to identify, access and evaluate federal, state and local legal
requirements?
c. Objectives and Targets. (ISO 14001, Section 4.3.3; VHA GEMS Guidebook,
Sections 2.4, 2.5 and 3.2 Step 6 and Document 5B1-3).
1) Setting Objectives and Targets. Has a procedure been developed to identify and
document environmental objectives and targets for each relevant function and level?
2) Setting Objectives and Targets. Does the procedure consider legal requirements,
significant aspects and other operational requirements?
d. Plan For Achieving Objectives and Targets. (Environmental Programs) (ISO 14001,
Section 4.3.4; VHA GEMS Guidebook, Sections 2.4 and 2.5 and Documents 5B1-3 and
5B1-4).
1) Plan for Objectives and Targets. Is there a procedure to achieve objectives and
targets and identify the means and acceptable timeframes for accomplishment?
2) Plan for Objectives and Targets. Does the procedure include a designation of
responsibility at each relevant function and level?
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
3. Category 3 - Implementation and Operation.
a Accountability (Structure and Responsibility). (ISO 14001, Section 4.4.1; VHA
GEMS Guidebook, Sections 2.6, 3.1 and 3.2 Steps 1-2 and Document 5B1-4).
1) Accountability. Has top management provided adequate resources? Has top
management appointed a GEMS Coordinator and a GEMS Committee to oversee,
track and report GEMS status and performance?
2) Accountability. Have roles, responsibilities and authorities been defined,
documented and communicated to facility staff to ensure effective environmental
management?
b. Training. (ISO 14001, Section 4.4.2; VHA GEMS Guidebook, Sections 2.7 and 3.2
Steps 2 and 7 and Document 5B1-5).
1) Training. Has the organization identified training needs for those workers who may
create a significant impact on the environment?
2) Training. Does the training include significant environmental impacts, emergency
response procedures and nonconformance with standard operating procedures?
c. Communications. (ISO 14001, Section 4.4.3; VHA GEMS Guidebook, Section 2.8 and
Document 5B1-6).
1) Communications. Is there a procedure for internal communication between the
various levels/functions of the facility, the GEMS Coordinator and the GEMS
Committee?
2) Communications. Is there a procedure in place to coordinate and document inquiries
from external public, private and regulatory organizations?
d GEMS Documentation and Record Keeping. (ISO 14001, Section 444, 453; VHA
GEMS Guidebook, Sections 2.9, 2.10 and 2.15 and Documents 5Bl-5and 5B1-7).
1) GEMS Documentation. Is there a procedure requiring the documenting of the core
elements of the GEMS and explaining their interaction with other facility-related
documents?
2) Record Keeping. Is there a procedure to identify, maintain and dispose of
environmental, training and audit records?
3) Record Keeping. Are environmental records identifiable, legible, readily retrievable
and traceable to activity, product and service?
e. Operational Control. (ISO 14001, Section 4.4.6; VHA GEMS Guidebook, Sections
2.11 and 3.2 Step 5 and Documents 5B1-7 and 5B1-8).
1) Operational Control. Are the operations aligned with significant environmental
aspects and objectives?
2) Operational Control. Are procedures in place to communicate the GEMS
requirements to suppliers and contractors?
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Sample GEMS Documents Department of Veterans Affairs
f. Emergency Response. (ISO 14001, Section 4.4.7; VHA GEMS Guidebook, Section
2.12 and Document 5B1-9).
Emergency Response. Is there an emergency preparedness and response procedure to
recognize and mitigate potential environmental impact?
4. Category 4 - Checking and Corrective Action.
a. Monitoring and Measurement. (ISO 14001, Section 4.2; VHA GEMS Guidebook,
Sections 2.13 and 3.2 Steps 8 and 9 and Document 5B1-10).
1) Monitoring and Measurement. Is there a documented monitoring and measuring
procedure for operations and activities related to significant aspects?
2) Monitoring and Measurement. Does the procedure include requirements for
calibration and recording of information to track performance, operational controls
and conformance objectives and targets?
3) Monitoring and Measurement. Has a periodic (every 3 years) and/or baseline
environmental compliance audit been conducted?
b. Corrective and Preventive Action. (ISO 14001, Section 4.5.2; VHA GEMS
Guidebook, Sections 2.14 and 3.2 Step 9 and Document 5B1-11).
1) Action Plans. Is there a procedure covering the definition of roles and
responsibilities for investigating and determining a cause of nonconformance?
2) Action Plans. Does the procedure include action needed to mitigate impact and
necessary preventive action?
3) Action Plans. Do corrective and preventive action plans address the causes of the
deficiency?
4) Action Plans. Is the effectiveness of corrective and preventive actions verified
before considered completed?
5) Action Plans. Are resources assigned to corrective and preventive actions in order to
complete them in a reasonable timeframe?
6) Action Plans. Are corrective and preventive actions tracked to completion in the
GEMS committee?
d. Gap Analysis. (ISO 14001, Section 4.5.4; VHA GEMS Guidebook, Sections 2.16 and
3.2 Step 8 and Document 5B1-12).
1) Gap Analysis. Does the program have procedures for conducting annual gap
analyses of GEMS?
2) Gap Analysis. Is the scope based on the environmental importance of the activity
and the results of the previous audit?
3) Gap Analysis. Are the results reviewed by the GEMS Committee and the
recommendations forwarded to top management for review?
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
5. Category 5 - Management Review. (ISO 14001, Section 4.2; VHA GEMS Guidebook,
Sections 2.17 and 3.2 Step 9 and Document 5B1-13).
a. Annual Review. Is the management review conducted and documented on an annual
basis and reported in the GEMS Committee?
b. Annual Review. Does the GEMS Committee use the gap analysis results to address the
need for changes to policy, objectives and other GEMS elements?
c. Annual Review. Is there evidence that the facility director (top management)
participates in the annual review (for instance, by signing annual review report)?
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Green Environmental Management Systems (GEMS) Guidebook
Sample Documents
Attachment to Document 5B1-13
SAMPLE
GEMS Committee Report of Annual Effectiveness Review
Excerpt From the Minutes of the GEMS Committee, November 4, 2004
Approved and Signed by the Medical Center Director
1. The Committee found the GEMS effective in its first year, as indicated by:
• Completion of 60 % of the corrective actions for the GEMS Gap Analysis conducted
June 2003
• Completion of 25% of the corrective actions for the baseline Environmental Compliance
Audit, conducted August 2003
• Achievement of the objectives and targets (as modified at the Jan 14 GEMS Committee
Meeting)
2. The Committee recommends the following new objectives and targets for FY 2005:
• 5 % reduction in lawn management chemical usage in FY 2005 compared with FY 2004
(see attached plan for monitoring and accomplishment)
• 10 % reduction in hazardous waste generation in the Research Lab (see attached plan for
monitoring and accomplishment)
3. The following GEMS dashboard summarizes the status of effectiveness evaluations:
GEMS Gap Analysis
Performance
Objectives
Performance Target
Status
Appoint a GEMS
Coordinator and a GEMS
Committee
Coordinator and Committee
will be appointed no later
that the end of the first
quarter.
Mr/Ms, was appointed the GEMS Coordinator
with participants from all organizational units.
Mr/Ms., Associate Director, was appointed
committee chairman.
Conduct a Gap Analysis
to Determine Disparity in
our Present Program
Gap analysis will be
completed by the end of the
second quarter.
The gap analysis was completed February 2004,
with new policies developed as needed and
routed for comments.
Develop and Implement a
GEMS Program
The program will be
published and in effect by
the end of FY 04.
The newly established written GEMS program
was established September 1, 2004.
Environmental Rounds
are Conducted Quarterly
in all Areas (Patient and
Non-Patient) of the
Medical Center to
Demonstrate Compliance
with GEMS.
Surveys conducted 90% of
the time and deficiencies
are corrected within 30
days.
This performance standard was significantly
met during FY 2004. All surveys were
performed as scheduled in MCM 00-46,
Environmental Rounds and in accordance with
the Environment of Care Standards (JCAHO).
However, not all deficiencies were abated
within 30 days. Although 89% (1030/1154) of
the items noted were abated within 30 days, the
percentage fell below the stated goal of 100%.
It should be noted that there was no duplication
5- 1
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
GEMS Gap Analysis
Performance
Objectives
Performance Target
Status
of deficiencies when making rounds the second
time in FY 1999.
Environmental Compliance Audits/Inspections
Compliance
Standard
Safe Drinking Water
(SOW)
Resource Conservation
and Recovery Act
(RCRA)
Air Emissions
Compliance Problem
The well exceeds safe
drinking water standards.
Inspection log not up-to-
date.
Boiler exceeds air emission
standards in permit.
Status
Standards met as evidenced by
Standards met as evidenced by
Standards met as evidenced by
GEMS Targets and Objectives
Performance
Objectives
Red Bag Waste
Pesticide Use
Performance Target
Reduce red-bag waste by
3% by weight by end of
fiscal year.
Change practice of
scheduled pesticide
application to apply when
determined necessary by
sampling through fiscal
year.
Status
Standards met as evidenced by
Standards met as evidenced by
Submitted by:
Date:
Approved by:
Date:
5-2
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Sample GEMS Documents
Department of Veterans Affairs
Attachment to Document 5B2-12
Index of Chemical Classifications
The following index identifies 38 common chemicals (in alphabetical order) found in healthcare
facilities. The reader may utilize this index to identify the chemical classification and
Reportable Quantity (RQ) for each chemical listed. Chemicals not found on the list can be
found in 40 CFR Part 302 or on the Material Safety Data Sheet (MSDS).
Chemical Reportable Name Chemical Classification Reportable Quantity (RQ)
Acetic Acid
Acetone
Acetylene
Alcohol(s)
Ammonium Hydroxide
Ammonium Thiosulfate
Butane
Carbon Dioxide
Chemotherapeutic Drugs
Chlorine (Gas)
Cyanide
Ether
*Ethylene Oxide
Freon
* Formaldehyde
Hydrochloric Acid
Mercury
Methylene Chloride
Methyl-Ethyl-Ketone
Mineral Spirits
Acid
Flammable Liquid 10 Ibs
Flammable Gas
Flammable Liquid
Caustic 1,000 Ibs
Caustic 1,000 Ibs
Flammable Gas
Nonflammable/Asphyxiant
Carcinogen/Chemo Drugs 1 Ib
Nonflammable/Asphyxiant 10 Ibs
Poisons 10 Ibs
Explosive 100 Ibs
Flammable Gas/Carcinogen 10 Ibs
Nonflammable/Asphyxiant
Flammable 1,000 Ibs
Liquid/Carcinogen
Acid 5,000 Ibs
Toxic-Metal 1 Ib
Flammable Liquid 1 Ib
Flammable Liquid 5,000 Ibs
Flammable Liquid
Methyl Methacrylate
Flammable Liquid
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Green Environmental Management Systems (GEMS) Guidebook
Sample GEMS Documents
Muriatic Acid
Naphtha
Nitric Acid
Nitrous Oxide
Perchloric Acid
Phenol
Phosphoric Acid
Picric Acid
Potassium Hydroxide
Propane
Sodium Hydroxide
Sulfuric Acid
Toluene
Trichlorotriflouromethane
Tetra Hydrofuran
Trichloracetic Acid
Xylene
Acid
Flammable Liquid 1,000 Ibs
Oxidizer/Asphyxiant 100 Ibs
Nonflammable Gas
Oxidizer/Acid
Poison
Acid 1 Ib
Explosive/Oxidizer/Acid 1,000 Ibs
Caustic
Flammable Gas
Caustic 1,000 Ibs
Oxidizer/Acid 1,000 Ibs
Flammable Liquid 100 Ibs
Nonflammable Asphyxiant 1,000 Ibs
Flammable Liquid
Acid
Flammable Liquid 1,000 Ibs
*Note: Ethylene Oxide and Formaldehyde are fully regulated chemicals and are, therefore,
addressed with separate Spill Response Guides.
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Sample GEMS Documents
Department of Veterans Affairs
Attachment A to Document 5B2-9
Hazardous Waste Stored for Collection
Date to
Storage
Person
Responsible
Waste
Material
Waste
Phase
Waste
Amount
Container
Size/Type
Container
Number
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Blood Bank/Phlebotomy
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Blood Drawing
Cleaning and
Disinfecting Surfaces and
Equipment
Aspect
Energy Consumption
Hazardous Waste
Disposal, Wastewater
Discharge
Potential for Spills
Use of Paper
Medical Waste
Generation
Handling of Detergent
Disinfectants
Impact
Use of Natural
Resources
Environmental
Contamination
Contamination of
Soil/Water
Use of Natural
Resources
Environmental
Contamination Due
to Improper
Disposal
Potential
Employee/Patient
Exposure
Compliance
1
1
1
0
0
1
Risk
1
1
1
0
4
2
Frequency
Of Activity
3
1
1
2
4
4
VAMC
Control
1
1
1
3
4
2
TOTAL
SCORE
6
4
4
5
12
9
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Clean Air Act Basics
The role of the Federal Government -
The Clean Air Act is a federal law covering the entire country. The
states do most of the work in implementing the Act. The EPA sets
national limits on how much of an air pollutant can be in the air
anywhere in the US. But it makes more sense for the states to take the
lead in carry out the Act because pollution control problems require
specific understanding of local industries, geography, demographics, etc.
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EXPANDED OVERVIEW (Terms)
National Ambient Air Quality Standards
Sets threshold concentrations of criteria air pollutants nationwide.
Criteria Air Pollutants
Carbon Monoxide (CO), Nitrogen Oxides NOx, Sulfur Dioxide (SO2),
Volatile Organic Hydrocarbons (VOC), Particulate Matter (PM).
Threshold concentrations based on human health criteria.
Hazardous Air Pollutants
Toxic air pollutants that cause serious health effects, such as
carcinogens, mutagens, disease causing agents, e.g., benzene, pesticides,
dry cleaning fluid, etc. There are 189 listed, and are subject to MACT
requirements.
Stratospheric Ozone
Ozone depleting substances
Chlorofluorocarbons (CFCs), Hydrcholorfluorocarbons (HCFCs).
Acid Rain
SO2 and NOx, combine with rain to produce sulfuric acid and nitric acid
respectively. Damage to vegetation, lakes, and rivers.
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CAA Regs Impacting Hospitals
BOILERS
ASBESTOS
OZONE DEPLETING SUBSTANCES
HAZARDOUS AIR POLLUTANTS
INCINERATORS
-------
BOILERS - What is Subject to Regulation?
Regulated according to size and date of construction:
Large Boilers - Subpart Db - > 100 MMBtu/hr or 29 MW - Const. After
June 19, 1984
Small Boilers - Subpart DC - > 10 MMBtu/hr or 2.9 MW - Const. After
June 8, 1989
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BOILERS - What is required?
Performance testing
When boilers are constructed (or installed) an initial stack test is
required with results reportable to EPA and the State.
Emission Monitoring
Must monitor for SO2, Opacity, and possibly NOx.
Recordkeeping and reporting
Must Notify EPA when units are constructed. Must keep records of
emission monitoring.
SIP provisions (State permit conditions)
May or not be federally enforceable. Must comply with terms of state
permits.
-------
BOILERS - Compliance Issues
Reporting failures
Monitoring failures
Opacity monitors not installed or not working
Failure to notify EPA upon construction/installation
-------
ASBESTOS
National Emission Standards For Hazardous Air Pollutants
(NESHAPS) for asbestos.
The EPA standards for asbestos operations (applicable in all states)
State regs, City Regs
Varies from state to state. Usually more stringent than federal standards.
Usually requires third party air monitoring and physical containment of
work area.
Threshold amounts, RACM, Category I and II non-friable
Federal: 260 linear ft, 160 square feet, or 1 cubic yard of asbestos
containing material.
NY & NJ - Usually greater than 25 square or linear feet
Work practices. Monitoring, waste manifests, reporting,
recordkeeping
Always requires adequate wetting, waste manifests, notification, and
recordkeeping. NY & NJ also require monitoring, and containment of
work area.
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OZONE DEPLETING SUBSTANCES
Stratospheric Ozone Protection
Regulations that provide for the protection of the stratosphereic ozone
layer by regulating, banning, recycling, or otherwise controlling the
release of Chlorofluorocarbons (CFCs) into the atmosphere.
Applies to equipment with at least 50 Ibs. of CFC - If a leak is detected,
it has to be repaired within 30 days. 15% leak rate for comfort cooling,
and 35% leak rate for all other. Check methods for detecting leaks.
Repair must bring unit below the leak rate.
When equipment is disposed of the equipment must be evacuated. Must
have certified technician. Must go through EPA approved training.
CFC should be recovered and reused. Recordkeeping is required when
systems are evacuated. Evacuation equipment must be certified by
EPA. When purchasing the equipment the certification must be sent to
EPA.
EPA Inspection: Look for the number of units with greater than 501bs.
of CFCs. Look for records of service or repair, purchases of CFCs, and
mechanic certifications.
-------
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Canteen
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Cooking
Cleaning and
Disinfecting Surfaces and
Equipment
Handling of Cardboard,
Plastics, Steel and
Aluminum Cans, etc.
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Generation of Grease
and Food Waste
Handling of Detergent
Disinfectants
Generation of Solid
Waste
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Solid Waste
Generation, Grease
Disposal
Potential
Employee/Patient
Exposure
Generation of Solid
Waste or Potential
for Recycling
Compliance
1
1
1
0
1
1
1
Risk
1
1
1
0
1
2
1
Frequency
Of Activity
3
3
3
3
4
3
4
VAMC
Control
1
3
3
4
3
2
3
TOTAL
SCORE
6
8
8
7
9
8
9
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Cardiac Catheterization Laboratory
Date:
Activity or Service
Patient Preparation
Procedure Maintenance
Film Processing
Operation of Lab
Equipment
Report Generation
Aspect
Improper Disposal of
Betadine Disinfectant
Improper Disposal of
Biomedical Waste
Toner Cartridge
Disposal
Energy Consumption
Use of Paper
Impact
Medical Waste,
Contamination
Contamination
Environmental
Contamination
Use of Natural
Resources
Use of Natural
Resources
Compliance
2
1
0
1
0
Risk
2
4
1
1
0
Frequency
Of Activity
4
4
2
3
1
VAMC
Control
3
3
2
1
3
TOTAL
SCORE
11
12
5
6
4
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Clinical Laboratory
Date:
Activity or Service
Blood Drawing
Receive
Specimens
Handling of
Micro-Organisms
Chemical Usage
Histology Slide
Preparation
Rinsing Slides
Report
Generation
Aspect
Medical Waste Generation and
Disposal
Improper Disposal of
Biomedical Waste
Microbial Contamination,
Release of Microbes Into the
Environment
Hazardous Waste Disposal
Generation of Hazardous
Waste, Transportation of
Hazardous Waste, Disposal to
Sewage System
Wastewater Discharges,
Chemical Disposal
Use of Paper
Impact
Generation and
Contamination
Environmental
Contamination
Disease, Patient
Safety, Employee
Health
Environmental
Contamination
Environmental
Pollution, Water
Usage
Contamination of
Sewage Treatment
Plant, Damage to
Infrastructure
Use of Resources
Compliance
1
1
0
1
0
1
0
Risk
4
O
3
4
4
O
0
Frequency
Of Activity
4
4
2
1
3
2
4
VAMC
Control
4
4
4
3
1
3
0
TOTAL
SCORE
13
12
9
9
8
9
4
-------
7.2 Criteria Statements
1. Category 1 - Environmental Policy (ISO 14001-2004, Section 4.2; VA Directive
0057, paragraph 2.k; VHA GEMS Guidebook, Sections 2.1 and 5B (Sample MCM).
a. Policy. Is there a published environmental policy in place that supports pollution
prevention, regulatory compliance and continual environmental improvement?
b. Policy. Is the policy communicated to the employees and available to the public?
2. Category 2 - Planning
a Environmental Aspects and Impacts. (ISO 14001-2004, Section 4.3.1; VA
Directive 0057, paragraph 2e; VHA GEMS Guidebook, Sections 2.2, 3.2 (Step 4)
and 4.2 and Documents 5B1-1, 5B1-2 and 5B1-3).
1) Aspects and Impacts. Has the facility established a written procedure to
identify the environmental aspects and impacts of its activities, products and
services?
2) Aspects and Impacts. Have significant environmental aspects been
determined and considered in setting environmental objectives and targets?
b. Legal Requirements. (ISO 14001-2004, Section 4.3.2; VHA GEMS Guidebook,
Sections 2.3 (Step 4) and Document 5B1-2).
Legal. Is there a written procedure to identify, access and evaluate federal, state
and local legal requirements?
c. Objectives and Targets. (ISO 14001-2004, Section 4.3.3; VHA GEMS
Guidebook, Sections 2.4, 2.5 and 3.2 (Step 6) and Documents 5B1-3, 5B1-4, 5B2
and 5B3).
1) Setting Objectives and Targets. Is there a written procedure to achieve
objectives and targets. Identify and document environmental objects and
targets for each relevant function and level? Consider legal requirements and
significant aspects and other operational requirements. Identify the means and
acceptable time frames for accomplishment. Designate responsibility at each
relevant function and level.
3. Category 3 - Implementation and Operation
a Accountability (Structure and Responsibility). (ISO 14001-2004, Section 4.4.1;
VA Directive 0057, paragraph 2.b, and 2.c; EO 13148, Section 404(b); VHA
GEMS Guidebook, Sections 2.6, 3.2 (Step 1) and Document 5B1-4).
1) Accountability. Has top management provided adequate resources? Has top
management appointed a GEMS Committee to oversee, track and report
GEMS status and performance?
2) Accountability. Have roles, responsibilities and authorities been defined,
documented and communicated to facility staff to ensure effective
environmental management?
-------
b. Training. (ISO 14001-2004, Section 4.4.2; VA Directive 0057, paragraph 2.j;
VHA GEMS Guidebook, Sections 2.7 and 3.2 (Steps 2 and 7) and Document
5B1-5, Enclosure 6-6).
1) Training. Has GEMS awareness been conducted for all employees?
2) Training. Does New Employee Orientation include GEMS awareness training?
3) Training. Has the organization identified training needs for those workers
who may create a significant impact on the environment?
4) Training. Are employees aware of environmental aspects/impacts associated
with their work activities?
5) Training. Does the worksite specific GEMS training include significant
environmental impacts, emergency response procedures and environmental
consequences of nonconformance with standard operating procedures?
c. Communications. (ISO 14001-2004, Section 4.4.3; VHA GEMS Guidebook,
Section 2.8 and Document 5B1-6).
1) Communications. Is there a written procedure for internal communication
between the various levels/functions of the facility, the GEMS Coordinator
and the GEMS Committee?
2) Communications. Is there a written procedure in place to coordinate and
document inquiries from external public, private and regulatory
organizations?
d GEMS Documentation and Record Keeping. (ISO 14001-2004, Section 444
and 4.4.5; VA Directive 0057, paragraph 2.f; VHA GEMS Guidebook, Sections
2.9, 2.10, 2.15 and 3.2 (Step 5) and Documents 5B1-5 and 5B1-7).
1) GEMS Documentation. Is there a written procedure to ensure all GEMS
policies and procedures are fully integrated and consistent with all other
VAMC policies and procedures?
2) Record Keeping. The written GEMS document control procedure specifies:
1. approval of documents for adequacy prior to issue
2. review and update as necessary and re-approval of documents
3. ensuring that changes and all the current revision status of documents are
identified
4. ensuring that relevant versions of applicable documents are available at
points of use
5. ensuring that documents remain legible and readily identifiable
6. ensuring that documents of external origin, determined by the VAMC to
be necessary for the planning and operation of the GEMS, are identified and
their distribution controlled and
7. preventing the unintended use of obsolete documents and apply suitable
identification to them if they are retained for any purpose.
-------
3) Record Keeping. Is there a written procedure to identify, maintain and dispose
of environmental, training audit records?
4) Record Keeping. Are environmental records identifiable, legible, readily
retrievable and traceable to activity, product and service?
e. Operational Control. (ISO 14001-2004, Section 4.4.6; VA Directive 0057,
paragraph 2.f; VHA GEMS Guidebook, Sections 2.11 and 3.2 (Step 5) and
Documents 5B1-7 and 5B1-8; Construction Safety Guidebook, Chapter 1).
1) Operational Control. Are the VAMC environmental operations aligned with
significant environmental aspects and objectives?
2) Operational Control. Are procedures in place to communicate the GEMS
requirements to suppliers and contractors?
f. Emergency Response. (ISO 14001-2004, Section 4.4.7; VHA GEMS Guidebook,
Section 2.12 and Document 5B1-9; VHA Emergency Management Guidebook).
Emergency Response. Is there an emergency preparedness and response
procedure to recognize and mitigate potential environmental impacts?
4. Category 4 - Checking and Corrective Action.
a. Monitoring and Measurement. (ISO 14001-2004, Section 4.5.land 4.5.2.1; VHA
GEMS Guidebook, Sections 2.13 and 3.2 (Steps 8 and 9) and Document 5B1-10).
1) Monitoring and Measurement. Is there a written monitoring and measuring
procedure for operations and activities related to significant environmental
aspects?
2) Monitoring and Measurement. Does the monitoring and measuring
procedure include requirements for calibration and recording of information to
track performance, operational controls and conformance objectives and
targets?
3) Monitoring and Measurement. Has a periodic (every 3 years) and/or baseline
environmental compliance audit been conducted?
b. Corrective and Preventive Action. (ISO 14001-2004, Section 4.5.3; VHA GEMS
Guidebook, Sections 2.14 and Documents 5B1-4 and 5B1-11).
1) Action Plans. Is there a written procedure covering the definition of roles and
responsibilities for investigating and determining a cause of nonconformance?
2) Action Plans. Does the preventive and corrective action procedure include
action needed to mitigate impact and necessary preventive action?
3) Action Plans. Do corrective and preventive action plans address the causes of
the deficiency?
4) Action Plans. Is the effectiveness of corrective and preventive actions verified
before considered completed?
-------
c. Gap Analysis. (ISO 14001-2004, Section 4.5.5; VA Directive 0057, paragraph 2.c;
VHA GEMS Guidebook, Sections 2.16 and 3.2 (Step 3 and Documents 5B1-11
and 5B1-12).
1) Gap Analysis. Does the program have procedures for conducting annual gap
analyses of GEMS?
2) Gap Analysis. Is the scope based on the environmental importance of the
activity and the results of the previous GEMS gap analysis?
3) Gap Analysis. Are the results of the GEMS gap analysis reviewed by the
GEMS Committee and the recommendations forwarded to top management
for review?
4) Action Plans. Are resources assigned to corrective and preventive actions in
order to complete them in a reasonable timeframe?
5) Action Plans. Are corrective and preventive actions tracked to completion in
the GEMS committee?
5. Category 5 - Management Review.
a.) Annual Review. (ISO 14001-2004, Section 4.6; VHA GEMS Guidebook,
Sections 2.17 and 3.2 (Step 9) and Document 5B1-13).
1) Annual Review. Is the management review conducted and documented on an
annual basis and reported in the GEMS Committee?
2) Annual Review. Does the GEMS Committee use the gap analysis results to
address the need for changes to policy, objectives and other GEMS elements?
3) Annual Review. Is there evidence that the facility director (top management)
participates in the annual review (for instance, by signing annual review
report)?
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Dental Clinic/Laboratory
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Radiography
Tooth Restoration
X-raying Teeth
Generation of Regulated
Medical Waste
Aspect
Energy Consumption
Hazardous Waste
Disposal,
Employee/Patient
Exposure
Hazardous Waste
Disposal and Spills
Use of Paper
Generation of Spent
Photo Processing
Fluids
Use of Mercury
Amalgam and Other
Precious Metals
Generation of Lead
Foil
Exposure to Biological
Contaminants
Impact
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Discharge of
Hazardous Waste,
Employee Exposure
to Hazardous
Chemicals
Generation of
Mercury Waste, Use
of Silver and Gold
Generation and
Disposal of Lead
Products
Disease
Transmission,
Environmental
Contamination
Compliance
1
1
0
0
0
0
1
1
Risk
1
1
2
0
2
3
1
O
Frequency
Of Activity
O
3
4
2
3
4
O
4
VAMC
Control
1
4
4
O
3
3
O
4
TOTAL
SCORE
6
9
10
5
8
10
8
12
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Dialysis
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Disposal of Dialysis
Filters
Analysis of Patient Blood
Ozone Used in Water
Treatment System
Drug Preparation and
Administration
Aspect
Energy Consumption
Hazardous Waste
Disposal, Wastewater
Discharge
Hazardous Waste Spills
Use of Paper
Medical Waste
Generation
Regulated Medical
Waste Generation
Energy Consumption,
Air Emissions
Improper Disposal
Impact
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Environmental
Contamination,
Occupational
Disease
Compliance
1
1
0
0
0
0
0
0
Risk
1
2
2
0
4
4
1
1
Frequency
Of Activity
3
3
3
2
3
4
3
4
VAMC
Control
1
2
2
3
4
4
4
4
TOTAL
SCORE
6
8
7
5
11
12
8
9
-------
Generation of Regulated
Medical Waste
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Exposure to Biological
Contaminants
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Disease
Transmission,
Environmental
Contamination
Employee/Patient
Disease
Potential
Employee/Patient
Disease
1
1
1
3
2
2
4
4
4
4
3
2
12
10
9
-------
Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
Directory of Acronyms
AEE Agency Environmental Executive
ALARA As low as reasonably achievable
A&MM Acquisition and Materiel Management
AMSTM American Society of Testing and Materials
ANSI American National Standards Institute
AP Affirmative Procurement
AST Aboveground Storage Tank
BMP Best Manufacturing Practice
CAA Clean Air Act
CBOC Community Based Outpatient Clinic
CEMP Code of Environmental Management Principles
CEOSH Center for Engineering & Occupational Safety and Health
CERCLA Comprehensive Environmental Response, Compensation and Liability Act
CFR Code of Federal Regulations
CNG Compressed Natural Gas
CPG Comprehensive Procurement Guideline
CWA Clean Water Act
dBA Decibel
DEP Department of Environmental Protection
DOD Department of Defense
DOT Department of Transportation
ECI Environmental Condition Indicator
EHS Extremely Hazardous Substance
EO Executive Order
EPA Environmental Protection Agency
EPCRA Emergency Planning and Community Right-To-Know Act
xv
-------
Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
EPI Environmental Performance Indicator
ESA Environmental Site Assessment
E-SAFE Environmental Safety Automated Facility Evaluation
ESD Executive Services Department
EtO Ethylene Oxide
FAR Federal Acquisition Regulations
FIFRA Federal Insecticide, Fungicide and Rodenticide Act
GEMS Green Environmental Management Systems
GSA General Services Administration
HAZCOM Hazard Communication
HAZMAT Hazardous Material
HMTA Hazardous Materials Transportation Act
IL Information Letter
IPM Integrated Pest Management
IRAP Independent Remedial Action Program
ISO International Organization for Standardization
JCAHO Joint Commission on Accreditation of Healthcare Organizations
LEED Leadership in Energy and Environmental Design
MCM Medical Center Memorandum
MPI Management Performance Indicator
MSDS Material Safety Data Sheet
NEPA National Environmental Policy Act
NESHAP National Emissions Standard for Hazardous Air Pollutants
NHPA National Historic Preservation Act
NPDES National Pollution Discharge Elimination System
ODS Ozone Depleting Substances
OMB Office of Management and Budget
OPI Operational Performance Indicator
P2 Pollution Prevention
P&D Processing & Decontamination
xvi
-------
Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
PCB
PDSA
PL
PPA
PPE
ppm
PRV
PVC
QA
RCRA
RPG
RQ
SARA
SDWA
SOP
SPCC
STEL
T&E
TRI
TSCA
TSD
TWA
use
USDA
USEPA
UST
VA
VACO
VAMC
VHA
Polychlorinated Biphenyl
Plan, Do, Study, Act
Public Law
Pollution Prevention Act
Personal Protective Equipment
Parts Per Million
Pressure Relief Valve
Polyvinyl Chloride
Quality Assurance
Resource Conservation and Recovery Act
Recycled Products Guide
Reportable Quantity
Superfund Amendments and Reauthorization Act
Safe Drinking Water Act
Standard Operating Procedure
Spill Prevention, Control and Countermeasures
Short Term Exposure Limit
Threatened and Endangered
Toxic Release Inventory
Toxic Substance Control Act
Treatment, Storage or Disposal
Time-Weighted Average
United States Code
United States Department of Agriculture
U.S. Environmental Protection Agency
Underground Storage Tank
Department of Veterans Affairs
VA Central Office
VA Medical Center
Veterans Health Administration
xvn
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
VISN Veterans Integrated Service Network
VOC Volatile Organic Compound
xvin
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Domiciliary
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Generation of Regulated
Medical Waste
Activities to Include
Ceramics, Wood Shop,
Horticulture, etc.
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Exposure to Biological
Contaminants
User of Paints,
Solvents, Glazes,
Pesticides, Herbicides,
etc.
Impact
Use of Natural
Resources
Health Effect,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Disease
Transmission,
Environmental
Contamination
Health Effects,
Environmental
Contamination
Compliance
1
1
1
0
1
1
Risk
1
1
1
0
3
O
Frequency
Of Activity
3
2
2
4
2
2
VAMC
Control
1
4
4
4
4
3
TOTAL
SCORE
6
8
8
8
10
9
-------
Enclosure 1-5
\ Formatted
Highlights
• All 21 VISNs provide complete sifcmissions.
• Cost of waste disposal decreased 32.1% since FY '96.
• Recycling efforts generate $414,711 in revenue.
Inside
» FY '02 costs for all waste categories sirveyed.
» FY '02 poinds or Cu. Ft. generated in each category.
» FY '02 recycling data and
VHA's Environmental Goals.
FY '02 Waste Minimization & Compliance Report
The Office of Facilities
Management (18)
January 2004
Environmental Programs Service (181C)
FY '02 Waste Minimisation Survey on Waste Minimisation
and Recycling Activities within Veterans Health Administration
Veterans Health Administration (VHA) Directive 99-
037 provides the format for reporting data on waste
categories, volume, environmental compliance, and
recycling activities to the Environmental Protection
Agency (EPA), the Office of the Federal
Environmental Executive (OFEE), the Agency
Environmental Executive (AEE), as well as other
Administrations within the Department of Veterans
Affairs (VA).
The FY '02 Waste Minimization and
Compliance Report represents the ninth in a
series of annual efforts by VHA to accurately
track waste minimization and recycling
programs within VHA health care facilities.
This report includes the total cost, total
pounds (except for Radioactive Waste),
highest and lowest cost, and highest and
lowest amount generated for the Veterans
Integrated Service Networks (VISNs) in the
following reporting areas: Solid Waste,
Regulated Medical Waste, Hazardous Waste,
Radioactive Waste, Recycling Programs and
Procurement of Recycled Products. It should
be noted that at the time of this survey, there
were 21 VISNs. All reporting areas were
compared with the results of the FY '96
survey that is used as the baseline survey.
The total FY '02 cost for all waste disposal was
$16,163,626. Compared to FY '96, this represents a
decrease of 32.1%. The FY '02 total pounds of waste
generated were 244,936,045. Compared to FY '96,
this represents a decrease of 1.1%.
The FY '02 highest total cost per VISN of
waste generated was $1,656,652. The lowest
total cost of waste generated was $305,726
in VISN 2. The highest total pounds per VISN
of waste generated were 38,247,006. The
lowest total pounds of waste generated were
4,047,546 in VISN 2.
The FY '02 average cost of waste disposal excluding
radioactive waste was 6.4 cents per pound.
Compared to FY '96, this represents a decrease of
26%. The highest average cost per VISN was 18.1
cents per pound. The lowest average cost was 3.1
cents per pound in VISN 16.
- - .x */
u f- ml%X
» "' "'/ ! I5"'
» ',. » i «fi
-------
FY '02 PERCENT COST OF WASTE DISPOSAL BY CATEGORY
TOTAL COST=$16,163,626
D Regulated Medical Waste
• Hazardous Waste
D Solid Waste
D Radioactive Waste
COST OF WASTE DISPOSAL IN $ PER POUND
TOTAL EXPENDITURES FOR WASTE REMOVAL/DISPOSAL IN VHA
$30,000,000
$25,000,000
$20,000,000
$15,000,000
$10,000,000
$5,000,000
$-
FY '92 FY '93 FY '94 FY '95 FY '96 FY '99 FY'OO FY'01 FY'02
Deleted: 2
-------
Solid Waste
The term "solid waste" refers to any garbage, refuse,
sludge and other discarded materials including solid,
liquid, semisolid or contained gaseous material.
Although these wastes are not normally designated as
hazardous, they must still be managed to prevent
pollution of the environment.
Many of the key components of the typical
health care facility solid waste stream
include packing, waste from central supply
and dietary services, non-hazardous
biological wastes, non-hazardous
combustible and non-combustible wastes.
Wastes generated from construction,
renovation and demolition activities are also
included.
The FY '02 total cost of solid waste disposal was
$8,903,864. Compared to FY '96, this represents a
decrease of 36%. The highest total cost per VISN of
solid waste disposal was $997,430. The lowest total
cost of solid waste disposal was $111,822 in VISN 2.
The FY '02 total pounds of solid waste
generated were 213,835,696. Compared to
FY '96, this represents an increase of 2.9%.
The highest total pounds per VISN of solid
waste generated were 34,952,373. The
lowest total pounds of solid waste generated
were 3,417,700 Ibs in VISN 2.
Regulated Medical Waste
Regulated Medical Waste (RMW) is also referred to as
infectious waste, potentially infectious medical waste,
etc., and includes any waste material or article that
harbors, or may be reasonably expected to harbor
pathogens that might be expected to produce disease
in healthy individuals. This category may include
cultures and stocks, pathological wastes, human and
blood products, used sharps, animal wastes and
isolation wastes.
Due to the increasing regulations in air
quality, many VHA health care facilities do
not treat their RMW but contract directly for
transportation and disposal. Where treated
on site, treatment methods identified in the
Waste Minimization Survey included steam
sterilization, incineration and other
alternative methods of treatment.
The costs for disposal of RMW included treatment
costs (where utilized) plus contract disposal costs.
This was because where RMW was treated onsite, the
residue, ash or unrecognizable materials were
disposed of off site by contract.
The FY '02 total cost of RMW disposal alone
was $5,449,901. Compared to FY '96, this
represents a decrease of 29%. However, the
cost per pound for disposal increased 2.2%.
The highest cost per VISN for RMW disposal
was $762,922. The lowest cost for RMW
disposal was $115,402 in VISN 9.
The FY '02 total pounds of RMW generated were
30,369,592. Compared to FY '96, this represents a
decrease of 20.2%. The highest total pounds per
VISN of RMW generated were 6,183,007. The lowest
total pounds of RMW generated were 281,849 in
VISN 21.
The FY '02 total pounds of RMW treated on
site were 10,129,076. The highest total
number of pounds per VISN of RMW treated
on site was 2,629,571. The lowest total
number of pounds of RMW treated on site was
6,528 in VISN 1.
Deleted: 2
-------
Hazardous Waste
The EPA has designated hazardous waste as waste
that meets one or more of the following
characteristics: (1) igmtable, (2) corrosive, (3) reactive
and (4) toxic. The Resource Conservation and
Recovery Act (RCRA) regulates the storage, treatment
and disposal of hazardous waste.
The Hazardous Waste section of the Waste
Minimization Survey asked for specific
responses from each VHA health care facility
as to the number of pounds generated, costs
for disposal from the waste disposal
manifests, spill control plans, date of last
chemical inventory, presence of a waste
minimization program, and waste disposal
costs for research activities. In addition,
questions were developed to identify the
number of pounds of halon present in
extinguishing systems and the status of any
replacement projects.
The FY '02 total cost of hazardous waste disposal was
$1,431,631, which represented a 7.7% decrease over
FY '96. The highest total cost per VISN of hazardous
waste disposal was $198,943. The lowest was $8,086
in VISN 2. It is important to note that the cost per
pound of disposal increased 100% to $1.96 per pound
during this period.
The FY '02 total pounds of hazardous waste
generated were 730,757. Compared to FY
'96, this represents a decrease of 45.5%. The
highest total pounds per VISN of hazardous
waste generated were 112,067. The lowest
was 9,607 in VISN 19.
Virtually every facility identified a waste minimization
program in place for hazardous waste, written
agreements with the local publicly owned treatment
works for effluent discharge, and a completed
chemical inventory within FY '02. VHA health care
facilities were using solvent recovery systems with
xylene and alcohols being the most frequently
recovered items. For FY '02 VHA spent $ 85,051 to
remove 26,476 Ibs of mercury and materials
containing mercury from the health care
environment.
The cost of hazardous waste disposal in VHA
from research activities was $529,967 or 37%
of the total VHA cost.
The amount of halon remaining in extinguishing
J o o o
systems was 1,346 Ibs.
Radioactive Waste
The survey collected information on radioactive
materials primarily subject to regulation by the
Department of Transportation and the Nuclear
Regulatory Commission that comes from sources
such as dry solid, biological waste, scintillation vials,
absorbed, regulated, mixed and other.
In FY '02, 9.606 cubic feet of radioactive
waste was generated with a disposal cost of
$378,630 and $78,302 in permits and fees.
Compared to FY '96, this represents a
decrease of 35.3% in cost. The highest total
cost per VISN of radioactive waste disposal
was $91,000, and the lowest was $2,565 in
VISN 1. The most frequently identified land
disposal site was Barnwell, SC.
Recycling Programs
For the purpose of collecting accurate data on
recycling programs, VHA health care facilities were
required to indicate proceeds (+) or costs (-) and
Deleted: 2
-------
pounds of recycled materials for a variety of items,
which historically have been major components of a
recycling program. These included, but were not
limited to wood, paper, glass, metal, plastics, rubber,
batteries, silver, fluorescent lamps, etc. It is important
to note that facilities may have difficulty in collecting
accurate proceeds/cost and pounds of recycled
materials. This information is often kept by a number
of services and individuals and is not often
centralized.
Waste Management Policy is currently
defined in M-1, Part 7, Chapter 14, and further
information is available in VHA Program
Guide 1850.1, Recycling Program. A
recycling coordinator can help to monitor the
recycling programs and nominate the facility
for a number of environmental award
programs. Effective recycling programs may
not always generate proceeds, but may
realize direct dividends in cost avoidance.
Proceeds from the recycling program may be retained
and utilized locally to promote environmental
programs at the discretion of the VHA health care
facility director.
There were a substantial number of
successful new initiatives in recycling in VHA
for the FY '02 reporting period that resulted in
increased proceeds or cost avoidance in
other areas. The most frequently identified
problems were the lack of a local market and
disposal of construction debris. However,
the overall result was a net proceed.
The FY '02 total proceeds were $414,711. Compared
to FY '96, this represents a decrease of 11%. The
greatest total proceeds of recycled materials were
$2,478,295 in VISN 15. The greatest cost per VISN
of recycled materials was $157,359.
The FY '02 total pounds of materials recycled
were 36,307,349. Compared to FY '96, this
represents an increase of 19.3%. The
greatest total number of pounds of materials
recycled was 4,765,272 in VISN 3. The
lowest number of pounds per VISN of
materials recycled was 421,043.
The FY '02 new? initiatives in recycled programs
resulted in total cost avoidance of $875,879. The
greatest cost avoidance was $136,969 in VISN 23.
The lowest cost per VISN avoidance was $0.
Recycling initiatives generated from this report
Procurement of Recycled Products
The procurement of recycled items is normally
addressed separately in the RCRA 6002 Report. This
report is forwarded annually to the Federal
Environmental Executive at the OFEE.
The data requested includes the dollar
amount spent in each Federal agency in
procuring recycled, re-refined and reusable
items for a variety of specified categories.
The FY '02 total dollar amount of recycled, re-refined
and reusable materials was $21,070,153.
The highest total dollar amount of these materials
purchased was $2,512,607 in VISN 8. The lowest
total dollar amount per VISN of these materials
purchased was $231,948.
Deleted: 2
-------
PERCENT OF ATTAINMENT OF ENVIRONMENTAL GOALS
Pounds of Waste
Generated
Cost of Waste Generated
Pounds of Materials
Recycled
Proceeds From Recycled
Materials
Environmental Goals
Executive Order 13101, Greening the Government
Through Waste Prevention, Recycling, and Federal
Acquisition, required each Federal Agency to establish
goals in waste prevention, recycling and acquisition of
recovered materials for the years 2000, 2005 and
2010.
On April 5, 1999, the Under Secretary for
Health established the environmental goals
for January 1, 2000. The baseline data for
developing these goals was the data derived
from the FY '96 Waste Minimization Survey,
although no accurate data on the
procurement of recovered materials was
available at that time.
For the waste prevention category, the January 1,
2000, goals were 234,010,010 Ibs in total waste
generated with $20,901,010 in total disposal costs.
The measured results were 244,936,890 Ibs in total
waste generated (4.7% short of the goal) and
$16,071,799 (23.1% above the goal).
For the recycling category, the January 1,
2000, goals were 32,010,010 Ibs of total
materials recycled with $323,010 in
proceeds. The measured results were
36,307,349 total pounds of materials
recycled, 13.4% above the goal, and $414,711
in proceeds, 28.3% above the goal.
For Further Assistance
The FY '02 Waste Minimization and Compliance
Report was the collaborative effort of many dedicated
professionals. This report is part of an ongoing
review? of the waste minimization, recycling and
pollution prevention (P2) programs in VHA.
The survey questionnaire will be updated
annually as requirements for environmental
compliance and agency responsibilities
continue to evolve.
Your opinions are important to us. For further
information or clarification on this report, please
contact Mr. Gregory L. Winters, Program Manager,
Environmental Programs Service (181C), at (202)
565-8525, or e-mail to his attention using the Service's
address at, yHACOEPSl 81 C@hq.med.va.gov. The_
report is also available at this Web address: T
http://www. va.gov/facmgt/environmental.
Deleted:
VHACOEPS181CfaJha.med.Yii.poY
Deleted: htto://www.va.irov/facmp-t/en
Deleted: 2
-------
VHA Environmental Training Program Plan
Training
Agenda
Audience
Forum
Resources
Regulatory Compliance Training
National
Environmental VA
Meeting Kick-off
Environmental
Compliance 101
RCRA Hazardous
Waste Mgmt
Training and Annual
Refresher
Identification of
Hazardous Waste
for Healthcare
Required
Certification
Training
Laboratory-Specific
Environmental
Training
DOT training
Intro by top VA mgmt. to show
environmental commitment, overview
of major statutes, and environmental
management systems.
Overview of major statutes (i.e.,
RCRA/ UST, CAA, CWA [SPCC,
storm water, wetlands] EPCRA, TSCA
[Lead, PCBs], SDWA, FIFRA).
Compliance with other requirements
such as Executive Orders and VA
policy, etc.
Required EPA hazardous waste
management training.
Detailed discussion on waste
characterization.
Necessary training to be certified to
perform task.
Describes the environmental
requirements and best management
practices that relate to laboratories
such as RCRA, CWA, and CAA. At a
minimum, it will satisfy the training
requirements of RCRA 265. 16. Also,
covers auditing questions.
Environmental Coordinators, HQs
& VISN Safety/Health, Medical
Center Directors/ Associate
Directors
Environmental Coordinators,
HQs, VISN Safety/Health,
Program/Service Managers,
Director/ Associate Directors
Environmental Coordinators,
VISN Safety/Health
Environmental Coordinators,
HQs, VISN Safety/Health
Employees such as HVAC,
wastewater treatment, pesticides
applicators, boiler plant operators
Environmental Coordinator,
VISN Safety/Health, Laboratory
employees, including the
Laboratory Program Manager
Environmental Coordinators,
Warehouse shippers
4 day (2 day
compliance, 2 day
GEMS) conference
face-to-face in Spring
2004. Taped for future
use by VA.
1-1 !/2 day face-to-face
in each EPA Region
during FY2004 that
will be taped for future
use by VA.
Distance Learning by
VA.
1 day - could be
broadcast or
videotaped.
As required.
CD-ROM or interactive
video developed by
VA.
With EPA HQ & regional help
(suggestion to make it a
civilian-wide conference &
add RCRA training).
EPA Regions FFPMs -
Region 1 will hold in October
2003.
Numerous contractors give
course. NETI RCRA Inspector
Training CD-ROM.
EPA Region 2 has developed -
to be given November 12th.
Many contractors give course.
GEMS guide for small
Laboratories. Lab 21 Web
site.
-------
Training
UST Training
Module
SPCC Training
Module.
Clean Water Act
Training Module.
Toxic Substances
Training Module
Facilities
Maintenance
Module
Clean Air Act
Training Module
Medical Waste
Training Module
EPCRA Training
Module
Agenda
Review of the underground storage
tank requirements. Includes auditing
questions.
Review of the SPCC requirements at a
facility. Includes how to develop a
SPCC plan and auditing questions.
Review of the CWA requirements at a
facility such as NPDES, pre-treatment,
wetlands, and storm water. Includes
auditing questions. May want to
include security issues as relates to
wastewater plants.
Describes requirements and best
management practices related to
Asbestos, Lead-Paint, PCBs and
Mercury. Includes auditing questions.
Environmental Requirements & best
management practices that apply to the
facilities maintenance operations such
as CAA, CWA, SDWA (UIC), FIFRA,
RCRA, Universal Waste, TSCA,
beneficial landscaping, etc. It must
meet the RCRA 260. 16 training
requirements. Includes auditing
questions.
Review of Clean Air Act requirements
that apply to healthcare facilities.
Includes auditing questions.
Review of requirements related to
medical waste. Includes auditing
questions.
Review of EPCRA requirements.
Includes auditing questions.
Audience
Environmental Coordinators,
VISN Safety/Health, Facility
Engineer
Environmental Coordinators,
VISN Safety/Health, Facility
Engineer
Environmental Coordinators,
VISN Safety/Health, Wastewater
Plant Operators, COTR if
construction project
Environmental Coordinators,
VISN Safety/Health, COTR if
demolition/renovation project
Environmental Coordinators,
VISN Safety/Health, Facilities
maintenance personnel (e.g.,
motor pool, paint shop, grounds
keeping, HVAC, plumbing,
electricians, carpentry, etc.)
Environmental Coordinators,
VISN Safety/ Health, Boiler
personnel
Environmental Coordinators,
VISN Safety/ Health,
Housekeeping
Environmental Coordinators,
VISN Safety/ Health
Forum
CD-ROM or interactive
video developed by
VA.
CD-ROM or interactive
video developed by
VA.
CD-ROM or interactive
video developed by
VA.
CD-ROM or interactive
video developed by
VA.
CD-ROM or interactive
video developed by
VA.
CD-ROM or interactive
video developed by
VA.
CD-ROM or interactive
video developed by
VA.
CD-ROM or interactive
video developed by
VA.
Resources
UST guidebooks & website.
EPA UST presentations. UST
auditing protocol.
SPCC website. EPA SPCC
presentations. SPCC booklets.
EPA NPDES website. EPA
presentations. Construction
Compliance Assistance
Center.
EPA Asbestos webpage.
Numerous Mercury
elimination documents.
Auditing Protocol for TSCA.
EPA's national CA centers.
EPA Web site. CFC
checklists.
State Agencies.
EPA Web site. EPA TRI
courses.
-------
Training
Agenda
Audience
Forum
Resources
SDWA Training
Module
Review of SDWA requirements. May
want to include security issues as
related to drinking water plants.
Includes auditing questions.
Environmental Coordinators,
VISN Safety/ Health, Drinking
Water Treatment Plant Operators
CD-ROM or interactive
video developed by
VA.
EPA Web site.
Dental
Environmental
Compliance Module
Review of requirements and best
management practices related to dental
facilities, such as RCRA. Including
auditing questions.
Environmental Coordinators,
VISN Safety/ Health, Dental
personnel
CD-ROM or interactive
video developed by
VA.
Vermont's Dental Guide.
Pharmacy
Environmental
Compliance Module
Review of requirements and best
management practices related to
pharmacies, such as RCRA. Includes
auditing questions.
Environmental Coordinators,
VISN Safety/ Health, Pharmacy
personnel
CD-ROM or interactive
video developed by
VA.
Pharmacology Web site.
Environmental
Compliance for
Lawyers
Review major environmental laws
applicable to VAMCs, state and federal
regulator's procedures for inspections,
violations, fines; and VAMC legal
defense strategies.
District Counsel
Green Environmental Management Systems Training
GEMS Training For
Top Management
Designing Your
GEMS - Federal
Facility Workshop
GEMS Element-By-
Element Hands-On
Training
Facility-Specific
GEMS Training
ISO 14001 Lead
Auditor Course
Overview of GEMS Elements.
More detailed discussion of
GEMS elements and hands-on
workshop with VA examples.
Detailed discussion of
elements - one element at a
time with facility -specific
help.
Training on facility-specific
policies and procedures.
Training on how to conduct a
GEMS audit.
Directors and
Associate Directors at VAMC, HQs
and VISN level GEMS Coordinators
and Auditors
GEMS Coordinators & Auditors
GEMS Coordinators,
Program/Service Managers (or
designated person)
Employees
VISN GEMS Auditor
2 Hour broadcast by VA.
2-day conference. Same as
what is offered in Kick-off.
V-TELbyVISN. Done once
a month until EMS complete.
Varies depending on facility
developed by facility.
Classroom for 5 days.
See metal finishing GEMS
workshops
Offered by many contractors.
-------
Pollution Prevention/Environmental Stewardship
Environmental
Preferable
Purchasing/ RCRA
60027 Executive
Orders
Waste
Minimization/
Product Substitution
Green Cleaning
Green Building
Indoor Air Quality
P2 Training for
Auto Repair Shops
Best Management
Practices for
Outdoor Shooting
Ranges
Training on buying
environmentally preferable
products and complying with
RCRA 6002 and Executive
Orders.
Training on waste
minimization at healthcare
facilities.
Awareness of more
environmentally and safer
cleaning products.
Awareness of building and
renovating in a greener
manner.
Training on indoor air quality.
Training on pollution
prevention techniques
available to auto repair
shops/fleet maintenance.
Best management practices for
outdoor shooting ranges.
Environmental Coordinators, VISN
Safety/Health, COTRs, COs, Credit
Card Holders, Chief, Acquisition &
Materiel Management
Environmental Coordinators, VISN
Safety/ Health, Program/Service
Managers, Credit Card Holders,
COTRs, COs
Environmental Coordinators, VISN
Safety/Health,
Housekeeping/Laundry
Environmental Coordinators, VISN
Safety/Health, COTRs
Environmental Coordinators, VISN
Safety/Health, COTRs
Motor Pool, Environmental
Coordinators, VISN Safety/ Health
Outdoor shooting ranges if built.
CD-ROM, interactive videos,
PowerPoint presentations.
CD-ROM, videos
CD-ROM, videos.
CD-ROM, videos.
CD-ROM by VA.
Video and workbooks.
Guidance Document.
H2E, EPA EPP Program,
OFEE. Lyons VA.
H2E, EPA Wastewise.
EPA EPP Program, Greening
Govt CD EPA Regions 1-3.
EPA.
Completed.
EPA Region 9 has completed.
EPA Region 2 Guide.
-------
Green Environmental Management Systems (GEMS) Training Needs Assessment
VA Personnel
Top Management - VAMC and Network
Directors/Associate Directors, VACO Research,
Medical Center Chief of Staff, District Counsel
GEMS Coordinators & other GEMS Committee
Members
VISN GEMS Auditor
Program/Service Managers (Engineering,
Laboratories, Housekeeping, Acquisition,
Clinical)
Clinical, Research, and Dental Laboratory &
Morgue Employees
Facility Maintenance (HVAC, Motor Pool, Paint
Shop, Plumbers, Electricians, Carpentry, Grounds
Keeping, Silver-Recovery)
Warehouse - shippers & receivers
Facility Engineer
Wastewater Plant Operators
Drinking Water Treatment Plant Operators
Facilities Management - Contracting Officer
Technical Representative
Acquisition and Materiel Management -
Contracting Officers
Training Needed
GEMS for Top Managers, Environmental Compliance 101 for Top Managers.
GEMS for Top Managers, Designing your GEMS workshop, GEMS monthly
workgroup, Environmental Compliance 101, RCRA & Universal Waste required
training, Identification of Hazardous Waste Training, Environmental Coordinator
Training (series of modules on statutes to be able to audit the facility).
Everything above and GEMS ISO 14001 auditor training.
GEMS for top managers, GEMS monthly workgroup, Environmental Compliance 101,
Modules of Environmental Coordinator Training that applies to specific program/service.
Laboratory-Specific Environmental Training Module. Facility-specific GEMS training
(after GEMS developed).
Facility Maintenance Environmental Training Module. CAA/Section 608 & 609
required training if needed. Pesticide Applicator Training if needed. P2 for Auto Repair
(R9) training if applicable. Facility-specific EMS training (after GEMS developed).
DOT Training, Facility-specific GEMS training (after GEMS developed).
UST and SPCC modules, Facility-specific GEMS training (after GEMS developed).
CWA module, Applicable Wastewater Certification Training, Facility-specific GEMS
training.
SDWA module, Applicable Drinking Water Certification Training, Facility-Specific
GEMS Training.
Environmental Compliance 101, Environmental Preferable Purchasing/RCRA 6002
Training, Waste Minimization Module, Asbestos, Storm water, Indoor Air Quality,
Wetlands, Green Building, Real Property Transition Due Diligence & Lead Paint
Modules as need arises, Facility-specific GEMS training.
Environmental Compliance 101, Environmentally Preferable Purchasing/RCRA 6002,
Waste Minimization.
-------
VA Personnel
Housekeeping/Laundry Workers
Dental Clinics that are not labs
Pharmacists, Pharmacy Technicians, & other
clinicians who handle disposal of drugs
Boiler Plant Operators
Shooting Range Operator
District Counsel
Training Needed
Pesticides Applicator Training as required, Medical Waste Module, Green Cleaning,
Integrated Pest Management, Facility-Specific GEMS training.
Dental Clinic-specific Environmental Training. Facility-specific GEMS training.
Pharmacy-specific environmental training. Facility-specific GEMS training.
CAA module. Facility-specific GEMS training.
EPCRA/TRI module, RCRA module, Best Management Practices for Outdoor Shooting
Ranges if applicable, Facility-specific GEMS training.
Environmental compliance for lawyers.
-------
GEMS Concepts
What is GEMS?
The VHA GEMS (Green Environmental
Management Systems) is a formal system for
integrating the environmental footprint into the
overall management of the organization.
Required by presidential Executive Order 13148,
the goal of GEMS is to achieve continual
improvement in environmental protection.
GEMS and JCAHO.
GEMS follows the plan-do-check-act model,
making it easy to integrate with the JCAHO
Environment of Care programs at healthcare
facilities. In fact, many of the requirements for
GEMS are already in place and being tracked by
facility Safety or Environment of Care
Committees.
PLAN - DO - CHECK - ACT
Management
Review
— *-
/ ixunmuai
I Improvemei
Checking &
Corrective
Action
it
Environmental
Policy &
Planning
2
Implementation
& Control
PLAN
The planning phase includes creating an
environmental policy, identifying environmental
aspects and impacts of the healthcare facility
activities, and establishing environmental
objectives and targets and the plans for
achieving them.
DO
Accountability for GEMS activities is established
by identifying the structure and responsibilities
through medical center memoranda, conducting
training on GEMS concepts and for specific
environmental activities, and by establishing
GEMS documentation and operational controls.
CHECK
Ongoing monitoring and measuring of
operational controls is augmented by periodic
evaluations of the GEMS (gap analysis) and
environmental compliance audits, all of which
generate preventive and corrective actions
which are tracked in the GEMS Committee.
ACT
Similar to other Environment of Care program
elements, an annual evaluation of the
effectiveness of the GEMS and
recommendations for continual improvement
are submitted for approval to the facility
director.
Nine Steps to a Successful
Green Environmental
Management System
(GEMS)
1. Appoint GEMS Coordinator & GEMS
Committee.
A GEMS Coordinator will be appointed at each
VA Medical Center to ensure that the
requirements of GEMS are established,
implemented and periodically reviewed in
accordance with principles of the ISO 14001
model.
The GEMS Committee is a multi-disciplinary
committee established to coordinate and
oversee the GEMS.
2. Train GEMS Committee.
The GEMS Committee is trained first, so they
can develop, monitor, and continually improve
the GEMS.
3. Conduct Initial GEMS Gap Analysis.
The purpose of the initial gap analysis is to help
the facility understand what it is already doing in
terms of the requirements for GEMS, and to build
on existing programs and activities in order to
close the gap between requirements and reality.
4. Identify Significant Environmental
Aspects.
This involves a process starting with identifying
legal and other requirements applicable to the
activities of each operating unit. Operating Units
then identify and score the impacts they have on
the environment. The GEMS Committee
determines significant aspects for further control.
5. Establish Operational Controls.
The GEMS Committee ensures operational
controls are adequate for all significant aspects.
This includes developing, publishing, and
distributing GEMS and other environmental
policies and procedures.
6. Set Objectives and Targets.
The GEMS Committee sets environmental
objectives and targets and the plans to achieve
them. Success with these is evidence of continual
improvement.
7. Train Staff on GEMS Policies and SOPS.
The training program should provide sufficient
training to employees to ensure that the GEMS is
operating at the highest level.
8. Conduct Environmental Compliance
Baseline and Periodic Follow-Up Audits.
The purpose of this audit is to determine the
compliance status of the facility and address any
non-compliance issues.
9. Annual Program Effectiveness Review
and Report.
To maintain continual improvement, management
will periodically review the GEMS to ensure it is
operating as planned.
-------
How Does Your Job
Impact the
Environment?
Do you...
Use, dispose, and/or store paint?
Use, dispose, and/or store solvents?
Use and dispose of fluorescent light bulbs?
Use paper, computers, batteries?
Repair/operate motor vehicles?
Use aerosol sprays?
Store waste?
Operate a boiler?
Dispose of hazardous, radiological waste, or
solid waste?
Manage construction projects?
Work with asbestos?
Work with ozone depleting substances?
Use large amounts of electricity or water?
Purchase chemicals, medical or other
supplies?
Your job activities could impact the
environment by...
• Causing an unplanned spill or release of
hazardous chemicals that could pollute the
air, soil, or water
• Causing incorrect storage or disposal of
waste that could pollute the soil and water
• Not recycling when possible and creating
more waste in landfills that can pollute the
soil and water
Work to...
Maintain regulatory compliance
Implement controls
Prevent unplanned spills and releases
Ensure sampling and monitoring devices are
calibrated and operating correctly
Conserve energy and water
Use recycled products
Prevent pollution by substituting "green"
products
Environmental
Contacts:
(Please write name and phone number)
VAMC GEMS Coordinator:
Department of
Veterans Affairs
VISN Safety/Industrial Hygiene Manager:
Resources:
Green
Environmental
Management
Systems
This brochure, GEMS Guidebook,
Environmental Compliance Guidebook, and
RCRA Guidebook are available at the CEOSH
web site:
vaww.ceosh.med.va.gov
-------
SAMPLE
Green Environmental Management Systems (GEMS) Aspects Rating Template
OPERATING UNIT:
Blood Bank/Phlebotomy
Date:
Activity or Service
Operation of
Equipment
Chemical Usage
Chemical Storage
Report Generation
Blood Drawing
Compliance
1 - Activity is not
regulated, but VAMC has
taken steps to reduce
energy consumption.
1 - The activity is
regulated, and compliance
measures are in place.
1 - The activity is
regulated, and compliance
measures are in place.
0 - The activity is not
regulated, but a recycling
program is in place.
0 - The activity is highly
regulated; however,
VAMC is in full
compliance.
Risk
1 - VAMC operation of
equipment in Blood Bank
is a moderate risk to
human population and
environment.
1 - Due to limited
amount of chemical
usage, there is a
moderate risk to sensitive
human population and
ecosystem.
1 - Due to limited
amount of chemical
storage, the risk is
moderate.
0 - There is a minor risk
to the human population
and ecosystem.
4 - There is a high risk to
the human population
and ecosystem in the
event of improper
disposal.
Frequency
of Activity
3
1
1
2
4
VAMC Control
1 - VAMC has little
control over use of energy
due to operational
necessity.
1 - VAMC has little
control over use of energy
due to operational
necessity.
1 - VAMC has little
control over use of energy
due to operational
necessity.
3 - VAMC has significant
influence over paper
generation (vs. electronic
data storage).
4 - VAMC has total
control over medical waste
disposal.
TOTAL
SCORE
6
4
4
5
12
-------
Cleaning &
Disinfecting Surfaces
and Equipment
1 - The activity is
regulated, and compliance
measures are in place.
2 - Semi-hazardous
chemicals are used but in
small quantity; therefore,
there is a moderate risk
to the human population
and environment.
2 - VAMC has influence
over the amount of
chemical usage; however,
the amount of cleaning is
out of VAMC control.
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Date:
Activity or Service
Aspect
Impact
Compliance
Risk
Frequency
Of Activity
VAMC
Control
TOTAL
SCORE
-------
-------
Technical Resources Department of Veterans Affairs
Enclosure 6-7
1.
DEPARTMENT OF VETERANS AFFAIRS
SAMPLE APP Facility-Level Audit Questions
a) Does your facility have policy specifically requiring an Affirmative Procurement
Program (APP), and compliance with RCRA 6002 and EO 13101?
Yes No
If yes, please attach a copy of the policy or provide the web address
(URL)
If no, does your facility follow VA's APP Policy?
Yes No
2. Planning:
a) Has your facility established objectives/targets for APP performance (or purchases of
Comprehensive CPG items/materials with recycled content) that are consistent
with the nature and quantity of purchases normally made by your facility?
Yes No
b) Do you have a process for routine review and updating of APP objectives/targets?
Yes. Describe:
No
3. Implementation and Operation:
a) Does your facility have an APP awareness-training program?
Yes. Describe:
No
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Is your APP awareness-training program tailored specifically to the nature and
quantity of purchases typically made by your facility?
Yes. Describe:
No
Does your facility's APP policy assign responsibility for implementation of the
APP awareness-training program to a specific person/office?
Yes. Describe:
No
b) Is the APP awareness training program provided in initial and refresher training to all
personnel involved with preparation of specifications/ statements of work,
purchases with government credit cards, contracting/ procurement?
Yes. Describe:
No
c) Does your facility's policy provide a process for measurement of progress toward
APP objectives?
Yes. Describe:
No
d) Does your facility's policy assign responsibility for routine measurement, evaluation,
and reporting of APP performance data?
Yes. Describe:
No
4. Checking and Corrective Action:
a) Has your facility incorporated APP requirements into self-assessments, compliance
inspection protocols, and management system audit protocols?
Yes. Describe:
No
b) Do your inspection protocols include evaluations of APP awareness training,
performance measurement, and responsibility/accountability?
Yes. Describe:
No
-------
Technical Resources Department of Veterans Affairs
Does your APP policy call for routine self-assessments of the effectiveness of
awareness training and the completeness and integrity of APP performance data?
Yes. Describe:
No
c) Do your self-assessment, compliance inspections, and management system audit
procedures include requirements for follow-up action and documented closure of
deficiencies in APP?
Yes. Describe:
No
5. Management Review:
a) Do you have a process for management review of APP performance data?
Yes. Describe:
No
b) Does the management review process provide facility senior leadership with accurate
and timely data regarding your facility's APP performance?
Yes. Describe:
No
c) Does your management review process include provisions for feedback and policy
changes to ensure continuous improvement in APP performance?
Yes. Describe:
No
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - Above/Underground Storage Tanks
Date:
Activity or Service
Emergency Generation
Gasoline Dispensing
Aspect
Storage of Oil,
Gasoline and Diesel
Fuel
Storage of Gasoline
Impact
Soil and
Groundwater
Contamination
Soil and
Groundwater
Contamination
Compliance
0
0
Risk
4
4
Frequency
Of Activity
4
4
VAMC
Control
4
4
TOTAL
SCORE
12
12
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - Boiler/Chiller Plant
Date:
Activity or
Service
Chemical Usage
Chemical Storage
Fuel Usage
(Vehicles, Energy
Production)
Asbestos
Abatement
Operation of
Machinery /Power
Tools
Report
Generation
Boiler Plant
Containing
Asbestos
Aspect
Hazardous Waste Disposal
Potential for Spills
Air Emissions (SO2, NOx,
CO), Environmental
Contamination, Energy
Consumption
Hazardous Waste Disposal
Energy Consumption, Noise,
Heat
Use of Paper
Air Emission (Explosion)
Impact
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Employee Health,
Air Pollution
Use of Natural
Resources
Use of Natural
Resources
Air Pollution
Compliance
1
0
0
0
1
0
0
Risk
4
3
4
4
1
0
4
Frequency
Of Activity
3
4
4
2
3
3
0
VAMC
Control
4
4
3
4
1
3
2
TOTAL
SCORE
12
11
11
10
6
6
6
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - BMET Shop
Date:
Activity or Service
Chemical Storage
Chemical Usage
Radiology Transformer
(PCB)
Use of Oils and
Hydraulic Fluid
Fuel Usage (Vehicles)
Battery Disposal
Use of Fume Hood
Operation of Machinery/
Power Tools
Report Generation
Material Waste (Plastics)
Aspect
Potential for Spills
Hazardous Waste
Disposal
Air Emissions
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Universal Waste
Disposal
Air Emissions, Energy
Consumption
Energy Consumption
Use of Paper
Waste Disposal
Impact
Environmental
Contamination
Environmental
Contamination
Air Pollution
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Environmental
Contamination
Air Pollution, Use
of Natural
Resources
Use of Natural
Resources
Use of Natural
Resources
Use of Landfill
Space
Compliance
0
1
0
0
1
0
0
1
0
0
Risk
2
O
4
O
2
O
1
1
0
1
Frequency
Of Activity
4
2
1
1
2
1
3
3
3
1
VAMC
Control
4
3
4
4
2
3
2
1
3
3
TOTAL
SCORE
10
9
9
8
7
7
6
6
6
5
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - Carpentry/Lock Shop
Date:
Activity or Service
Chemical Storage
Chemical Usage
Fuel Usage (Vehicles)
Metal Shavings
Operation of Machinery/
Power Tools
Report Generation
Aspect
Potential for Spills
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Disposal, Use of
Landfill Space
Energy Consumption
Use of Paper
Impact
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Water Pollution
(Leaching of Heavy
Metals)
Use of Natural
Resources
Use of Natural
Resources
Compliance
0
1
1
1
1
0
Risk
2
2
2
2
1
0
Frequency
Of Activity
4
2
2
3
3
3
VAMC
Control
4
3
2
2
1
3
TOTAL
SCORE
10
8
7
8
6
6
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT: Engineering - Electrical Shop
Date:
Activity or Service
Chemical Storage
Chemical Usage
Fuel Usage (Vehicles)
Lamp Disposal
(Mercury-Containing)
Operation of Machinery/
Power Tools
Report Generation
Battery Disposal
Metal Fabrication
Aspect
Potential for Spills
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Universal Waste
Disposal
Energy Consumption
Use of Paper
Universal Waste
Disposal
Air Emissions
Impact
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Environmental
Contamination
Use of Natural
Resources
Use of Natural
Resources
Environmental
Contamination
Air Pollution
Compliance
0
1
1
1
1
0
0
1
Risk
O
2
2
3
1
0
3
2
Frequency
Of Activity
4
3
2
1
3
3
1
2
VAMC
Control
4
3
2
4
1
3
4
4
TOTAL
SCORE
11
9
7
9
6
6
8
9
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - HVAC Shop
Date:
Activity or Service
Chemical Storage
Chemical Usage
Fuel Usage (Vehicles)
Portable/Non-Portable
Refrigerants
Operation of Machinery/
Power Tools
Report Generation
Roofing Projects
Aspect
Potential for Spills
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Waste Disposal
Energy Consumption
Use of Paper
Air Emissions (PM)
Impact
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Air Pollution,
Environmental
Contamination
Use of Natural
Resources
Use of Natural
Resources
Air Pollution
Compliance
0
1
1
0
1
0
1
Risk
O
O
2
3
1
0
2
Frequency
Of Activity
4
3
2
3
3
3
2
VAMC
Control
4
3
2
4
1
3
2
TOTAL
SCORE
11
10
7
10
6
6
7
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - Mason Shop
Date:
Activity or Service
Chemical Storage
Chemical Usage
Fuel Usage
Operation of Machinery/
Power Tools
Cement Mixing
Report Generation
Aspect
Potential for Spills
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Energy Consumption
Air Emissions (PM)
Use of Paper
Impact
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Use of Natural
Resources
Air Pollution
Use of Natural
Resources
Compliance
0
1
1
1
1
0
Risk
O
3
2
1
1
0
Frequency
Of Activity
4
2
2
4
3
1
VAMC
Control
4
4
2
1
2
3
TOTAL
SCORE
11
10
7
7
7
4
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - Motor Pool
Date:
Activity or Service
Chemical Storage
Chemical Usage
Fuel Usage
Operation of Machinery/
Power Tools
Report Generation
Aspect
Potential for Spills
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Energy Consumption
Use of Paper
Impact
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Use of Natural
Resources
Use of Natural
Resources
Compliance
0
1
1
1
0
Risk
O
3
2
1
0
Frequency
Of Activity
4
3
2
3
2
VAMC
Control
3
3
3
1
3
TOTAL
SCORE
10
10
8
6
5
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - Paint Shop
Date:
Activity or Service
Chemical Storage
Chemical Usage
Fuel Usage
Operation of Machinery/
Power Tools
Report Generation
Aspect
Potential for Spills
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Energy Consumption
Use of Paper
Impact
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Use of Natural
Resources
Use of Natural
Resources
Compliance
0
1
1
1
0
Risk
O
4
2
1
0
Frequency
Of Activity
4
3
2
3
2
VAMC
Control
4
3
2
1
3
TOTAL
SCORE
11
11
7
6
5
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Engineering - Pipe Shop
Date:
Activity or Service
Chemical Storage
Asbestos Abatement
Chemical Usage
Drain Cleaner
Fuel Usage
Metal Fabrication
Operation of Machinery/
Power Tools
Report Generation
Aspect
Potential for Spills
Hazardous Waste
Disposal
Hazardous Waste
Disposal
Hazardous Waste
Disposal
Air Emissions, Energy
Consumption
Hazardous Waste
Disposal, Air
Emissions, Energy
Consumption
Energy Consumption
Use of Paper
Impact
Environmental
Contamination
Employee Health,
Air Pollution
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources, Air
Pollution
Environmental
Contamination, Use
of Natural
Resources
Use of Natural
Resources
Use of Natural
Resources
Compliance
0
1
1
1
1
1
1
0
Risk
O
4
O
O
2
2
1
0
Frequency
Of Activity
4
3
3
4
2
2
3
2
VAMC
Control
4
4
3
3
2
3
1
3
TOTAL
SCORE
11
12
10
11
7
8
6
5
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Executive Summary
The Green Environmental Management Systems (GEMS) Program represents a systematic
approach to environmental management, but it is not another environmental program.
Rather, it is a management tool that provides a framework to weave existing environmental
programs into the Environment of Care management processes, which enables the
organization to achieve continual improvement in performance. The Green Environmental
Management Systems (GEMS) Program within the Environment of Care Program will
provide for environmental regulatory compliance and conformance with Veterans Health
Administration (VHA) policy and Executive Order 13148. VHA facilities already have
active environmental programs with many of the GEMS elements in place, but these
programs are individual and separate entities. The primary purpose of the GEMS is to
coordinate these activities into one integrated framework that enhances and improves the
overall efficiency and effectiveness of these environmental programs.
Background
In August 2002 VHA and the United States Environmental Protection Agency (EPA) signed an
agreement to collaborate on a number of projects to improve the level of environmental
compliance at VHA facilities nationwide. This agreement was signed as both agencies
recognized the need to improve environmental programs, and VHA appreciated the offer of
EPA to work with VHA in a collaborative effort. This partnership has been very successful,
and a number of initiatives are underway or have been completed by VHA alone or in
collaboration with EPA.
To assist in the development of a facility Green Environmental Management Systems (GEMS)
Program and to support compliance with federal mandates, VA Central Office (VACO)
organized a task force comprised of VACO and facility representatives to develop the Green
Environmental Management Systems (GEMS) Guidebook. The task force collaborated with
the Center for Engineering & Occupational Safety and Health (CEOSH) who prepared and
produced this guidebook (Book 6A). This is one of a two-volume set on environmental
programs and compliance. Environmental Compliance, Book 6B, focuses on all
environmental regulations that impact VA and non-VA hospitals. Source material is based
upon federal legislation and is provided to assist your facility in complying with these
requirements.
The Nine Step process in Section 3 is designed to provide facilities with a useful tool and a
complete step-by-step process to assist in their development of a facility environmental
management system. It is based on the process developed for the Emergency Management
Guidebook (February 2002), because of its proven effectiveness and usefulness of the
samples provided.
in
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Software provided is enhanced with desktop publishing quality formatting so that medical
centers can easily produce documents with professional appearance at a similar level of
quality as the guidebooks. All material in this guidebook is provided on CD-ROM using
Word 6.0 and Excel 5.0 for Windows. This will enable each VA medical center to easily
customize these documents for their own use.
Additional copies of this Guidebook, as well as other guidebooks, may be obtained upon request
from the Center for Engineering & Occupational Safety and Health (CEOSH) at
314-543-6700 and can be downloaded from their web site at:
vaww.ceosh.med.va.gov
Questions regarding the use and application of this guidebook can be addressed to
Mr. Arnold Bierenbaum, Director, Safety and Technical Services, VA Central Office, at
202-273-5844.
IV
-------
Figure 3-1: Process to Evaluate Environmental Aspects
Remains on
Aspect List
No or yes
but want to
do more?
Objectives and
Targets
Operational
Controls
No (still must have controls)
Plan for meeting
Objectives and
Targets and
Operational
Control
Deployed in
Environmental
Management System
Courtesy of Office of Federal
Environmental Executive.
-------
Sample GEMS Documents
Department of Veterans Affairs
Figure 5-1: GEMS Documentation Scheme
VA Environmental Policy,
Directive ## (pending)
VHA Environmental Policy,
Directive ## (pending)
B
VA Medical Center
Memorandum
(GEMS Policy)
VAMC Policy Statement and Roles/Responsibilities
Bl
GEMS Implementation
Procedures, Tools, Checklists
13 Documents including:
Identifying Aspects
Monitoring and Measuring
Document Control, etc.
B3
Objectives, Targets and Plans for
Meeting Objectives and Targets
B2
Operational Procedures
for Significant Aspects
Examples:
Biohazardous Waste Management MCM
Energy Management MCM
Pollution Prevention Plan
Mercury Reduction Program, etc.
5- 1
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT: Fire Department - Emergency Medical Service
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Response to Hazardous
Materials Spills
Maintenance of Fire
Extinguishers
Generation of Regulated
Medical Waste
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Waste Handling and
Generation
Exposure to Chemicals
Exposure to Biological
Contaminants
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Waste Disposal
Considerations,
Environmental
Contamination
Exposure, Disposal
Disease
Transmission,
Environmental
Contamination
Compliance
1
1
1
0
0
1
1
Risk
1
1
1
0
3
1
O
Frequency
Of Activity
3
4
4
3
1
2
4
VAMC
Control
1
4
4
4
2
2
4
TOTAL
SCORE
6
10
10
7
6
6
12
-------
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Potential
Employee/Patient
Exposure
Potential
Employee/Patient
Exposure
1
1
2
2
4
4
3
2
10
9
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Food and Nutrition
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Cooking
Cleaning and
Disinfecting Surfaces and
Equipment
Handling of Cardboard,
Plastics, Steel and
Aluminum Cans, etc.
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Generation of Grease
and Food Waste
Handling of Detergent
Disinfectants
Generation of Solid
Waste
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Solid Waste
Generation, Grease
Disposal
Potential
Employee/Patient
Exposure
Generation of Solid
Waste or Potential
for Recycling
Compliance
1
1
1
0
1
1
1
Risk
1
1
1
0
1
2
1
Frequency
Of Activity
3
3
3
3
4
3
4
VAMC
Control
1
3
3
4
3
2
3
TOTAL
SCORE
6
8
8
7
9
8
9
-------
Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
GEMS Policies and Procedures at a Glance
These Policies and Procedures appear in Section 5.
VA Environmental Policy,
Directive ## (pending)
VHA Environmental Policy,
Directive ## (pending)
B
VA Medical Center
Memorandum
(GEMS Policy)
VAMC Policy Statement and Roles/Responsibilities
Bl
GEMS Implementation
Procedures, Tools, Checklists
13 Documents including:
Identifying Aspects
Monitoring and Measuring
Document Control, etc.
B3
Objectives, Targets and Plans for
Meeting Objectives and Targets
B2
Operational Procedures
for Significant Aspects
Examples:
Biohazardous Waste Management MCM
Energy Management MCM
Pollution Prevention Plan
Mercury Reduction Program, etc.
XI
-------
Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
GEMS Policies and Procedures at a Glance
These Policies and Procedures appear in Section 5.
VA Environmental Policy,
Directive ## (pending)
VHA Environmental Policy,
Directive ## (pending)
B
VA Medical Center
Memorandum
(GEMS Policy)
VAMC Policy Statement and Roles/Responsibilities
Bl
GEMS Implementation
Procedures, Tools, Checklists
13 Documents including:
Identifying Aspects
Monitoring and Measuring
Document Control, etc.
B3
Objectives, Targets and Plans for
Meeting Objectives and Targets
B2
Operational Procedures
for Significant Aspects
Examples:
Biohazardous Waste Management MCM
Energy Management MCM
Pollution Prevention Plan
Mercury Reduction Program, etc.
XI
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
GI Procedures
Date:
Activity or Service
Report Generation
Operation of Lab
Equipment
Facility Maintenance
Equipment Maintenance
Scope Procedure
Scope Procedure
Procedure Results
Aspect
Use of Paper
Energy Consumption
Use ofWexideto
Clean Surfaces
Enzyme Cleaner Used
to Disinfect Scope
Lenses
Regulated Biomedical
Medical Waste
Sharps Waste
Generation
Formulin Used for
Biopsy Specimens
Impact
Use of Natural
Resources
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination,
Employee Health
Employee Health,
Environmental
Contamination
Employee Health
Employee Health,
Environmental
Contamination
Compliance
0
1
1
1
1
0
0
Risk
0
1
2
2
4
4
2
Frequency
Of Activity
2
3
3
3
3
2
3
VAMC
Control
3
1
2
3
3
2
2
TOTAL
SCORE
5
6
8
9
11
8
7
-------
Glossary Department of Veterans Affairs
Glossary
-A-
Accreditation - Procedure by which an authoritative body formally recognizes that a body or
person is competent to carry out specific tasks.
Activities - Key operational (industrial) operations conducted to meet mission. Examples
include vehicle maintenance, heating-ventilation-air conditioning, and facilities operation and
maintenance. Activities and operations generally include multiple "practices."
Aspect - A characteristic of a practice that can cause, in normal operation or upset mode, an
impact to an environmental or other resource. Each practice may have several aspects.
Typical aspects of practices operated include:
• Spill/release
• Air release
• Hazardous material use
• Hazardous waste generation
• Solid waste generation
• Medical waste generation
• Noise
• Electricity use
• Fuel use
• Physical presence
• Particulate matter generation (dust, smoke)
• Fire
• Excavation
• Soil disturbance
Asset (or Vulnerable Asset) - A resource on which the installation depends or over which it has
some responsibility, and which may be impacted (adversely or beneficially) by the conduct
of practices, such as environmental, historical, and cultural areas on and off the installation;
personnel health and safety; mission effectiveness; real property; financial resources; and
public relations status.
Audit - A planned, independent and documented assessment to determine whether agreed upon
requirements are being met.
Audit Cycle - The period of time in which all the activities in a given site are audited.
Audit Team - Group of auditors, or a single auditor, designated to perform a given audit; the
audit team may also include technical experts and auditors-in-training. (Note: One of the
auditors on the audit team performs the function of lead auditor.)
G-l
-------
Green Environmental Management Systems (GEMS) Guidebook Glossary
-c-
Causal Analysis - An informal analysis of the combination of factors that in sequence lead to a
given outcome, and to determine the actions that must be taken to prevent recurrence. A
causal analysis is usually performed by the person or persons directly involved with the
incident.
Certification - The environmental management system of a company, location or plant is
certified for conformance with ISO 14001 after it has demonstrated such conformance
through the audit process. When used to indicate environmental management system
certification, it means the same thing as registration.
Certification Body - A third party that assesses and certifies/registers the environmental
management system of organizations with respect to published environmental management
system standards and any supplementary documentation required under the system.
Checklists - Checklists are series of questions, in either paper or automated format, for use in
evaluating compliance and/or environmental management system effectiveness. Checklists
occur in several forms for use by varying levels of personnel
Compliance - An affirmative indication or judgment that the supplier of a product or service has
met the requirements of the relevant specifications, contract, or regulation; also, the state of
meeting the requirements. In ISO terms, compliance to regulations. Compare with
Conformance.
Compliance Evaluation - Identification, characterization, and documentation of compliance
deficiencies related to either practices or environmental programs conducted by
environmental management office personnel or other environmental professionals designated
by the installation. Includes oversight of any inspections that have been performed by
practice owners.
Conformance/Conformity - Action in accordance with customs, rules, prevailing opinion. In
terms of GEMS, conformance to ISO 14001. Compare with compliance. An affirmative
indication or judgment that a product or service has met the requirements of the relevant
specifications, contract, or regulations; also the state of meeting the requirements.
Continual Environmental Improvement - Mechanisms in place to improve, cultural change,
management commitment (Including fixing nonconformances and improving performance).
Enshrined in the published Standards for environmental management system is the principle
of continual improvement, which is intended to ensure that an organization does not simply
adopt an environmental management systems for cosmetic purposes and thereby remain
static, without commitment to reduce its impact on the environment. Continual improvement
is the process of enhancing the environmental management system to achieve improvement
in overall environmental performance in line with the organization's environmental policy.
Controls - Means used to ensure that the impacts on resources are effectively prevented or
minimized. Three types of controls are defined as follows:
• Management Controls define and affect the administrative environmental behaviors
associated with practices, and are applied by environmental staff as well as by practice
G-2
-------
Glossary Department of Veterans Affairs
owners Management controls are described by the elements of the environmental
management system implementation component (e.g., programs, responsibilities,
training, communication, etc.) and are evaluated through the environmental management
system corrective action component.
• Operational Controls define behaviors and actions applied in the course of operating or
maintaining the practice (and associated physical controls) to eliminate or reduce their
negative impacts on environmental or other resources. Common examples include
labeling drums, maintaining equipment operating logs, opening/closing discharge valves
on a containment berm, etc.
• Physical Controls are not behaviors or actions, but physical devices or equipment (e.g.,
containment structures, process control equipment, etc.) designed to physically minimize
or prevent impacts to the environment or other resources. Physical controls are similar to
practices in that they may be subject to operational or management controls to ensure
their environmentally sound operation and maintenance. Some physical controls may be
managed as part of their associated practices (e.g., oil water separators with washrack,
berm/valve with aboveground storage tank).
Corrective Action - Steps taken to eliminate the cause(s) of actual and potential
nonconformances, including verifying that the corrective action is effective.
-E-
Effectiveness - Meeting military mission while fully meeting executive, federal, state, local,
environmental regulations and VA environmental policy.
Efficiency - Achieving effectiveness at the lowest possible cost (considering time, personnel
resources, and money). A risk-based prioritization of practices and their impacts is the basis
for efficiency enhancements under the environmental management system.
Emergency Response Plan - A detailed plan that describes the logistics and reporting
requirements in the event of either fire, erosion or spills.
Environment - Surroundings in which an organization operates, including air, water, land,
natural resources, flora, fauna, humans and their interrelation.
Environmental Aspect - Element of the operating unit's activities and services that can interact
with the environment. An environmental aspect signifies the potential for an environmental
impact. Environmental impacts and aspects include both positive and negative events such
as recycling paper and leaking drums.
Environmental Cost Accounting - The modification of cost attribution systems and financial
analysis practices specifically to directly track environmental costs that are traditionally
hidden in overhead accounts to the responsible products, processes, facilities or activities.
Environmental Impact - Any change to the environment, or to the health or safety of people,
whether adverse or beneficial, wholly or partially resulting from the operating unit's
activities or services.
G-3
-------
Green Environmental Management Systems (GEMS) Guidebook Glossary
Environmental Management Representative - The clearly identified environmental
management system team leader who has responsibility for the environmental management
system from start to finish and has the designated authority of senior manager to get the job
done.
Environmental Management System - A management approach, which enables an
organization to identify, monitor and control its environmental aspects. An environmental
management system is part of the overall management system that includes organizational
structure, planning activities, responsibilities, practices, procedures, processes and resources
for developing, implementing, achieving, reviewing and maintaining the environmental
policy. The environmental management system emphasizes pollution prevention,
environmental compliance, and continual improvement.
Environmental Management System Audit - A systematic documented verification 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 organization, and for communication of the results of this process to
management.
Environmental Objective - Site-specific goal that the medical center sets for itself to achieve.
Objectives are selected from the significant aspects and are consistent with the environmental
policy. Example: Waste reduction.
Environmental Plan for Achieving Targets and Objectives - Detailed performance
requirement and how the VAMC intends to achieve it, including measurement and
monitoring. It may include new operational controls such as procedures or the purchase of
new equipment.
Environmental Performance - Measurable results of the environmental management system
related to an organization's control of its environmental aspects, based on its environmental
policy, objectives and targets.
Environmental Policy - Statement by the organization of its intentions and principles in relation
to its overall environmental performance, which provides a framework for action and for the
setting of its environmental objectives and targets.
Environmental Target - The measurable elements of the environmental plan, including a
measure of the objective (such as 10% reduction of waste) and a timeframe for achievement
(such as by the end of the fiscal year).
Environmentally Benign Pressure Sensitive Adhesives - Adhesives for stamps, labels, and
other paper products that can be easily treated and removed during the paper recycling
process.
-F-
Facility - Any building, installation, structure, land, and other property owned or operated by, or
constructed or manufactured and leased to, the Federal Government, where the Federal
G-4
-------
Glossary Department of Veterans Affairs
Government is formally accountable for compliance under environmental regulation (e.g.,
permits, reports/ records and/or planning requirements) with requirements pertaining to
discharge, emission, release, spill, or management of any waste, contaminant, hazardous
chemical, or pollutant. This term includes a group of facilities at a single location managed
as an integrated operation, as well as government owned contractor operated facilities.
-G-
Gap Analysis - An analysis of the existing environmental management system to identify the
variances from the GEMS standard.
GEMS - The VA Green Environmental Management System Program for ensuring
environmental compliance with ISO 14001 and Executive Order 13148, 13123 and 13101,
Greening the Government Executive Orders.
Greening the Government Executive Orders - Executive Order 13148 and the series of orders
on greening the government including Executive Order 13101 of September 14, 1998,
Executive Order 13123 of June 3, 1999, Executive Order 13134 of August 12, 1999, and
other future orders as appropriate.
-H-
Hazard - A source of potential harm or damage, or a situation with potential for harm or
damage.
-I-
Impact - An effect of operating a practice on an environmental resource. Each practice may have
several impacts. Typical impacts associated with practices operated on Navy installations
include:
• Personnel exposure
• Indoor air quality degradation
• Outdoor air quality degradation
• Surface water degradation
• Groundwater degradation
• Soil quality degradation
• Species (endangered) population/habitat disturbance
• Water consumption
• Electricity consumption
• Other resource (e.g., landfill space) consumption
• Cost to mitigate risk
G-5
-------
Green Environmental Management Systems (GEMS) Guidebook Glossary
• Adverse regulatory exposure
• Negative public perception
• Real property damage
• Historic/cultural resource damage
• Natural resource disturbance
• Soil erosion
• Human health effects
Interested Party - Individual or group concerned with or affected by the environmental
performance of an organization.
Inspection - On-site examination of practices and related environmental control measures by or
on behalf of practice owners to determine whether environmental compliance requirements
are being satisfied. Includes documentation and reporting of deficiencies as arranged with
the installation's environmental management office and any sampling, analysis, or other
monitoring activities that the practice owners perform in order to maintain compliance.
ISO - The International Organization for Standardization (ISO) is a worldwide federation of
national standards bodies from some 140 countries, one from each country. ISO is
responsible for the development of ISO 14001.
ISO 14001 - An international voluntary standard for environmental management systems. This
is one standard in the ISO 14000 series of International Standards on environmental
management.
-L-
Life Cycle Assessment (LCA) - Systematic set of procedures for compiling and examining the
inputs and outputs of materials and energy and the associated environmental impacts directly
attributable to the functioning of a product or service system throughout its life cycle.
Life Cycle - Consecutive and inter-linked stages of a product system, from raw material
acquisition or generation of natural resources until disposal.
Lead Auditor - Person qualified to manage and perform environmental management system
audits.
-N-
Nonconformity - The non-fulfillment of a specified requirement. Any or all of the following:
a) one or more environmental management system requirements have not been addressed; or
b) one or more environmental management system requirements have not been implemented;
or c) several nonconformities exist that, taken together, lead a reasonable auditor to conclude
that one or more environmental management system requirements have not been addressed
or implemented.
G-6
-------
Glossary Department of Veterans Affairs
-o-
Objectives - Qualitative goals that a facility sets to reduce significant impacts leading to
improved environmental performance (i.e. reduced wastewater discharges)
Observation - A practice, while not in strict violation of environmental management system
requirements, may constitute a poor practice that can lead to a nonconformance.
Operating Unit Activity - A recurring activity or series of activities that is performed by the
operating unit in the accomplishment of its mission.
Ozone-Depleting Substance - Any substance designated as a Class I or Class II substance by
EPA in 40 Code of Federal Regulations (CFR) Part 82.
-P-
Pollution Prevention - Pollution prevention means "source reduction," as defined in the
Pollution Prevention Act (PPA), and other practices that reduce or eliminate the creation of
pollutants through: a) increased efficiency in the use of raw materials, energy, water, or
other resources; or b) protection of natural resources by conservation.
Practice - Any activity conducted by an installation or its tenants in performing their missions
that has an actual or potential impact on the installation's assets. The term includes the
processes, equipment, and facilities used in conducting the activities. Practices may be
further distinguished as business practices and management practices:
• Business Practice - Work-related activities including operation and maintenance of
industrial processes, pollution control equipment, and mission-critical equipment and
facilities; weapons systems training operations; etc.
• Management Practice - Activities conducted to manage, coordinate, or support business
practices, such as provision of environmental training for personnel, documentation of
environmental management system elements, development and implementation of plans
and standard procedures, etc.
Practice Owner - The person, unit, or organization that operates, conducts, controls, or is
otherwise responsible for a "practice".
-R-
Registrar - Third party, which audits and registers the environmental management system of an
organization with respect to the ISO 14001 environmental management system standard.
Resources (Environmental) - Sensitive environmental receptors (e.g., air, water, natural
resources, etc.) or cultural or historic assets on an installation or regional complex, in the
surrounding community, within the ecosystem or beyond, that can be impacted by the
operation of practices.
G-7
-------
Green Environmental Management Systems (GEMS) Guidebook Glossary
Resources (Other Resources) - Other assets that may be impacted by conduct of practices, such
as personnel health and safety, real property, financial resources, public relations status, and,
mission capability.
Root Cause Analysis - A formal process for identifying the basic or contributing causal factors
that underlie variations in performance associated with Adverse Events or Close Calls. A
root cause analysis is usually performed by an impartial, interdisciplinary team
knowledgeable of the process(s) or systems.
-s-
Senior Management - Senior management is defined as the Office of the Director for VA
Facilities.
Significant Environmental Aspect - An environmental aspect that has or can have a significant
environmental impact.
Significant Environmental Impact - A significant potential change to the environment, wholly
or partially resulting from the organization's activities or services.
Stakeholders - Those groups and organizations having an interest or stake in an organization's
environmental management system program (e.g., regulators, shareholders, customers,
suppliers, special interest groups, residents, competitors, investors, bankers, media, lawyers,
geologists, insurance companies, trade groups, unions, ecosystems and cultural heritage).
-T-
Target - Measurable, quantitative goals with set schedules to meet an objective (i.e. reduce
wastewater discharges by 10 percent within one year).
-V-
Verification - The act of reviewing, inspecting, testing, checking, auditing, or otherwise
establishing and documenting whether items, processes, services, or documents conform to
specified requirements.
-w-
Waste Minimization - Simple strategic reduction of waste at source, through improved
manufacturing methodologies, more careful work procedures, revised, usually improved
product specifications; is capable of releasing massive cash returns, either for use in the
business, returning to stakeholders or rewarding workers, thus upgrading their ability to
become consumers of the goods being produced.
G-8
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Grounds Maintenance
Date:
Activity or Service
Pest Control
Weed Control
Fertilizing
Mowing, Trimming,
Pruning
Ice/Snow Removal
Aspect
Use of Chemicals
Use of Chemicals
Use of Chemicals
Use of Power
Equipment, Disposal of
Yard Waste
Use of Chemicals, Use
of Power Equipment
Impact
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination
Air Pollution,
Potential
Inappropriate
Disposal of Waste
Materials
Environmental
Contamination,
Air Pollution
Compliance
1
1
1
1
1
Risk
3
3
2
1
1
Frequency
Of Activity
1
1
1
4
1
VAMC
Control
2
2
2
2
2
TOTAL
SCORE
7
7
6
8
5
-------
Health Care Resources
Alternatives to Mercury Containing Products
Common Violations and Problems Found at Hospitals
Environmental Self-Assessment for Health Care Facilities - NY State Department of
Environmental Protection
Examples of Potentially Incompatible Waste
Hospitals for a Healthy Environment Website
Healthcare Environmental Resource Center
Hospital Chemotherapy and Mercury Wastes
Major Federal Environmental Regulations Applicable to Hospitals
Reducing Mercury Use in Health Care: Promoting a Healthier Environment
Recycling of Elemental Mercury and Dental Amalgam by Dentists
How to Manual for Mercury Pollution Prevention
Instruments and Products Used in Hospitals That May Contain Mercury
Sustainable Hospitals Website
Green Guide to Healthcare
Add the Following (Note: they are not organized in any particular
order)
-------
Lamp Recycling Outreach Project (tep://www.almr.org/almr_projectweb.html)
The State of North Carolina's information sheet "Management of Aerosol
Cans for Businesses and Industries" (http://www.p2pays.org/ref/01/00007.htm)
Minnesota Pollution Control Agency fact sheet on aerosols (www.pca.state.mn.us/waste/pubs/4_00.pdf)
The Steel Recycling Institute's Information on the Recycling of Aerosol Cans (http://www.recy cle-
steel.org/)
Managing Waste Chemotherapeutic Agents: What to Know and What to Find Out
H2E Teleconference March 11, 2005 (http://h2e-online.org/teleconferences/moly desc.cfm?Date=2005-03-
ll&teleconfid=49)
Identifying and Managing Hazardous Waste H2E Teleconference September 12, 2003 (http://www.h2e-
online.org/teleconferences/moly desc.cfm?Date=2003-09-12&teleconfid=9)
Best Management Practices fpr Pharmaceutical Wastes H2E Teleconference May 12, 2006
(http://www.h2e-online.org/teleconferences/moly desc.cfm?Date=2006-05-12&teleconfid=249)
California Medical Waste Management Act
(http ://www. dhs. ca. gov/ps/ddwem/environmental/Med_Waste/LawRegs/default. htm)
Recommendations for Chemotherapy Spill Response are detailed in the OSHA Technical Manual C.5,
(http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html#5)
Recommendations for Respirator Protection are detailed in the OSHA Technical Manual B.6.c,
(http://www.osha.gov/dts/osta/otm/otm vi/otmvi 2.html#5)
New Hampshire Department of Environmental Services Guidance for Chemotherapy Spills on Carpet
(http://www.des. nh.gov/nhppp/Heal thcare_P2/default.asp?link=faq6)
Tri-TAC Memo to California POTW Pretreatment Coordinators and Managers, September 23, 2003, RE:
Disposal of Pharmaceutical Wastes in Sewer
(http://www.ciwmb.ca.gov/WPIE/HealthCare/TriTACMemAtt.pdf)
Locate Information on Hazardous Waste Transport, Storage, and Disposal Facilities Nationwide
(http ://www. epa.gov/enviro/html/rcri s/rcri s_query J ava. html)
EPA Pharmaceutical Industry Sector Notebook
(http://www.epa.gov/compliance/resources/publications/assistance/sectors/notebooks/pharmaceutical.html)
Cradle-to-Cradle Stewardship of Drugs for Minimizing Their Environmental Disposition While Promoting
Human Health (http://www.epa.gov/nerlesdl/chemistry/ppcp/images/greenl.pdf and
http://epa.gov/nerlesdl/chemistry/ppcp/images/green2.pdf)
-------
The State of Ohio's Guidance on Handling Expired Chemicals and Guidance on How to Properly Manage
Photo & X-Ray Chemicals (http://www.epa.state.oh.us/dhwm/pdf/NotifierSpring06.pdf)
EPA's Hazardous Waste Management Guide for Photo Processing
(http://www.epa.gov/epaoswer/hazwaste/id/infocus/photofm.pdf)
EPA's Hazardous Waste Management Guide for Construction, Demolition, & Renovation
(http://www.epa.gOv/epaoswer/hazwaste/i d/infocus/rif-c&d.pdf)
EPA's Hazardous Waste Management Guide for Vehicle Maintenance
(http://www.epa.gov/epaoswer/hazwaste/id/infocus/vehicle.pdf)
Environmentally Beneficial Landscaping (http://www.epa.gov/epaoswer/non-hw/green/pubs.htm)
Department of Energy Chemical Safety Handbook
(http://www.eh.doe.gov/techstds/standard/hdbkll39/doe-hdbk-1139-l-2006.pdf)
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Hematology/Oncology
Date:
Activity or Service
Operation of Equipment
Chemical Usage to
Include Cytotoxic Agents
Chemical Storage
Report Generation
Drug Preparation and
Administration
Generation of Regulated
Medical Waste
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Improper Disposal
Exposure to Biological
Contaminants
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination,
Employee Health
Disease
Transmission,
Environmental
Contamination
Potential
Employee/Patient
Exposure
Potential
Employee/Patient
Exposure
Compliance
1
0
1
0
0
1
1
1
Risk
1
O
1
0
1
3
2
2
Frequency
Of Activity
3
4
4
4
4
4
4
4
VAMC
Control
1
4
4
4
4
4
3
2
TOTAL
SCORE
6
11
10
8
9
12
10
9
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Histology Laboratory
Date:
Activity or Service
Operation of Lab
Equipment
Chemical Usage
Chemical Storage
Report Generation
Use of Fume Hoods
Receive Specimens
Slide Preparation
Aspect
Energy Consumption
Hazardous Waste
Disposal, Wastewater
Discharge
Potential for Spills
Use of Paper
Energy Consumption,
Air Emission
Biomedical Waste,
Chemical Waste
Generation of
Hazardous Waste,
Transportation of
Hazardous Waste,
Disposal to Sewage
System
Impact
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Use of Natural
Resources,
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination,
Water Usage
Compliance
1
1
0
0
0
0
0
Risk
1
4
4
0
3
3
4
Frequency
Of Activity
3
4
4
2
4
4
3
VAMC
Control
1
4
4
3
3
4
3
TOTAL
SCORE
6
13
12
5
10
11
10
-------
Cleaning and
Disinfecting Surfaces and
Equipment
Generation of Regulated
Medical Waste
Reclamation of Solvents
Storage and Handling of
Hazardous Waste
Handling of Detergent
Disinfectants
Exposure to Biological
Contaminants
Filtration and
Purification of Spent
Solvents
Generation of
Hazardous Waste
Associated With
Histology Procedures
Potential
Employee/Patient
Exposure
Disease
Transmission,
Environmental
Contamination
Potential for
Fire/Explosion,
Employee Exposure
Environmental
Contamination
0
1
1
1
2
3
O
4
4
4
3
4
2
4
3
4
8
12
10
13
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Housekeeping
Date:
Activity or Service
Operation of Electrical
Equipment
Report Processing
Cleaning, Stripping,
Refinishing
Chemical Storage
Waste Handling
Pest Control
Clean Up of Hazardous
Waste
Aspect
Energy Consumption
Paper Usage, Potential
Usage of Non-
Recycled Paper
Disposal and Use of
Chemicals
Potential for Spills
Handling, Storage,
Transport and Disposal
of Hazardous Waste
Use of Chemicals
Hazardous Waste
Disposal
Impact
Use of Natural
Resources
Use of Natural
Resources
Employee Health,
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination,
Potential for Spills
Environmental
Contamination,
Employee Exposure
Employee Exposure,
Environmental
Contamination
Compliance
1
1
1
1
1
2
1
Risk
1
1
2
O
2
2
2
Frequency
Of Activity
3
1
3
4
4
O
1
VAMC
Control
2
2
2
2
2
2
2
TOTAL
SCORE
7
5
8
10
9
9
6
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
How to Use This Guidebook
This Guidebook was developed as part of the Veterans Health Administration (VHA) Safety
Guidebook Series, a multi-volume set of basic safety and health guidebooks to assist VHA
facilities in establishing and developing their occupational safety and health and
environmental compliance programs. This Guidebook contains criteria statements applicable
to VA Medical Centers and used in the Environmental Safety Automated Facility Evaluation
(E-SAFE), a computerized tool for assessing conformance with the requirements of the
Executive Order 13148, Greening the Government through Leadership in Environmental
Management.
Each Section of the guidebook provides a general discussion of the Section topic and information
on requirements contained in the criteria statements (available in Section 7). At the end of
each Section, enclosures are listed identifying the documents contained in the hardcopy of
the Guidebook or on the accompanying CD-ROM. Resources, including reference
publications and web sites, are also provided as additional background material.
The Green Environmental Management Systems (GEMS) Guidebook is divided into seven
sections, as described below:
Section 1 - Introduction to GEMS
This section discusses key elements of an environmental management system and
presents the principles on which it is based (Code of Environmental Management
Principles [CEMP] and International Organization of Standards [ISO] 14001). Executive
Order 13148 is included as an enclosure. The pending VA Directive, Department of
Veterans Affairs Environmental Policy, and the pending VHA Directive, Veterans Health
Administration Environmental Policy, will be provided for inclusion in this Guidebook
upon publication.
Section 2 - Concepts of the GEMS Program
This section introduces the principles of environmental management systems as the
foundation to developing a medical center program.
Section 3 - Nine Steps to Establish a Successful GEMS
A systematic approach to establishing a GEMS program is presented in a simple nine-
step process. Most of the steps will be familiar to medical center management because of
their involvement in committee work, audits and continuous improvement activities.
Section 4 - Operating Unit Environmental Aspect Templates
As a part of the GEMS program, facilities must identify significant environmental aspects
and rank the level of impact each has on the environment. This section contains sample
forms showing how to list each aspect and identify the environmental impact. A sample
vn
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
facility form is included showing how the aspects were ranked at one VA Medical
Center. Also included is a blank form for facility use.
Section 5 - Sample GEMS Documents
This section lists and describes categories of documents and provides samples to illustrate
the concepts, as well as to serve as guidelines for evaluating existing documents or
creating new ones (see diagram on page 5-3). The Section is divided as follows:
Tab A VA Environmental Policy Directive - (pending)
VHA Environmental Policy Directive - (pending)
Tab B VA Medical Center Memorandum (GEMS Policy)
Tab Bl GEMS Implementation Procedures, Tools and Checklists (Sample
Memoranda)
Tab B2 Operational Procedures for Significant Aspects (Plans/Guidance)
Tab B3 Objectives, Targets and Plans for Meeting Objectives and Targets
Section 6 - Technical Resources
The Green Environmental Management Systems Professional Advisory Group (PAG)
assembled an extensive list of resources, including web sites, etc. (Note: Web site
information was current at the time of publication.)
Section 7 - E-SAFE
This Section contains the Environmental Safety Automated Facility Evaluation (E-SAFE)
criteria statements as a program evaluation guide.
Glossary
Several acronyms are used throughout the guidebook and, to avoid redundancy in
defining these acronyms each time they are used, an acronym list is situated in the front
of the guidebook. A Glossary of defined terms is located in the back of the guidebook.
Master Index
A Master Index is in the back of each guidebook as a cross-reference for all topics in the
guidebook series collectively.
Topic Index
A Topic Index for ease of cross-reference in locating policies, samples and material is
also provided.
The entire Guidebook, including enclosures, is located on the accompanying CD-ROM and at
the CEOSH web site:
vaww.ceosh.med.va.gov
Vlll
-------
DISCARDED MATERIAL
#!Faxbackll958
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/26b5303990
594f348525670f006c202e!QpenDocument
#2Faxbackll012
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b630cd51dc
85edc58525670f006bce84!OpenDocument
#3 To: Cothern
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b70fab5e63e
f29948525670f006bf791! OpenDocument
#4 Sep 6 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/2b6eba889b
64e2f28525670f006bdc21! OpenDocument
#5 Mar 22 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/0909e3a0ef5
68a7c8525670f006bdae2! OpenDocument
#6Nov30 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a4eaf8f089e
62c8a8525670f006bd9ca!OpenDocument
#7 Sep 29 1986
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/5886fa0103
16533a852568e300467f7f! OpenDocument
#8
#9 May 12 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b438f0ec57
8f5e9c8525670f006bd416!OpenDocument
#10 Dec 17 1984
-------
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/c61fl4db4a
52411a8525670f006clc28!QpenDocument
SOLID WASTE EXCLUSIONS
#1 Wastes- Solvent-Contaminated Industrial Wipes website
www.epa.gov/cgi-bin/epaprintonly.cgi
#2 google: applicability of household hazardous waste exemption in university
dormitories
http://www.epa.gov/ne/assistance/univ/pdfs/householdHWinterpr.pdf
#3 U.S. Nuclear Regulatory Commission EA-99-171 website
http://www.nrc.gov/reading-rm/doc-
collections/enforcement/actions/materials/ea99171 .html
#4 May 16 1991
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a3a7a7a8f29
7438b8525670f006be5d8!QpenDocument
#5 Faxback 12996
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/e57f94877b
7ac7208525670f006bc496!OpenDocument
#6Augll 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/f718b0337d
a018df8525670f006bdfa3!OpenDocument
#7 google: rcra superfund hotline monthly summary January 89
http://vosemite.epa.gov/OSW%5Crcra.nsf/Documents/B42E09BAE4B25783852565DAO
06F068F
#8 Aug26 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/9el6ad6a39
689e658525670f006bdbfa!QpenDocument
-------
#9
#10 Dec 10 1987
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/e5c9841752
ede3dc8525670f006bd9f9!OpenDocument
#11
#12
#13 Jun26 1987
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/73e8036dd5
fd73fl852568e300468015!QpenDocument
#14 Jun 10 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/bl4ellc723
50615f8525670f006bd7d5!OpenDocument
#15
#16 To: Stringham From: Williams
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/c86ebef3d31
8fc418525670f006bd609!QpenDocument
#17 google: rcra superfund hotline monthly summary July 86
http://vosemite.epa.gov/OSW%5Crcra.nsf/Documents/55184A9460D8F96C852565DAO
06F024E
#18 To: Devine From: Williams
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/463998327c
adOf4d8525670f006bf817!OpenDocument
#19
#20
#21
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HAZARDOUS WASTE EXCLUSIONS
#1 Wastes- Solvent-Contaminated Industrial Wipes website
www.epa.gov/cgi-bin/epaprintonly.cgi
#2 google: applicability of household hazardous waste exemption in university
dormitories
http://www.epa.gov/ne/assistance/univ/pdfs/householdHWinterpr.pdf
#3 U.S. Nuclear Regulatory Commission EA-99-171 website
http://www.nrc.gov/reading-rm/doc-
collections/enforcement/actions/materials/ea99171 .html
#4Faxbackll606
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a3a7a7a8f29
7438b8525670f006be5d8!QpenDocument
#5 Faxback 12996
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/e57f94877b
7ac7208525670f006bc496!OpenDocument
#6 Jun6 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/711fa2568f8
6ccea8525670f006cOc32!QpenDocument
#7
#8Novl 1988
http://vosemite.epa. gov/osw/rcra.nsf/0c994248c23 9947e85256d090071175f/2fd5191521
4ef63c8525670f006bdc88!OpenDocument
#9
#10 May 2 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/36ca81a964
3439bd8525670f006bdb4c!QpenDocument
#11 Jan 13 1988
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http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/48e80bab72
Obed538525670f006bda62!OpenDocument
#12
#13
#14
#15
#16
#17 Apr 21 1986
http://vosemite.epa. gov/osw/rcra.nsf/0c994248c23 9947e85256d090071175f/b 1 ea401018
5041df8525670f006c22c7!QpenDocument
#18
#19 Mar 17 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/38f54fab80c
e79338525670f006bf83e!OpenDocument
#20
#21 Jan 13 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/5bc5a247af7
d059f8525670f006cl8a4!OpenDocument
#22 google: rcra superfund hotline monthly summary February 86
http://vosemite.epa.gov/OSW%5Crcra.nsf/Documents/DA492DFCOA876946852565DA
006FOA30
#23 Jan 28 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b2213cdl35
0031738525670f006c22bd!QpenDocument
#24 Apr 19 1984
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http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/e6b7595d51
d865bc8525670f006bf7ed!OpenDocument
LISTED HAZARDOUS WASTE
#1 Apr 25 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/290273f6e2
5343758525670f006bdb36!OpenDocument
#2 Jun 16 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a84d28e4c5
73528e8525670f006clbcc!QpenDocument
#3 Jan 27 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/8bffd6al4a5
e3ec98525670f006bd311!OpenDocument
#4 Dec 13 1985
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/fee5ealafa5
237498525670f006bd29e!QpenDocument
#5 To: Baltay From Claussen
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/blecb949e5
be8f238525670f006clc3c!OpenDocument
#6 May 30 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b5b350332e
ad3e8d8525670f006clcl2!QpenDocument
#7 Mar 5 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b41736892f
7162b38525670f006bff3f!OpenDocument
-------
#8 Sep28 1989
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/ea2d57481c
3685038525670f006be045!QpenDocument
#9 google: rcra superfund hotline monthly summary august 89
http://vosemite.epa.gov/osw/rcra.nsf/Documents/651B9B4309E33BD2852565DA006FO
6E9
#10 Jun28 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/29f32f77405
bd37d8525670f006bdee3!QpenDocument
#11
#12 Jul 30 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/0afd43badb
d436cb8525670f006cl789!OpenDocument
#13 Apr 14 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/41dfda20cb
6626818525670f006bf892! OpenDocument
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DELISTED WASTES
#1
#2 Dec 11 1986
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/7d8423ec9f
709bl68525670f006cll84!QpenDocument
** This document doesn't have the attachments it has in the binder
#3 Apr 24 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/c79a25b76f
be8ed68525670f006cl4ea!OpenDocument
#4
#5
#6 Jan 7 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/0143379b88
ced7978525670f006bd2d9!QpenDocument
#7Nov27 1985
http://vosemite.epa.gov/osw/rcra.nsf/Oc994248c239947e85256d090071175f/57304ca3dO
05a8d68525670f006cl68e!OpenDocument
#8Oct23 1985
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/lc3a09ae2b
aeed8f8525670f006bd26f!QpenDocument
-------
#9Oct23 1984
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/dc00bde7d2
999b828525670f006cl66e!QpenDocument
"MIXTURE" AND "DERIVED-FROM" RULES
#1 Revision to the Mixture and Derived-From Rule
#2 Apr 14 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/9dl5dl012b
84eefc8525670f006bde29!QpenDocument
#3 May 23 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/7a3af51a21d
ab94e8525670f006clc31 JOpenDocument
#4 Jun22 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/cdle86c360
6bOa638525670f006bd7f9!QpenDocument
#5 Apr 30 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/02dd5ac8dl
7a915e8525670f006bd75b! OpenDocument
#6 Apr8 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/d5749159bd
17caOa8525670f006cl08c!QpenDocument
#7 SAME AS #6 but signed
#8 To: Didier
-------
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/0a3224bdl8
a388ed8525670f006bd66a!OpenDocument
#9 To: Cooper From: Williams
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/efdb9dc6e46
3621b8525670f006cl4f5!QpenDocument
#10
#HNovl3 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/2607ace458
acf47e8525670f006cOcld!OpenDocument
#12Sep25 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/4feecl6f53f
e34f28525670f006bd526!OpenDocument
#13 Sep 15 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b89431a9d4
ld24c38525670f006bd51c!OpenDocument
#14 google: rcra superfund hotline monthly summary September 86
http://vosemite.epa.gov/OSW/rcra.nsf/Documents/4AlEB8D230F3E3AB852565DA006
F0279
#15 Jun 17 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/76fc3d744fl
98ed08525670f006bd7df!OpenDocument
#16 Jan 22 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/ee91057995
a9ba5e8525670f006bd2f7!OpenDocument
#17
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HAZARDOUS WASTE CHARACTERISTICS
#1
#2 To: Lataille
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/c8d8a546d6
23a7708525670f006bd39d!QpenDocument
#3
#4 To: Stone
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/9ad9f4568a
71e81a8525670f006bdc92!OpenDocument
#5 Monthly Hotline Report website
http://vosemite.epa.gov/OSW/rcra.nsf/Docutnents/41E160BD479A0147852565DA006F
0909
#6
#7 To: Mastalerz
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/bcfa96341ab
f27668525670f006bdfd2!OpenDocument
#8
-------
#9
#10 Jul 28 1988
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b34efe5db4
68b5908525670f006bdbb4!QpenDocument
#11 From: Stelmack
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/4cbl877415
c8890e8525670f006cl395!OpenDocument
#12 May 2 1988
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/cabb8a85e8
d32d958525670f006bdb42!QpenDocument
#13Nov30 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a4eaf8f089e
62c8a8525670f006bd9ca!OpenDocument
#14Nov20 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/4902a8e0fce
8fdf58525670f006bd9cO!QpenDocument
#15 Sep 14 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/541bl46173
c6c8a98525670f006bf4ce!OpenDocument
#16
#17Augl8 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/5776afl004
588e588525670f006bd8c9!QpenDocument
#18
#19 Apr 16 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/f91d07ef8cf
5063e8525670f006cl2f7!OpenDocument
-------
#20 Feb 25 86
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b0c0124c4f
7dOcfc8525670f006bd354!QpenDocument
#21 Jul 16 1985
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/f20declc8ba
73ec8852567ba00708cl5!OpenDocument
#22 Feb 26 1985
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/1583b4a20b
9288dl8525670f006bd04b!QpenDocument
#23Nov30 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/3232a02467
elf45a8525670f006cl3e7!OpenDocument
#24Nov29 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/fll0e4dbec2
dl4e2852567baQ0708bfd!QpenDocument
#25Nov23 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/9ade29776e
355b578525670f006bf887!OpenDocument
#26Nov7 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/ceab213dll
449bcb8525670f006cl2bc!QpenDocument
#27Sep 11 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a2eaa3ca8a9
6b83f8525670f006bffl3!OpenDocument
#28
#29 Mar 7 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/35c2d71d6e
7aa7fl8525670f006bcf60!QpenDocument
-------
#30
#31 Jan 10 1983
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/830bc3090b
35eaa08525670f006bfefe!QpenDocument
RECYCLED MATERIALS
#1 Jul 29 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/23c546051b
9d66868525670f006bdbc9!OpenDocument
#2 Jul 29 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/d8a378d42b
b9a5668525670f006bdbbe!QpenDocument
#3 Apr 20 1988
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b61f3c5c94
b7b83d8525670f006bdblc!OpenDocument
#4 ONLY HALF A LETTER IS IN BINDER
#5 Dec 9 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/7cf538d771
8984478525670f006bd9e7!QpenDocument
#6
#7 google: rcra superfund hotline monthly summary February 87
-------
http://vosetnite.epa.gov/osw%5Crcra.nsf/Docutnents/EOBBE2DE4EOC25D3852565DAO
06F032B
#8 Sep 8 1985
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/ccdel0efe9d
96e5a8525670f006bf432!QpenDocument
#9
#10 Jun2 1986
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/39a090d2af
564a9d8525670f006bf9b6!OpenDocument
#11 google: rcra superfund hotline summary may 86
http://vosemite.epa.gov/osw/rcra.nsf/Documents/BD3408B3ED345B00852565DA006FO
A81
#12Novl7 1980
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/ae4a76f2bdf
e2f988525670f006clae6!QpenDocument
UNIVERSAL WASTE RULE
#1
#2
#3
#4
#5
#6 April 12 1999
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http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/644953f829
elbe67852569c900623e3d!QpenDocument
#7 Mar 24 1994
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/bd9ce8a8bl
a3ff728525670f006bee8e!OpenDocument
GENERATOR REQUIREMENTS
#1 Faxback 12894
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/910el6c8e6
87a5c585256817006e303c!QpenDocument
#2 Faxback 12018
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/c3bd2bd5eb
a057018525670f006cla7e!OpenDocument
#3 Faxback 12341
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http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/0a27b831ac
5407648525670f006bbd8f!QpenDocument
#4 Faxback 12245
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/08737b7294
3eOd418525670f006c210f!OpenDocument
#5 Jan 10 1984
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/2f8345e753
b925388525670f006bcf4d!QpenDocument
#6Novl8 1980
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/f59clbf7d80
7d76e852567ba00708af7!OpenDocument
#7Nov4 1994
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/c97cc02567
Obc4858525670f006bfl31!QpenDocument
#8 google: Thomas Balf large quantity generator
http://www.epa.gov/ne/assistance/univ/pdfs/generationTransportationInterpr.pdf
#9 SAME AS #8
#10 Jun 5 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/5fl74e53a9
8f732a85256e9e005e3560!OpenDocument
#11Jun5 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/de9a5964db
01d03d8525670f006cldf9!QpenDocument
#12 Apr 27 1989
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/fl7ada70efe
9d8f58525670f006bde93!OpenDocument
#13 Title: Regulation and Permitting of Laboratories
-------
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/53beb79c99
b5d6cc8525670f006bdcl 8! OpenDocument
**MISSING CHART THAT IS IN BINDER
#14Augll 1988
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/fc54ea3aed6
753858525670f006bdbe6!QpenDocument
#15
#16
#17
#18 May 13 1987
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/db643cca56
2270f58525670f006bd789!OpenDocument
#19 Apr 30 1987
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/de319f3422
ld85e98525670f006cll5e!QpenDocument
#20 google: rcra superfund hotline monthly summary December 86
http://vosemite.epa.gov/OSW/rcra.nsf/Documents/36D54A516C29F66B852565DA006F
02BE
#21 Sep 3 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/854367697e
Oe852a8525670f006cl832!QpenDocument
#22
#23 Jan 7 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/1735466e0e
85fcda8525670f006cl530!OpenDocument
#24 Jan 7 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a88675ee35
b4c76b8525670f006c22d2! OpenDocument
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#25 May 20 1985
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/bdf961belcf
a6acf8525670f006cl546!OpenDocument
#26Nov28 1984
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/dbd2d2c6ff6
324ec8525670f006bcfeO!QpenDocument
SPECIAL MANAGEMENT PRACTICES
#1 Jun 14 1990
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/964cldl056
3319028525670f006be27f!QpenDocument
#2 July 31 1985
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http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/23eeebc2f4f
d01028525670f006bfe5b!OpenDocument
#3 Jun 5 1989
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/de9a5964db
01d03d8525670f006cldf9!QpenDocument
#4 Faxback 12894
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/910el6c8e6
87a5c585256817006e303c!OpenDocument
#5 Title: Hazardous Waste Generated in Laboratories
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/e56a8c54ab
eee32885256c6700700eel!QpenDocument
#6 Faxback 14079
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/bb2879161b
2f88798525670f006c2bec!OpenDocument
#7 Jan 30 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/0f7f73d04c4
dcb8a8525670f006clbb7!QpenDocument
#8 Feb 4 1986
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/218cl2ae21
5al9928525670f006bd31b!OpenDocument
#9 Faxback 13622
http://vosemite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/6c539dfd38f
fd84985256e390068c321!QpenDocument
#10 Faxback 13718
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/lcldeb3648
a62a868525670f006bccd2!OpenDocument
#11 Faxback 11156
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http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/b771e62996
2c652e8525670f006bd429!QpenDocument
#12 Faxback 12946
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/a84d28e4c5
73528e8525670f006clbcc!OpenDocument
#13 Faxback 11343
http://vosetnite.epa.gov/osw/rcra.nsf/0c994248c239947e85256d090071175f/290273f6e2
5343758525670f006bdb36!QpenDocument
#14Novl8 1980
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#15 Sep 13 1990
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#16 Faxback 12307
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#21 Sept 2 1987
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aObe9f8525670f006bd928!OpenDocument
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GENERATOR REQUIREMENTS
#1
#2 Dec 2 1980
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#3
#4
#5 Jan 10 1984
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#7Nov4 1994
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Obc4858525670f006bfl31!QpenDocument
#8
#9 SAME AS #8
#10 Jun 5 1989
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8f732a85256e9e005e3560!OpenDocument
#11 JuneS 1989
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#12 Apr 27 1989
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#13 Title: Regulation and Permitting of Laboratories
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#14Augll 1988
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#15
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Intensive Care Unit (ICU)
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Drug Preparation and
Administration
Generation of Regulated
Medical Waste
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Patient Safety, Disposal
of Hazardous Drugs
Exposure to Biological
Contaminants
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Improper Disposal
Disease
Transmission,
Environmental
Contamination
Potential
Employee/Patient
Exposure
Potential
Employee/Patient
Exposure
Compliance
1
1
1
0
2
1
0
0
Risk
1
1
1
0
1
3
2
2
Frequency
Of Activity
3
4
4
4
4
4
4
4
VAMC
Control
1
4
4
4
4
4
3
2
TOTAL
SCORE
6
10
10
8
11
12
9
8
-------
[47 FR 32367, July 26, 1982]
APPENDIX V TO PART 264—EXAMPLES OF POTENTIALLY
INCOMPATIBLE WASTE
Many hazardous wastes, when mixed with other waste or materials at a
hazardous waste facility, can produce effects which are harmful to
human health and the environment, such as (1) heat or pressure, (2) fire
or explosion, (3) violent reaction, (4) toxic dusts, mists, fumes, or gases,
or (5) flammable fumes or gases.
In the lists below, the mixing of a Group A material with a Group B
material may have the potential consequence as noted.
GROUP 1-A
Acetylene sludge
Alkaline caustic liquids
Alkaline cleaner
Alkaline corrosive liquids
Alkaline corrosive battery fluid
Caustic wastewater
Lime sludge and other corrosive alkalies
Lime wastewater
Lime and water
Spent caustic
GROUP 1-B
Acid sludge
Acid and water
Battery acid
Chemical cleaners
Electrolyte, acid
Etching acid liquid or solvent
Pickling liquor and other corrosive acids
Spent acid
Spent mixed acid
Spent sulfuric acid
Heat generation; violent reaction.
GROUP 2-A
Aluminum
Beryllium
Calcium
Lithium
Magnesium
Potassium
Sodium
Zinc powder
Other reactive metals and metal hydrides
GROUP 2-B
Any waste in Group 1-A or 1-B
Fire or explosion; generation of flammable hydrogen gas.
GROUP 3-A
Alcohols, Water
GROUP 3-B
Any concentrated waste in Groups 1-A or 1-B
Calcium
Lithium
Metal hydrides
Potassium
S02 C12, SOC12, PC13, CH3 SiCl3
Other water-reactive waste
Fire, explosion, or heat generation; generation of flammable or
toxic gases.
GROUP 4-A
Alcohols
Aldehydes
Halogenated hydrocarbons
Nitrated hydrocarbons
Unsaturated hydrocarbons
Other reactive organic compounds and solvents
GROUP 4-B
Concentrated Group 1-A or 1-B wastes
Group 2-A wastes
Fire, explosion, or violent reaction.
GROUP 5-A
Spent cyanide and sulfide solutions
GROUP 5-B
Group 1-B wastes
Generation of toxic hydrogen cyanide or hydrogen sulfide gas.
GROUP 6-A
Chlorates, Chlorine, Chlorites
Chromic acid
Hypochlorites
Nitrates
Nitric acid, fuming
Perchlorates
Permanganates
Peroxides
Other strong oxidizers
GROUP 6-B
Acetic acid and other organic acids
Concentrated mineral acids
Group 2-A wastes
Group 4-A wastes
Other flammable and combustible wastes
Fire, explosion, or violent reaction.
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Inpatient Clinics
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Drug Preparation and
Administration
Generation of Regulated
Medical Waste
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Improper Disposal
Exposure to Biological
Contaminants
Employee/Patient
Exposure to
Contaminated Linen
Handling of Detergent
Disinfectants
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination,
Employee Health
Disease
Transmission,
Environmental
Contamination
Disease
Transmission
Employee/Patient
Exposure
Compliance
1
1
1
0
0
1
1
2
Risk
1
1
1
0
1
3
2
2
Frequency
Of Activity
3
4
4
4
4
4
4
4
VAMC
Control
1
4
4
4
4
4
3
2
TOTAL
SCORE
6
10
10
8
9
12
10
10
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Instructions for the CD-ROM
The enclosed CD-ROM provides an electronic version of the Green Environmental Management
Systems (GEMS) Guidebook, and contains the policies and procedures exactly as they
appear in the guidebook, along with additional resources that may be helpful in establishing a
facility environmental management plan.
This Guidebook was produced using Microsoft Word for Windows Version 6.0, Excel for
Windows Version 5.0, Microsoft PowerPoint and Adobe Acrobat 5.0.
• Word for Windows documents have an extension of *.doc.
• Excel documents have an extension of *.xls.
• Adobe Acrobat documents have an extension of *.pdf.
(The * represents the name of the file.)
This Guidebook, as well as the entire Occupational Safety, Fire Protection and Industrial
Hygiene Guidebook series, is available on the CEOSH web site:
vaww.ceosh.med.va.gov
Additional copies of this guidebook may be obtained by contacting the CEOSH Administrative
Library at 314-543-6700.
Xlll
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
xiv
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Interior Design
Date:
Activity or Service
Unpacking Furniture
Report Generation
Chemical Usage
Chemical Usage
Product Storage
Furniture Replacement
Furniture Replacement
Aspect
Excess Cardboard,
Plastic and Styrofoam
Use of Paper
Maintenance and
Fueling of Forklifts
Maintenance and
Fueling of Moving
Trucks
Pallet Usage and
Disposal
Disposal of Metal
Furniture
Disposal of Wooden
Furniture
Impact
Waste Production
Use of Natural
Resource
Contamination
Contamination
Waste Production
Waste Production
Waste Production
Compliance
1
1
0
0
1
1
1
Risk
2
1
2
2
1
1
1
Frequency
Of Activity
O
3
1
2
2
2
1
VAMC
Control
2
3
2
2
3
3
3
TOTAL
SCORE
8
8
5
6
7
7
6
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Information Resource Management (IRM)
Date:
Activity or Service
Operation of Equipment
Uninterruptible Power
Supply Systems
Disposal of Video
Display Terminals
Report Generation
Printing
Maintenance of
Equipment
Aspect
Energy Consumption
Generation of Waste
Batteries
Generation of
Universal Waste
Use of Paper
Disposal of Printer
Cartridges
Generation of Waste
Batteries
Impact
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Compliance
1
1
0
0
0
1
Risk
1
1
1
0
0
1
Frequency
Of Activity
4
1
3
4
3
2
VAMC
Control
2
3
3
3
2
2
TOTAL
SCORE
8
6
7
7
5
6
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Laundry Plant
Date:
Activity or Service
Operation of Equipment
Production Services
(Laundering)
Operation of Washers
Report Generation
Aspect
Energy Consumption
Chemical Usage
Natural Resource
(Water) Consumption
Use of Paper
Impact
Use of Natural
Resources
Disposal,
Environmental
Contamination
Use of Natural
Resources
Use of Natural
Resources
Compliance
1
1
1
1
Risk
1
3
1
1
Frequency
Of Activity
4
4
4
2
VAMC
Control
2
2
2
2
TOTAL
SCORE
8
10
8
6
-------
DRAFT
Lowell Center for
Sustainable Production
^^^^^j^^^^j^^^^^^^^^*
University of Massachusetts Lowell
An Investigation of
Alternatives to Mercury
Containing Products
DRAFT: October 25,2002
Prepared for
The Maine Department
of Environmental Protection
by
Catherine Galligan
Gregory Morose
Jim Giordani
-------
Lowell Center for Sustainable Production
-------
Table of Contents
EXECUTIVE SUMMARY 5
1.0 INTRODUCTION 7
2.0 MERCURY NOTIFICATION DATA REVIEW 8
3.0 MERCURY PRODUCT PRIORITIZATION 10
4.0 FINDINGS 15
4.1 Costs of Using Mercury 16
4.2 Sphygmomanometers 18
4.3 Esophageal Dilators (Bougies) and Gastrointestinal Tubes 21
4.4 Manometers 23
4.5 Thermometers (non-fever) 24
4.6 Barometers 27
4.7 Psychrometers/Hygrometers 27
4.8 Hydrometers 28
4.9 Flow meters 29
4.10 Pyrometers 30
4.11 Thermostats (industrial and manufacturing) 30
4.12 Float Switches 31
4.13 Tilt Switches 40
4.14 Pressure Switches 46
4.15 Temperature Switches 50
4.16 Relays 54
4.16. A Mercury Displacement Relay 56
4.16.B Mercury Wetted Reed Relay 57
4.16.C Mercury Contact Relay 58
Lowell Center for Sustainable Production :
-------
4.17 Flame Sensor 63
5.0 CONCLUSIONS AND RECOMMENDATIONS 66
5.1 Conclusions 66
5.2 Recommendations 70
6.0 SOURCES 71
Appendix 1: Medical Device Reports for Spilled Mercury 74
Appendix 2: Cost of Mercury Spills 75
Appendix 3: Transition to Mercury Free Products 76
Appendix 4: Maine DEP Letter to Manufacturers of Mercury-added Products 80
Lowell Center for Sustainable Production
-------
Executive Summary
The Maine Department of Environmental
Protection (DEP) will issue a report on January 1,
2003 that will include a comprehensive strategy
to reduce the mercury content of products. To
assist in gathering information for this report, the
Maine DEP commissioned the Lowell Center for
Sustainable Production of the University of
Massachusetts Lowell to conduct a study of
alternatives to mercury containing products.
Mercury's chemical and physical properties
have been applied to meet the requirements of
thousands of products and applications including:
dental amalgams, scientific instruments,
electrical components, batteries, lamps, and
medical devices. These mercury containing
products are widely used in residential,
commercial, industrial, military, marine, and
medical environments.
Mercury from these products can be released
to the environment during various stages of the
product life cycle including production,
transportation, manufacturing, use, and disposal.
Once released, the mercury can transform to
organic forms, and can readily disperse in the
environment through the air, soil, and water.
Mercury is persistent in the environment, and
also accumulates in concentration as it
biomagnifies within the food chain. Mercury is
highly toxic to humans; exposure can damage
kidneys and the central nervous system. The fetus
is particularly sensitive to mercury's toxic
effects. Mercury also has adverse effects on
wildlife including early death, weight loss, and
reproductive issues.
In February 2002, the Interstate Mercury
Education and Reduction Clearinghouse
(IMERC) was formed under the auspices of the
Northeast Waste Management Officials'
Association (NEWMOA). IMERC is an
umbrella organization designed to assist the eight
northeast states in their implementation of
mercury reduction laws and programs aimed at
getting mercury out of consumer products, the
waste stream, and the environment.
The LCSP study included a review of the
mercury product notification data submitted by
manufacturers to IMERC. The notification data
included a description of mercury added
components, number of components, amount of
mercury per unit, amount of mercury in total
domestic sales, and purpose of mercury in the
product. At the time of the review, this included
seventy-six manufacturers reporting 390 mercury
containing products. The LCSP study also
included discussions with mercury product
experts, discussions with manufacturers of
mercury products, review of responses to a May
1, 2002 State of Maine letter to mercury product
manufacturers (see Appendix 4), review of
published mercury product studies, and review of
pertinent data available on the internet.
Since there are thousands of products that
contain mercury, a prioritization effort was
needed to focus on a core set of products that
could then undergo further detailed study. The
criteria for this prioritization included: amount of
mercury released to the environment, amount of
mercury contained within the product, total
amount of mercury reported for all product sales,
product coverage by current regulation, and the
availability of mercury-free alternatives.
Products and components were reviewed as part
of the prioritization process. Components are
typically sold to original equipment
manufacturers to be incorporated within a
product. For example, the mercury tilt switch is
a component that is incorporated in automobiles,
vending machines, cranes, wheelchairs, and
numerous other products.
The priority products selected for further
detailed study included sphygmomanometers,
gastrointestinal tubes, manometers, non-fever
thermometers, barometers, hygrometers,
psychrometers, hydrometers, flow meters,
pyrometers, and thermostats (industrial and
manufacturing only). The priority components
selected for further detailed study included float
switches, tilt switches, pressure switches,
temperature switches, displacement relays,
wetted reed relays, mercury contact relays, and
flame sensors.
After the priority products and components
were selected, detailed research and analysis was
Lowell Center for Sustainable Production
-------
then conducted. The findings from this research
include:
• Description of how the mercury
product/component operates
• Typical applications of the mercury
product/component
• Mercury-free alternatives available
• Cost range for the mercury
product/component and mercury free
alternatives
• Advantages and disadvantages of the
mercury products/components and their
mercury free alternatives
• Manufacturer information for mercury
free alternatives
• Summary of findings for each mercury
product/component
In general, cost competitive mercury-free
alternatives were identified that meet the
functionality requirements for most priority
mercury products. Therefore, these products
could be targets for mercury reduction efforts.
The two products where alternative replacements
cannot be recommended are the gastrointestinal
tubes and the industrial thermostats.
For the following components there are cost
competitive mercury free alternatives available
for new products and applications: flame sensors,
float switches, tilt switches, temperature
switches, and pressure switches. However,
mercury free relays can cover most, but not all,
combinations of design parameters for new relay
products or applications.
Certain retrofit situations for mercury
switches and relays exist where the mercury-free
alternative is not cost competitive. Efforts to
reduce the sale of mercury switches and relays
for retrofitting existing products or applications
should take this into consideration.
There are many opportunities for substituting
mercury free alternatives for mercury containing
products and components. Many alternatives are
not simple drop-in substitutions. Although a
mercury free alternative may ultimately achieve
the same desired functionality, such as providing
an accurate measure of blood pressure or sensing
a flame, there are often design considerations or
different techniques or practices that must be first
learned and communicated.
Lowell Center for Sustainable Production
-------
1.0 Introduction
The Maine Department of Environmental
Protection (DEP) will issue a report on January 1,
2003 that is required under An Act to Phase Out
the Availability of Mercury Added Products, PL
2001, c. 620. The report will include a summary
of mercury product data and a comprehensive
strategy to reduce the mercury content of the
products.
To assist in gathering information for this
report, the Maine DEP commissioned the Lowell
Center for Sustainable Production (LCSP) to
conduct a study of alternatives to mercury
containing products. This report summarizes the
findings of the LCSP investigation.
The LCSP develops, studies and promotes
environmentally sound systems of production,
healthy work environments, and economically
viable work organizations. The LCSP is based at
the University of Massachusetts Lowell, where it
works closely with the Massachusetts Toxics Use
Reduction Institute (TURI) and the Department
of Work Environment.
Because of its persistent, bioaccumulative and
toxic nature, the management of mercury
presents a hazard to the environment that should
be addressed and minimized wherever feasible.
Reducing mercury exposure can be accomplished
by source reduction, by minimizing uses that
disperse the material into the environment, and
by diverting and reclaiming any mercury
containing products prior to disposal. While
regulations on use and waste diversion strategies
are necessary, an effective and economically
efficient strategy would be, wherever possible, to
substitute mercury containing products with
products containing less hazardous materials.
The objective of this study is to accomplish
the following:
• Investigate mercury product information
in the public domain
• Identify priority products for investigating
non-mercury alternatives
• Identify non-mercury alternatives to the
products identified
• Conduct a qualitative evaluation of viable
alternatives, including their cost and
performance
The research methodology undertaken to
complete this study included:
• Telephone communication and meetings
with Northeast Waste Management
Officials' Association (NEWMOA) and
Maine DEP personnel were conducted to
understand the information received on
mercury-containing products.
• An internet search was conducted to
obtain data and understand the flow of
mercury associated with products. This
data provided a reference against which
the NEWMOA and DEP mercury
product submissions could be compared.
• Telephone interviews of mercury
reduction experts were held to gain
insight on their perspectives and to
reinforce or challenge conclusions drawn
by the researchers.
• An internet search and phone interviews
were conducted to identify the function
of mercury in products and to identify
alternatives for mercury containing
components and products.
• Telephone interviews were conducted
with manufacturers to develop
information on the alternatives, their
applications, and their advantages and
disadvantages.
• Interviews were held with product users
to understand what made a product
preferable from the user's perspective.
• A search and review of literature in the
public domain was conducted to provide
data on mercury products and
components and their performance.
Lowell Center for Sustainable Production
-------
2.0 Mercury Notification Data
Review
The Maine statutes (see 38 MRS A § 1661-A)
prohibit the sale of mercury-added products
unless the manufacturer has provided written
notification disclosing the amount and purpose of
the mercury. New Hampshire, Rhode Island, and
Connecticut have passed similar mercury
notification laws.
In February 2002, the Interstate Mercury
Education and Reduction Clearinghouse
(EVIERC) was formed. IMERC is an umbrella
organization designed to assist the eight
Northeast states in their implementation of
mercury reduction laws and programs aimed at
getting mercury out of consumer products, the
waste stream, and the environment.
Launched under the auspices of the Northeast
Waste Management Officials' Association
(NEWMOA), IMERC has coordinated regional
mercury reduction efforts and assisted state
environmental agencies in developing and
implementing specific legislation and programs
for manufacturer notification, labeling,
collection, and eventual phase-out of products
that contain mercury.
IMERC has consolidated the mercury
notification information obtained by the
individual states prior to February 2002, and has
served as the clearinghouse for all mercury
notification information received since that time
for Maine, New Hampshire, Rhode Island, and
Connecticut. IMERC has used two notification
forms to collect this data:
Mercury Added Product Notification Form:
The term "mercury added" is used to
indicate that the mercury was intentionally
added to the product. This form requests
manufacturer contact information, as well
as information pertaining to the mercury in
the product such as description of mercury
added components, number of components,
amount of mercury, and purpose of mercury
in the product.
Total Mercury in all Mercury Added
Products Form: This form requests
manufacturer contact information, as well
as total amount of mercury in all units sold
in the United States for a particular product.
Approximately 500 letters in December 2001
and 700 letters in June 2002 were sent to
manufacturers to request such information for
mercury containing products. EVIERC has
reviewed the received mercury notification forms
for adherence to the requested information. The
majority of notification forms received require
follow-up communications with the manufacturer
to address missing or erroneous data. Once the
review of the notification forms has been finished
and has been considered complete, the
information is entered into an EVIERC electronic
database.
For this study, the mercury notification
information in the IMERC electronic database
was reviewed in June and July of 2002. At the
time of this review, there was notification
information for seventy-six manufacturers
reporting 390 mercury containing products. The
total amount of mercury for all units sold in the
United States was available for ninety-eight of
these products. The following table illustrates
the distribution of EVIERC data for the various
product types:
Table 2.1: IMERC Data
Product
Barometer
Battery - button cell
Battery - general
Gas plasma display
Lamp
Lamp - cold cathode
Lamp - fluorescent
Lamp - HID
Lamp - LCD
Lamp - mercury
xenon
Number of
Products
Reported
1
O
13
7
16
1
32
36
115
18
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Product
Lamp - ultraviolet
Manometer
Relays
Sensor - flame
Sphygmomanometer
Switch - float
Switch - pressure
Switch - temperature
Switch - tilt
Thermometer
Thermostat
Total:
Number of
Products
Reported
1
7
2
52
3
15
2
1
36
9
20
390
Source: NEWMOA Database, July 2002
Of the 1,200 notification request letters sent
by IMERC, only seventy-six manufacturers have
provided data sufficient to be deemed complete
and entered into the IMERC database. The
majority of notification requests have either not
been returned, or have been returned with
missing or erroneous data and remain in the
review process. Substantially more mercury data
is therefore anticipated to be available from
IMERC in the near future.
The IMERC mercury product data were one
of several important sources of data for this
report. IMERC information was valuable for the
prioritization process discussed in section 3, and
for identifying the initial manufacturers to be
contacted for further information. Other sources
of mercury product information included
discussions with mercury product manufacturers
and experts, review of mercury product reports,
and review of relevant data available on the
internet.
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3.0 Mercury Product
Prioritization
A broad search was conducted to determine
the scope of products that contain mercury. The
intent of this search was not to develop a
comprehensive list of products, but rather to
develop background information on:
• How is mercury being used in
products?
• Why is mercury being used in
products?
• How much mercury is in various
products?
• What are common mercury
components for various products?
• Are mercury free alternatives
available for these mercury containing
products?
These questions were investigated through
discussions with mercury product experts,
discussions with manufacturers of mercury
products, review of IMERC mercury notification
results, review of responses to a May 1, 2002
State of Maine letter to mercury product
manufacturers (see Appendix 4), review of
published mercury product studies, and review of
pertinent data available on the internet.
This review has shown that for most mercury-
added products, the mercury is found in a number
of common components. For example, tilt
switches are a common component in hundreds
of products and applications such as building
security systems, automobile trunk lights,
scanners, and robotics. This is also true for
batteries, relays, and fluorescent lamps which are
each used in hundreds of products and
applications.
The universe of products that use mercury is
extensive. Mercury's chemical and physical
properties have been applied by design engineers
to meet the needs of thousands of diverse
products and applications. The following table
illustrates examples of products that employ
some of these properties.
Table 3.1: Properties of Mercury
Product Example
Mercury wetted reed
relays
Position sensing
products such as
level sensors
Barometer
Thermometer
Dental amalgam
Gastrointestinal tubes
Fluorescent lights
Tilt switches utilize
both the electrical
conductivity and
liquid at ambient
conditions properties
Property of Mercury
Electrical
conductivity
Liquid at ambient
conditions
Precise movement in
response to air
pressure differential
Precise
expansion/contraction
in response to
temperature change
Easily alloys with
many metals such as
gold, silver, and tin.
Density
When energized,
mercury in vapor
form emits ultraviolet
energy
Combination of
properties
Since there are thousands of products that
contain mercury, the research effort focused on
identifying a core set of priority products or
common components that could then undergo
further detailed study. For the purpose of this
report, the terms product and component will be
defined as followed:
Product: A product is predominately sold to
the consumer in its final product state. For
example, a thermometer is sold to the
consumer for temperature measuring
purposes.
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Component: A component is predominately sold
to an original equipment manufacturer to be
incorporated within another product. For
example, the tilt switch is sold to automobile
manufacturers to be incorporated into an
automobile.
The following five criteria were selected as
the basis for this prioritization:
1. What is the contribution of the product
category to the total mercury released to
the environment for all product
categories?
Only limited data is available on mercury
released on an individual product basis.
More information is available on mercury
released by product category. Thus, total
mercury released by product category was
chosen as a screening criterion. The more
mercury released by a product category,
the more likely that products in that
category would be a priority for further
research.
The following report was selected as a
basis to support this criterion: "Substance
Flow Analysis of Mercury in Products"
prepared by Barr Engineering Company
for the Minnesota Pollution Control
Agency on August 15, 2001. (Barr, 2001)
This report was chosen because it
provided a comprehensive review of total
mercury releases from numerous product
categories, it included mercury releases to
each environmental media (land, air, and
water), and it was recently published. In
addition, the states of Maine and
Minnesota are both leaders in fostering
mercury reduction programs, and they
have comparable demographic and
commercial characteristics such as retail
sales per capita. The releases by product
category from this report have been
categorized as high for releases greater
than 20% of total releases, medium for
releases from 5% to 20% of total releases,
and low for releases less than 5% of total
releases.
2. What is the amount of mercury within the
product?
The higher the amount of mercury
contained within a product, the more
likely it would be a priority for further
research. Various sources were used to
obtain this information including:
discussions with manufacturers of
mercury products, review of EVIERC
mercury notification results, review of
published mercury product studies, and
review of pertinent data available on the
internet.
3. What is the total amount of mercury
reported for all sales of a specific type of
product in the U.S.?
The higher the total amount of mercury
reported for all U.S. product sales, the
more likely it would be a priority for
further research. The primary source for
this data was a review of EVIERC mercury
notification results. However, this
information was reported and available
for only a few product types at the time of
this study.
4. Is the product addressed by existing
mercury regulations?
Mercury-added products already
regulated by either the State of Maine or
federal Environmental Protection Agency
(EPA) were eliminated as a priority for
further study as part of this report. The
Maine statutes on mercury-added
products, 38 MRS A §1661 et seq., as well
as pertinent EPA regulations were used as
sources for this information.
5. Have readily available mercury free
alternatives been identified?
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If mercury-free alternatives are available
in the marketplace, then the product is
more likely to be a priority for further
study. The data sources for this effort
included discussions with mercury
product experts, discussions with
manufacturers of mercury products,
review of published mercury product
studies, and review of pertinent data
available on the internet.
• Displacement/plunger relays
• Wetted reed relays
• Mercury contact relays
• Flame sensors
The results of applying these five criteria are
summarized on the following page in Table 3.3
Priority Product Selection. The shaded cells
indicate the priority products selected.
Certain mercury products did not fall into a
product category. For many of these products
very limited information was available about
their current use, manufacture, and mercury
content. This included counterweights, jewelry,
and advanced mercury alloys used in products
such as converters, oscilloscopes,
semiconductors, solar cells, satellites, and
infrared sensors. These products were therefore
not considered a priority for this project.
As a result of applying these five criteria to
mercury containing products, the following
products and components were selected for
further study as part of this report:
Table 3.2: Priority Products and Components
Products
• Sphygmomanometers
• GI tubes
• Manometers
• Thermometers (non-fever)
• Barometers
• Hygrometers
• Psychrometers
• Hydrometers
• Flow meters
• Pyrometers
• Thermostats (industrial and
manufacturing)
Components
• Float switches
• Tilt switches
• Pressure switches
• Temperature switches
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Table 3.3: Priority Product Selection
Product
Sphygmo-
manometers
Manometers
GI Tubes
Flame sensors
Thermometers (non-
fever)
Barometers,
hygrometer,
psychrometer,
hydrometer, flow
meter, pyrometer
Permeter, barostat,
oscillator, gyroscope,
otoscope, sequential
multiple analyser,
phanotron, ignitron
Amalgam
Fever Thermometers
Fluorescent Lamps
Float switch
Tilt switch
Pressure Switch
Temperature Switch
Displacement/plunger
relay
Wetted reed relay
Other mercury
contact relays
Manufacturing and
industrial thermostats
HID & Other Lamps
Product
Category
Releases1
Other
measurement &
control devices
(High)
Dental
(High)
Fever
Thermometers
(Medium)
Fluorescent
Lamps
(Medium)
Other Relays &
Switches
(Medium)
Thermostats
(Medium)
HID & Other
Lamps
(Low)
Mercury
Content
(mg)2
> 1,000
> 1,000
> 1,000
> 1,000
> 1,000
> 1,000
None
reported
> 1,000
100 - 1,000
Predom-
inately
<100
> 1,000
100 to 1,000
> 1,000
> 1,000
> 1,000
10 to 50, 50
to 100
100 to 1,000
> 1,000
10 to 50, 50
to 100
100 to 1,000
> 1,000
0 to 5, 5 to
10
10 to 50
100 to 1,000
> 1,000
100 - 1,000
> 1,000
Predom-
inately
<100
Total
Mercury Use
(g)3
1,815,000
6,956
None reported
1,267,000
765,443
None reported
None reported
Ty tin Alloy:
8,811,270
None reported
2,092
1,914,418
11,329
None reported
None reported
16,174,300
2,400
None reported
2,162
16,051
Addressed
in Existing
Legislation4
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Alternatives
Identified
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Priority
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
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Product
Batteries
Bulk Liquid Mercury
Automobile Switches
Chlor-alkali products
Pharmaceuticals
Latex Paint
Fungicides
Film
Converter,
oscilloscope,
semiconductors, solar
cells, satellites,
infrared sensors
Cleaners, detergents,
catalysts, reagents,
pigments, cosmetics,
other
industrial/laboratory
use
Jewelry,
counterweights
Product
Category
Releases1
Batteries
(Low)
Bulk Liquid
Mercury
(Low)
Automobile
Switches
(Low)
Chlor-alkali
products
(Low)
Pharmaceuticals
(Low)
Latex Paint
(Low)
Fungicides
(Low)
Film
Advanced
Materials
(HgCdTe, HgTe,
HgSe)
Chemical
Compounds
Miscellaneous
Mercury
Content
(mg)2
Predom-
inately
<100
Not
applicable
0-5
100 - 1,000
> 1,000
Misc-
ellaneous
ppm/ppb
Misc.
ppm/ppb
Misc.
ppm/ppb
Misc.
ppm/ppb
0-5
Not readily
available
Misc-
ellaneous
ppm/ppb
Not readily
available
Total
Mercury Use
(g)3
50,085
None reported
24,885
None reported
None reported
None reported
None reported
164
None reported
None reported
None reported
Addressed
in Existing
Legislation4
No
No
Yes
No
No
Yes
No
No
No
No
No
Alternatives
Identified
Yes
No
Yes
Yes
No
Yes
Yes
No
No
No
No
Priority
No
No
No
No
No
No
No
No
No
No
No
Source: "Substance Flow Analysis of Mercury in Products" Prepared for the Minnesota Pollution Control Agency,
August 15, 2001. Film, advanced materials, chemical compounds, and miscellaneous were not explicit product categories
within this report. High: greater than 20% of total releases, Medium: 5% to 20% of total releases, Low: less than 5%
of total releases.
2 From IMERC database, IMERC paper files, and other miscellaneous sources.
3 Total amount of mercury used in all products sold in calendar year 2001 as reported to IMERC. The value in the table
indicates the highest amount reported from a single manufacturer for a particular product. Total amounts have not yet
been reported by all manufacturers.
4 The Maine statutes on mercury-added products, 38 MRSA §1661 et seq., as well as pertinent EPA regulations were used
as sources for this information.
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4.0 Findings
Once the prioritization process was completed
and accepted by the Maine Department of
Environmental Protection, the analysis of the
priority products and components was initiated.
After conducting research and analysis of the
priority products and components, the findings
were prepared. The findings of this study are
here presented in the following format:
Description
This section includes an overview of how the
product/component operates, background
information on the product/component, and
typical applications of the product/component.
Alternatives
This section identifies the mercury free
product/component available to replace the
function and performance characteristics of the
mercury containing product/component.
Costs
The costs in this section are often provided in a
range. The range includes only list prices
available on the internet or by manufacturer
inquiry as part of this study. The range does not
necessarily include every model or every
manufacturer listed for a particular technology.
The prices for a specific model may vary
considerably based upon options required,
quantity ordered, customer discount, and other
factors. The price ranges are only presented to
provide a gross cost comparison between the
various technologies.
Advantages/Disadvantages
This section compares the effectiveness of the
mercury free alternative product/components to
the mercury containing products or components.
The function of the mercury containing
product/components will be considered, and the
merits and shortcomings of the alternatives will
be presented.
Manufacturers
This section lists in table format the
manufacturers of mercury containing
products/components and manufacturers of the
mercury free alternatives. This table also
provides product/component name, manufacturer
phone number, and manufacturer website
information.
Format
There are two formats used in this report to
present findings. The priority products are
covered in sections 4.2 through 4.11 utilizing the
following format:
Description
Alternatives
Costs
Advantages/Disadvantages
Manufacturers
Summary
The priority components are covered in sections
4.12 through 4.17 utilizing a slightly different
format. Since the components are used in a wide
variety of products and applications, the
description, costs, advantages/disadvantages, and
manufacturers information will be provided for
each mercury free alternative identified. Also,
the manufacturers of both mercury and non-
mercury manufacturers are provided. The
following is the format for priority components:
Description
Costs
Advantages/Disadvantages
Manufacturers
Summary
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4.1 Costs of Using Mercury
Traditionally the cost of using mercury has
been focused on the purchase price of the device.
What is often not recognized are the other costs
that go along with the use of mercury. These
other costs include potential for costly spills,
adverse health effects, liability, regulatory
compliance costs and maintaining equipment and
trained personnel to handle mercury releases.
Tellus Institute's report "Healthy Hospitals:
Environmental Improvements Through Better
Environmental Accounting" proposes that
environmental costs and benefit information can
be incorporated into accounting practices to
attain a more meaningful cost. It considers
environmental costs, which are defined as
"impacts, both monetary and non-monetary,
incurred by a firm or organization resulting from
activities affecting environmental quality. These
costs include conventional costs, potentially
hidden costs, and less tangible costs." (Tellus
Institute, 2000)
Table 4.1: Mercury Costs
Potentially Hidden
Costs
• Up-front: site
preparation,
permitting,
installation
• Back-end: site
closure,
disposal of
inventory, post-
closure care
• Regulatory:
training,
monitoring,
recordkeeping
Less Tangible Costs
• Liability:
Superfund,
personal injury,
property damage
• Future regulatory
compliance costs
• Employee safety
and health
compensation
• Organizational
image
Source: Tellus Institute, 2001
The same report provides a case study of
Kaiser Permanente's mercury minimization
efforts. Kaiser Permanente is the largest not-for-
profit Health Maintenance Organization (HMO)
in the United States. Kaiser considered the costs
in addition to the purchase price of mercury
thermometers and sphygmomanometers that
could be avoided by using alternative mercury
free products. For sphygmomanometers, Kaiser
found that "the aneroid alternative is significantly
more expensive to purchase on a unit basis.
When associated lifecycle costs are included ...
total costs per unit drop to about 1/3 the total
costs of the mercury unit." The findings of the
LCSP study indicate that in 2002, the purchase
cost of mercury and aneroid
sphygmomanometers are now comparable. This
further reduces the lifecycle costs for the mercury
free sphygmomanometers.
Kaiser's mercury minimization efforts
reduced costs avoidance by reducing the
incidence of spills, exposure incidents and
liability, and staff toxics training, as detailed in
the Table 4.2. Kaiser's estimates suggest that for
every $1 spent on spill response, there is
potentially another $1.75 for training, fines, and
treatment of exposure. (Tellus Institute, 2000)
Although clean up costs are not well
documented in the literature, an internet search
revealed numerous reports that provide insight
into the financial impact of a mercury spill. A
summary of these reports is presented in
Appendix 2.
While the LCSP study does not present the
full life cycle costs for each of the mercury and
non-mercury products, the costs delineated in this
section should be considered when evaluating
these products.
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Table 4.2 : Kaiser Permanente Case Study
Avoided Cost
Category and
Amount
Spill preparation
and response
$20,000/year
Compliance and
liability
$15,000/year
Treatment of
exposure
Additional soft
savings
(environmental
staff were aware
of these costs, but
they were not
quantified)
Sources of cost avoidance
estimate
The cost of a mercury spill kit is
known, as is the cost of a spill
response by Kaiser Permanente's
contractor. These costs,
combined with the average
historical number of spill
incidents from broken devices in
a year, permit an avoided cost
estimate to be made.
Use of mercury-containing
devices necessitates staff
spill/exposure training.
Further, given staff training,
careful use and appropriate spill
procedures, the presence of
mercury-containing devices
gives rise to the possibility of
fines from facility inspections or
spill incidents. The probabilistic
costs of mercury related
penalties were estimated using
representative statutory and
regulatory penalties multiplied
by the probability of a fine being
assessed for any particular
violation.
A probabilistic cost. Even
assuming very high standards of
appropriate and careful use,
some small number of mercury
exposures from broken devices
are likely when mercury-
containing devices are employed
throughout the Kaiser system.
Cost is determined from the
expected yearly cost of long-
term treatment of a single
pediatric exposure case
($100,000-plus), and the
probability of an exposure
incident within a given year.
"Soft cost" savings were not
estimated, but could, include:
environmental contamination
from mercury release,
subsequent health impact, and
negative media attention.
Source: Tellus Institute, 2000
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4.2 Sphygmomanometers
Description
Blood pressure is generated by the activity of the
heart and blood vessel system and is widely
accepted as a measure of cardiovascular
performance. Therefore blood pressure levels and
variations are considered to be a valid indicator
of cardiovascular function and overall health.
Most blood pressure devices use an air filled
cuff to temporarily block blood flow through the
artery, then apply a particular technique to obtain
blood pressure data while the cuff deflates. The
two most common techniques for pressure
measurement are the auscultatory method
(listening for characteristic blood flow sounds) or
oscillometric technique (using a pressure
transducer).
The two main considerations for this
discussion of blood pressure devices are 1) how
the blood pressure is sensed (e.g. by ear or by
using a pressure transducer) and 2) the gauge or
indicator for the pressure value (mercury column,
dial gauge, or microprocessor/digital display). A
mercury column is the traditional method of
indicating blood pressure.
Alternatives
In the field, two alternatives to mercury are
widely marketed for clinical blood pressure
measurement. They are aneroid (mechanical dial)
Sphygmomanometers and low-end professional
electronic blood pressure monitors. There are
other non-mercury blood pressure monitors
available as well, including home monitors,
ambulatory blood pressure monitors, and high-
end vital signs monitors. These are not covered in
this report because they are generally not
considered direct replacements for mercury
Sphygmomanometers.
Auscultatory Sphygmomanometers (mercury and
aneroid)
Mercury and aneroid Sphygmomanometers
rely on the auscultatory technique, in which a
clinician determines systolic and diastolic blood
pressures (SBP and DBF) by listening for
Korotkoff sounds, or sounds that characterize
different stages of blood flow during cuff
deflation. At certain points in the sound pattern,
the clinician reads the pressure using a column of
mercury or the dial of an aneroid (mechanical)
gauge. This technology is the most widely used
because of its low cost and simplicity.
The familiar mercury sphygmomanometer
uses a column of mercury (manometer) to
provide the pressure readout. Mercury's liquid
state and its precise expansion and contraction in
response to pressure are very suitable for
pressure indication. The manometer reads from 0
to 300 mmHg.
A common aneroid gauge consists of a dial
that reads in units of 0 to 300 mmHg and a thin
brass corrugated bellows inside. There is a shaft
which connects two pins at right angles to each
other; one of these rests on the bellows, the other
is inside a concave sided triangle which meshes
with a pinion connected to the dial pointer. A thin
coiled spring (known as a hair spring) is also
connected to the pinion and returns the pointer to
zero when the pressure is released. The gauge is
connected to a blood pressure cuff around the
patient's arm. As the pressure in the cuff rises, the
pin resting on the expanding bellows is lifted.
This movement is transmitted by the other pin
which moves the triangle and therefore the pinion
and pointer. (Yeats, 1993)
Welch Allyn has recently introduced the Dura
Shock aneroid sphygmomanometer that utilizes a
new internal design. The new concept results in a
sphygmomanometer that is lighter in weight,
considerably lower in cost, and more shock
resistant than a conventional aneroid
sphygmomanometer. Further research is
warranted to understand the internal design.
Oscillometric Blood Pressure Monitors
The oscillometric blood pressure monitor uses
a pressure sensor and a microprocessor in place
of the ear and simple gage. During cuff deflation,
a pressure sensor transmits an electric signal
representing the distention of the artery. Within
the microprocessor, this signal is translated to
systolic and diastolic blood pressure (SBP and
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DBF) using empirically derived algorithms.
Manufacturers spend considerable effort
validating their algorithms for accuracy.
In addition to SBP and DBF, this type of
device can display more comprehensive
information about blood pressure patterns, which
can be useful for diagnostics. Because of its
higher cost and technical sophistication, this type
of device is not as prevalent as the auscultatory
devices. The cost of these devices has dropped
significantly over the past few years and
companies are now marketing these to hospitals
based on the breadth of information they can
provide.
Electronic equipment using the oscillometric
technique is common in two types of equipment:
1. A mid-price blood pressure monitor, designed
to compete with auscultatory devices. In the
past few years several companies have begun
promoting this type of device and as their
cost has decreased, use is becoming more
widespread.
2. Vital signs monitors - This class of device is
often found in hospital settings where
simultaneous monitoring of multiple vital
signs (e.g. temperature, blood pressure, heart
rate, blood oxygen level) is desirable or
critical for patient outcomes. The
instrument's electronic box includes multiple
modules, each for measuring a different sign.
They are available from several device
manufacturers. These devices, though
relatively common in hospitals, are not
considered further because they are not
considered a one-for-one replacement for a
mercury sphygmomanometer.
Cost
Most manufacturers of auscultatory devices offer
both mercury and aneroid sphygmomanometers.
A sampling of prices for mercury and aneroid
devices revealed essentially no difference
between the two, as shown in the following table.
Table 4.3 Cost of Comparable Mercury and
Aneroid Sphygmomanometers
Manufacturer
& Style
Welch Allyn
Wall unit
Welch Allyn
Mobile unit
Welch Allyn
Pocket unit
(portable)
ADC
Wall Unit
ADC
Mobile Unit
Trimline
Mobile Unit
Trimline
Wall Model
Trimline
Desk Model
Trimline
Hand-held
Type
Mercury
Aneroid
Mercury
Aneroid
Mercury
DuraShock3
aneroid
Aneroid
Mercury
Aneroid
Mercury
Aneroid
Mercury
Aneroid
Mercury
Aneroid
Mercury
Aneroid
Mercury
Aneroid
List or
Suggested
price1
$132
$134
$258
$253
Not
available2
$59
$162
$111
$105
$204
$204
$299
$264
$120
$137
$148
$151
Not
available2
$98
Model
5097-26
5091-38
5097-29
5091-41
DS45-
11
5098-02
952B
750W
972
750M
0103N
4103N
0303N
4303N
0403N
4203N
2273N
These prices were obtained by contacting each
manufacturer and/or their websites and requesting
pricing on comparable mercury and aneroid units.
2 No comparable unit because Hg column must be
rigidly mounted in perfectly vertical position;
incompatible with hand-held or portable units.
3 The DuraShock is a new product for Welch Allyn
that is more resilient than a traditional aneroid. This
design also results in a significantly lower cost.
Oscillometric blood pressure monitors are
considerably higher in price, as shown in the
following table.
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Table 4.4 Cost of Oscillometric Blood Pressure
Monitors
Manufactur
er & Style
Pulse Metric
VSM
MedTech
Ltd.
Welch Allyn
Medical
Products
List or
Suggested
price
$995
$645
$805
Model
DynaPulse
Pathway
BPTru
Spot Vital
Signs™
Advantages/Disadvantages
From the perspective of clinicians and hospital
systems, the considerations for blood pressure
devices include cost, accuracy, ease of use,
maintenance and calibration, and environmental
impact. One needs to consider the merits and
shortcomings of the following two aspects of
blood pressure devices:
1. The method of pressure sensing; i.e.
auscultatory (listening to sounds) versus
oscillometric (using pressure transducers).
2. The pressure readout mechanism; i.e.
mercury manometer, aneroid gauge, or
microprocessor with digital display.
Auscultatory devices (mercury and aneroid)
rely on the human ear to detect and distinguish
sounds and there is a possibility for measurement
error due to individual skill and levels of auditory
acuity and sensitivity. Auscultatory devices allow
measurement of just SBP and DBF. In contrast,
the oscillometric monitors are less dependent on
operator technique and many offer a greater
breadth of baseline data including mean arterial
pulse (MAP) and pulse rate. Some monitors also
allow addition of modules for other vital signs
(temperature, pulse oximetry), pulse waveforms,
and data analysis. One manufacturer's technical
representative reported that he continues to learn
about the utility of the oscillometric device as
doctors phone in and describe how they are using
the data for diagnostics. In short, the breadth of
information may allow doctors to better
understand and manage a patient's condition.
Mercury gauges are familiar, have a long
history of use, are on the low end of the cost
spectrum and they have the unique advantage of
being perceived as the gold standard for blood
pressure. The primary disadvantages of the
mercury gauge are associated with the toxicity of
mercury. Mishandling may result in a mercury
spill and there is potential for a costly mercury
cleanup. Even with proper handling and
maintenance, mercury gauges eventually require
either handling of elemental mercury during
maintenance or disposal of mercury as a
hazardous waste. For the clinician, mercury
gauges require positioning one's head at the
proper, but often awkward, angle to read the
glass tube's mercury meniscus.
Aneroid gauges are familiar, have a long
history of use, are on the low end of the cost
spectrum, are easy to read, and the clinician can
easily perform a rudimentary function check by
observing the zero resting point and the
smoothness of dial rotation. Mishandling may
result in damage to the gauge. Aneroid gauges
have been maligned in the press recently, and
there is an unsubstantiated perception that
accuracy of aneroid gauges is inferior to mercury
columns. The calibration is different from, but
comparable in complexity, to proper calibration
of the mercury devices.
The electronic monitors on the oscillometric
devices are easy to use and provide an easy-to-
read digital display of the DBF and SBP. The
devices go through a self-calibration routine on
start up. In addition to SBP and DBF, many of
the devices display comprehensive data that
provides greater insight into patient health; as the
devices are used more widely it is likely that the
full utility of features will be better recognized
and reported. Some disadvantages of the
electronic blood pressure monitors are initial cost
and the need for A/C power or a battery pack.
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Manufacturers
The following are manufacturers of alternative
sphygmomanometers:
Mercury and Aneroid Sphygmomanometers
Manufacturer
Name
American
Diagnostic
Corporation
Trimline
Medical
Products
Welch Allyn
Medical
Products
Product
ADC
Sphygmo-
manometer
Trimline
Sphygmo-
manometer
WelchAllyn
Tycos
sphygmo-
manometer
Phone Number &
Website
613-273-9600
www.adctodav.co
m
800-526-3538
www.trimlinemed.
com
315-685-4100
www.welchallyn.c
om
Oscillometric Blood Pressure Monitors
Manufacturer
Pulse Metric
VSM
MedTechLtd.
Welch Allyn
Medical
Products
Vital Signs
Products
Product
DynaPulse
Pathway
BpTRU™
Spot Vital
Signs™
Phone Number &
Website
866-3962-78573
www.pulsemetric.c
om
913-307-9527
www.vsmmedtech.
com
800-535-6663
www.welchallyn.c
om
Summary
Research on sphygmomanometers suggests that
there are numerous good alternatives to mercury
sphygmomanometers. Aneroid sphygmo-
manometers are cost competitive, have a long
history in the field, and have been found
acceptable by many hospitals. Blood pressure
monitors are more costly, but are becoming more
popular as costs are dropping and medical
practitioners are seeing advantages to their ease
of use and the breadth of information provided.
The Mayo Medical Center in Rochester,
Minnesota is an example of a facility that has
successfully converted to non-mercury
sphygmomanometers. Since 1993, Mayo Clinic
replaced approximately 1,500 mercury
sphygmomanometers with wall-mounted aneroid
devices. At the same time a maintenance protocol
was developed to ensure proper function and
accuracy of these devices. In March 2001, Mayo
published the results of an internal study in which
they concluded that the aneroid
sphygmomanometers provide accurate pressure
measurements when properly maintained.
(Canzanelloetal, 2001)
4.3 Esophageal Dilators (Bougies)
and Gastrointestinal Tubes
Esophageal Dilators (Bougies)
Description
An esophageal dilator, also called a bougie, is a
long, weighted flexible tube that is passed down
a patient's esophagus to dilate a narrowed area.
In the past, mercury was commonly used in the
bougie. Its density and liquid state made mercury
ideal as a flexible weight that assisted passing the
tube down the throat into the esophagus,
conforming to the shape of the esophagus and
exerting the pressure needed to enlarge the
narrowed section. The mercury-filled devices
have a thick latex outer coating that contains
about two pounds of mercury. Esophageal
dilators may be found in thoracic surgery,
otolaryngology, and the medical procedure units.
Alternatives
The alternatives to mercury bougies use a
tungsten gel to provide the flexible weight.
Because tungsten is a solid at room temperature,
the tungsten within the device is a powder
suspended in a gel. This allows the dilator to flex
and conform to the shape of the esophagus, have
a "feel" similar to the density of mercury, and to
apply the proper pressure to enlarge the narrow
area of the esophagus.
Cost
Mercury bougies are no longer widely available.
Of the three manufacturers that were identified,
only one company still offers mercury bougies at
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a cost of $3,395 for a full set. The cost of a set of
replacement tungsten gel bougies listed in the
range of $3,000 to $4,400. At the $4,400 end of
the range, one manufacturer was offering 10%
discounts and a free mercury bougie take-back
option.
Advantages/Disadvantages
Bougies have an expiration date, due to the
potential for degradation of the outer rubber
casing. At the end of its useful life, a mercury
bougie must be disposed of as a hazardous
material. Mercury containing esophageal dilators
have been known to rupture during handling or
use causing potential environmental, patient, and
employee hazards. The FDA Medical Device
Report (MDR) system includes reports of
bougies rupturing and leaving mercury inside the
patient as well in the room. Examples of MDRs
for ruptured bougies are included in Appendix 1.
The tungsten bougie is considered to be a
safer, more environmentally benign alternative.
The tungsten gel filled bougies perform like
mercury filled bougies, so there are no changes in
technique required. At the end of its useful life, a
tungsten filled bougie can be disposed of in the
trash. Tungsten bougies have either a silicone
covering or a PVC covering. An advantage of the
silicone surface is that it is non-slip when dry and
slippery when wet, making handling easier. Some
healthcare facilities are moving away from PVC
because of a concern that when PVC is
incinerated as waste, there is potential for the
formation of dioxins during incineration.
Manufacturers
The following are manufacturers of non-mercury
and mercury esophageal dilators:
Manufacturer
Medovations,
Inc
Product
Weightright™
Bougie
Phone Number
& Website
800-558-6408
www.medovatio
ns.com
Manufacturer
Pilling
Rusch
Product
Bougie Tubes
(Maloney style
and Hurst
style bougies
are weighted
with tungsten
gel)
Bougie Tubes
(Maloney style
and Hurst
style bougies
are tungsten
filled)
Phone Number
& Website
800-523-6507
www.pillingsurg
ical.com
800-524-7722
www.myrusch.c
om
Summary
Phone interviews with manufacturers and
medical practitioners suggest that tungsten filled
bougies are widely available and well received as
alternatives to mercury containing bougies. For
example, a seasoned practitioner in a hospital in
the northwest suburbs of Boston who was
interviewed recalled her hospital's much earlier
use of mercury bougies. Her recollection was that
the hospital had been using tungsten filled
bougies for years and the mercury free devices
performed just fine.
Gastrointestinal Tubes
Description
Another family of tubes, including Miller Abbott,
Blakemore, and Cantor tubes, are used for
addressing intestinal obstructions. Historically
these tubes used mercury as a flexible weight to
guide the tube into place through gravity.
This family of products represents a data gap
in this report. Research suggested that these
devices are no longer widely used and no
manufacturers of mercury-containing devices
were identified. Unweighted tubes are available,
and although the manufacturers do not supply
mercury they believe some customers add their
own mercury.
Alternatives
Two manufacturers were identified that described
their products as viable alternatives for this type
of application. Andersen offered unweighted and
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tungsten weighted tubes that they described as
alternatives for Miller-Abbott and Cantor tubes.
Rusch's Product Manager suggested that
practitioners can add sterile water to the Cantor
tube, as a weight to help move the tube.
Cost
A cost comparison is not relevant since mercury
products were not located. However, the cost of
the non-mercury Miller Abbott and Cantor tubes
were approximately $300 to $400.
Advantages/Disadvantages
One manufacturer reported that sterile water can
be used as a weight for the cantor tube, in the
place of mercury. The disadvantage is that the
tube passes much more slowly, a disadvantage
that translates to a longer medical procedure
time.
Manufacturers
The following are manufacturers of gastro-
intestinal tubes for which the buyer must provide
the weighted liquid:
Manufacturer
Andersen
Rusch
Product
Miller Abbott
& Cantor
Tubes
Cantor Tubes
Phone
Number &
Website
800-523-1276
800-524-7722
www.myrusch.
com
Summary
Research on gastrointestinal tubes suggests that
this family of products is no longer widely used
in hospitals. It is unclear whether mercury is still
used in settings where gastrointestinal tubes have
not become obsolete and if so, whether an
alternative practice or product might be
acceptable.
Dartmouth Hitchcock Medical Center
reported that in 1995 they eliminated the use of
mercury in Miller Abbott Tubes by replacing the
mercury with water and a contrast media. When
the change was implemented, there was a
concern that because water is not as heavy as
mercury, the procedure might take longer than
with mercury. However the Safety and
Environmental Programs office did not receive
complaints from clinicians about the
replacement. It was reported that the nursing and
housekeeping staff were pleased with the
elimination of mercury because they were
responsible for mercury spills.
4.4 Manometers
Description
Manometers are used to measure air, gas, and
water pressure. The mercury in manometers
responds to air pressure in a precise way that can
be calibrated on a scale. Manometers are used in
laboratories, the dairy industry milking process,
and for calibrating outboard motors and
motorcycle carburetors. Manometers are also
used by HVAC contractors for testing, balancing,
and servicing equipment.
Alternatives
The three alternatives to a mercury manometer
include the needle/bourdon gauge, the aneroid
manometer, and the digital manometer. The
needle/bourdon gauge operates under a vacuum
with a needle indicator as a method to measure
pressure. The aneroid manometer operates in a
similar fashion to the needle/bourdon gauge. The
digital manometer uses a digital computer
programmed memory and gauges to measure the
pressure.
Cost
Many digital manometers are manufactured for
various purposes and most pressure-sensing units
can be used interchangeably for different
applications. Digital manometers can range in
price from $100 to $700 depending on the
application it is being used for. Needle/bourdon
gauges range from $50 to $200 depending on the
application and manufacturer.
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Advantages/Disadvantages
Digital manometers, mercury manometers, and
needle/bourdon gauges require calibration. This
calibration ensures the accuracy of the instrument
reading. A digital manometer can be more
precise than the mercury manometer if properly
calibrated.
Manufacturers
The following are manufacturers of non-mercury
manometers.
Manufacturer
Name
Mannix
Testo
Extech
Instalments
Carbtune
Alnor
Dwyer
Instalments
Product
Digital
manometer
Digital
manometer
Digital
manometer
Aneroid
manometer
Digital
manometer
Digital
manometer,
Needle/
bourdon
gauge
Phone Number &
Website
516-887-7979
www.mannix-
inst.com
973-252-1720/1-
800-227-0729
www.testo.com
781-890-7440
www.extech.com
01144289023
9007
www.carbtune.com
1-800-424-7427
www.alnor.com
219-879-8000
www.dwyerinstru
ments.com
Summary
It appears that the alternatives to a mercury
manometer are cost competitive, reliable, and
widely manufactured and used throughout the
United States. An example of a successful
mercury manometer replacement project is the
effort undertaken for dairy farms in Wisconsin
with a $40,000 grant from the EPA. Dairy
equipment service providers participated in this
program by collecting the mercury manometers
used on dairy farms and replacing them with non-
mercury manometers. Under this program, more
than 100 manometers have been removed from
Wisconsin dairy farms. (Wisconsin Department
of Natural Resources, 2002)
4.5 Thermometers (non-fever)
Basal Thermometers
Background
An individual's basal body metabolism is
reflected in basal metabolic temperature, or the
lowest normal body temperature of a person
immediately on waking in the morning. Day-to-
day variations in basal temperature are indicative
of the body's cyclical changes. For example,
basal temperature is a useful index for evaluating
ovulation.
This baseline temperature is measured with a
basal thermometer, which is more sensitive than
a conventional fever thermometer. The smallest
division on a basal thermometers is 0.1 degree,
compared with 0.2 degree on a conventional
fever thermometer.
Mercury basal thermometers are similar in
function to mercury fever thermometers. A
column of mercury within a glass tube expands
with increasing temperature and registers a
reading at the peak temperature.
Alternatives
Alternatives to basal thermometers are galinstan-
in-glass (liquid in a glass tube) and compact
digital thermometers.
Galinstan basal thermometers are sold under
the brand name Geratherm. Like mercury
thermometers, the Geratherm thermometer
consists of silvery liquid in a glass tube. The
liquid is a mixture of gallium, indium, and tin
that expands with temperature to provide a
reading. These are similar to Geratherm fever
thermometers.
Battery-powered digital basal thermometers
are the most common option for basal
thermometers. These are similar in appearance
and function to digital fever thermometers.
Cost
Basal thermometers are fairly inexpensive and
technologies are readily available for under $15.
The cost of devices is historically lowest for
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mercury basal thermometers, mid-range for
Geratherm, and highest for digital devices.
A data gap exists for the cost of mercury basal
thermometers as our research was unable to
easily identify a current manufacturer. Becton
Dickenson, a large medical manufacturer,
reported that they no longer offer mercury basal
thermometers. Pharmacies in the researchers'
local area have also eliminated mercury basal
thermometers, although anecdotal information
suggests that mercury basal thermometers are
still available in other geographic locations.
According to one manufacturer, their list price
for the Geratherm basal thermometer is $7.69-
$7.99. Another manufacturer reported that the
average list price for its digital basal thermometer
is $12.
Advantages/Disadvantages
The primary selling points for mercury are cost
and familiarity. The disadvantages of mercury
basal thermometers are: lengthy dwell time to
peak temperature (3-5 minutes), shake down is
required between readings, difficulty reading the
column of mercury, fragile glass structure, and
mercury basal thermometers may not be widely
available.
The Geratherm liquid-in-glass thermometer is
comparable in function to mercury. That is, it
consists of a glass tube containing a silvery liquid
that rises in a column with increasing
temperature. The Geratherm is lower in cost than
digital thermometers. Galinstan thermometers
have several disadvantages: the toxicity of the
gallium-indium-tin mixture is not well researched
or understood, the silvery liquid may be mistaken
for mercury, the fragile glass structure can break
easily, and the Geratherm is slightly larger than a
mercury basal thermometer.
Digital basal thermometers appear to be the
most commonly available alternative to mercury
devices. There are a number of reasons that the
digitals are easily accepted: the time for taking a
temperature is approximately 1 minute (vs. ~4
minutes for mercury), the thermometer provides
beeps to signal when peak temperature is
reached, and there is a memory chip that recalls
the last reading. The main drawback of a digital
thermometer is that it uses a battery, which
requires proper recycling/disposal at the end of
its useful life. The digital basal thermometers are
also more expensive than either mercury devices
or Geratherm thermometers.
Manufacturers
The following are manufacturers of basal
thermometers:
Manufacturer
Becton
Dickinson
Mabis
Healthcare
Omron
Healthcare,
Inc.
R.G. Medical
Diagnostics
(U.S.
Distributor)
Product
Digital basal
thermometer
Digital basal
thermometer
Digital basal
thermometer
Geratherm
basal
thermometer
(Galinstan
liquid-in-glass
thermometer)
Phone Number &
Website
201-847-6800
http://www.bd.com
800-728-6811
http://www.mabis.
net
800-231-3434
http://www.omronh
ealthcare.com
888-596-9498
http://www. Itherm
ometer.com
Summary
Based on discussions with manufacturers and
visits to local pharmacies, it appears that suitable
alternatives are readily available for mercury
basal thermometers.
Other Thermometers (non-fever)
Description
Non-fever thermometers are used for various
industrial, laboratory, and commercial
applications including food preparation, freezers,
laboratory refrigerators, and testing. The
protocol for certain lab requirements and food
preparation codes require that the thermometers
be of a high quality.
Alternatives
The spirit-filled glass thermometer is the most
common replacement to the mercury
thermometer. The liquids used in such glass
thermometers are common organic liquids such
as alcohol, kerosene, and citrus extract based
solvents that are dyed blue, red or green. Digital,
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bi-metal or infrared thermometers are also
alternatives to mercury thermometers and are
used in many of the same applications.
Cost
The costs of a thermometer can vary based upon
the requirements of a particular application.
The following table illustrates these cost
differences.
Table 4.5: Thermometer Costs
Application
Food
Preparation
Industrial
Laboratory
Freezer/
Refrigeration
Thermometer
Type
Mercury
Bi-metal
Digital
Spirit filled
Infrared
Mercury
Digital
Spirit filled
Infrared
Bi-metal
Spirit filled
Cost
$10 -$40
$13 -$138
$14 -$20
$2 - $28
$92 - 270
$15 -$60
$20 -$100
$20 - $60
$92 - $270
$6 -$15
$2 - $28
Advantages/Disadvantages
The benefits of using a digital or infrared
thermometer are that they are very accurate and
easy to read. Infrared thermometers are much
more costly than digital thermometers but in
some applications the use of an infrared
thermometer is necessary. All thermometers,
whether they are mercury, digital, bi-metal or
organic liquid, do need to be re-calibrated at least
annually. Re-calibration is required due to the
gradual relaxation of residual mechanical strains
in the glass that can affect the volume of the
bulb.
A disadvantage of all liquid thermometers is
the possibility of column separation. When a
separated column occurs, the thermometer cannot
be used until the column is rejoined and
recalibrated.
Evidence provided by manufacturers indicates
that alternatives to mercury thermometers are as
effective and reliable as the mercury thermometer
with regular calibration. The most common
barrier to change is the widespread use of
mercury thermometers as the "standard" for all
temperature sensing devices.
Manufacturers
The following are manufacturers of alternatives
to mercury thermometers.
Manufacturer
Name
ICL
Calibration
Laboratories
Ertco (ever
ready
thermometers)
Comark
Miller Weber
Taylor
Weiss
Instruments
Cooper
Instrument
Corporation
Becton
Dickenson
Mannix
Product
Alcohol/spirit
filled,
Digital
thermometer
Alcohol/spirit
filled,
Digital
thermometer
Alcohol/spirit
filled,
Digital
Thermometer
Alcohol/spirit
filled,
Digital,
Bi-metal
thermometer
Alcohol/spirit
filled,
Digital,
Bi-metal
thermometer
Alcohol/spirit
filled,
Digital,
Bi-metal
thermometer
Alcohol/spirit
filled,
Digital
thermometer
Alcohol/spirit
filled,
Digital
thermometer
Infrared,
Digital
thermometer
Phone Number
& Website
www.icllabs.com
1-800-453-7826
www.ertco.com
1-800-555-6658
/ 503-643-5204
www.comarkltd.
com
718-821-7110
www.millerwebe
r.com
630-954-1250
www.taylorusa.c
om
631-207-1200
www.weissinstru
ments.com
860-349-3473
www.cooperinstr
ument.com
201-847-6800
www.bd.com
516-887-7979
www.mannix-
inst.com
Summary
It is apparent that there are many alternatives to
mercury thermometers that are cost effective and
acceptable. However, a Food and Drug
Administration procedure for food processing
was identified that requires at least one mercury-
in-glass thermometer for each retort. This
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requirement is outlined in the Code of Federal
Regulations under: 21 CFR Ch. 1 Part 113 -
Thermally Processed Low-acid Foods Packaged
in Hermetically Sealed Containers.
An example of a successful mercury
thermometer replacement program is the
"Mercury Thermometer Swap" program
undertaken by the University of Vermont. More
than 1,400 mercury thermometers were replaced
with non-mercury alternatives under this
program. The majority of these replacements
occurred in laboratories within the chemistry
department. (Winkler, 1999)
4.6 Barometers
Description
Barometers are used to measure the atmospheric
pressure. The barometer is a long cylindrical
tube filled with mercury. The mercury is
displaced by the atmospheric pressure. When the
mercury level rises in a barometer it indicates
increasing air pressure; when the mercury level is
decreasing it indicates decreasing air pressure.
Alternatives
The aneroid barometer is more compact and
consists of an evacuated metal diaphragm linked
mechanically to an indicating needle. As
atmospheric pressure increases or decreases the
diaphragm compresses or expands, causing the
indicating needle to show the change in pressure.
The digital barometer contains a sensor with
electrical properties (resistance or capacitance)
that change as the atmospheric pressure changes.
These sensors are considered to be just as
accurate as a traditional or an aneroid barometer.
Additional electronic circuitry converts the
sensor output into a digital display. There is also
a device called a water barometer that is similar
to a traditional mercury barometer. Changes in
air pressure cause the water to rise and fall in the
spout. Low water level indicates high pressure
and fair weather. The water level rises as the air
pressure falls.
Cost
The digital barometer can cost between $50 -
$300 depending on the manufacturer and the
other applications the digital barometer can
perform. Because mercury barometers and
aneroid barometers are often considered
collector's items, their prices are much higher,
ranging from $100 to over $1000.
Advantages/Disadvantages
Aneroid barometers have been used for
approximately 200 years and are considered just
as accurate as the traditional mercury barometer.
The digital barometer is programmable and is
considered to be as accurate as the mercury
barometer.
Manufacturers
The following are manufacturers of alternatives
to mercury barometers.
Manufacturer
Name
Howard Miller
Weems &
Plath
Bacharach
Kestrel
Product
Aneroid
barometer
Aneroid
barometer
Digital
barometer
Digital
barometer
Phone Number/
Website
www . ho wardmiller. c
om
410-263-6700
www.weems-
plath.com
724-334-5000/1-800-
736-4666
www.bacharach.com
610-447-1555
www.nkhome.com
Summary
The aneroid and digital barometers are cost
effective, in use, and acceptable alternatives to
the mercury barometer.
4.7 Psychrometers/Hygrometers
Description
A hygrometer is an instrument used to measure
the moisture content of air or any gas. The most
common type of hygrometer is the "dry and wet-
bulb psychrometer." The psychrometer is best
described as two mercury thermometers, one
with a wetted base, and one with a dry base. The
water from the wet base evaporates and absorbs
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heat causing the thermometer reading to drop.
Using a calculation table, the reading from the
dry thermometer and the reading drop from the
wet thermometer are used to determine the
relative humidity.
The sling psychrometer is also used to
determine relative humidity and is reliably
measured by both digital and alcohol type
psychrometers. The sling psychrometer is
basically a thermometer encased in a swiveling
mechanism that is swung around rapidly to
record an accurate reading for relative humidity.
Psychrometers function the same as a
hygrometers, however the names are different
due to the applications for which they are used.
For example, the hygrometer is used to monitor
the moisture in the storage area for cigar tobacco
used by manufacturers and cigar aficionados.
Atmospheric scientists and weather enthusiasts
use the psychrometer to monitor outdoor
humidity and moisture content.
Alternatives
Spirit-filled thermometers can be used in
psychrometers instead of the mercury
thermometers and provide equally accurate
results. Another alternative is the digital
hygrometer that uses electronic sensors and a
digital program to measure the humidity of the
air. Both the digital hygrometer and spirit filled
hygrometer are relatively inexpensive, are readily
available, and currently in use.
Cost
The spirit-filled sling psychrometer and the
spirit-filled hygrometer are both similar in
pricing when compared to mercury versions of
the same product. The digital psychrometer was
found to be more expensive than the spirit filled
version, but the digital hygrometer was found to
be less expensive than the spirit filled version,
ranging from $15 to $60.
Advantages/Disadvantages
The digital hygrometer and digital psychrometer
provide much more accurate results when
properly calibrated because the possibility of
human error is eliminated.
Manufacturers
The following are manufacturers of alternatives
to mercury psychrometers and hydrometers:
Manufacturer
Name
Bacharach
Testo
Miller Weber
Mannix
Tramex
Product
Spirit filled
psychrometers
Digital
psychrometers
Digital
hygrometer
Spirit filled
psychrometers
Digital
hygrometer
Phone Number
& Website
1-800-736-4666
www.bacharach.
com
973-252-1720/1-
800-227-0729
www.testo.com
718-821-7110
www.millerwebe
r.com
516-887-7979
www.mannix-
inst.com
+353-1-282 3688
www.tramexltd.c
om
Summary
The spirit filled psychrometers and digital
hydrometers appear to be acceptable, cost
effective alternatives to mercury filled devices.
4.8 Hydrometers
Description
A hydrometer is a device that measures the
density or specific gravity of a liquid.
Hydrometers are calibrated based upon the
specific gravity of water at 60°C being 1.000.
Liquids denser than water will have a higher
specific gravity, while liquids less dense will
have a lower specific gravity. The hydrometer is
used for many applications. For example it is
used in the petroleum and dairy industries, as
well as in amateur wine and beer making.
Alternatives
An alternative to a mercury hydrometer is the
spirit filled hydrometer. The spirit filled
hydrometer comes customized to suit individual
applications. The manufacturer should be
consulted to use the most appropriate
hydrometer.
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Cost
The cost of a mercury hydrometer ranges from
$12 to $30, or about $2 less on average than a
spirit filled hydrometer.
Advantages/Disadvantages
The accuracy of a spirit filled hydrometer is
considered to be comparable to a mercury
hydrometer.
Manufacturers
The following are manufacturers of alternatives
to mercury hydrometers:
Manufacturer
Name
Miller Weber
Ertco (ever
ready
thermometers)
ICL
Calibration
Laboratories
Product
Alcohol/spirit
filled
hydrometer
Alcohol/spirit
filled
hydrometer
Alcohol/spirit
filled
hydrometer
Phone
Number
Website
718-821-7110
www.millerwe
ber.com
1-800-453-
7826
www.ertco.co
m
www.icllabs.c
om
Summary
The spirit filled hydrometer is cost effective, in
use, and an acceptable alternative to the mercury
hydrometer.
4.9 Flow meters
Description
Flow meters are used in many areas for
measuring the flow of gas, water, air, and steam.
They are used in water treatment, sewage plants,
power stations, and other industrial applications.
Alternatives
The manufacturers contacted stated that they did
not use mercury in the manufacturing of new
flow meters. However, most older flow meters
still in use contain mercury. Non-mercury
alternatives include digital and ball actuated flow
meters.
Cost
The cost associated with flow meters depends on
the application. Some flow meters are custom
designed for certain applications, which can
increase the cost. The manufacturers contacted
declined to provide a price range because they
felt it would be misleading.
Manufacturers
The following are manufacturers of alternatives
to mercury containing flow meters:
Manufacturer
Name
Eldridge
Products, Inc
Flow
Technology
Alloborg
Instruments &
Controls
John C. Ernst
Lake Monitors
Universal
Flow Monitors
DigiFlow
Turbine Mass
Flow Meter
Primary Flow
Signal, Inc.
Product
Digital and
ball actuated
flow meters
Digital and
ball actuated
flow meters
Digital and
ball actuated
flow meters
Digital and
ball actuated
flow meters
Digital and
ball actuated
flow meters
Digital and
ball actuated
flow meters
Digital flow
meters
Digital and
ball actuated
flow meters
Phone
Number
Website
1-800-321-
3569
www.epiflow.
com
602-437-1315
www.ftimeters
.com
1-800-866-
3837
www.aalbors.c
om
973-989-0300
www.iohnerns
tcom
1-800-850-
6110
www.lakemon
itors.com
248-542-9635
www.flowmet
ers.com
419-756-1746
www.flow-
meters-
turbine-
flowmeters-
mass-
disiflow.com
877-737-3569
www.primaryf
lowsignal.com
Summary
It appears that mercury flow meters are no longer
being manufactured, and alternatives to older
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mercury flow meters are in use, cost effective,
and acceptable.
4.10 Pyrometers
Description
Pyrometers are used to measure the temperature
of extremely hot materials, and are used
primarily in foundry applications. No
manufacturers were identified that currently
provide mercury pyrometers. Some pyrometers
still in use do have mercury within the
temperature-sensing device.
Alternatives
There are two alternatives available, the optical
pyrometer and the digital pyrometer. An optical
pyrometer is a device that allows temperature to
be measured by using incandescence color. The
theory behind an optical pyrometer is that when a
substance is heated to about 700°C, it begins to
glow a deep red color. This indicates that the
object is emitting enough energy in the visible
portion of the spectrum for detection. As the
temperature increases, the object changes from
red to orange to white, with concurrent dramatic
increases in brightness. The hot target is viewed
through an optical system that contains a lamp
filament whose brightness can be adjusted until it
equals that of the target, and gives you an already
known temperature that has been measured and
recorded into the pyrometer. Digital pyrometers
are also available, and use a thermocouple with a
digital output screen that relays the temperature.
Cost
The cost of an optical pyrometer is in the range
of $3000. The cost of a digital pyrometer is less
than an optical pyrometer, and can cost between
$180 to $300 depending on the manufacturer.
No manufacturers of a mercury pyrometer could
be located, and therefore a price for a mercury
pyrometer could not be determined.
Manufacturers of the alternatives would not
speculate about the cost of a mercury pyrometer.
Advantages/Disadvantages
Optical pyrometers are used in applications of
extreme heat and are extremely accurate. The
digital pyrometers are also considered to be
functional and reliable for temperature reading
but not as accurate as an optical pyrometer at
higher temperatures.
Manufacturers
The following are manufacturers of alternatives
to mercury pyrometers:
Manufacturer
Name
EDL
MIFCO
Spectrodyne
Precision
Pyrometer
Product
Optical/digital
pyrometers
Digital
pyrometer
Optical/
pyrometers
Optical/
pyrometers
Phone
Number
Website
1-800-342-
5335
www.edl-
inc.com
217-446-0941
www.mifco.co
m
215-977-7780
www.spectrod
vne.com
1-800-468-
7976
www.pyromet
er.com
Summary
It appears that the mercury pyrometer is no
longer being manufactured, but may be in use in
some locations. The digital and optical
pyrometers are reliable technologies which
function as alternatives to the mercury
pyrometer.
4.11 Thermostats (industrial and
manufacturing)
Description
Industrial thermostats provide temperature
control in manufacturing and industrial settings.
The mercury thermostat uses a mercury switch to
activate the heating/cooling device. The mercury
in the switch is part of an electric current relay
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which relies on an electric current to activate and
deactivate the heating/cooling device when the
mercury in the switch is tipped.
Alternatives
Digital electronic thermostats are available for
industrial type workloads and temperature
control. Digital thermostats use a simple device
called a thermistor to measure temperature. A
thermistor is a resistor whose electrical resistance
changes with temperature. The microcontroller in
a digital thermostat can measure the resistance
and convert that number to a temperature
reading.
Costs
Manufacturers were unable to provide specific
price quotes because industrial thermostats are
often custom tailored to meet the requirements of
a specific application. The price is then derived
on an application specific basis. Manufacturers
believed it would be misleading to provide a
price range of industrial thermostats they had
previously manufactured for specific
applications.
Advantages/Disadvantages
Digital thermostats have limits that should be
researched by the buyer to determine the type of
thermostat best suited for an industrial purpose.
Many industrial thermostats are needed to
regulate higher temperatures than household
thermostats. Industrial thermostats are created to
be more durable and withstand higher
temperatures and harsher environments.
Manufacturers who supply digital thermostats for
light industrial purposes report that they may not
meet the most demanding applications.
Situations in which digital thermostats would not
perform as well as mercury products are cases of
extreme environmental conditions and areas at
risk of explosions or fire.
Manufacturers
The following are manufacturers of industrial
thermostats:
Manufacturer
Name
Chromalox
Kelvin
Technologies
Product
Thermostats
Thermostats
Phone Number
& Website
412-967-3800
http://www.myc
hromalox.com/
1-800-458-5246
www.kelvintech.
com
Summary
It appears that no functional alternatives to
mercury thermostats for industrial settings with
harsh environmental conditions are available.
4.12 Float Switches
There are two basic types of float switches: 1)
a float switch can be located in a buoyant float
housing and is actuated based upon rising and
falling liquid levels, or 2) a float switch can be
stationary and is actuated by the presence or
absence of liquid. Float switches are used for
liquid monitoring and control in tanks, wells,
chambers, drillings, and other containers. Float
switches are used to actuate alarm and control
circuits. Float switches have been used for
monitoring various liquids including, among
others, water, sewage, wet sludge, oil, chemicals,
grease, and liquid nitrogen.
A float switch is a versatile component used
to meet the needs of thousands of varied products
and applications. A float switch can be
incorporated into a product (e.g. bilge pumps,
automobiles, etc.), or can be purchased as a
component to be used in a customer specific
application (e.g. waste treatment plant).
Examples of some float switch products and
applications are provided below:
• Pump control: bilge, sump, utility,
shower, effluent, waste, lubrication, etc.
• Equipment Control: magnetic valve,
cooling equipment, motors, etc.
• Alarm/Outputs: programmable logic
controllers, distributed control systems,
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supervisory control and data acquisition,
etc.
• Industrial/manufacturing: processing
liquids, waste treatment, air conditioners,
semiconductor manufacturing, automatic
plating machinery, etc.
• Residential: sump pumps, septic tanks,
hot water heaters, automatic plumbing
fixtures, etc.
• Marine: bilge pumps, shower pumps,
ocean liner sewage disposal, balance tank
on ships, etc.
• Automobile: fuel tank, windshield wash
reservoir, etc.
• Municipal: pumping stations, waste water
treatment, sewage plants, etc.
• Commercial: boilers, vending machines,
electrical equipment such as liquid
insulated transformers, etc.
• Miscellaneous: food processing, irrigation
systems, petrochemical processing,
laundry tray, food warmers, steam
cookers, mineral processing, hydraulic
equipment, water filters, pharmaceutical
processes, food processing, power
stations, etc.
There are numerous design parameters that
affect the specification and selection of a float
switch for a particular product or application.
Float switch design and product options vary
greatly by manufacturer. The design
requirements have a significant impact on
technology selection, manufacturer selection,
product model selection, product option
selection, and ultimate product cost. The
following is a concise listing of some of the more
critical design parameters:
• Switch points: number of control points,
number of alarm points, field adjustable
points, etc.
• Level detection: point level, continuous
level
• Accuracy: tolerances, calibration
requirements
• Liquid environment: viscosity,
conductivity, foam, bubbles, turbulence,
contaminants, debris, etc.
• Mounting: side, bottom, or top of
enclosure, free standing/suspended cable,
pipe mount, stem mount, etc.
• Output contact rating: inductive load,
resistive load, current, voltage, power,
etc.
• Buoyancy: ball, counterweight, specific
gravity, etc.
• Life expectancy: switch, controlled
equipment, etc.
• Regulatory approval: Underwriters
Laboratories, Canadian Standards
Association, etc.
• Operating parameters: differential
between control/alarm points, angle of
operation, etc.
• Environmental conditions: temperature,
pressure, explosiveness, shock, vibration,
corrosiveness, moving equipment, etc.
• Input power requirements: 115 Volts AC,
230 Volts AC, 24 Volts DC, 12 Volts DC,
other
• Switch: number of poles, number of
throws, normally open, normally closed,
relay, etc.
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Other parameters: signal time delay (to
compensate for wave action), float switch
enclosure material, intrinsically safe,
cleaning requirements, space available for
operation, etc.
Mercury Float Switch
Description
A mercury float switch is typically located in a
buoyant float housing and is actuated based upon
the rising and falling liquid levels. The mercury
float switch contains a small tube with electrical
contacts at one end of the tube. As the tube lifts,
the mercury collects at the lower end, providing a
conductive path to complete the circuit. When
the switch is tilted back the circuit is broken.
The mercury float switch operates in a similar
fashion to the mercury tilt switch. The mercury
content reported to IMERC for float switches
was in the range of greater than 1,000 mg/switch.
Cost
The cost of a mercury float switch is
approximately $15 to $150 depending upon
product type or application requirements. Two
manufacturers were identified that have both
mercury and mercury free float switches with the
same functionality. These manufacturers charge
the same price for the mercury float switch and
the mercury-free mechanical float switch. One
manufacturer was identified that provides the
mercury-free mechanical float switch at a cost
less than the mercury float switch for the same
functionality.
One manufacturer charged more for a metallic
ball float switch than for a mercury float switch
with comparable functionality.
Advantages/Disadvantages
The mercury float switch has high reliability and
long operational life because it has few
components and is not subject to arcing. Life-
cycle testing has been conducted for more than
one million cycles. The mercury float switch can
handle a high inductive load, has a quiet
operation, has no bounce on contact, and can be
hermetically sealed to provide increased
protection from various environmental factors
(e.g. dust, moisture, etc.). The mercury float
switch can use one float for both on and off
functions.
The mercury float switch requires a swing
area to properly operate. If the application is in a
tight location (e.g. windshield washer reservoir),
then a magnet/reed float switch may be more
appropriate. Because the switch contains
mercury, it is becoming less desirable for many
applications, including the food and beverage
industry.
Manufacturers
The following are manufacturers of mercury float
switches.
Manufacturer
Name
Advanced
Control
Technology,
Inc.
Comus
International
Conery
Manufacturing
Inc.
Contegra Inc.
Electro-
sensors, Inc.
ITT Industries
McDonnell &
Miller
ITT Industries
Rule Industries
Mercury
Displacement
Industries Inc.
Scientific
Technologies
Inc.
Product
7000
Series
Numerous
models
2900
Series
FS96
MLS
Series
E-8, 80,
65, and
165 series
Models
35, 37, &
40
A, B, C,
&D
Series
FG Series
Phone Number &
Website
888-340-8820
www.actsensors.com
973-777-8405
www.comus-
intl.com
419-289-1444
www.conervmfs.co
ffl
651-905-0900
www.contesra.com
800-328-6170
www.electro-
sensors.com
773-267-1600
www.mcdonnellmill
er.com
978-281-0440
www.rule-
industries.com
616-663-8574
www.mdius.com
888-525-7300
www.levelandflow.c
om
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Manufacturer
Name
Septronics,
Inc.
Signal
Systems
International
Inc.
Product
4701,
4704
Series
FS121,
CW101
Series
Phone Number &
Website
888-565-8908
www . septronic sine . c
om
732-793-4668
www. sisnalsvstem.c
om
The mechanical float switch typically needs a
swing area to properly operate. However, this is
not the case for mechanical float switches that
use magnets in a vertical stem to activate the
micro-switch.
Manufacturers
The following are manufacturers of mechanical
float switches:
Alternative 1: Mechanical Switch
Description
A mechanical float switch is typically located in
a buoyant float housing and is actuated based
upon the rising and falling liquid levels. The
mechanical switch can be a snap switch or micro-
switch that can be actuated using a variety of
methods. The most common method is that the
lever arm is actuated by a metallic rolling ball
that changes position based upon gravity and the
position of the buoyant float housing.
Cost
The cost of a mechanical float switch is
approximately $10 to $150 depending on product
or application requirements. Two manufacturers
were identified that have both mercury and
mercury-free float switches with the same
functionality. These manufacturers charge the
same price for the mercury float switch and the
mercury free mechanical float switch. One
manufacturer was identified that provides the
mercury free mechanical float switch at a cost
less than the mercury float switch for the same
functionality.
Advantages/Disadvantages
The mechanical float switch has high reliability,
long operational life, can handle high inductive
loads, and can be hermetically sealed to provide
increased protection from various environmental
factors (e.g. dust, moisture, etc.). Mechanical
switches are often designed to have an
operational life in excess of one million cycles.
The mechanical float switch can use one float for
both on and off functions.
Manufacturer
Name
Advanced
Control
Technology,
Inc.
Aggressive
Systems, Inc.
Attwood
Marine
Contegra Inc.
Dwyer
Instruments,
Inc.
(Mercoid)
ITT Industries
Jabsco
ITT Industries
Rule Industries
Kari-Finn
(Finland)
U.S. Rep:
STI
Automation
Sensors
Division
Kobold
Lovett Marine
Mercury
Displacement
Industries Inc.
Product
7300
Series
AMF
Series
4201 and
4202
Series
FS90
Series
L6, L8
Series
FS20
ECO-
Switch
Model 39
Numerous
models
NGS
series
Models
3208 and
3209
Numerous
models
Phone Number
Website
888-340-8820
www.actsensors.com
248-477-5300
www.assressivesvste
ms.com
Steelcase: 616-897-
2376
www.attwoodmarine.
com
651-905-0900
www.contesra.com
219-879-8000
www.dwver-inst.com
949-609-5106
www.jabsco.com
978-281-0440
www.rule-
industries.com
Scientific
Technologies Inc.:
888-525-7300
www.kari-finn.fi
800-998-1020
www.kobold.com
800-673-5976
www.lovettmarine.co
m
616-663-8574
www.mdius.com
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Manufacturer
Name
MJK
Automation
(Denmark)
Danfoss
Graham -U.S.
Representative
Nivelco
(Hungary)
Hitech-U.S.
Representative
Scientific
Technologies
Inc.
Septronics,
Inc.
Zoeller
Product
7030
Series
Nivofloat
and
NivoMag
MK-200
Series
FT, FTN,
and MLS
Series
SDand
HD
models
Numerous
models
Phone Number
Website
Danfoss Graham:
414-355-8800
www.mik.dk
Hitech
215-321-6012
www.nivelco.com
888-525-7300
www.levelandflow.c
om
888-565-8908
www.septronicsinc.c
om
800-928-7867
www.zoeller.com
Alternative 2: Magnetic Dry Reed
Switch
Description
Permanent magnets are embedded in the float
housing that move vertically along the tubing or
stem. The reed switches are embedded in the
stem. The magnets activate the reed switches in
the stem at pre-determined levels for control or
alarm purposes.
Cost
The magnetic dry reed float switch cost is
approximately $6 to $500 depending on product
or application requirements.
Advantages/Disadvantages
The magnetic dry reed switch is ideal for use in
small or narrow enclosures. The magnetic dry
reed switch has a long operational life.
The magnetic dry reed switch cannot handle a
high inductive load, and therefore has a low
contact rating. The magnetic dry reed switch
must be used in a clean environment, because
debris collected on the stem will impair proper
functioning. The reed switch can have its
contacts welded together when exposed to high
voltage sources.
Manufacturers
The following are manufacturers of magnetic dry
reed switches:
Manufacturer
Name
Advanced
Control
Technology, Inc.
Aggressive
Systems, Inc.
Barksdale, Inc.
Clark Reliance
Corporation
Jerguson Gage
and Valve
Division
Comus
International
Crydom
Magnetics (UK)
Dwyer
Instruments, Inc.
Flowline Liquid
Intelligence
Innovative
Components
Kobold
K-Tech
Industrial
Products Inc.
Product
Numerous
models
AOE model
BLS Series
Magnicator
II Model
RS-2
Numerous
models
RSF Series
F7 Series
Numerous
models
LS and SM
Series
Model N
Numerous
models
Phone Number
Website
888-340-8820
www.actsensors.
com
248-477-5300
www.aggressive
svstems.com
800-835-1060
www.barksdale.c
om
281-240-4243
www.clark-
reliance.com
973-777-8405
www.comus-
intl.com
619-210-1600
www.crvdom.co.
uk
219-879-8000
www.dwyer-
inst.com
562-598-3015
www.flowline.co
m
860-621-7220
www.liquidlevel.
com
800-998-1020
www.kobold.co
m
905-840-7106
www.process-
controls.com/KT
ech
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Manufacturer
Name
Nivelco
(Hungary)
Hitech-U.S.
Representative
Scientific
Technologies
Inc.
Signal Systems
International Inc.
Product
NivoPoint
FCN, LF,
FL, SLS,
and TLS
Series
Numerous
models
Phone Number
Website
Hitech
215-321-6012
www.nivelco.co
m
888-525-7300
www.levelandflo
w.com
732-793-4668
www.signalsyste
mcom
Manufacturer
Name
Kobold
Pulnix
America Inc.
Scientific
Technologies
Inc.
Product
OPT Series
FL, FLH
Series
OPL Series
Phone Number
Website
800-998-1020
www.kobold.com
800-445-5444
www.pulnix.com
888-525-7300
www . levelandflo w .
com
Alternative 3: Optical Float Switch
Description
The optical float switch utilizes optical principles
to detect the presence or absence of a liquid as
compared with air. The sensor contains a small
infrared LED and a phototransistor light receiver
to detect the presence of liquid.
Cost
The cost of an optical float switch is
approximately $120 to $400 depending on
product or application requirements.
Advantages/Disadvantages
The optical sensor is unaffected by liquid color or
density. The optical float switch has very slight
hysteresis, high repeatability, and is highly
chemical resistant.
The optical float switch has a higher price
range than other float switch technologies.
Manufacturers
The following are manufacturers of optical float
switches:
Manufacturer
Name
Com
connection
Dwyer
Instruments,
Inc.
Product
Fiber Optic
Float Switch
OLS Series
Phone Number
Website
954-600-1962
http ://comconnecti
on.triDod.com
219-879-8000
www.dwyer-
inst.com
Alternative 4: Conductivity
Description
The conductivity float switch uses electrodes to
measure conductivity and sense the presence or
absence of a liquid. It relies on the conducting
properties of liquids to complete an electrical
circuit between electrodes, or between an
electrode and the metal tank.
Cost
The cost of a conductivity float switch is
approximately $40 to $800 depending on product
or application requirements.
Advantages/Disadvantages
The conductivity float switch has no moving
parts and is therefore very reliable and can be
used in vessels with moving equipment that may
damage other types of float switches. The
conductivity sensor can sense the presence of
different liquids. For bilge pump applications, it
can detect gas, oil, and diesel fuel in bilge water
that can trigger an automatic shutdown of the
pump. This prevents pumping of contaminants
into waterways.
The conductivity float switch must be used in
a conductive liquid for proper operation.
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Manufacturers
The following are manufacturers of conductivity
float switches:
Manufacturer
Name
Advanced
Control
Technology, Inc.
Aggressive
Systems, Inc.
ITT Industries
McDonnell &
Miller
Kari-Finn
(Finland)
U.S. Rep:
STI Automation
Sensors Division
Kobold
MJK
Automation
(Denmark)
Danfoss Graham
-U.S.
Representative
Nivelco
(Hungary)
Hitech-U.S.
Representative
Product
Innovators
Scientific
Technologies
Inc.
Product
Numerous
models
IFF model
LPC series
Numerous
models
NEH,NEW
Models
Conduct-
ivity Level
Switch 501
NivoCont K
Series
Bilge Buddy
ELS Series
Phone Number
Website
888-340-8820
www.actsensors.
com
248-477-5300
www.aggressive
svstems.com
773-267-1600
www.mcdonnell
miller.com
STI: 888-525-
7300
www.kari-finn.fi
800-998-1020
www.kobold.co
ffl
Danfoss
Graham:
414-355-8800
www.mjk.dk
Hitech
215-321-6012
www.nivelco.co
m
Leif Lindvall
845-796-4526
www.411web.co
m/P/
PRODUCTINN
OVATORS/
Default, htm
888-525-7300
www.levelandflo
w.com
Alternative 5: Metallic Ball
Description
A rolling metallic ball is used to make or break
the actual electrical connection for a circuit. The
metallic ball moves based on the float movement
as the liquid level rises and falls.
Cost
One manufacturer reported that the cost of their
metallic ball switch is about 10 - 15% higher
than their mercury float switch with similar
functionality.
Advantages/Disadvantages
The metallic ball float switch can have a long life
if it is only used for small rated loads.
The metallic ball float switch is not suitable
for applications subject to shock or vibration
because it can experience false contacts due to
bounce. The metallic ball float switch requires a
swing area for proper operation. The metallic
ball can become welded to the electrical contacts
due to overheating or arcing. The metallic ball
float switch cannot handle loads greater than two
amps without experiencing arcing issues.
Manufacturers
The following is a manufacturer of metallic ball
float switches:
Manufacturer
Name
Comus
International
Product
Numerous
models
Phone Number
Website
973-777-8405
www.comus-
intl.com
Alternative 6: Sonic/Ultrasonic
Description
The sonic/ultrasonic float switch utilizes a sensor
containing a piezo-electrical crystal. The crystal
excites oscillations, allowing the liquid level to
be measured by oscillation frequency. As the
probe tip becomes immersed in liquid, the
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crystals acoustically couple and the switch
changes state.
Cost
The cost of a sonic/ultrasonic float switch is
approximately $150 to $600 depending on
product or application requirements.
Advantages/Disadvantages
The sonic/ultrasonic float switch is highly
accurate and can be used for non-conductive
liquids as well as highly viscous liquids. The
sensor can be quickly removed for cleaning as
required by the food, beverage, and
pharmaceutical industries.
The sonic/ultrasonic sensor needs to be rigid
mounted for proper operation.
Manufacturers
The following are manufacturers
sonic/ultrasonic float switches:
of
Manufacturer
Name
Advanced
Control
Technology, Inc.
Cosense Inc.
Dwyer
Instalments, Inc.
Flowline Liquid
Intelligence
Kobold
MJK
Automation
(Denmark)
Danfoss Graham
-U.S.
Representative
Ohmart Vega
Product
ELC-8
LL Series
GS Series
Numerous
models
NWS Model
MJK 7005
Vegaswing
Series
Phone Number
Website
888-340-8820
www.actsensors.
com
631-231-0735
www.cosense.co
ffl
219-879-8000
www.dwver-
inst.com
562-598-3015
www.flowline.co
m
800-998-1020
www.kobold.co
m
Danfoss
Graham:
414-355-8800
www.mjk.dk
800-367-5383
www.ohmartveg
a.com
Manufacturer
Name
Scientific
Technologies
Inc.
Siemens
Milltronics
Product
DFN-30
Series
ULS 200
Series
Phone Number
Website
888-525-7300
www.levelandflo
w.com
817-277-3543
www.milltronics.
com
Alternative 7: Pressure Transmitter
Description
The pressure transmitter float switch utilizes one
of two technologies:
1) The float switch is actuated by a piezo-
recitative mechanism that senses the
hydrostatic pressure within a container.
2) The float switch is actuated by
compression of a captive air column in
the detecting pipe beneath a diaphragm.
Cost
One manufacturer sells one of its pressure
transmitter models for $825. A cost range for all
available models was not determined, but will
depend on product or application requirements.
Advantages/Disadvantages
The piezo-recitative technology provides highly
reliable results. The diaphragm technology can
be used in applications where electrical power is
not available or hazardous conditions exist.
Manufacturers
The following are manufacturers of pressure
transmitter float switches:
Manufacturer
Name
Dwyer
Instruments, Inc.
Product
PLT
Series
Phone Number &
Website
219-879-8000
www.dwver-
inst.com
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Manufacturer
Name
MJK
Automation
(Denmark)
Danfoss Graham
-U.S.
Representative
Scientific
Technologies
Inc.
Product
MJK
7050,
7060
NLS
Series
Phone Number &
Website
Danfoss Graham:
414-355-8800
www.mjk.dk
888-525-7300
w ww . levelandflo w .
com
Manufacturer
Name
Comus
International
Product
Alloy float
switch
Phone Number
Website
973-777-8405
www.comus-
intl.com
Alternative 8: Alloy
Description
A gallium indium alloy replicates the fluid and
electrical properties of mercury. This alloy is
used as a direct replacement of mercury within
the switch.
Cost
The alloy float switch has limited commercial
usage and is still in the early development stage.
The cost of an alloy float switch is significantly
higher than a mercury switch, ball contact switch,
or magnetic/reed switch.
Advantages/Disadvantages
The gallium indium alloy functions as a direct
replacement for mercury within the switch and
therefore provides similar advantages such as
quiet operation, high reliability, and long
operational life. This alloy eliminates bounce
problems and false contacts associated with the
metallic ball contact device.
The gallium indium alloy cannot be used in
applications less than 20 degrees Fahrenheit.
This precludes its use for many non-water
applications. The gallium indium alloy is
difficult to handle, will oxidize easily, and is
potentially toxic.
Manufacturers
The following are manufacturers of alloy float
switches:
Alternative 9: Thermal
Description
The thermal float switch utilizes the thermal
dispersion principle of the dissipation of heat by
a liquid to detect the presence or absence of a
liquid as compared with air. The sensor typically
contains a resistor in the form of a thermistor. A
thermistor is a semiconductor material that
detects heat and converts heat into an electrical
signal. The switch is actuated when heat
generated by the thermistor is dissipated by a
liquid.
Cost
The cost of a thermal float switch was obtained
for one model from one manufacturer for $87. A
range of values was not available at the time this
report was completed.
Advantages/Disadvantages
The thermal float switch can be used for caustic
liquids such as acids and alkalines. Light to
moderate buildup on the sensor will not affect
thermal dispersion performance.
The thermal float switch is not suited for high
temperature applications, and cannot be used for
high viscosity liquids.
Manufacturers
The following are manufacturers of thermal float
switch sensors:
Manufacturer
Name
JC Controls
Scientific
Technologies
Inc.
Product
SN Series
TDL
Series
Phone Number &
Website
877-837-6677
www.ln2.net
888-525-7300
www.levelandflow.co
ffl
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Alternative 10: Capacitance
Description
The capacitance level float switch is typically
comprised of two electrodes separated by an
insulating medium. Air provides a reference
capacitance value, and when the probe is covered
by liquid the resultant capacitance change causes
a signal to actuate the switch.
Cost
The cost of a capacitance float switch is
approximately $150 to $500 depending on
product or application requirements.
Advantages/Disadvantages
The capacitance float switch contains no moving
parts, has extremely high chemical resistance,
and moderate vibration resistance.
The capacitance float switch cannot be used
for highly viscous liquids.
Manufacturers
The following are manufacturers of capacitance
float switches:
Manufacturer
Name
Dwyer
Instalments,
Inc.
Flowline
Liquid
Intelligence
Kobold
Robertshaw
Scientific
Technologies
Inc.
Product
CLS
Series
Numerous
models
NTS
Series
Model
304B
CP30
Series
Phone Number
Website
219-879-8000
www.dwver-inst.com
562-598-3015
www.flowline.com
800-998-1020
www.kobold.com
865-981-3100
www.robertshawindu
strial.com
888-525-7300
www.levelandflow.c
om
products and applications. It appears that these
mercury free alternatives are cost competitive
and can meet the functional requirements for new
float switch products and applications. However,
these mercury free alternatives may not meet the
requirements for retrofitting all existing float
switch products and applications.
Summary
There are numerous mercury free alternative
technologies currently in use for float switch
4.13 Tilt Switches
Tilt switches sense changes in position or
rotation and actuate a switch based upon these
changes. The tilt switch can be used to activate
alarms, control equipment, turn on lights, or
accomplish other functions.
A tilt switch is a versatile component used to
meet the needs of hundreds of position
monitoring/control products and applications. A
tilt switch can be incorporated into a product (e.g.
video cameras, motion detectors, etc.), or can be
purchased as a component to be used in a
customer specific application (e.g. mining
operations). Examples of some tilt switch
products and applications are provided below:
• Test & Laboratory Equipment: precision
measuring devices, plotters, power
supplies, etc.
• Heavy equipment: construction vehicles,
cranes, hoists, chutes, scissor lifts, static
platforms, etc.
• Industrial: processing equipment,
conveyor controls, extruders, speed
controls, foot pedals, coal level
monitoring, etc.
• Marine: rudder controls, deep sea
manipulators, salt water platforms, ship &
barge leveling etc.
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Medical equipment: x-ray machines, MRI
scanners, position controls, wheelchairs,
etc
• Robotics: analog inputs, remote operated
vehicles, creature animation, etc.
• Agriculture: tractors, conveyor controls,
food processing, bins, silos, grain level
monitoring, etc.
• Other: signaling alarms, lights, interfacing
with programmable logic controllers,
personnel digital assistants, cell phones,
computer security, anti tamper devices,
utility metering, pump control, digital
cameras, video cameras, portable space
heaters, pinball game machine, swimming
pools, payphones, survey leveling
equipment, gyroscopes, steam irons, anti-
locking brake systems, digital compass
correction, submarines, virtual reality
equipment, oil rig leveling, laser
instruments, geophysical monitoring,
laser leveling, grading, continuous
casting, weapons platform leveling, wheel
alignment, land navigation, auto security,
RVs, exercise equipment, automobiles,
glove compartments, video cameras,
commercial popcorn poppers, electric
organs, space heaters, oil well pump
control, machine tools, fishing lures,
greenhouses, motion detectors, pneumatic
tube communication, man-lifts, antenna
positioning, mining, aircraft,
transportation, etc.
There are numerous design parameters that
affect the specification and selection of a tilt
switch for a particular product or application.
Tilt switch basic design and product options vary
greatly by manufacturer. The design
requirements have a significant impact on
technology selection, manufacturer selection,
product model selection, product option
selection, and ultimate product cost. The
following is a concise listing of some of the more
critical design parameters:
• Measurement requirements: tilt or
rotation angle, number of axes, etc.
• Switch points: number of control points,
number of alarm points, field adjustable
points, etc.
• Accuracy: tolerances, calibration
requirements
• Output contact rating: inductive loading
(amps, voltage, power), resistive loading
(amps, voltage, power)
• Life expectancy: switch, controlled
equipment, etc.
• Regulatory approval: Underwriters
Laboratories, Canadian Standards
Association, etc.
• Operating parameters: differential
between control/alarm points, angle of
operation, etc.
• Environmental conditions: temperature,
pressure, explosiveness, shock, vibration,
corrosiveness, moving equipment, etc.
• Input power requirements: 115 Volts AC,
230 Volts AC, 24 Volts DC, 12 Volts DC,
other
• Switch output: single pole single throw,
double pole double throw, normally open,
normally closed, relay, etc.
• Other parameters: display requirements,
enclosure material, intrinsically safe,
cleaning requirements, space available for
operation, signal time delay, etc.
Mercury Tilt Switches
Description
Mercury tilt switches are small tubes with
electrical contacts at one end of the tube. As the
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tube lifts, the mercury collects at the lower end,
providing a conductive path to complete the
circuit. When the switch is tilted back the circuit
is broken. The mercury content reported by
manufacturers to EVIERC for tilt switches ranged
from 400 mg to 71,000 mg/switch.
Cost
The cost of a mercury tilt switch is approximately
$2 to $300 depending on product or application
requirements.
Advantages/Disadvantages
The mercury tilt switch has high reliability and
long operational life because it has few
components and is not subject to arcing. Life
cycle testing has been successfully conducted for
more than one million cycles. The mercury tilt
switch can handle a high inductive load, has a
quiet operation, has no bounce on contact, and
can be hermetically sealed to provide increased
protection from various environmental factors
(e.g. dust, moisture, etc.).
The mercury tilt switch contains mercury,
which is becoming less desirable for many
applications including the food and beverage
industry.
Manufacturers
The following are manufacturers of mercury tilt
switches.
Manufacturer
Name
Abra Electronics
Celduc Relais
(France)
Laube
Technology -
US
Representative
Comus
International
Electro-Sensors,
Inc.
Product
Model 35-
760
IB600099
Series
Numerous
models
MTS
Series
Phone Number &
Website
800-717-2272
www.abra-
electronics.com
Laube Technology:
805-388-1050
www.celduc-
relais.com
973-777-8405
www.comus-
intl.com
800-328-6170
www.electro-
sensors.com
Manufacturer
Name
George Risk
Industries
Kahl Scientific
Instrument
Corporation
Siemens
Milltronics
Signal Systems
International Inc.
Product
4561
Series
Series
03EA
Mill-
tronics
Tilt
Switches
Series
3004
Phone Number &
Website
800-523-1227
www.srisk.com
619-444-2158
www.kahlsico.com
817-277-3543
www.milltronics.c
om
732-793-4668
www. signalsvstem.
com
Alternative 1: Metallic Ball
Description
A rolling metallic ball is used to make the actual
electrical connection. The metallic ball moves
based on the movement of the tilt switch housing,
or can be moved by actuator magnets using the
principle of spherical magnetism.
Cost
The cost of a metallic ball tilt switch is
approximately $1 to $11 depending on product or
application requirements.
Advantages/Disadvantages
The metallic ball tilt switch is suited for
applications with high levels of electromagnetic
interference (EMI) such as generators and
motors, or high stress applications that require a
robust switch. The metallic ball tilt switch can
have a long life if it is only used for small rated
loads.
The metallic ball tilt switch is not suitable for
applications subject to shock or vibration because
it can experience false contacts due to bounce.
The metallic ball can become welded to the
electrical contacts due to overheating or arcing.
The metallic ball tilt switch cannot handle loads
greater than two amps without experiencing
arcing issues.
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Manufacturers
The following are manufacturers of metallic ball
tilt switches:
Manufacturer
Name
Comus
International
Magnasphere
Corp.
Signal
Systems
International
Inc.
Product
Numerous
Models
Magna-
sphere
Switch
NM 1001,
NM 2001,
NM 3001,
NM4001
Phone Number
Website
973-777-8405
www.comus-
intl.com
262-792-1306
www.magnasphereco
rp.com
732-793-4668
www. sisnalsvstemc
om
Alternative 2: Electrolytic Tilt Switch
Description
The electrolytic tilt switch contains multiple
electrodes and is filled with an electrically
conductive fluid. As the sensor tilts, the surface
of the fluid remains level due to gravity. The
conductivity between the electrodes is
proportional to the length of electrode immersed
in the fluid. Electrically, the sensor is similar to
the potentiometer, with resistance changing in
proportion to tilt angle. The electrolyte material
can vary in conductivity and viscosity to meet
different design parameters.
Cost
The cost of an electrolytic tilt switch is
approximately $5 to $50 depending on product or
application requirements.
Advantages/Disadvantages
Electrolytic tilt switches provided excellent
repeatability, stability, and accuracy. These
sensors are rugged and can be used in
environments of extreme temperature, humidity,
and shock. Electrolytic tilt sensors have low
power consumption.
Electrolytic tilt switches are complex devices
due to their sensitivity to internal circuitry and
external environmental influences.
Manufacturers
The following are manufacturers of electrolytic
tilt switches:
Manufacturer
Name
Advanced
Orientation
Systems, Inc.
(AOSI)
Applied
Geomechanics
Fredericks
Company
Nanotron, Inc.
Spectron Glass
and
Electronics,
Inc.
Product
SW Series
755, 756,
757, and
758 Series
Numerous
models.
Ultimate I
and II
Series
The
SP5000
and
AU6000
series
Phone Number
Website
908-474-9595
www.aositilt.com
831-462-2801
www.seomechanic
s.com
215-947-2500
www.fredericksco
m.com
480-966-9006
www.nanotronusa.
com
631-582-5600
www.spectronsens
ors.com
Alternative 3: Potentiometers
Description
Potentiometers consist of a curved conductive
track with a connection terminal at each end and
a moveable wiper connected to a third terminal.
As the shaft of the potentiometer is rotated, the
length of the electrical path and resistance
changes proportionally. Potentiometers can be
used to detect linear motion as well as single turn
or multiple turn rotation.
Cost
Potentiometers were found to range from
approximately $0.25 for simple, high volume
applications to $300 for high quality audio
applications.
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Advantages/Disadvantages
Potentiometers are inexpensive, reliable, and
have long operational life, often greater than 20
million cycles. Potentiometers are also available
in micro-miniature size for space saving design
requirements.
Manufacturers
The following are manufacturers of
potentiometers:
Manufacturer
Name
ETI Systems
Precision
Electronic
Tocos
America, Inc.
Vishay
Product
LCP8,
SP12B,
Series
RV4, RV6
Series
G3, G4
Series
249, 357,
533 Series
Phone Number
Website
760-929-0749
www.etisvstems.co
m/sinsledesisn.htm
416-744-8840
www.precisionelect
ronics.com
847-884-6664
www.tocos.com
402-563-6866
www.vishav.com
switches are often designed to have an
operational life in excess of one million cycles.
The mechanical tilt switch requires only a small
amount of pressure to actuate the switch action.
The mechanical tilt switch can be used as a limit
switch to detect the position of some moving
part. Numerous limit switches can be used to
sense multiple positions.
Manufacturers
The following are manufacturers of mechanical
tilt switches:
Manufacturer
Name
Binmasater
Monitor
Technologies
LLC
Omron
Electronics
Product
BM-T
Series
TC Series
D7E
Series
Phone Number &
Website
800-278-4241
www.binmaster.com
800-601-6302
www.monitortech.co
ffl
847-882-2288
www.omron.com
Alternative 4: Mechanical Switch
Description
The mechanical tilt switch can be a snap switch
or micro-switch that can be actuated in a variety
of methods. The most common method is that
the lever arm is actuated by a metallic rolling ball
that changes position based upon gravity and the
changing position of the switch housing.
Cost
The cost of a mechanical tilt switch is
approximately $100 to $350 depending on
product or application requirements.
Advantages/Disadvantages
The mechanical tilt switch has high reliability,
long operational life, can handle high inductive
loads, and can be hermetically sealed to provide
increased protection from various environmental
factors (e.g. dust, moisture, etc.). Mechanical tilt
Alternative 5: Solid-State
Description
The solid-state tilt switch is often referred to as
an inclinometer or accelerometer depending upon
the application. Various operational methods are
used including:
• Using a Hall effect integrated circuit
sensor that provides a voltage output ratio
as a function of the mechanical angle of
the shaft
• Using a highly stable silicon micro-
machined capacitive inclination sensor
element
• Using force balance accelerometer
technology
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Cost
The cost of a solid-state tilt switch is
approximately $100 - $250 depending on product
or application requirements.
Advantages/Disadvantages
The solid-state tilt switch offers high resolution,
accuracy, fast response, and maintains its
accuracy over temperature ranges. The solid-
state tilt switch requires a low supply voltage and
has a long operational life, often greater than ten
million cycles. The solid-state tilt switch can be
used in strong vibration and shock environments.
The initial cost is higher than mercury,
potentiometer, or electrolytic tilt switches.
Manufacturers
The following are manufacturers of solid-state tilt
switches:
Manufacturer
Name
Clarostat
Sensors and
Controls
Columbia
Research Labs
Crossbow
Jewell
Instruments
LLC
Omron
Electronics
Product
HRS100
Series
SI-701
Series
CXTA and
CXTLA
Series
LSO Series
D6B Series
Phone Number &
Website
800-872-0042
www.clarostat.com
800-813-8471
www.columbia
researchlab.com
408-965-3300
www.xbow.com
800-227-5955
www . i ewellins tram
ents.com
847-882-2288
www.omron.com
Alternative 6: Capacitive
Description
The capacitive tilt switch utilizes a capacitive
based sensor that produces output directly
proportional to the relative tilt. The sensor is
typically composed of hermetically sealed
capacitive domes with a high dielectric constant
fluid that fills the space between the domes.
Cost
The cost of a capacitive tilt switch is
approximately $80 to $250 depending on product
or application requirements.
Advantages/Disadvantages
The capacitive tilt switch has high accuracy, high
long-term stability, and low power requirements.
The capacitive tilt switch is suitable for
applications requiring high measurement
accuracy with low linearity deviations, and for
measurement of relatively large inclination
angles.
Manufacturers
The following are manufacturers of capacitive tilt
switches:
Manufacturer
Name
Measurement
Specialties
Rieker Inc.
Seika
(Germany)
Reiker Inc. -
U.S.
Representative
Product
Accustar and
Accuswitch
Series
N Series and
NG Series
NG2, NG3,
andNG4
Series
Phone Number
Website
800-745-8008
www. schaevitz.co
ffl
610-534-9000
www.riekerinc.co
m
Reiker Inc.
610-534-9000
www.seika.de
Summary
There are numerous mercury free alternative
technologies currently in use for tilt switch
products and applications. It appears that these
mercury free alternatives are cost competitive
and can meet the functional requirements for new
tilt switch products and applications. However,
these mercury free alternatives may not meet the
requirements for retrofitting all existing tilt
switch products and applications.
An example of a successful tilt switch
replacement program is the "Switch the Switch"
program initiated by the Michigan based Clean
Car Campaign. Mercury tilt switches in hood
lights and trunk lights were replaced with
mercury free tilt switches in automobiles across
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the nation. This was a simple, drop-in exchange
that took about ten minutes per switch to
accomplish. Across the United States, thirteen
tilt switch replacement events took place. Some
participating dealerships replaced mercury
switches in vehicles on their lots, while other
dealerships offered the service, free of charge, to
their customers. The participating municipal and
state agencies replaced the mercury tilt switches
in their fleets of vehicles. (Clean Car Campaign,
2002)
4.14 Pressure Switches
A pressure switch is a device that converts a
pressure change into an electrical switching
function. The pressure change might be measured
as pressure, vacuum, or differential between two
pressure inputs. In every case, the pressure
switch will employ a diaphragm, piston, or other
pressure-responsive sensor, which has been
coupled to actuate a mechanical switch, mercury
switch, or transistor. Examples of pressure
responsive sensors used in pressure switches
include:
• Diaphragm: A diaphragm actuated
pressure switch has a large surface area
and very flexible diaphragm
material. This type of sensor is able to
convert a relatively small amount of
pressure or vacuum into sufficient
mechanical force to actuate a snap-action
switch. In a pressure switch, positive
pressure pushes the diaphragm. In a
vacuum switch, negative pressure pulls
the diaphragm. In a differential switch,
both sides of the switch housing are
linked to two pressure sources, and the
diaphragm responds to the resulting net
force.
• Piston: A piston actuated pressure switch
uses a metal piston as the sensor. Its
robust design and stronger materials
enable this type of sensor to work at high
pressures, or in hostile media.
• Bellows: A bellows actuated pressure
switch uses a bellows elastic element that
expands and contracts axially with
changes in pressure. Changes in the
measured pressure cause the bellows to
work against an adjustable spring. This
spring determines the pressure required to
actuate the switch. Through suitable
linkage, the spring causes the contacts to
open or close the electrical circuit
automatically when the operating pressure
falls below or rises above a specified
value.
• Flex Circuit: A flex circuit diaphragm is a
small metal diaphragm etched from one
layer of a circuit board. This diaphragm is
able to make contact with another layer,
combining sensor and switch. The
advantage of this device is that it can
open and close at a very high frequency
over a very long duty cycle.
Each type of sensor provides performance
tradeoffs that must be evaluated for each
particular application. For example, bellows
actuated pressure switches have excellent
sensitivity, however they are subject to metal
fatigue in rapidly cycling applications.
A pressure switch is a versatile component
used to meet the needs of hundreds of pressure
monitoring/control products and applications. A
pressure switch can be incorporated into a
product (e.g. boiler, air conditioner, vacuum
cleaner, etc.), or can be purchased as a
component to be used in a customer specific
application (e.g. semiconductor processing).
Examples of some pressure switch products and
applications are provided below:
• Heating, ventilation, and air conditioning:
electrostatic air cleaners, filter indicators,
reservoir level, gas fired heating,
ventilation, utility heaters, heat pumps,
furnaces, flue gas, fuel delivery, etc.
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• Medical: respiratory sensors, therapy tent
nebulizers, automated blood pressure
systems, sip and puff movement controls,
anesthesia leak detection, saline pumps,
tourniquet systems, reverse osmosis
purification systems, dental aspirator
pumps, respiratory therapy, disposable
surgical vacuum systems, etc.
• Automotive: tire pressure, emission
control, manifolds, air conditioning,
engine crankcase pressure, air brakes,
lumbar seat pressure, exhaust gas re-
circulation, etc.
• Appliance: commercial dishwashers,
floor scrubbers, vacuum cleaners, food
storage sealers, air conditioners,
commercial fryers, hot water dispensers,
hot water heaters, etc.
• Other: fire pump controllers, scrubbers,
venting hoods, construction equipment,
tape braking systems, tape tension
controls, door safety, spa pumps, machine
tools, automated test equipment,
packaging machinery, pulp digesters,
boilers, well heads, polymerization
reactor vessels, mine gas samplers, garage
doors, industrial gas pressure sensing,
vacuum radon detection, missile guidance
applications, spray painting equipment,
semiconductor process equipment,
injection water systems, submarine
navigation control, robotics, organs,
pump control, automobiles, pressurized
air systems, bioprocess applications,
sanitary systems, hydraulic systems,
sprayers, pressurized tanks, altitude
sensing, portable test equipment, fire
protection systems, and waste treatment
plants.
There are numerous design parameters that affect
the specification and selection of a pressure
switch for a particular product or application.
Pressure switch basic design and product options
vary greatly by manufacturer. The design
requirements have a significant impact on
technology selection, manufacturer selection,
product model selection, product option
selection, and ultimate product cost. For
example, sensor selection is a key determinant of
range, sensitivity, accuracy, life expectancy, and
cost of a pressure switch. The following is a
concise listing of some of the more critical design
parameters:
• Variable measured: pressure, vacuum,
differential
• Operating parameters: set-point, dead-
band, factory set, field adjustable
• Enclosure: general purpose, weather
resistant, explosion proof, etc.
• Regulatory approval: Underwriters
Laboratories, Canadian Standards
Association, etc.
• Switch type: mercury, snap switch,
micro-switch, transistor, etc.
• Switch: number of poles, number of
throws, amperage, voltage, hermetically
sealed, etc.
• Load: resistive, inductive, other
• Accuracy: repeatability, calibration
requirements
• Monitoring: local, remote
• Mounting: vertical, horizontal
• Materials: enclosure, sensor, switch, etc.
• Visual display: status, power on, etc.
• Sensor type: diaphragm, bellows, piston,
bulb & capillary, etc.
• Pressure: range to be measured,
maximum operating pressure, etc.
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• Life expectancy: time in service, number
of cycles
• Electrical connection: terminal block,
conduit, etc.
• Physical: size, weight, etc.
• Power input: 120/240Volts AC,
12/24Volts DC, current, etc.
• Environmental conditions: shock,
vibration, explosion, corrosiveness,
temperature, humidity, radio frequency
interference, etc.
• Other: pressure surge protection, test
button, reset button, etc.
Mercury Pressure Switches
Description
The mercury pressure switch typically uses a
piston, diaphragm, or bellows acting as the
pressure sensor to actuate the mercury switch.
The mercury content reported by manufacturers
to IMERC for pressure switches was in the range
of greater than 1,000 mg.
Cost
The cost of a mercury pressure switch is
approximately $150 to $170 based on pricing
obtained for only two product models. The range
could be much greater depending on various
product and application requirements. One
manufacturer provides comparable pricing for
mercury pressure switches and mechanical
pressure switches with similar functionality.
Advantages/Disadvantages
The mercury pressure switch has high reliability
and long operational life because it has few
components and is not subject to arcing. Life
cycle testing has been successfully conducted for
more than one million cycles. The mercury float
switch can handle a high inductive load, has a
quiet operation, has no bounce on contact, and
can be hermetically sealed to provide increased
protection from various environmental factors.
The mercury pressure switch contains
mercury, which is becoming less desirable for
many applications including the food and
beverage industry.
Manufacturers
The following are
pressure switches.
manufacturers of mercury
Manufacturer
Name
Dwyer
Instalments
(Mercoid)
Encertec
Product
PQ, PR,
BB, DP,
and DA
Series
Model
AP-153-
37
Phone Number &
Website
219-879-8000
www.dwver-inst.com
336-288-7226
http://www.encertec.co
m/
spare%20parts%201ist.h
tm
Alternative 1: Mechanical Pressure
Switches
Description
The mechanical pressure switch typically uses a
piston, diaphragm, bellows, or combination
piston/diaphragm as the pressure sensor. The
sensor can either 1) directly actuate the switch, or
2) use a pushrod, lever, or compression spring to
actuate a snap acting micro-switch.
Cost
The cost of a mechanical pressure switch is
approximately $40 to $600 depending on product
or application requirements.
Advantages/Disadvantages
Mechanical pressure switches have high
reliability, a long operational life, and can also
provide high accuracy when used with a
diaphragm sensor. Certain models of the
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mechanical pressure switch use a diaphragm and
negative rate Belleville spring that provides
superior resistance to shock and vibration.
Manufacturers
The following are manufacturers of mechanical
pressure switches:
Manufacturer
Name
Weed
Instrument
Product
Model
GR2/4
Phone Number &
Website
800-880-9333
www. weedins tram
ent.com
Manufacturer
Name
Barksdale, Inc.
Custom
Control
Sensors, Inc.
Dwyer
Instruments
(Mercoid)
Hobbs
Corporation
(Invensys
Company)
Kobold
Micro
Pneumatic
Logic, Inc.
(MPL)
Neo-dyn/ITT
Industries
SOR Inc.
Tecmark
Corporation
Texas
Instruments
United Electric
Controls
Product
D1,B1,
E1S, C9612
Series
6800 and
6900 Series
PG, DP,
APS, AVS,
and DS-
7300 Series
Series 3000
and 5000,
Series III
andV
KPH 8000
andKPH
8200 Series
MPL 500
Series
100P, 152P,
160P, 142P,
and 182P
Series
Series 20
Series 3000
Numerous
models
Spectra 10,
Deltapro 24,
and Spectra
12 Series
Phone Number &
Website
800-835-1060
www.barksdale.co
m
818-341-4610
www.ccsdualsnap.
com
219-879-8000
www.dwver-
inst.com
217-753-7752
www.hobbs-
corp.com
800-998-1020
www.kobold.com
954-973-6166
www.pressureswitc
h.com
661-295-4000
www.neodyn.com
800-676-6794
www.sorinc.com
440-205-7600
www.tecmarkcorp.
com
888-438-2214
www.ti.com
617-926-1000
www.ueonline.com
Alternative 2: Solid-State Pressure
Switches
Description
Solid-state pressure switches contain one or more
strain gauge pressure sensors, a transmitter, and
one or more switches all in a compact package.
In addition to opening or closing the pressure
switch circuit, they can provide a proportional
analog or digital output. Diffused silicon
piezoresistive sensors are widely used in solid-
state pressure switches. The sensor contains
homogeneous silicon measuring cells containing
two vacuum-welded silicon plates. The
piezoresi stive effect causes element resistance to
change proportionally with measured pressure.
Thin film strain gauges can also be used as the
pressure sensor. A microprocessor is used to
process the strain gauge sensor information and
actuate the switching element. The switching
element is typically a transistor.
Cost
Solid-state pressure switches cost approximately
$200 - $350 depending on product or application
requirements. This is higher than the cost for
mechanical or mercury pressure switches. Solid-
state pressure switches become more cost
effective when monitoring more than one point
and other of its various features are needed.
Advantages/Disadvantages
Solid-state pressure switches provide higher
accuracy than mechanical switches. Solid-state
pressure switches can improve process quality,
resulting in reduced scrap and waste. Solid-state
pressure switches have long life at rated loads
that can often be ten million cycles or greater.
Solid-state sensors usually have built-in
temperature compensation to ensure accuracy
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over a wide temperature range. The solid-state
pressure switch can provide proportional analog
or digital output. The electronic control unit can
be mounted remotely from the sensor. Solid-
state pressure sensors often have a built-in
keypad and display to simplify setup and ongoing
field adjustments. Solid-state pressure switches
provide a wide range of set-point and dead-band
adjustment. The transistor switch is highly
reliable, has no contact bounce, accommodates
fast switching, and has no arcing.
The transistor is usually restricted to low-level
direct current voltage applications. High
temperatures or transient pressure spikes can
damage a solid-state pressure sensor.
Manufacturers
The following are manufacturers of solid-state
pressure switches:
Manufacturer
Name
Barksdale, Inc.
Kobold
SOU Inc.
United Electric
Controls
Product
PS Series
FDD
Series
SGT
Series
One
Series
Phone Number
Website
800-835-1060
www.barksdale.com
800-998-1020
www.kobold.com
800-676-6794
www.sorinc.com
617-926-1000
www.ueonline.com
Summary
There are numerous mercury-free alternative
technologies currently in use for pressure switch
products and applications. It appears that these
mercury-free alternatives are cost competitive
and can meet the functional requirements for new
pressure switch products and applications.
However, these mercury free alternatives may
not meet the requirements for retrofitting all
existing pressure switch products and
applications.
4.15 Temperature Switches
A temperature switch is a device that converts a
temperature change into an electrical switching
function. The temperature switch uses a
temperature responsive sensor that is coupled to a
switch. The switch can be a mercury switch,
solid state, micro-switch, or snap switch. The
following are examples of temperature sensors
commonly used in temperature switches:
Thermocouple: A thermocouple is comprised
of two wire strips of dissimilar metals. These
metal wires are joined at one end and the
voltage is measured at the other end. Changes
in the temperature at the juncture induce a
change in electromotive force at the other
end. As the temperature goes up, the output
electromotive force of the thermocouple rises.
There are many different types of
thermocouples made of different types of
wire with very different properties.
Resistance Temperature Detectors (RTD): An
RTD is based on the fact that the electrical
resistance of a metal changes as its
temperature changes. The resistance will rise
more or less linearly with temperature. RTDs
use a length of conductor (platinum, nickel,
iron or copper) wound around an insulator.
Newer styles use a thin film of the conductor
deposited on a ceramic substrate. RTDs are
stable and have a fairly wide temperature
range, but are not as rugged and inexpensive
as thermocouples. Since they require the use
of electric current to make measurements,
RTDs are subject to inaccuracies from self-
heating.
Thermistor: A thermistor is also based on the
fact that the electrical resistance of a material
changes as its temperature changes.
Thermistors rely on the resistance change in a
ceramic semiconductor, with the resistance
dropping non-linearly with a temperature rise.
Thermistors tend to be more accurate than
RTDs and thermocouples, but they have a
much more limited temperature range
because of their marked non-linearity.
Thermistors can be a low cost solution to
temperature measurement. They tend to have
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large signal outputs and their small size
permits fast response to temperature changes.
Integrated Circuit Sensor: The newest type
of temperature sensor on the market is the
integrated circuit temperature transducer.
Integrated circuit sensors can be designed to
produce either voltage or current output and
are extremely linear. Integrated circuit
sensors are a very effective way to produce
an analog voltage proportional to
temperature. They have a limited temperature
range and are used to measure temperatures
from -50° to 300° F.
A temperature switch is a versatile component
used to meet the needs of hundreds of
temperature monitoring/control products and
applications. A temperature switch can be
incorporated into a product (e.g. food warming
trays, hot water boilers, etc.), or can be purchased
as a component to be used in a customer specific
application (e.g. plastics injection molding
process). Examples of some temperature switch
products and applications are provided below:
Ovens, sterilizers, moulding machines, heat
exchangers, labelling machines, water baths,
heat sealers, refrigerating equipment,
ventilating equipment, alarm systems,
bearings, gear reducers, bucket elevators,
hammer mills, generators, conveyors, dryer
bearings, mechanical drives, grinders, pumps,
motors, presses, mixers, appliances, vending
machines, platens, plastic laminating presses,
dental equipment, popcorn machines, hot
stamping, food warming trays, hydraulic
laminating presses, livestock applications, hot
water boilers, hot water storage tanks, heavy
oil pre-heaters, watering fountains, label
adhesive applicators, paint drying equipment,
typesetting machines, hot stamp printers,
vending machines, deep fat cookers, and
textiles.
There are numerous design parameters that
affect the specification and selection of a
temperature switch for a particular product or
application. Temperature switch basic design
and product options vary greatly by
manufacturer. The design requirements have a
significant impact on technology selection,
manufacturer selection, product model selection,
product option selection, and ultimate product
cost. For example, sensor selection is a key
determinant of range, sensitivity, accuracy, life
expectancy, and cost of a temperature switch.
The following is a concise listing of some of the
more critical design parameters:
• Operating parameters: Set-point, dead-
band, factory set, field adjustable
• Enclosure: general purpose, weather
resistant, explosion proof, etc.
• Regulatory approval: Underwriters
Laboratories, Canadian Standards
Association, etc.
• Switch type: mercury, snap switch,
micro-switch, transistor, etc.
• Switch: number of poles, number of
throws, amperage, voltage, hermetically
sealed, etc.
• Load: resistive, inductive, other
• Accuracy: repeatability, calibration
requirements
• Monitoring: local, remote
• Mounting: vertical, horizontal
• Materials: enclosure, sensor, switch, etc.
• Visual display: status, power on, etc.
• Sensor type: RTD, integrated circuit,
thermistor, thermocouple, etc.
• Temperature: range to be measured,
maximum operating temperature, storage
temperature, etc.
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• Life expectancy: time in service, number
of cycles
• Electrical connection: terminal block,
conduit, etc.
• Physical: size, weight, etc.
• Power input: 120/240VAC, 12/24VDC,
current, etc.
• Environmental conditions: shock,
vibration, explosion, corrosiveness,
temperature, humidity, RFI, etc.
• Other: temperature surge protection, test
button, reset button, etc.
inductive load, has a quiet operation, has no
bounce on contact, and can be hermetically
sealed to provide increased protection from
various environmental factors.
The mercury temperature switch contains
mercury, which is becoming less desirable for
many applications including the food and
beverage industry.
Manufacturers
The following table lists a manufacturer of
mercury temperature switches.
Manufacturer
Name
Dwyer
Instruments
(Mercoid)
Product
M-51, FM,
DA-36, DA-
37 Series
Phone Number &
Website
219-879-8000
www.dwver-
inst.com
Mercury Temperature Switches
Description
The temperature switch employs a temperature
responsive sensor, which is coupled to the
mechanical means of actuating a mercury switch.
The temperature responsive sensor is typically
either a thermocouple, resistance temperature
detector (RTD), or gas actuated bourdon tube.
The mercury content reported by manufacturers
to IMERC for temperature switches was in the
range of greater than 1,000 mg.
Cost
The cost of a mercury temperature switch is
approximately $150 to $250 depending on
product or application requirements. For one
manufacturer, the cost of a temperature switch
with a snap action switch is less than the cost of a
mercury temperature switch with the same
functionality.
Advantages/Disadvantages
The mercury temperature switch has high
reliability and long operational life because it has
few components and is not subject to arcing.
Life cycle testing has been successfully
conducted for more than one million cycles. The
mercury temperature switch can handle a high
Alternative 1: Mechanical Temperature
Switches
Description
The mechanical temperature switch employs a
temperature responsive sensor, which is coupled
to the mechanical means of actuating a
mechanical switch. The temperature responsive
sensor can typically be a thermocouple, bulb and
capillary, resistance temperature detector (RTD),
welded alloy, or gas actuated bourdon tube.
Cost
The cost of a mechanical temperature switch is
approximately $8 to $600 depending on product
or application requirements. For one
manufacturer, the cost of a temperature switch
with a snap action switch is less than the cost of a
mercury temperature switch with the same
functionality.
Advantages/Disadvantages
The mechanical temperature switch has high
reliability, long operational life, and can handle
high inductive loads. The reliability and
accuracy of a mechanical temperature switch is
largely dependent on the sensor technology used.
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The mechanical temperature switch provides
similar functionality to the mercury temperature
switch without the attendant mercury
management issues.
Manufacturers
The following are manufacturers of mechanical
temperature switches:
Manufacturer
Name
Barksdale, Inc.
Chromalox
Custom
Control
Sensors, Inc.
Dwyer
Instruments
(Mercoid)
Kidde-Fenwal,
Inc.
Kobold
Neo-dyn/ITT
Industries
Selco
United Electric
Controls
Weed
Instrument
Product
THR, TPR,
T1X, L1X
Series
AR, ARR, and
3000 Series
6900 and 604
Series
RRT, D-7435,
DA-36, and
DA-37 Series
Series 15000,
16000, 17000,
and 18000
TWR and TRS
Series
Series 100T
and 132T
S200 and SIO
Series
55 Series
C54S-103
B54-103
Model PR7
Series
Phone Number
Website
800-835-1060
www.barksdale.c
om
800-443-2640
www.chromolox.
com
818-341-4610
www.ccsdualsna
p.com
219-879-8000
www.dwver-
inst.com
508-881-2000
www.fenwalcont
rols.com
800-998-1020
www.kobold.co
m
661-295-4000
www.neodyn.co
m
800-257-3526
www.selcoprodu
cts.com
617-926-1000
www.ueonline.c
om
800-880-9333
www.weedinstru
ment.com
Alternative 2: Solid State Temperature
Switches
Description
The solid-state temperature switch utilizes
temperature coefficient thermistors, RTDs, or
integrated circuits sensor to monitor temperature,
and a semiconductor for the switching output.
Cost
The cost of a solid-state temperature switch is
approximately $350 to $600 depending on
product or application requirements. The cost of
a solid-state temperature switch is generally
higher than the cost of a mercury or mechanical
temperature switch.
Advantages/Disadvantages
The use of solid-state technology provides
improved accuracy, repeatability, and reliability
as compared with mechanical or mercury
temperature switches. Switching point,
hysteresis, and other parameters are often field
programmable. Solid-state temperature switches
provide tighter control that can increase the life
of controlled equipment. Solid-state temperature
switches operate with low voltage and low
current consumption. Solid-state temperature
switches do not require calibration.
Solid-state temperature switches usually have
a higher initial cost than mechanical or mercury
temperature switches.
Manufacturers
The following are manufacturers of solid-state
temperature switches:
Manufacturer
Name
Kobold
Maxitronic
Seiko
Instruments
USA
Product
TDD -2,
TDD -4
HB Series
S-8130AC
Series
Phone Number
Website
800-998-1020
www.kobold.com
800-659-8520
www.maxitronic.com
310-517-7771
www.seiko-usa-
ecd.com
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Manufacturer
Name
United Electric
Controls
Product
D1C2L1N,
D1C2L2A,
D1A2L1N
Phone Number
Website
617-926-1000
www.ueonline.com
Summary
There are numerous mercury free alternative
technologies currently in use for temperature
switch products and applications. It appears that
these mercury free alternatives are cost
competitive and can meet the functional
requirements for new temperature switch
products and applications. However, these
mercury free alternatives may not meet the
requirements for retrofitting all existing
temperature switch products and applications.
4.16 Relays
A relay is an electrically controlled device that
opens or closes electrical contacts to effect the
operation of other devices in the same or another
electrical circuit. Relays are often used to switch
large current loads by supplying relatively small
currents to a control circuit. There are two
general families of relays: electro-mechanical
and semiconductor. Electro-mechanical relays
include mercury displacement, mercury wetted
reed relay, mercury contact relay, dry reed relay,
and other miscellaneous electro-mechanical
relays. Semiconductor relays include solid-state
relays and silicon controlled rectifiers.
A relay is a versatile component used to meet
the needs of hundreds of varied products and
applications. A relay can be incorporated into a
product (e.g. copiers, heaters, conveyors, etc.), or
can be purchased as a component to be used in a
customer specific application (e.g. petrochemical
processing). Examples of some relay products
and applications are provided below:
• Commercial aircraft: power control,
master power switches, motor control
switching, heavy current load switching,
instrument panel, generator switching,
alternator power switching, antenna
changeover, channel selection, etc.
• Air conditioning and heating equipment:
compressor motors, fan motors, coolant
pump motors, duct heaters, etc.
• Lighting controls: street lamps, dimmer
controls, parking lots, scoreboards, high
intensity lamps, traffic signals, tungsten
lamps, etc.
• Telecommunications: trunk switching,
test panels, telecomm circuit boards, load
switches, radio base stations, ground start,
input/output cards, control panel
exchanges, antenna switches, loop current
test, etc.
• Hospitals: surgical equipment, X-ray
machine control, energy management
systems, surgical lighting, etc.
• Food Industry: food processing, deep
fryers, pizza ovens, baking ovens, electric
grills, dishwashers, etc.
• Office equipment: copiers, computer
power supplies, blue print machines, etc.
• Manufacturing: injection molding
machines, kilns, ink heating, vacuum
forming, soldering systems,
semiconductor processing, programmable
logic controllers, etc.
• Production test equipment: component
testers, cable testers, circuit testing, etc.
• Laboratory test instruments: voltmeters,
ohmmeters, recorders, environmental
chambers, etc.
• Machine tool control: solenoid operated
valves, heavy motor starting, signal lights,
etc.
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• Miscellaneous: mining equipment, pool
heaters, dry cleaning equipment,
notebook computers, ceramic heaters,
industrial furnaces, alarm systems, battery
chargers, farm incubators, chemical tank
heaters, film packaging, glass furnaces,
engraving equipment, plastic extruders,
steam generators, automobiles, printing
machines, silicon carbide heaters,
controlled rectifiers, graphite heaters,
infrared dryers, book binding machines,
trucks, conveyors, appliances, missiles,
aerospace, petrochemical processing, coin
operated machines, ships, laboratory
baths, flask heaters, robotics, packaging
machines, pharmaceutical processes,
textiles, paper & pulp drying, infrared
ovens, high temperature materials
processing, electric ranges, multiplexers,
communication modules, modems, data
access arrangement circuits, etc.
The global market for relays was $4.658
billion in 2001 revenues. Approximately 89.1%
of these revenues were for electromechanical
relays and 10.9% was for semiconductor relays.
The three largest industry applications were
telecommunications (25.3%), transportation
(18.4%), and industrial automation (12.4%).
There are numerous design parameters that
affect the specification and selection of a relay
for a particular application. The following is a
concise listing of some of the more critical
factors:
• Mounting: printed circuit board, din rail,
bracket/flange mount, socket/plug-in
style, surface mount, etc.
• Reliability: failure rate, mean cycles
before failure (MCBF), etc.
• Enclosure: open, National Electrical
Manufacturers Association (NEMA),
hermetically sealed, etc.
• Pole specifications: single pole, double
pole, triple pole, etc.
• Throw specifications: single throw,
double throw, etc.
• Isolation: optically isolated, etc.
• Contact ratings: maximum switching
current (amps), maximum switching
voltage, maximum switching power
• Contacts: normally open, normally
closed, contact material, etc.
• Materials: contacts, insulation, soldering
fluxes, finishes, etc.
• Regulatory approval: Underwriters
Laboratories, Canadian Standards
Association, etc.
• Resistance: contacts, coil, insulation
• Voltage: Direct current or alternating
current
• Load types: inductive, motor, lamp, etc.
• Load characteristics: inrush current, step
up, ramp up, soft start, etc.
• Life expectancy: electrical components,
mechanical components, controlled
equipment, etc.
• Physical: weight, size, noise level, etc.
• Coil ratings: voltage range, resistance
range, nominal power, etc.
• Performance specifications: make/operate
time, break/release time, contact chatter,
contact bounce, time delay, etc.
• Environment: operating temperature,
shock, vibration, acceleration, humidity,
etc.
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• Control panel: space available, natural
convection available, etc.
• Output device for solid-state relays:
metal oxide semiconductor field effect
transistor (MOSFET), silicon controlled
rectifier, bipolar transistor, triac, etc.
• Other features: time delay, instrinsically
safe, visual indicators, sealed enclosure,
test button, latching controls, energy
efficiency, etc.
Original equipment manufacturers that use
relays as a component within their products or
equipment were interviewed by Venture
Development Corporation. They were asked to
identify the most important criterion for their
selection of relays in their products. The
following table illustrates the results:
Table 4.6: Most Important Relay Product
Selection Criteria
Product Selection Criteria
Reliability/Quality/Durability
Contact Current Specifications
Physical Characteristics
Lifespan/Cycles
Coil/Control Specifications
Resistance Parameters
Ease of Maintenance &
Replacement
Isolation Parameters
Regulatory /Customer
Requirements
Energy Efficiency
Other
Percent of OEM
Respondents
Citing as Most
Important
41.4%
27.6%
27.6%
24.1%
19.0%
15.5%
13.8%
15.5%
10.3%
3.4%
12.1%
Source: Venture Development Corporation
4.16.A Mercury Displacement Relay
Description
The mercury displacement relay uses a metallic
plunger device to displace mercury. The plunger
is lighter than mercury so it floats on the
mercury. The plunger also contains a magnetic
shell or sleeve, so it can be pulled down into the
mercury with a magnetic field. The plunger
provides the same functionality in a mercury
displacement relay as an armature in a
mechanical relay. When the coil power is off,
the mercury level is below the electrode tip and
no current path exists between the insulated
center electrode and the mercury pool. When
coil power is applied the plunger is drawn down
into the mercury pool by the pull of the magnetic
field and the plunger centers itself within the
current path. Upon removing the coil power, the
buoyancy force of the mercury causes the
plunger assembly to again rise to the starting
position. This drops the level of the mercury and
breaks the current path through the center
electrode and the mercury pool.
The amount of mercury in mercury
displacement relays varies considerably based on
number of poles, current rating, termination
requirements, and other factors. The mercury
content reported by manufacturers to IMERC for
relays was in the range of greater than 1,000 mg.
The mercury can be released to the environment
during product use. For example, if the load is
short circuited, the MDR can burst. Some
manufacturers offer free take-back programs for
their mercury relays.
Mercury displacement relays are used in high
current, high voltage applications such as
industrial process controllers, power supply
switching, resistance heating, tungsten lighting,
welding, high current/voltage lighting, flood
lights, copiers, battery chargers, energy
management systems, and industrial ovens.
Cost
The cost of a mercury displacement relay is
approximately $20 to $150 depending on product
or application requirements. The cost of a
mercury displacement relay is comparable with
other electromechanical relays. The cost of a
mercury displacement relay is less than a solid
state relay for low current applications, but cost
becomes comparable for higher current
applications.
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Advantages/Disadvantages
Mercury displacement relays have hermetically
sealed contacts that provide internal and external
protection from arcing and environmental abuse.
The mercury rewets the contact electrode
providing a new contact surface with each
actuation, so the surface does not pit or weld.
Mercury displacement relays can cycle faster
than a mechanical relay, and have low contact
resistance because large electrodes and
surrounding mercury volume creates large
contact mating areas. Mercury displacement
relays have quiet operation because acoustical
noise from rebounding contacts is eliminated.
Mercury displacement relays have long life
because they contain one moving part and no
pivots, hinges, pins or mechanical linkages
resulting in limited wear. Mercury displacement
relays last on average between 1,000,000 to
10,000,000 cycles. Factors that affect the
longevity of the relay include: voltage being
switched, ratio of line voltage to rated voltage,
and number of cycles per hour. Mercury
displacement relays have bounce free operation
because the mercury surface tension enable the
mercury to bridge the contacts during the plunger
settling time.
Mercury displacement relays need to be
mounted in a specific orientation in order for the
mercury to function properly. Mercury
displacement relays can burst, causing an on-site
hazardous waste problem, if the relay is
overheated due to rapid cycling or if the load is
short-circuited. In addition, disposal of worn out
contactors can be expensive. Control of
equipment is limited compared with solid-state
relays. Thermal shock can occur for the
equipment being controlled by the relay.
Manufacturers
The following are manufacturers of mercury
displacement relays:
Manufacturer
Name
Chromalox
Magnecraft &
Struthers-Dunn
Mercury
Displacement
Industries Inc.
Watlow Electronic
Manufacturing
Company
Product
HGR
series
WM and
WML
Series
Numerous
models
HG Series
Phone Number &
Website
800-443-2640
www.chromolox.com
843-393-5778
www.masnecraft.com
616-663-8574
www.mdius.com
507-454-5300
www.watlow.com
4.16.B Mercury Wetted Reed Relay
Description
A mercury wetted reed relay is a type of electro-
mechanical relay that employs a hermetically
sealed reed switch. The reeds are thin flat
ferromagnetic blades that serve as a contact,
spring, and magnetic armature. The mercury
wetted reed relay consists of a glass encapsulated
reed with its base immersed in a pool of mercury
and the other end capable of moving between two
sets of contacts. The mercury flows up the reed
by capillary action and wets the contact surface
of the reed and the stationary contacts. The
mercury wetted reed relay is usually actuated by
a coil around the capsule.
Wetted mercury reed relays are typically
small circuit controls that are used in electronic
devices for switching or signal routing functions.
Reed relays are primarily used in test, calibration,
and measurement equipment applications where
stable contact resistance over the life of the
product is necessary.
Cost
Prices for the mercury wetted reed relay ranged
from approximately $10 for printed circuit board
mounted low amperage devices, to $40 for larger
5 amp devices. For one manufacturer, the cost of
mercury wetted relay was the same as a dry
magnetic reed relay for a similar device. For
another manufacturer, the cost of a mercury
wetted relay was double the cost of a dry
magnetic reed relay for a similar device. Overall,
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prices for mercury wetted relays appear to be
comparable to prices for dry reed relays.
However, life cycle costs are higher for the
mercury wetted reed relay due to the higher costs
associated with shipping, management, and
disposal of the mercury containing device.
Advantages/Disadvantages
Hermetically sealed contacts in a clean
atmosphere are unaffected by dust, corrosion, or
oxidation, and also eliminate the opportunity for
sticking, binding, or wearing of hinged joints.
With proper circuitry, magnetic reed relays can
offer a life span in excess of one billion
operations. The mercury wetted reed relay can
operate in the millisecond range. Although
slower than solid-state relays, reed relays are
sufficiently faster than other electro-mechanical
relays and therefore can be used in high speed
switching applications. When compared to solid-
state relays, the necessary coupling circuitry
between the logic and input and output devices is
less complicated and less expensive for reed
relays. The mercury wetted reed relay has the
following advantages over a dry reed relay: no
contact bounce, longer life, and lower contact
resistance.
Reed relays used for inductive loads such as
motors, relay coil, solenoids, etc., are subject to
high induced voltages during opening of the load
circuit contacts. This high transient voltage may
cause damage to the reed switch or significantly
reduce its life. Reed relays used for capacitive
loads such as capacitors, incandescent lamps or
long cables, are subject to high surge/inrush
current. Therefore, protective circuits such as
surge suppressors or current limiting resistors are
often used. Reed relays located near sources of
strong magnetic interference such as steel plates,
transformers, etc. can experience changes in
operational characteristics and false operation is
likely. The wetted mercury reed relay must be
mounted in the vertical position for proper
operation.
Mercury wetted reed relays can be replaced by
dry reed magnetic relays for most applications
with the exception of applications that require no
contact bounce, long operational life, or low
contact resistance.
Manufacturers
The following are manufacturers of mercury
wetted reed relays:
Manufacturer
Name
American
Relays, Inc.
Celduc Relais
(France)
Laube
Technology -
US
Representative
Computer
Components,
Inc.
Crydom
Magnetics
(UK)
Meder
Electronic,
Inc.
SRC Devices
Product
Numerous
DIP, SIP,
and
encapsulated
, models
F81A,
F72C2
Series
Numerous
models
DIP Series
MREand
MT Series
MSS Series,
HGWM
Series
Phone Number &
Website
562-944-0447
www.americanrela
vs.com
Laube Technology:
805-388-1050
www.celduc-
relais.com
800-864-2815
www.relavs-
unlimited.com
Crydom USA
619-210-1600
www.crvdom.co.uk
800-870-5385
www.meder.com
858-292-8770
www . srcdevice s . co
m
4.16.C Mercury Contact Relay
Description
The mercury contact relay establishes contact
between electrodes in a sealed capsule as a result
of the capsule being tilted by an electro-
magnetically actuated armature, either on pickup
or dropout. No manufacturers were identified
that currently produce this type of mercury relay,
and therefore there will be no further coverage of
this type of relay in this report.
Alternative 1: Dry Magnetic Reed
Relay
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Description
A dry magnetic reed relays consists of a pair of
low reluctance, ferromagnetic, slender flattened
reeds. These reeds are hermetically sealed into a
glass tube with a controlled atmosphere in
cantilever fashion so that the ends align and
overlap with a small air gap. Since the reeds are
ferromagnetic, the extreme ends will assume
opposite magnetic polarity when brought into the
influence of a magnetic field. When the magnetic
flux density is sufficient, the attraction force of
the opposing magnetic poles overcomes the reed
stiffness causing them to flex toward each other
and make contact. This operation can be repeated
millions of times at extremely high speeds.
Energizing the coil sets up a magnetic field that
acts in the same manner as the permanent
magnet. At the contact area, these relays are
usually plated with rhodium, ruthenium, or gold
to provide a low contact resistance when they
meet.
Dry magnetic reed relays are typically small
circuit controls that are used in electronic
devices. Reed relays are primarily used in test,
calibration, and measurement equipment
applications where stable contact resistance over
the life of the product is necessary.
Cost
The cost of dry magnetic reed relays are
approximately $2 to $15 depending on product or
application requirements. For one manufacturer,
the cost of mercury wetted relay was the same as
a dry magnetic reed relay for a similar device.
For another manufacturer, the cost of mercury
wetted relay was double the cost for a dry
magnetic reed relay for a similar device.
Advantages/Disadvantages
The dry magnetic reed relay has long operational
life, fast cycling time, no mercury life cycle
impacts to address, and can be mounted in any
position for proper operation.
The dry magnetic reed relay experiences
similar effects from electromagnetic interference
as the mercury wetted reed relay. Exposure to
high voltage may cause the contacts to weld
together. The dry magnetic reed relay has more
contact bounce than mercury wetted reed relays,
shorter operational life than mercury wetted reed
relays, and has higher contact resistance than the
mercury wetted relay.
Manufacturers
The following are manufacturers of dry magnetic
reed relays:
Manufacturer
Name
American
Relays, Inc.
Celduc Relais
(France)
Laube
Technology -
US
Representative
Computer
Components,
Inc.
Coto
Technology
Crydom
Magnetics
(UK)
Magnecraft &
Struthers-
Dunn
Meder
Electronic,
Inc.
NTE
Electronics,
Inc.
SRC Devices
Product
Numerous
models
DSland
D41
Series
Numerous
models
Numerous
models
S Series
W107
Series
H, LI, HE,
MRX,MT
and other
series
R56
Series
Series
DSS4 and
PRMA
Phone Number &
Website
562-944-0447
www.americanrelavs
.com
Laube Technology:
805-388-1050
www.celduc-
relais.com
800-864-2815
www.relavs-
unlimited.com
401-943-2686
www.cotorelav.com
Crydom USA
619-210-1600
www.crvdom.co.uk
843-393-5778
www.masnecraft.co
ffl
800-870-5385
www.meder.com
973-748-5089
www.nteinc.com
858-292-8770
www.srcdevices.com
Alternative 2: Other Electro-
Mechanical Relays
Description
There are several classifications of electro-
mechanical relays including mercury
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displacement, mercury wetted reed, dry reed, and
other electro-mechanical relays. This section
will focus on the other electro-mechanical relays
that include general purpose, definite purpose,
heavy duty, and printed circuit board mounted
relays. Most electromechanical relays are driven
electro-magnetically, by passing a current
through a coil and generating a magnetic flux.
This flux then causes an armature to move
prompting isolated electrical contacts to open or
close.
Cost
The cost for other electro-mechanical relays is
approximately $1 to $35 depending upon product
or application requirements. As the power level
requirement goes up, the price for other electro-
mechanical relays rises and they become less cost
competitive with solid-state relays.
Advantages/Disadvantages
Other electro-mechanical relays are often used as
safety devices because of the complete
mechanical break in the electrical circuit,
whereas solid-state units are subject to leakage
current. Other electro-mechanical relays are
often selected because of their low initial cost.
Electromechanical relays are desirable when
electrical interference is likely to be present or
when low heat dissipation is required.
Other electro-mechanical relays will typically
wear out either mechanically or electrically
within several hundreds of thousands of cycles.
This is a shorter operational life than for either
mercury or solid-state relays. Labor costs and
production down time to change a failure are
significant when selecting this type of relay for
high cycling applications. Other electro-
mechanical relays also have a slow cycle time.
Therefore, the control of equipment is poor for
many sensitive applications. The controlled
equipment may be damaged and heater life can
be shortened due to thermal shock.
Manufacturers
The following are manufacturers of other electro-
mechanical relays:
Manufacturer
Name
Chromalox
Computer
Components,
Inc.
Magnecraft &
Struthers-
Dunn
Meder
Electronic,
Inc.
NTE
Electronics,
Inc.
Omron
Electronics
SRC Devices
Teledyne
Product
CONT
Series
Numerous
models
W199
Series
TC Series
RIO
Series
MJNand
MGN
Series
LM Series
Numerous
models
Phone Number &
Website
800-443-2640
www.chromolox.co
m
800-864-2815
www.relavs-
unlimited.com
843-393-5778
www.magnecraft.co
ffl
800-870-5385
www.meder.com
973-748-5089
www.nteinc.com
847-882-2288
www.omron.com
858-292-8770
www.srcdevices.com
800-284-7007
www.teledvnerelavs.
com
Alternative 3: Solid State Relay
Description
A solid-state relay is a semiconductor, electronic
switching device that operates a load circuit
without the use of physical mechanical contacts.
The solid-state relay contains an input circuit, an
opto-coupler chip, and an output circuit designed
to switch either an alternating current or direct
current voltage. Solid state relays control power
by switching on and off at the zero cross point.
Cost
The cost of a solid-state relay is approximately
$1 to $150 depending on product or application
requirements.
Advantages/Disadvantages
Solid state relays provide the following
advantages: very long operational life, immunity
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to electromagnetic interference, lower power
consumption, high operating speeds, bounce-free
operation, low level control signals, small
package size, and multi function integration. The
printed circuit board mounted solid-state relay
has a tremendous size advantage over the
electromagnetic relay, resulting in critical printed
circuit board space savings. The solid-state relay
is also more immune to physical shock, vibration,
and damage. Solid-state relay operational testing
by one manufacturer resulted in a mean time
between failure (MTBF) of thirty-three years.
Compared to the dry reed relay, the solid-state
relay has no contact bounce, and longer
operational life.
Solid-state relays experience voltage drops
across the device resulting in heat generation.
The more current put through the device, the
greater the quantity of heat that needs to be
dissipated. Overheating protection is usually
provided by heat sinks or cooling fans. Solid-
state relays require proper fusing for short circuit
protection. Solid-state relays also may require
protection from transient voltage spikes. This is
usually provided by metal oxide varistors. Solid-
state relays only turn circuits on or off, resulting
in controlled equipment receiving either full
current or no current. Some solid-state relay
manufacturers use infrared light emitting diodes
(LEDs) made of gallium/aluminum/arsenic to
control the optically coupled input. The solid-
state relay experiences current leakages, and the
contact resistance is typically higher than
mercury wetted relays.
Manufacturers
The following are manufacturers of solid-state
relays:
Manufacturer
Name
ABB SSAC
Carlo Gavazzi
(Switzerland)
U.S. Rep -
Allied
Product
Numerous
models
RNand
RSI A Series
Phone Number &
Website
315-638-1300
www.ssac.com
Allied:
800-433-5700
www.carlogavazzi.
com
Manufacturer
Name
Celduc Relais
(France)
Laube
Technology -
US
Representative
Chromalox
Clare
Computer
Components,
Inc.
Continental
Industries Inc.
Crouzet
Corporation
Crydom
Magnetics
(UK)
International
Rectifier
NTE
Electronics,
Inc.
Solid State
Optronics, Inc.
Teledyne
Tyco
Electronics
Vishay
Watlow
Electronic
Manufacturing
Company
Product
SC Series
7750 Series
CPC, LCA
Series
Numerous
models
SV, RS, and
RV Series
84132 and
84130 Series
H12 Series
PV Series
RSI and
RS3 Series
Numerous
models
C3P24D25
Model
SSRD,
SSRQ, and
SSRT Series
LH Series
SSR Series
Phone Number &
Website
Laube Technology:
805-388-1050
www.celduc-
relais.com
800-443-2640
www . chromolox. c
om
978-524-6700
www.clare.com
800-864-2815
www.relavs-
unlimited.com
703-669-1306
www.ciicontrols.co
ffl
972-471-2555
www.crouzet.com
Crydom USA
619-210-1600
www.crvdom.co.uk
310-322-3331
www.irf.com
973-748-5089
www.nteinc.com
888-377-4776
www. ssousa.com
800-284-7007
www.teledvnerelav
s.com
800-468-2023
www.relav.tvcoele
ctronics.com
402-563-6866
www.vishav.com
507-454-5300
www.watlow.com
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Alternative 4: Silicon Controlled
Rectifiers
Description
The silicon controlled rectifier functions as a
switch that can rapidly turn power on or off in a
variety of applications. The silicon controlled
rectifier is made up of four layers of
semiconductor material. Silicon controlled
rectifiers can deliver electrical power to
controlled equipment in several ways:
• Phase-angle-fired controls - Provides
smooth, variable application of power to
heaters.
• Zero-voltage switching controls -
Proportionally turns on and off each full
cycle of the power line.
• On/off controls - Function similar to
electro-mechanical or mercury relays, but
has much faster cycle times.
Cost
The cost of a silicon controlled rectifier is
approximately $30 to $150 depending on product
or application requirements. The cost of silicon
controlled rectifiers is higher than electro-
mechanical relays at low power, but becomes
more comparable with electromechanical relays
at mid to high power levels.
Advantages/Disadvantages
The silicon controlled rectifier is an extremely
fast switch that can be cycled in milliseconds.
Silicon controlled rectifiers offer the following
advantages: improved response time, closer
process control, extended life of controlled
equipment, reduced maintenance costs, silent
operation, and reduced peak power consumption.
The level of process control that can be achieved
with a silicon controlled rectifiers is unattainable
with any other relay type. Silicon controlled
rectifiers are excellent for addressing high inrush
current, soft start, step up, ramp up, or other
applications where variable power is required and
satisfied by using phase angle functionality.
The silicon controlled rectifier needs to be
physically disconnected before servicing
controlled equipment, and has heat dissipation
requirements. The silicon controlled rectifier
costs more than other relays for low current
applications.
Manufacturers
The following are manufacturers of silicon
controlled rectifiers:
Manufacturer
Name
Avatar
Instruments
Carlo Gavazzi
(Switzerland)
U.S. Rep -
Allied
Chromalox
Tyco
Electronics
Watlow
Electronic
Manufacturing
Company
Product
A1P, ASP,
B, C1P, D,
CZ, and R
Series
RMlAand
RE Series
4001 SCR
Series
SSR Series
DIN-A-
MITE Series
Phone Number &
Website
610-543-5155
www.avatarinstrum
ents.com
Allied:
800-433-5700
www carlo gavazzi
com
800-443-2640
www.chromolox.c
om
800-468-2023
www.relav.tvcoele
ctronics.com
507-454-5300
www.watlow.com
Alternative 5: Hybrid (Electro-
mechanical and Solid-State)
Description
Hybrid relays combine electromechanical and
solid-state technologies, offering the advantages
of both without the disadvantages associated with
either individually. The switching of a hybrid
relay is controlled by a microprocessor. When
switched on, the circuit is closed by the solid-
state element and the load energized, while
absorbing transient peaks. The solid-state
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element is then short-circuited a few milliseconds
later by an electromechanical relay contact,
which maintains the load. The reverse cycle
operates when the control signal disappears and
the circuit is de-energized. The hybrid power
relay is designed to cycle power on and off for a
variety of applications including heating,
ventilation, air conditioning and lighting.
Cost
The cost of a hybrid relay is approximately $40
to $140 depending on product or application
requirements. One manufacturer prices its hybrid
relay slightly less than its mercury displacement
relay with comparable functionality.
Advantages/Disadvantages
By combining solid state and electromechanical
relay technology, the hybrid relay eliminates the
internal heating effect caused by current flow
through electronic power components. This
eliminates the need for integrated heat sinks and
consequently reduces the physical size of the
relay. The hybrid relay provides a long
operation life, often greater than five million
cycles. The hybrid relay has a virtually silent
operation, enabling the relay to be mounted in
noise sensitive areas.
A wide range of hybrid relays is not currently
available to meet all design parameters.
However, the hybrid relay is a good alternative
for retrofitting mercury relays when the hybrid
relay can cover the necessary design parameters.
Manufacturers
The following are manufacturers of hybrid
relays:
Manufacturer
Name
Carlo Gavazzi
(Switzerland)
U.S. Rep -
Allied
Crouzet
Corporation
Watlow
Electronic
Manufacturing
Company
Product
RZ Series
84138
Series
E-Safe
Relay
Phone Number &
Website
Allied:
800-433-5700
www.carlosavazzi.com
972-471-2555
www.crouzet.com
507-454-5300
www.watlow.com
Summary
There are numerous mercury free alternative
technologies currently in use for relay products
and applications. It appears that these mercury
free alternatives are cost competitive and can
meet the functional requirements for most, but
not all new relay products and applications. In
addition, these mercury free alternatives may not
meet the requirements for retrofitting existing
relay products and applications in some
circumstances.
4.17 Flame Sensor
Mercury Flame Sensor
Description
Flame sensors are used as a safety device in gas
appliances. The flames sensor will stop the flow
of gas if there is no heat being produced by an
open flame meaning the pilot light is out, or the
product is malfunctioning. The mercury within
the bulb of the sensor vaporizes and expands
when the pilot light is on causing the gas valve to
open.
Cost
The difference in cost of flame sensors as a
component is difficult to find. One cost
comparison made was between gas ranges that
contain a mercury flame sensor and those that
have an electronic ignition system. The prices
were comparable ranging from $300 up to $1000.
A low-end quality name gas range with an
electronic ignition and a gas range with a
mercury flame sensor were both around $300.
The leading manufacturer of mobile home
products also offers an electronic ignition system
in its ranges and hot water heaters. No cost
difference was noted in any product literature,
and almost every model manufactured was
offered either as electronic ignition flame
detection or a mercury flame sensor.
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Advantages/Disadvantages
The mercury flame sensor provides the safety of
controlling the flow of gas when no flame is lit.
This prevents natural gas from leaking out and
creating a serious situation. A majority of the
manufacturers identified offered an electronic
ignition flame detection unit that does not use
mercury in its sensor.
Manufacturers
The following are manufacturers of mercury
flame sensors:
Manufacturer
Name
Andy Baumen
Associates,
Ltd.
Channel
Products Inc.
Key Gas
Components
White-Rodgers
Fenwal
Derlite
Limited
Harper-
Wyman Co.
Invensys
Appliance
Controls
Johnson
Controls
Major
International
Sit La Precisa
S.p.A.
Product
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Mercury
Flame Sensor
Phone Number
& Website
1-800-387-817
www.andvbaum
enltd.com
440-423-0113
216-881-1300
www.keygas.co
m
314-577-1300
www.white-
rodgers.com
508-881-2000
www.fenwalcont
rols.com
44-1208-72565
www.derlite.com
630-870-3300
www.harper-
wvman.com
804-756-6524
www.invensys.c
om
414-524-1200
www.johnsonco
ntrols.com
847-593-0796
www.majorinter
national.com
+39-049-
8293111
www.sitsroup.it
Alternative 1: Electronic Ignition
System
Description
Using an electronic ignition system in gas
appliances eliminates the need for a standing
pilot light. The electronic ignition sparks when
the gas is turned on to ensure rapid lighting of
gas and to prevent gas discharge before sparking.
Cost
The difference in cost between a range with an
electronic ignition and the cost of a range with a
mercury flame sensor is negligible. A low end
quality name gas range with an electronic
ignition starts at $300 and can run up to $1000.
A majority of the manufacturers identified
offered an electronic ignition flame detection unit
that does not use mercury in its sensor.
The leading manufacturer of mobile home
products also offers an electronic ignition system
in its ranges and hot water heaters. No cost
difference was noted in any product literature,
and almost every model manufactured was
offered either as electronic ignition flame
detection or a mercury flame sensor.
Advantages/Disadvantages
One key concern when using an electronic
ignition gas product is the fact that electricity
must be present in order to light the appliance. In
remote areas where electricity is not offered
safety becomes a concern. The electronic
ignition flame detection products can still be lit
without electricity, but offer no safety to control
the gas flow. The mercury flame sensors do not
require electricity to function, but ensure the
detection of a flame and the control of gas flow.
The electronic ignition system ranges do not
contain any mercury containing devices or
sensors, and are a good alternative.
Manufacturers
The following are manufacturers of electronic
ignition systems:
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Manufacturer
Name
Andy Baumen
Associates,
Ltd.
Ventronics,
Inc.
Trivar Inc.
Steelman
Industries, Inc.
Capable
Controls
Derlite
Limited
Harper-
Wyman Co.
Invensys
Appliance
Controls
Johnson
Controls
Major
International
Sit La Precisa
S.p.A.
Product
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Electronic
Flame Sensor
Phone Number
& Website
1-800-387-817
www.andybaum
enltd.com
908-272-9262
www.ventronicsi
nc.com
905-671-1744
www.trivar.com
903-984-3061
www.steelman.c
om
630-860-6514
44-1208-72565
www.derlite.com
630-870-3300
www.harper-
wvman.com
804-756-6524
www.invensvs.c
om
414-524-1200
www.johnsonco
ntrols.com
847-593-0796
www.majorinter
national.com
+39-049-
8293111
www.sitgroup.it
Summary
The electric ignition system is a cost effective
and functional replacement for the mercury flame
sensor. Electronic ignition systems are currently
in use for many applications. In remote areas
where electricity is intermittent or unavailable,
the electronic ignition system is not a safe
alternative to the mercury flame sensor.
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5.0 Conclusions and
Recommendations
5.1 Conclusions
Researching alternatives to the priority
mercury added products showed that many of
these mercury-containing products can be
replaced with non-mercury products of equal or
greater functionality at comparable costs.
For most priority products examined in this
study, at least one manufacturer of the mercury
free alternative was identified where the cost
differences between mercury and non-mercury
technologies were minimal. The research
findings suggest that many non-mercury
alternatives are available to address the full range
of functions required by consumer products.
Examples of some product specific mercury
replacement programs were discussed in the
findings section of this report. In addition, there
are mercury replacement programs that address
multiple mercury containing products. For
example, the Mercury Pollution Prevention
Initiative involves three Indiana steel mills that
are inventorying mercury containing products,
identifying non-mercury alternatives, and
replacing the mercury products with non-mercury
alternatives. Products included in this effort are
barometers, manometers, hydrometers,
pyrometers, thermometers, thermostats, pressure
switches, tilt switches, float switches, and relays.
The inventory effort identified approximately one
thousand pounds of mercury in equipment and
devices at these three steel mills. The three mills
have committed to a reduction of 330 pounds of
mercury in equipment by the end of 2000, a
reduction of 660 pounds by the end of 2004, and
a reduction of 900 pounds by the end of 2008.
(Delta Institute, 2001)
Legislation to address mercury containing
products has been in existence since the early
1990s. In 1993, Sweden banned or phased-out
the manufacture, import, or sale of thermometers,
barometers, manometers, tilt switches, float
switches, pressure switches, thermostats, relays,
and other types of measuring instruments. Some
exemptions remain for spare parts of existing
products and applications. Other European
countries have banned or restricted the import,
sale, and/or use of various mercury containing
products. (UNEP, 2002)
In the United States, there is legislation at the
state level to address the sale of various mercury
containing products. For example, Rhode Island
and Connecticut have recently adopted into law
mercury product phase-out legislation based on
the NEWMOA Mercury Model Legislation.
Sphygmomanometers
Alternatives to mercury sphygmomanometers are
available from a number of manufacturers. The
basic function and purchase price of the aneroid
(dial) sphygmomanometer appear to be
comparable to that of the mercury
sphygmomanometer. A relatively new class of
electronic blood pressure monitors is also now
available. This type of device, with an entry level
price of approximately $700 (roughly five times
the cost of the least expensive mercury gauge), is
promoted as being more forgiving of operator
technique and providing more comprehensive
information about blood pressure.
Esophageal (Bougie) Tubes
Tungsten gel-filled bougies are readily available
from medical device manufacturers and appear to
be quite acceptable to practitioners.
Gastrointestinal Tubes
The research suggests that gastrointestinal tubes
are not widely used and tubes seem to be
consistently sold empty of mercury. Thus, a
facility electing to use these tubes would supply
its own mercury for weighting. One manufacturer
advised using sterile water for weighting,
although it may result in a longer time for the
medical procedure.
Manometers
Mercury manometers can be replaced by digital
or vacuum gauge manometers. Both alternatives
are available and cost competitive. The digital
manometer is very accurate, and routine
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calibration of the digital manometer will ensure
its accuracy.
Basal thermometers
Mercury free basal thermometers are readily
available and it appears that digital and liquid-in-
glass alternatives would be functional and
acceptable to consumers. The digital basal
thermometers offer features that the mercury
thermometers lack: easy-to-read digital display,
beep upon achieving maximum temperature, and
memory functionality. One supplier offers a
liquid-in-glass thermometer that is similar in
appearance and function to a mercury basal
thermometer. Although mercury-free basal
thermometers are slightly more expensive than
the mercury counterpart (by a few dollars), this is
an infrequent purchase and is in the same price
range as some single-use fertility related products
(e.g. over-the-counter pregnancy test kits).
Thermometers (other non-fever)
Many viable alternatives exist to the mercury
thermometer for multiple applications. The
alternatives to mercury thermometers are widely
available in the United States, have been in use
and are considered to be comparable in accuracy
to mercury thermometers. The overall cost to
switch from mercury to non-mercury is minimal.
Barometers
Aneroid barometers can be manufactured with or
without mercury. Some digital barometers can
perform other tasks, and therefore cost more.
The digital barometer can be very inexpensive if
it is only needed to perform the task of measuring
atmospheric pressure. The aneroid and digital
barometers appear to be cost competitive
alternatives to the mercury barometer.
Hygrometer s/Psychrometers
Both the hygrometer and psychrometer are used
to measure the relative humidity. They both can
be replaced with a spirit-filled thermometer
instead of a mercury thermometer and provide
the same functionality at similar costs.
Hydrometers
The hydrometer has many different applications;
its primary use is in the beer and wine making
industry. The use of a spirit filled hydrometer is
preferable because it is reliable and cost
competitive with the mercury hydrometer.
Flow Meters
During this study, no manufacturers of mercury
flow meters were identified. The reliability of the
digital flow meters and other mercury free flow
meters are of high caliber, and are in use in
numerous application.
Pyrometers
During this study, no manufacturers of mercury
pyrometers were identified. The alternatives to a
mercury pyrometer (used mainly in foundries to
measure the temperature of extremely hot
materials) include the digital pyrometer and the
optical pyrometer. The optical pyrometer is
manufactured for large industrial type foundries.
The digital pyrometer seems to be a much more
economical choice than the optical pyrometer for
smaller foundries.
Thermostats
Rugged industrial thermostats are made to
withstand explosions and extreme environmental
conditions. The manufacturers of digital
thermostats indicated that they are not designed
for rugged industrial use, but can be used in low-
level industrial applications. In some
circumstances the mercury thermostat may be
replaced with a digital thermostat. However, for
extreme environmental conditions, the
manufacturer should be contacted to help
determine the appropriate technology.
Flame Sensors
The mercury containing flame sensor is used in
many applications as a safety device to prevent
the flow of gas when a pilot lamp is not lit. An
alternative to the mercury flame sensor is the
electronic ignition system. The electronic
ignition system can be used in similar
applications as the mercury flame sensor and is
available for most products. The mercury flame
sensor is often used in remote areas where
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electricity is not always available. Without
electricity the electronic ignition system cannot
automatically light the pilot or range. The pilot
or range can however be lit by hand, but this
poses a safety issue.
Switches and Relays
There were many common findings and
conclusions during this research for float
switches, pressure switches, temperature
switches, tilt switches, mercury wetted reed
relays, and mercury displacement relays. The
following is a summary of these similarities:
• These components are used in a wide
range of products and applications.
• Numerous design parameters need to be
considered prior to final component
selection.
• Several different mercury free alternative
technologies were identified to replace
each of the mercury switches and relays.
• Several manufacturers were identified for
most mercury free alternative
technologies.
• Manufacturers of mercury containing
products often provide mercury free
alternatives.
• Manufacturers often provide more than
one mercury free alternative technology.
• The mercury free technologies identified
provide a variety of options for each
major design parameter.
• Mercury free alternatives were identified
to meet the needs from low cost, simple
applications to higher cost, more
demanding applications.
• Although, it is difficult to precisely
compare pricing for the various switch
and relay technologies because there are
many design features and options
available for each component, it appears
that mercury and non-mercury
switches/relays with similar functionality
for many applications are comparable in
price.
• At least one manufacturer was identified
that produced both the mercury and non-
mercury relay/switch with comparable
functionality at comparable costs.
The key differences identified between
mercury switches and relays are as follows:
the
Switches: No design parameters for new
switch products/applications were identified
where the mercury containing component
could not be replaced by a mercury free
alternative for a comparable cost.
Relays: The majority of design parameters
for new relay products/applications could be
met by a mercury free alternative for a
comparable cost. However, in some cases the
design parameters could not be met by a
mercury free alternative. For example, a
mercury wetted reed relay application that
requires long life, no contact bounce, and low
contact resistance cannot be satisfied by any
single mercury free alternative.
Mercury free alternatives appear to be
available in the United States marketplace to
meet the various design parameters that specify
float, tilt, pressure, and temperature switches in
new products and applications. Mercury free
alternatives appear to be available in the United
States marketplace to meet most, but not all,
design parameters specifying the use of mercury
wetted reed and mercury displacement relays in
new products and applications.
Although there are readily available mercury
free alternatives for new products and
applications, complications can appear when
retrofitting existing mercury switches or relays in
existing products and applications. The relay or
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switch component of an existing product or
application can wear out and require replacement
before the end of service life for the product or
application. In some instances, the mercury
switch or relay is embedded in an existing
application in such a way that currently available
mercury free alternatives cannot be retrofitted
into the existing product or application. The
following two scenarios illustrate this situation:
Retrofit Scenario 1: Mercury Tilt Switch
The Michigan based Clean Car Campaign
initiated its "Switch the Switch" program in
2001 to replace mercury tilt switches with
mercury free tilt switches in automobiles
across the nation. This program used the
metallic ball tilt switch to replace mercury
tilt switches found in hood lights and trunk
lights. This was a simple, drop-in exchange
that took about ten minutes to accomplish.
Tilt switches are also used in antilock
braking systems (ABS) for certain trucks
and sport utility vehicles. However, the
ABS system usually consists of two to three
mercury tilt switches that are physically
embedded in a plastic box that is integrated
with the braking mechanism. Because of
this complex design, there is not a simple
drop-in mercury free tilt switch
commercially available for retrofitting the
ABS tilt switch system.
Retrofit Scenario 2: Mercury
Displacement Relay
An industrial application utilizes a control
panel populated with twenty mercury
displacement relays to control on-site
equipment that requires high current. This
equipment also requires fast cycling for
proper control. One of the mercury
displacement relays fails, and there is now a
need to replace this failed mercury relay in
the existing control panel. A review of the
mercury free alternatives reveals that a new
mercury displacement relay may be the
only cost effective option because of the
following:
1) Solid-state relays and silicon controlled
rectifiers have power dissipation issues
that need to be addressed. These relays
cannot be easily retrofitted to existing
control panels because they may not fit
in the available footprint, or there may
not be enough ventilation to cool the
device. In this case, a significant
control panel retrofit expense would be
required to accommodate the solid-state
relay or silicon controlled rectifier.
2) A mercury free electro-mechanical
relay may not be sufficient to meet the
demands of this fast cycle application.
3) A dry reed relay may not be sufficient
to meet the high current demands of this
existing application.
4) The market for hybrid relays appears to
not be mature enough to cover the other
design parameters for this particular
existing application.
As the two examples above illustrate, the
retrofitting of mercury switches and relays in
existing products or applications can present
challenges. The cost of the relay or switch
component is often a small fraction of the total
cost of the product or application. In situations
where a mercury free alternative cannot be used
for retrofit purposes, it would be unreasonable
and cost prohibitive to require the consumer to
replace the entire product or retrofit the
application.
Relays and switches are used in hundreds of
existing products and applications. Each product
or application would need to be examined on a
case-by-case basis to determine if retrofitting
with a non-mercury alternative is cost
competitive. Therefore, it is not possible to
specify situations in which retrofitting of existing
products or applications is cost competitive
without conducting further study of individual
products and/or applications. However, there are
certain common factors that could negatively
affect the cost competitiveness of retrofitting
with non-mercury alternatives. These factors
include:
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• Numerous switches and/or relays are
combined to perform a particular function
• The switch or relay is integrated with
other components of the product or
application
• There are heat dissipation issues
presented by using the mercury free
alternative
• The physical size limitations of the
product/application cannot be met by the
mercury free alternative
• A custom-designed rather than off-the-
shelf switch or relay is used to meet
unique operating requirements
5.2 Recommendations
The product research conducted for this report
suggests that there are cost competitive, viable
non-mercury alternatives for a large majority of
the priority mercury containing products. In most
cases, the purchase price of an alternative is
comparable to the mercury device and if the
downstream costs are considered, mercury free
alternatives can be considerably more cost
effective. Additional information to assist with
the transition to mercury free alternative products
is provided in Appendix 3.
Non-mercury alternatives have been
researched and recommended for the following
products: sphygmomanometers, esophageal
dilators, manometers, barometers, non-fever
thermometers, hygrometers, psychrometers,
hydrometers, flow meters, and pyrometers. The
two products where alternative replacements
cannot be recommended for all applications are
gastrointestinal tubes and industrial thermostats.
More research is needed to understand
gastrointestinal tubes applications and the
viability of mercury replacement.
It appears that digital thermostats cannot
withstand the harsh environmental conditions
demanded by certain industrial settings, and
mercury thermostats are currently the only
industrial type thermostats available that can
perform effectively.
There are cost competitive, viable mercury
free alternatives available and recommended for
the following components of new products and
applications: flame sensors, float switches, tilt
switches, temperature switches, and pressure
switches. The majority of design parameters for
new relay products/applications could be met by
a mercury free alternative for a comparable cost.
However, in some cases the design parameters
could not be met by a mercury free alternative.
Also, the use of electronic ignition systems is not
recommended to replace mercury flame sensors
in remote areas where electricity is unavailable.
Mercury free alternatives were identified and
recommended to meet the needs of retrofitting
existing relay/switch products or applications.
However, there are certain retrofit circumstances
in which the cost implications preclude the use of
the mercury free alternatives.
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6.0 Sources
Barr Engineering Company, "Substance Flow
Analysis of Mercury in Products" Prepared for
the Minnesota Pollution Control Agency, August
15,2001.
California DHS, A Guide to Mercury Assessment
and Elimination in Health Care Facilities.
California Poison Control System, University of
California (2000-2002). "Mercury and its Many
Forms". Available at:
http://www.calpoison.org/public/mercury.html
(August, 2002).
Canzanello, Vincent J., MD; P.L. Jensen, RN;
GL Schwartz, MD, "Are Aneroid
Sphygmomanometers Accurate in Hospital and
Clinic Settings?", Arch Intern Med.
2001;161:729:731.
Clean Car Campaign, Driving Forward - Switch
the Switch, Volume 3, March 2002.
Delta Institute, Inland Ispat Indiana Harbor
Works, Bethlehem Steel Burns Harbor Division,
United States Steel Gary Works, and Lake
Michigan Forum, "A Guide to Mercury
Reduction in Industrial and Commercial
Settings", July, 2001. Available at: http://delta-
institute.org/Steel-Hg-report-0627011 .pdf
(September, 2002).
Gordon, John A., Venture Development
Corporation, An Executive White Paper On: The
World Electromechanical and Solid State Relay
Industry, Fifth Edition, Volume I - North
America.
Gordon, John A., Venture Development
Corporation, An Executive White Paper On:
2001/2002 Global Relay Market Intelligence
Service, April 2002.
Hoerr, Donald, Solid-State Pressure Switches -
Technology for Today's Fluid Power
Applications, IICA Journal.
ICL Calibration Laboratories, www.iclslabs.com.
Inform, Inc., Purchasing for Pollution Prevention
Project (2002). "Mercury-Containing Products
and Alternatives in the Health Care Setting".
Available at:
http://www.informinc.org/fsmerchealth.pdf
(August, 2002).
Kansas Department of Health and Environment,
"Mercury Information Page". Available at:
http://www.kdhe.state.ks.us/mercury/ (August,
2002).
Knoop, Alan R., Fundamentals of Relay Circuit
Design, Reinhold Publishing, New York.
Maine Department of Environmental Protection,
"Mercury in Maine: A Status Report", February
2002.
Minnesota Pollution Control Agency, Managing
Mercury Switches: Hazardous Waste Fact sheet
#4.26 October 1998.
Minnesota Office of Environmental Assistance
Mercury applications in major appliances and
heating/cooling systems, April 1998.
Minnesota Office of Environmental Assistance,
Mercury in Households and Commercial
products and applications, John Gilkeson,
November 1997.
Minnesota Pollution Control Agency, "Mercury".
Available at:
http://hubble.pca.state.mn.us/air/mercury.html
(August, 2002).
National Association of Relay Manufacturers,
Engineers Relay Handbook 2nd and 5th Edition,
Hayden Book Company, New York.
New York Academy of Sciences, "Pollution
Prevention and Management Strategies for
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Mercury in the New York/New Jersey Harbor",
May 14, 2002.
Northeast Waste Management Officials'
Association, "Mercury-Added Product
Notification Form".
Northeast Waste Management Officials'
Association, "Total Mercury in All Mercury-
Added Products".
Northeast Waste Management Officials'
Association, "Reported Mercury Spills in the
Northeast States", October 2001.
Offner, Arnold, How do Relays Work, Motion
Control, July/August 1999.
Pollution Probe, A Study of the use of Mercury
Switches in Bilge Pumps of Pleasure Boats in
Ontario, March 2000.
Powell, William B. and Pheifer, David, "The
Electrolytic Tilt Sensor", Sensors, May 2000.
Pulse Metric, Inc., "Non-Invasive Blood Pressure
Measurement and Pressure Waveform Analysis",
(1996).
Purdue University, Department of Agricultural
and Biological Engineering. "What Devices
Contain Mercury?" Available at:
http://pasture.ecn.purdue.edu/~epados/mercbuild/
src/devicepage.htm (August, 2002).
Sedivy, David, Electronic Controls Spawn
Integration, Appliance Manufacturer.
State of California Department of Health
Services, "A Guide to Mercury Assessment and
Elimination in HealthCare Facilities", September
2000. Available at:
http://www.dhs.cahwnet.gov/ps/ddwem/environ
mental/med waste/guide to mercury assessmen
t_vl.00.pdf (August 2002).
State of Maine Statutes, Title 38, Chapter 16-B,
Mercury-added Products and Services.
Tellus Institute, "Healthy Hospitals:
Environmental Improvements Through Better
Environmental Accounting", July 2000.
Timbrell, J.A., "Introduction to Toxicology",
Second Edition, 1995, Taylor & Francis; pp. 118-
121.
United Nations Environment Programme
(UNEP), (July, 2002). "Global Mercury
Assessment". Available at:
http ://www. chem .unep. ch/mercury/WG-
meetingl-revised-report-download.htm (October,
2002).
United States Environmental Protection Agency,
Mercury Study Report to Congress, December
1997.
United States Environmental Protection Agency
and Environment Canada, "Background
Information on Mercury Sources and
Regulations; Appendix C. Regulations on
Products that Contain Mercury". Available at:
http://www.epa.gOv/grtlakes/bnsdocs/mercsrce/9
409merc.pdf (August 2002).
United States Geological Survey, "Mercury in
the Environment", Fact Sheet 146-00 (October
2000)
United States Geological Survey, 2002 Mineral
Commodity Summary - Mercury.
University of Michigan Pollution Prevention
Program, "Mercury-Filled Esophageal Devices".
Available at:
http://www.p2000.umich.edu/mercury reduction/
mrl.htm (August, 2002).
Von Rein, K. and Hylander L.D., Experiences
from Phasing out the Use of Mercury in Sweden,
Regional Environmental Change, 2000, 1:126-
134.
Williams, Raymond R., Sensors Magazine, April
1997, "An Introduction to Solid State Pressure
Switches".
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Winkler, Robert, and Wells Erik A., "The UVM
Mercury Thermometer Swap. January, 1999.
Available at:
http://esf.uvm.edu/chemsource/thermoswap/
(October, 2002)
Wisconsin Department of Natural Resources,
Draft Wisconsin Mercury Source Book.
Wisconsin Department of Natural Resources,
Success Stories & Partnerships, August, 2002.
Available at:
http://www.dnr. state, wi .us/org/caer/cea/proj ects/
pollution/reports/I999/report2_p6.htm (October
2002)
Yeats, Mike, Derriford Hospital, Plymouth, UK,
"The Maintenance of an Aneroid
Sphygmomanometer", Update in Anesthesia,
Issue 3 (1993) Article 8, World Federation of
Societies of Anaesthesiologists. Available at:
http://www.nda.ox.ac.uk/wfsa/html/u03/u03_018
.htm (August, 2002).
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Appendix 1: Medical Device Reports for Spilled Mercury
The United States Food and Drug Administration (FDA) regulates the use of medical devices in the
United States. In 1990, the Medical Device Reporting (MDR) system was implemented as a
mechanism for the Food and Drug Administration to receive significant medical device adverse events
from manufacturers, importers and user facilities, so they can be detected and corrected quickly. The
following MDRs demonstrated the potential for health or environmental problems with mercury in
healthcare. In addition to remediation associated with the mercury release (both environmental and
health related), each MDR requires investigation and documentation at the reporting facility, the
manufacturer, and the FDA.
Date FDA Received
Report
05/09/2002
10/23/2000
01/05/2000
10/12/1999
07/14/1999
Reference & Description
Baumanometer Stand-by Blood Pressure Machine
"A blood pressure unit blew, causing 2.5 ounces of
mercury to vaporize."
Baumanometer
"Glass tube containing mercury on Baumanometer cracked
causing mercury to spill in facility."
Rusch Maloney Esophageal Bougie
"It is reported that the tip of the bougie broke off during use.
Distal end was not retrieved at the time of the event. Upon
removal of the device, it was noted that mercury was
leaking from the broken end of the tube."
Pilling- Week Maloney Esophageal Dilator 24 Fr.
"During procedure, a bougie dilator for esophagus was
transected inside the stomach, allowing mercury from the
dilator to escape... The bougie that was used for the
procedure had been expired."
Rusch Cantor Tube
"It is alleged that a Cantor tube was inserted and mercury
instilled. A subsequent x-ray indicated the presence of
mercury in the stomach."
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Appendix 2: Cost of Mercury Spills
Cost Estimate for
Clean-up
Reference & Description
Small spill-$1000
Large spill - $tens of
thousands
http://www.melg.org/mcea/rcbmcrmt.htm
"Mercury Contamination Risk Control", Middle Cities Risk Management Trust, Okemos, MI
" A typical thermometer contains l/i to 3 grams (.018 to .11 ounces) of mercury. A typical
household mercury fever thermometer contains approximately 1 gram of mercury. A typical
barometer contains 1 pound (454 grams) of mercury and poses a significant spill risk. The
cost of cleaning up a spill will vary by the size of the spill and the degree of exposure to
property and people. Small spill clean-ups usually cost around $1,000 and large spills can go
into the tens of thousands of dollars."
3 oral fever
thermometers -
$5000
Not uncommon ...
to exceed $25,000
http://cc.ysu.edu/eohs/bulletins/MERCURY.htm
"The Hazards of the Element Called Mercury," Youngstown State University
"Unfortunately, it does not take a large amount of mercury to produce a problem. In one
specific instance, three oral fever thermometers were broken. The mercury fell onto the floor
in an office that was approximately ten square feet in size. Following the accident, the
mercury vapors present in the air of that room were about three times that permitted by
OSHA. Consequently, the room had to be decontaminated, all carpeting had to be discarded
at a total cost of about $5000. This was a very small mercury spill. It is not uncommon for
cleanup costs of mercury spills to exceed $25,000."
Reported costs went
up to $130,000
c) http://www.des.state.nh.us/nhppp/hospital_survey.htm
New Hampshire Mercury Reduction Project: Hospital Baseline Survey 1999 Preliminary
survey results, New Hampshire Department of Environmental Services
"Spills and Breakages - Seven hospitals indicated some kind of mercury spill or equipment
breakage and release during 1998. The actual number of spills may be higher, as small spills
and breakages may not always be reported. Most hospitals did not have any idea of the cost
of clean-up, but reported costs went up to $ 130,000!!"
~$5,000 for 1
broken
sphygmomanometer
One hospital spent
$10,054 to clean up
a spilled
sphygmomanometer
http://dnr.metrokc.gov/swd/bizprog/waste_pre/MIRTsem8.htm
Medical Industry Waste Prevention Round Table Reducing Mercury in Hospitals and
Biomedical Facilities (A MIRT Seminar, May 23, 2001), King County, Seattle, WA
" Economic Considerations
• Clean up costs - It often costs ~$5,000 for 1 broken sphygmomanometer - you could buy 30
or 40 non-mercury ones for that cost. One local hospital recently spent $10,054 dollars to
clean up a spilled sphygmomanometer.
• Regulatory Costs - 30-ppt pretreatment level in some places (fines)
• Hazardous Waste training costs
• Joint Commission on Accreditation of Health Care Organizations (JCAHO) compliance -
JAHCO is starting to ask questions"
$570,000 to clean up
after sink trap work
Environmental
service (alone) for
any spill costs
$1000-1500
http://dnr.metrokc.gov/swd/bizprog/waste_pre/MIRTsem8.htm
"Question: How did you get voluntary switch-out of Hg?
Answer: VA People remember the Hg spills and are willing to work to avoid going through it
again. UW always calls in Foss Env. for any spills. Just for Foss's services costs $1000-
$1500.
Someone at Bowling Green University changed their sink traps, piled them up and carried
them across campus. Mercury was spread everywhere. Cost $570,000 to clean up."
$3 50,000 to clean up
contamination and
restore building to
original condition
http://204.178.120.25/library/college.htm
XL Environmental, Exton, PA
" Spill Spreads Mercury Contamination - A large university in Ohio contracted plumbing
work on one of its science labs. While dismantling laboratory piping, the contractor
discovered an existing mercury spill that resulted in mercury contamination throughout the
building. Costs to clean up the contamination and restore the building to its original condition
were $350,000."
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Appendix 3: Transition to
Mercury Free Products
There are many challenges to substituting
more benign alternatives for mercury containing
products and components. Most alternatives are
not drop-in substitutions. That is, although an
alternative may ultimately achieve the same
outcome, such as providing an accurate measure
of blood pressure or sensing a flame, there are
usually design considerations or different
techniques or practices that must be learned and
communicated. Even under the best of
circumstances progress involves risk and there
may be unexpected outcomes, both favorable and
undesired.
On the bright side, one manufacturer reported
that he continues to learn about the utility of his
company's oscillometric blood pressure monitor
from doctors using the device. The breadth of
blood pressure information offered by the
monitor was unexpectedly revealing of a
patient's condition, far exceeding the diagnostic
utility of the simple systolic and diastolic blood
pressures provided by a mercury
sphygmomanometer. In another example, a
digital manometer used for calibrating
sphygmomanometers can result in more accurate
calibration than the mercury manometer.
Depending on the quality of instruments used, the
difference can be as great as having a
sphygmomanometer with an accuracy of +
3.1mm Hg by using a digital manometer for a
reference, versus + 6 mm Hg by using a mercury
manometer. (Welch Allyn, 2002)
On the negative side, many well designed
products and practices will need to be rethought
and mercury-free components may not even fit in
the footprint of an existing product. There is also
a learning curve associated with new designs and
components and it is likely that there will be
glitches and unintended outcomes as products are
changed over. One example is the replacement of
a mercury column thermometer in an industrial
setting. After a mercury thermometer broke in
use and required clean up, a mercury-free
alternative was sought. An alcohol thermometer
was chosen from a catalog because it was similar
in size, shape and temperature range and
appeared to be a drop-in substitution. The alcohol
thermometer proved to be unsuitable when the
alcohol column quickly separated due to the
bumping and jarring the thermometer received in
the application. When the supplier was consulted,
after the fact, a much more appropriate
alternative was recommended and it performed
capably.
Fortunately there are many resources available
for smoothing the transition away from mercury
components and products. These include
manufacturers' technical support staff, online
how-to guides, email lists that share questions
and answers, and pollution prevention
organizations that can provide guidance. A
sampling of useful resources follows. (Many of
these resources are related to healthcare, an
industry that has been at the forefront of mercury
reduction).
Organizations' Websites
Health Care Without Harm (HCWH)
http://www.noharm.org
The mercury section of the HCWH website
contains a wealth of information about reducing
mercury in healthcare. The Health Care Without
Harm coalition is an international campaign to
reform the environmental practices of the health
care industry. Health Care Without Harm
(HCWH) is comprised of more than 300
organizations in 27 countries and includes major
health care systems, regulatory bodies, and
industry leaders.
Hospitals for a Healthy Environment (H2E)
http://www.h2e-online.org/
The goal of H2E is to educate health care
professionals about pollution prevention
opportunities in hospitals and healthcare systems.
H2E fosters the development and communication
of best practices, model plans for waste
management, resource directories, case studies,
and how-to tools for minimizing the volumes of
waste generated and the use of persistent,
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bioaccumulative, and toxic chemicals. H2E is a
joint project of the American Hospital
Association (AHA), the Environmental
Protection Agency, Health Care Without Harm
and the American Nurses Association. In
addition, various state and local resources are
active participants in the effort to help hospitals.
Two areas of note are the Listserv, an online
forum for discussion, and the H2E website's
Mercury area.
» H2E Listserv
http://www.h2e-online.org/programs/list.htm
The Hospitals for a Healthy Environment (H2E)
Listserv is a communication tool for health care
professionals to share information about
minimizing the volume and toxicity of health
care waste. Healthcare facilities across the
country are designing and implementing many
projects, including starting recycling programs,
eliminating mercury containing devices, and
purchasing environmentally preferable products.
There are countless opportunities to share
questions, answers, and advice through this
Listserv.
* H2E Mercury Resources
http://www.h2e-online.org/tools/mercury.htm
The Mercury area of the H2E website includes
many resources and links for reducing mercury.
One very nice document is the "Mercury Virtual
Elimination Plan", found at: http://www.h2e-
online.org/tools/merc-over.htm
This is a comprehensive how-to guide to help
hospitals assess existing mercury sources,
develop action plans for elimination, and set up
an environmentally preferable purchasing plan to
keep a facility mercury-free.
Northeast Waste Management Officials'
Association (NEWMOA)
http://www.newmoa.org
http://www.newmoa.org/Newmoa/htdocs/prevent
ion/mercury/
The information resources available in the
mercury area of the NEWMOA website are
designed to help the NEWMOA states achieve
their "virtual elimination" goal for mercury by
focusing in particular on efforts to reduce or
eliminate mercury from the waste stream.
Sustainable Hospitals Project
http://www.sustainablehospitals.org
The Sustainable Hospitals Project (SHP)
provides technical support to the healthcare
industry for selecting products and work
practices that eliminate or reduce occupational
and environmental hazards. The SHP website
lists alternative products and manufacturer
contacts and SHP maintains a technical help line
(phone & email) to provide technical support and
help hospitals improve their practices.
Journal Article & Reports
Vincent J. Canzanello, MD; Patricia L. Jensen,
RN; Gary 1 Schwartz, MD, "Are Aneroid
Sphygmomanometers Accurate in Hospital and
Clinic Settings?", Arch Intern Med, 2001;
161:729-731.
This article summarizes an evaluation done at
Mayo Clinic in Rochester, Minnesota to assess
the accuracy of aneroid sphygmomometers used
in their hospitals. Their conclusion was "Aneroid
Sphygmomanometers provide accurate pressure
measurements when a proper maintenance
protocol is followed."
Maine Department of Environmental Protection,
(February, 2002). "Mercury in Maine: A Status
Report". This report provides an update to the
1997 report on Mercury in Maine and it
addresses the Maine mercury reporting
requirements enacted in May 2000. Available at:
http://www.state.me.us/dep/mercury/hginmerepo
rt.htm (September, 2002)
Tellus Institute, (July, 2000). "Healthy Hospitals:
Environmental Improvements Through
Environmental Accounting". This report
examines environmental accounting practices in
the health care industry and explores whether
environmental accounting is a useful approach
for uncovering waste minimization opportunities.
The report also considers opportunities for
influencing upstream procurement practices and
Lowell Center for Sustainable Production
-------
supply chain issues. Available at:
http://www.epa.gov/opptintr/acctg/pubs/hospitalr
eport.pdf (September, 2002)
United Nations Environment Programme
(UNEP), (July, 2002). "Global Mercury
Assessment". This report provides a global
assessment of mercury and mercury compounds,
including options for addressing significant
global adverse impacts of mercury. The
document examines and summarizes worldwide
efforts to control releases and limit use of and
exposure to mercury, including: national
initiatives, international agreements and
instruments, international organizations and
programs, and sub-regional and regional
initiatives. Sections that most relate to Maine
DEP study include:
8. Prevention and control technologies and
practices
9. Initiatives for controlling releases and
limiting use and exposure
Appendix. Overview of Existing and Future
National Actions, Including Legislation,
relevant to mercury; by Region.
Available at:
http: //www. chem. unep. ch/mercury/WG-
meetingl-revised-report-download.htm (October,
2002).
Manufacturer's Resources
Welch Allyn, Inc. (January 11, 2000). "Analysis
of Different Sphygmomanometer Technologies".
This provides a discussion on the different types
of blood pressure devices and their merits and
shortcomings. Available at:
(http://www.welchallyn.com/medical/support/ma
nual s/Ty coswhitepapers .PDF
(August, 2002).
Welch Allyn, Inc. (July 10, 2002) "Calibrating
Your Sphygmomanometer". This describes
considerations for routine calibration of
sphygmomanometers and describes how digital
reference meters can potentially offer a more
accurate calibration than mercury references.
Available at:
http://www.welchallyn.com/medical/support/man
uals/Aneroid%20Calibration%20Memo.pdf
(August, 2002)
Online Case Studies & Mercury Videos
Clean Car Campaign, "Switch the Switch",
Driving Forward: Volume 3, March 2002.
Available at
http://cleancarcampaign.org/pdfs/wol 3%20 Ma
rch 2002.pdf (September 2002).
The Delta Institute, Inland Ispat Indiana Harbor
Works, Bethlehem Steel Burns Harbor Division,
United States Steel Gary Works, and Lake
Michigan Forum, "A Guide to Mercury
Reduction in Industrial and Commercial
Settings", July, 2001. Available at: http://delta-
institute.org/Steel-Hg-report-0627011 .pdf
(September, 2002).
Sustainable Hospitals Project "Mercury
Reduction Case Studies", Available at:
http://www.sustainablehospitals.Org/HTMLSrc/I
P Merc CS Strong.html (September, 2002).
Tellus Institute, (July, 2000). "Healthy Hospitals:
Environmental Improvements Through
Environmental Accounting". Appendix B in this
report includes a mercury reduction case study at
Kaiser Permanente.
United States Environmental Protection Agency,
"Mercury Pollution Prevention in Michigan
Hospitals". Available at:
http ://www. epa. gov/seahome/mercury/src/prevca
se.htm (September, 2002).
University of Michigan, Occupational Safety and
Environmental Health, "Mercury-Filled
Esophageal Dilators". Available at:
http://www.p2000.umich.edu/mercury_reduction/
mrl.htm (September, 2002).
University of Vermont, "Mercury Thermometer
Swap". (Lab thermometers) Available at:
Lowell Center for Sustainable Production
-------
http://esf.uvtn.edu/chetnsource/thertnoswap/
(September, 2002).
Western Lake Superior Sanitary District, (March,
1997) "Addressing Sources of Mercury: Success
Stories". Available at:
http://www.wlssd.duluth.mn.us/Blueprint%20for
%20mercury/HG12.HTM (September, 2002).
The Michigan Department of Environmental
Quality , Bowling Green University, Ohio
Environmental Protection Agency and Radar
Environmental have produced two video clips
which allow viewers to see mercury vapor rising
from elemental mercury. Two short online videos
show mercury vapor at room temperature rising
from a petri dish of mercury and from mercury
spilled from a broken fever thermometer onto a
carpet. Available at:
http://www.ecosuperior.com/pages/mercuryvapo
ur.html (September, 2002).
Lowell Center for Sustainable Production
-------
Appendix 4: Maine DEP Letter to Manufacturers of Mercury-added
Products
The information request below was sent to manufacturers who filed information on mercury-added
products with the Interstate Mercury Education and Reduction Clearinghouse (IMERC). As explained
in section 2.0 of this report, IMERC was formed under the auspices of the Northeast Waste
Management Officials' Association to, among other things, coordinate implementation of state laws
that prohibit sale of mercury-added products unless the manufacturer has disclosed the amount and
purpose of the mercury. Maine, New Hampshire, Connecticut and Rhode Island have such laws.
May 1, 2002
Dear [manufacturer}:
Enclosed please find a copy of An Act to Phase Out the Availability of Mercury-added
Products as recently enacted by the Maine Legislature.
The law contains two sections. Section 1 prohibits the sale or distribution of a mercury-added
thermostat in Maine for most residential and commercial applications after January 1, 2006. It also
provides an exemption process from the prohibition where specified demonstrations can be made.
Section 2 of the bill requires the Department to review information on mercury-added products
and, based on that review, prepare a comprehensive strategy to reduce their mercury content. The
strategy is due to the Legislature by next January, and presumably will be considered by the
Legislature as it contemplates additional legislation regarding mercury-added products.
One of our main sources of information that will be utilized in this effort is the data you and
other manufacturers already provided under the mercury product notification law enacted last year. As
you will recall, that law-38 MRS A §1661-A-prohibits the sale of mercury-added products in Maine
after January 1, 2002 unless the manufacturer has notified the Department as to the amount and
purpose of the mercury.
Preparation of the strategy the Legislature seeks will also require additional information, such
as the availability of non-mercury alternatives, and on manufacturers' plans (if any) to phase out the
use of mercury. This is why I write to you now - to provide you with the opportunity to provide
specific information on your product(s) that can be considered by the Department in the development
of its strategy. The additional information you provide will be considered in conjunction with research
performed by a consultant the Department intends to retain shortly.
At this time, we are focusing our inquiry on mercury-added products (other than lamps and
dental amalgam) that contain more than 100 milligrams of mercury or, for formulated products like
cosmetics and cleansers; that have a mercury concentration exceeding 50 ppm. If you make such a
product or products, we invite you to submit the following information:
• Your plan, if any, for reducing or phasing out the use of mercury, including relevant
Lowell Center for Sustainable Production >"•/
-------
timetables for such reductions or elimination,
• Information bearing on the availability, feasibility and affordability of non-mercury
alternatives to the product;
• The public health, environmental or other societal benefits (if any) of continuing to use
mercury in the product; and
• Any other information you believe relevant to the development of the Department's
strategy.
The timetable for completing this strategy is driven by the Legislature's January 1, 2003
deadline. To meet this deadline, we need to receive your information by June 30, 2002 so that it can
be adequately considered by the Department and its consultant before preparation of a draft document.
The draft document should be available in early fall, and I will provide one at your request.
Thank you for your help, and please feel free to call me at (207) 287-8556 or email me at
Enid.Mitnik@state.me.us if you have questions.
Sincerely,
Enid Mitnik
Lowell Center for Sustainable Production
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Logistics, Contracting, Warehouse
Date:
Activity or Service
Operation of
Electrical/Gas Powered
Equipment
Report Processing
Wooden Pallet Usage
Chemical Storage
Silver Recovery
Aspect
Energy /Fuel
Consumption, Air
Emissions
Paper Usage, Potential
Usage of Non-
Recycled Paper
Resource Consumption
Potential for Spills
Disposal of Silver
Solution
Impact
Use of Natural
Resources, Air
Pollution
Use of Natural
Resources
Use of Natural
Resources
Environmental
Contamination
Chemical
Contamination
Compliance
1
1
1
1
2
Risk
1
1
1
3
1
Frequency
Of Activity
4
4
2
4
2
VAMC
Control
2
2
2
2
2
TOTAL
SCORE
8
8
6
10
7
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Master Index
Topic Guidebook Series
Accident Investigation [[[ Program Administration
Accreditation Process [[[ Environment of Care
Air Pollution Control Compliance [[[ Environmental Compliance
Air Sampling
Asbestos [[[ Industrial Hygiene
Chemicals [[[ Industrial Hygiene
Documentation [[[ Industrial Hygiene
Ethylene Oxide (EtO) [[[ Industrial Hygiene
Formaldehyde [[[ Industrial Hygiene
Lead [[[ Industrial Hygiene
Waste Anesthetic Gases (WAG) [[[ Industrial Hygiene
Alcohol Based Hand Cleaners [[[ Environment of Care
Anesthetic Gases
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic _ Guidebook Series
Asbestos
Abatement Compliance Requirements ........................................... Environmental Compliance
Assessment, Facility [[[ Industrial Hygiene
Assessment Updates, Annual [[[ Industrial Hygiene
Medical Surveillance [[[ Occupational Health
Program [[[ Industrial Hygiene
Program Training [[[ Industrial Hygiene
Project Specifications [[[ Industrial Hygiene
Schools, in [[[ Environmental Compliance
Annual Workplace Evaluation (AWE) Deficiencies ............................ Program Administration
Back Injury Prevention Program [[[ Program Administration
Bio Safety
Committee [[[ Occupational Health
Infection Control [[[ Occupational Health
Levels Guidelines [[[ Occupational Health
Program [[[ Occupational Health
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic Guidebook Series
-c-
Care Settings Environment of Care
Chemical Hygiene Plan Industrial Hygiene
Chemicals
Laboratories, in Occupational Health
Hazardous Environmental Compliance
Miscellaneous and Targeted (Chemicals) Industrial Hygiene
Clean Air Compliance Environmental Compliance
Clean Water Compliance Environmental Compliance
Comprehensive Environmental Response, Compensation
and Liability Act (CERCLA) Compliance Environmental Compliance
Compressed
Air General Safety
Gas Systems (Fixed) General Safety
Gases General Safety
Computer Workstations Ergonomics
Confined Space
Program Industrial Hygiene
Standard Operating Procedures (SOPs) Industrial Hygiene
Training Industrial Hygiene
Construction Fire Safety
Construction Safety Program Administration
Corridor Doors Fire Safety
Corridor Walls and Partitions Fire Safety
Cultural and Historic Resource Management Act Compliance Environmental Compliance
Cumulative Trauma Disorders (CTD) Occupational Health
M-3
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic Guidebook Series
Defibrillators, Quality Management of ................................................ General Safety
Dental Ergonomics [[[ Ergonomics
Deluge Systems [[[ Fire Safety
Discharges/Spills of Hazardous Waste ................................................. Environmental Compliance
Distribution System Valves and Fire Hydrants .................................... Fire Safety
Documentation
Air Sampling [[[ Industrial Hygiene
Compliance Audits [[[ Environmental Compliance
Employee Knowledge, of. [[[ Industrial Hygiene
Ethylene Oxide (EtO) [[[ Industrial Hygiene
Formaldehyde [[[ Industrial Hygiene
Waste Anesthetic Gases (WAG) [[[ Industrial Hygiene
Domiciliaries [[[ Fire Safety
Drinking Water Standards and Compliance ......................................... Environmental Compliance
Ecological Risk Assessment (ERA) [[[ Environmental Compliance
Electrical Safety
Program [[[ General Safety
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic Guidebook Series
Environment of Care Newsletter Indexes Environment of Care
Environmental
Audit Guide Environmental Compliance
Compliance Resources Environmental Compliance
Compliance Strategy Environmental Compliance
Concepts GEMS
Hygiene Technical Resources Program Administration
Operating Unit Aspect Templates GEMS
Policy GEMS
Technical Resources GEMS
Environmental Radiation Environmental Compliance
Ergonomics
Ergonomics Program Ergonomics
Ergonomics Training Ergonomics
Exposure Controls Ergonomics
Safe Patient Handling & Movement Ergonomics
Ethylene Oxide (EtO)
Medical Surveillance Occupational Health
Program Industrial Hygiene
Program Training Industrial Hygiene
Excavations General Safety
Experimental Use Permits (EUP) Environmental Compliance
Exposure Control
Antineoplastics Industrial Hygiene
Antineoplastics, Additional Controls/Disposals Industrial Hygiene
Asbestos Containing Material (ACM) Industrial Hygiene
Containment/Decontamination Occupational Health
Contaminated Equipment/Laundry Occupational Health
M-5
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic _ Guidebook Series
Exposure Control (Cont'd)
Ethylene Oxide [[[ Industrial Hygiene
Formaldehyde [[[ Industrial Hygiene
Hearing [[[ Industrial Hygiene
Laser [[[ Industrial Hygiene
Lead [[[ Industrial Hygiene
Minimization Techniques [[[ Occupational Health
Plan [[[ Occupational Health
Waste Anesthetic Gases (WAG) [[[ Industrial Hygiene
Exposure Control Strategies
Hazardous Waste [[[ Environmental Compliance
Heat Stress [[[ Industrial Hygiene
Non-Hazardous Waste [[[ Environmental Compliance
Personal Protective Equipment [[[ Occupational Health
Program [[[ Occupational Health
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic Guidebook Series
Federal Facility Standards and Compliance Environmental Compliance
Federal Fire Safety Act of 1992 Fire Safety
Federal Insecticide, Fungicide and Rodenticide Act (FIFRA)
Compliance Environmental Compliance
Fire Alarm, Manual Fire Safety
Fire and Smoke Control Fire Safety
Fire Department
Community Fire Safety
Connections Fire Safety
HazWoper Industrial Hygiene
HazWoper Training Industrial Hygiene
Respirator Program Industrial Hygiene
Staffing Fire Safety
VA Fire Safety
VA, IH Issues Industrial Hygiene
Fire Extinguishers, Portable Fire Safety
Fire Fighting Services Fire Safety
Fire Hazards, Severe Fire Safety
Fire Investigation Program Administration
Fire Protection Systems (Excluding Water) Fire Safety
Fire Pumps Fire Safety
Fire Safety - Life Safety Code Compliance Fire Safety
Fire/Explosion Hazards Fire Safety
Flammable/Combustible
Liquids Environmental Compliance
Materials Environmental Compliance
Storage Buildings/Warehouses Environmental Compliance
M-7
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic _ Guidebook Series
Formaldehyde
Medical Surveillance [[[ Occupational Health
Program [[[ Industrial Hygiene
Program Training (Formaldehyde) ................................................. Industrial Hygiene
-c-
Gasoline Dispensing [[[ Environmental Compliance
General
Fire Safety [[[ Fire Safety
Requirements [[[ General Safety
Storage [[[ General Safety
Generator Requirements [[[ Environmental Compliance
Green Environmental Management Systems (GEMS) ......................... GEMS
Ground Water Protection [[[ Environmental Compliance
Hand Tools [[[ Ergonomics
Hazard Awareness [[[ Program Administration
Hazard Communication (HazCom)
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic Guidebook Series
Hazardous Materials (HazMat) (Cont'd)
Asbestos Industrial Hygiene
Blood Borne Diseases Occupational Health
Ethylene Oxide Industrial Hygiene
Formaldehyde Industrial Hygiene
Lead Industrial Hygiene
Miscellaneous Chemicals Industrial Hygiene
Hazardous Materials Storage Areas Inspected Industrial Hygiene
Hazardous Substances, Specific Industrial Hygiene
Hazardous Waste Management Environmental Compliance
HazWoper
Evacuation Plan Industrial Hygiene
Medical Surveillance Occupational Health
Program Industrial Hygiene
Program Training Industrial Hygiene
Hearing Conservation
Audiometric Testing Occupational Health
Program Industrial Hygiene
Program Training Industrial Hygiene
Heat Stress
Control Industrial Hygiene
Program Industrial Hygiene
Program Training Industrial Hygiene
Healthcare Failure Mode and Effect Analysis (HFMEA) Environment of Care
High Value Equipment Fire Safety
Historical Properties Environmental Compliance
Hot Work Program Fire Safety
M-9
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic Guidebook Series
Incident Management [[[ Program Administration
Incinerators/Incineration [[[ Environmental Compliance
Industrial Hygiene
Program Audits [[[ Program Administration
Sampling Equipment [[[ Program Administration
Sampling Records [[[ Program Administration
Infection Control Program [[[ Occupational Health
Insecticide/Pesticide Standards and Compliance .................................. Environmental Compliance
Inspections and Evaluations - Other Facilities ...................................... Program Administration
Interior Finishes
Corridors and Exits [[[ Fire Safety
Rooms (Interior Finishes) [[[ Fire Safety
Investigation (Accident) [[[ Program Administration
JCAHO Standards [[[ Environment of Care
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic _ Guidebook Series
Laboratory (Cont'd)
Standard Training [[[ Industrial Hygiene
Ladders [[[ General Safety
Laser
Medical Surveillance [[[ Occupational Health
Safety Program [[[ Industrial Hygiene
Safety Program Training [[[ Industrial Hygiene
Lead
Medical Surveillance [[[ Occupational Health
Occupational Therapy, in [[[ Industrial Hygiene
Radiation Therapy, in [[[ Industrial Hygiene
Training [[[ Industrial Hygiene
Water, in [[[ Environmental Compliance
Lead-Based Paint Standards and Compliance ...................................... Environmental Compliance
Leak Detection [[[ Environmental Compliance
Leak Test
Ethylene Oxide (EtO) [[[ Industrial Hygiene
Waste Anesthetic Gases (WAG) [[[ Industrial Hygiene
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic _ Guidebook Series
Materials Handling [[[ Ergonomics
Medical Records [[[ Occupational Health
Medical Surveillance [[[ Occupational Health
Medical Waste Standards and Compliance ........................................... Environmental Compliance
Monitor and Exposure Control Strategies ............................................. Industrial Hygiene
Motor Vehicle Safety [[[ General Safety
Motorized Equipment, Other [[[ General Safety
Municipal Wastes [[[ Environmental Compliance
- jr-
National Emission Standards for
Hazardous Air Pollutants (NESHAP) ............................................. Environmental Compliance
National Environmental Policy Act (NEPA) ........................................ Environmental Compliance
National Pollutant Discharge Elimination System (NPDES) ............... Environmental Compliance
Nine Steps to a Successful GEMS Program ......................................... GEMS
Non-Hazardous Waste Management Standards and Compliance ........ Environmental Compliance
-o-
Occupational Health [[[ Program Administration
Occupational Health Unit Training [[[ Program Administration
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic Guidebook Series
Performance Standards Program Administration
Personal Protective Equipment (PPE)
Assessment/Training/Use General Safety
Program General Safety
Pesticide/Insecticide Standards and Compliance Environmental Compliance
Pesticide/Herbicide
Inventory Industrial Hygiene
Labeling/Distribution Environmental Compliance
Program Industrial Hygiene
Program Training Industrial Hygiene
Storage Industrial Hygiene
Pipe Systems
Dry Fire Safety
Wet Fire Safety
Placarding Guidelines Environmental Compliance
Pollution Prevention (P2) Plan Standards and Compliance Environmental Compliance
Poly chlorinated Biphenyls (PCB) Compliance Requirements Environmental Compliance
Labeling/Transportation Environmental Compliance
Spills/Storage/Disposal Environmental Compliance
Power Tools, Fixed General Safety
Powered Industrial Trucks General Safety
Program Management Program Administration
Project
Acceptance Program Administration
Design Reviews Program Administration
Management Program Administration
Specifications, Asbestos Industrial Hygiene
Promotional and Motivational Program Program Administration
M- 13
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic _ Guidebook Series
Protocols for Conducting Environmental Compliance Audits ............. Environmental Compliance
Radiation, Medical Surveillance [[[ Occupational Health
Radioactive Materials [[[ Environmental Compliance
Radioactive Waste Management [[[ Environmental Compliance
Resource Conservation and Recovery Act (RCRA) Standards
and Compliance [[[ Environmental Compliance
Record Keeping and Reporting [[[ Program Administration
Recycling [[[ Environmental Compliance
Research Labs
Training, Handling HBV/HIV [[[ Occupational Health
Transmission Containment in [[[ Occupational Health
Transmission Reduction/Spill Procedures in .................................. Occupational Health
Research Projects [[[ Occupational Health
Respirators
Cleaning and Storage [[[ Industrial Hygiene
Fit Testing [[[ Industrial Hygiene
Fit Testing Records [[[ Industrial Hygiene
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic Guidebook Series
Safe Drinking Water Standards and Compliance ................................. Environmental Compliance
Safe Patient Handling [[[ Ergonomics
Safety Committee [[[ Program Administration
Sampling Equipment [[[ Industrial Hygiene
Scaffolds
Scaffolds [[[ General Safety
Suspended and Elevating Platforms ................................................ General Safety
SCBA
Certification [[[ Industrial Hygiene
Inservice Inspections [[[ Industrial Hygiene
Sewage Sludge [[[ Environmental Compliance
Slips, Trips and Falls [[[ Program Administration
Smoke
Control [[[ Fire Safety
Detection and Alarm [[[ Fire Safety
Source Identification and Monitoring [[[ Industrial Hygiene
Spill Prevention, Control and Countermeasures (SPCC) ..................... Environmental Compliance
Sprinkler Systems
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
Topic _ Guidebook Series
Storage Tank Management Standards and Compliance ....................... Environment Compliance
Storage Tanks (Gravity Tanks), Elevated ............................................. Fire Safety
Superfund Amendments and Reauthorization Act (SARA) ................. Environmental Compliance
Surgical Fires, Prevention of. [[[ Environment of Care
-7-
TB
Control [[[ Occupational Health
Medical Surveillance [[[ Occupational Health
Training [[[ Occupational Health
Technical Library [[[ Program Administration
Toxic Substances Control Act (TSCA) Standards and Compliance ..... Environmental Compliance
Training
Aids [[[ Program Administration
Aids - Industrial Hygiene Issues [[[ Program Administration
OS&H, Management [[[ Program Administration
OS&H, Specialized [[[ Program Administration
OS&H, Supervisors [[[ Program Administration
-------
Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Topic Guidebook Series
Vertical Openings [[[ Fire Safety
-w-
Walking/Working Surfaces [[[ General Safety
Water Standards and Compliance [[[ Environmental Compliance
Water Distribution Systems [[[ Fire Safety
Water Supply [[[ Fire Safety
-------
Green Environmental Management Systems (GEMS) Guidebook Master Index
M- 18
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Medical Media
Date:
Activity or Service
Operation of Equipment
Disposal of Videotapes
Report Generation
Printing
Maintenance of
Equipment
Photo Processing
Chemical Usage
Chemical Storage
Adhesive Spray Booth
Aspect
Energy Consumption
Generation of Waste
Use of Paper
Disposal of Printer
Cartridges
Generation of Waste
Batteries
Generation of Waste
Batteries
Employee Exposure,
Waste Disposal
Potential for Spills
Air Emissions
Impact
Use of Natural
Resources
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination
Compliance
1
2
0
0
1
1
1
1
0
Risk
1
1
0
0
1
3
1
1
3
Frequency
Of Activity
4
3
4
3
2
3
4
4
2
VAMC
Control
2
3
3
2
2
4
4
4
3
TOTAL
SCORE
8
9
7
5
6
11
10
10
8
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Microbiology Laboratory
Date:
Activity or Service
Operation of Lab
Equipment
Chemical Usage
Chemical Storage
Report Generation
Use of Fume Hoods
Use of Autoclave
Slide Preparation
Aspect
Energy Consumption
Hazardous Waste
Disposal, Wastewater
Discharge
Potential for Spills
Use of Paper
Energy Consumption,
Air Emission
Energy Consumption,
Release of Microbes
Into the Environment
Generation of
Hazardous Waste,
Transportation of
Hazardous Waste,
Disposal to Sewage
System
Impact
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Use of Natural
Resources,
Environmental
Contamination
Use of Natural
Resources, Disease,
Employee Health
Environmental
Contamination,
Water Usage
Compliance
1
0
0
0
1
0
0
Risk
1
3
2
0
3
3
4
Frequency
Of Activity
3
4
3
2
4
4
3
VAMC
Control
3
3
3
3
3
4
3
TOTAL
SCORE
8
10
8
5
11
11
10
-------
Handling of Micro-
Organ! sms
Neutralization of Lab
Chemicals
Use of Bunsen Burner
Release of Microbes
Into the Environment
Potential for Explosive
Reactions, Employee
Exposure
Energy Consumption
Disease, Patient
Safety, Employee
Health
Environmental
Contamination
Use of Natural
Resource
1
2
0
3
3
1
2
3
1
4
4
4
10
12
6
-------
FACILITY AUDIT AGREEMENT
between the
ENVIRONMENTAL PROTECTION AGENCY
and
[Insert Name of Hospital!
INTRODUCTION
In recognition that environmental auditing plays a critical role in protecting human
health and the environment by identifying, correcting, and ultimately preventing
violations of environmental regulations, [Hospital] and the United States
Environmental Protection Agency, Region 2 (the
Region ) hereby agree that
[Hospital] shall conduct a self-audit program (the Audit Program ) for
A
compliance with the regulations promulgated or authorized by the United States
Environmental Protection Agency (I EPA ) set forth in Section II below. The
Agreement shall be governed by the terms of EPA Ms Policy entitled Incentives
A
for Self-Policing: Discovery, Disclosure, Correction and Prevention of
Violations, 65 Federal Register 19618 (4/11/00, the Policy ), exceptto the
A
extent that those terms are explicitly modified below.
SCOPE OF THE AUDIT
A. [Hospital] shall conduct an audit (the Audit ) of its compliance with the
A
regulations cited below in subsections 1 - 6 of Section II.B. The Audit will
encompass all (enter number) campuses of [Hospital], including any
associated off-site facilities such as (if applicable).
Appendix A attached hereto lists the campuses and other units associated
Page 1 of 13
-------
with each covered campus (I Covered Campuses ) that are covered by
A
this agreement.
B. Under the Audit Program, [Hospital] will audit compliance with the following
federal regulatory programs:
1. Air Programs
Part 511
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
The New Jersey Implementation Plan Regulations (promulgated
pursuant to Section 110 of the Clean Air Act), including the New
Source Review regulations 40 CFR Part 52 Subpart HH (52.1670
et seq.), New Jersey Administrative Code ("NJAC") 7:27
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 (N.J.A.C. 7:27-22)
Protection of Stratospheric Ozone
Oil Pollution Prevention
EPA Administered Permit Programs: The National Pollutant
Discharge Elimination System (N.J.A.C. 7:14A)
National Primary Drinking Water Regulations (N.J.A.C. 7:10)
National Primary Drinking Water Regulations Implementation
(N.J.A.C. 7:10)
National Secondary Drinking Water Regulations (N.J.A.C. 7:10)
Underground Injection Control ("UIC") Program (N.J.A.C. 8)
State UIC Program Requirements (N.J.A.C. 7:14A-8)
UIC Program: Criteria and Standards (N.J.A.C. 7:14A-8)
State UIC Programs (N.J.A.C. 7:14A-8)
Hazardous Waste Injection Restrictions (N.J.A.C. 7:14A-8)
General Pretreatment Regulations for Existing and New Sources of
Pollution (N.J.A.C. 7)
1 The term "Part" refers to the subdivisions of the subchapters of Title 40 Code of Federal Regulations
("C.F.R.").
Page 2 of 13
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3. Pesticide Programs
Part 160 Good Laboratory Practice Standards
Part 162 State Registration of Pesticide Products
Part 170 Worker Protection Standard
Part 171 Certification of Pesticide Applicators
Part 172 Experimental Use Permits
4. Solid and Hazardous Wastes
Part 260 Hazardous Waste Management System:General (N.J.A.C.7:26 G-4)2
Part 261 Identification and Listing of Hazardous Waste (N.J.A.C. 7:26G-5)
Part 262 Standards Applicable to Generators of Hazardous Waste (N.J.A.C.
7:26G-6)
Part 263 Standards Applicable to Transporters of Hazardous Waste
(N.J.A.C. 7:26G-7)
Part 264 Standards for Owners and Operators of Hazardous Waste
Treatment, Storage, and Disposal Facilities (N.J.A.C. 7:26G-8)
Part 265 Interim Status Standards for Owners and Operators of Hazardous
Waste Treatment, Storage, and Disposal Facilities (N.J.A.C.
7:26G-9)
Part 266 Standards for the Management of Specific Hazardous Wastes and
Specific Types of Hazardous Waste Management Facilities
(N.J.A.C. 7:26G-10))
Part 268 Land Disposal Restrictions (N.J.A.C. 7:26G-11)
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
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
2 New Jersey has been authorized by the Region for many of the federal regulations comprising Parts 260 - 268.
Once authorized, a state regulation becomes the applicable regulation. [Resource Conservation and Recovery Act
("RCRA"), as amended, §3006(b), 42 U.S.C. §6926(b)]. For purposes of this Agreement [Hospital] will audit for
compliance with authorized New Jersey State counterparts of the federal regulations, where applicable.
Page 3 of 13
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Part 745 Lead-Based Paint Poisoning Prevention in Certain Residential
Structures
Part 761 Poly chlorinated Biphenyls (PCBs) Manufacturing, Processing,
Distribution in Commerce, and Use Prohibitions
Part 763 Asbestos
C. The types of facilities and documents to be audited on the Covered
Campuses are set forth in Appendix B. The benefits of this Agreement shall
extend to only those facilities within the Covered Campuses that are audited.
III. DISCLOSURE
[Hospital] shall disclose all EPA-enforceable regulatory violations discovered during the
Audit and eligible under the Audit Policy. [Hospital] will voluntarily disclose these
violations to the Region, in accordance with the Policy, in written disclosure reports to be
submitted in accordance with the schedule set forth below in Section IV. Each such
disclosure report shall contain, with reference to each violation disclosed, the following
additional information: the actions selected by [Hospital] to correct the violation within
60 days, or as otherwise approved pursuant to Section V below; the status of the
corrective action; and the means taken by [Hospital] to prevent recurrence of the
violation. All disclosure reports will be submitted by the scheduled date, and the Region
agrees to waive the 21-day disclosure requirement provided for in the Policy.
Once the action designed to correct a particular violation has been completed, and a
report submitted to the Region notifying it of the completion of the corrective action, no
further reporting on that violation, or the status of corrective action, is required. On
[Date of Termination of Agreement - usually sixty days after the scheduled
submittal of the last disclosure report], this Agreement shall terminate for all
purposes, except that [Hospital] shall remain obligated to complete the action necessary
to correct any disclosed violation, and to report to the Region in writing (1) the
completion of any corrective action, previously unreported, within thirty days after such
corrective action has been completed, and (2) the costs of coming into compliance for
each violation disclosed under this Audit Agreement, and the amount of pollutants no
longer released to the environment as a result of the corrective actions.
This Audit Agreement does not cover any pre-Agreement activities, including regulatory
compliance issues discovered by [Hospital] or its environmental consultant(s) prior to
the effective date of this Agreement.
IV. SCHEDULE
Page 4 of 13
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A. Within 10 days of the effective date of this agreement, [Hospital] will identify
suitable personnel or consultants (where appropriate) to perform each of the six
regulatory program audits identified in Section II above and shall further identify
the applicable criteria pursuant to which each such regulatory program audit shall
be conducted. [Hospital] shall submit to EPA the audit protocols and audit
checklists for each of the six regulatory program audits, tailored to the Hospital,
and shall provide copies of these audit instruments to the Region. [Hospital] is
willing to share any materials it develops with other institutions and the U.S.
Environmental Protection Agency.
B. Within 30 days of the signing of the agreement, the Audit shall commence.
C. [Hospital] shall complete the regulatory audits required by the Sections listed in
this agreement, and shall submit disclosure reports to the Region, in accordance
with the Policy and the Agreement, identifying all EPA-enforceable violations
discovered during the course of these audits according to the schedule set forth in
Appendix C.
•4
V. CORRECTIVE ACTION
[Hospital] shall correct each violation identified during the Audit, and shall take steps
necessary to prevent the recurrence of each such violation. [Hospital] shall correct any
violations identified during the Audit as soon as possible, but within 60 days of
discovery. In those instances in which [Hospital] is unable to correct an identified
violation within the 60-day deadline, it shall request an extension of time from the
Region in writing and provide a correction schedule, accompanied by a justification of
the requested extension. Any extension of the 60-day correction period shall be subject to
the RegionlMIs approval. Such approval will not be unreasonably withheld.
T
If [Hospital] discovers or otherwise becomes aware of a concern or concerns that may
present an imminent and substantial endangerment to human health or the environment,
and such concern(s) may exist at other [Hospital] campuses covered by this Agreement,
notwithstanding any other language herein to the contrary, [Hospital] agrees to address
such concern(s) at all covered campuses as expeditiously as possible and promptly take
such action as may be necessary at all covered campuses to protect human health and the
environment. [Hospital] shall notify EPA (initial notice may be by phone) of such
concern(s) within 24 hours of discovery or becoming aware of such concern(s) and shall
notify EPA in writing within five business days of such discovery of [Hospital] 11 s
proposed remedial action.
Formatted: Left, Tabs: Not at 540
pt + 576 pt + 612 pt + 648 pt +
684 pt + 720 pt + 756 pt + 792 pt
+ 828 pt + 864 pt + 900 pt + 936
Pt
Deleted: '
Page 5 of 13
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VI. CIVIL PENALTIES FOR DISCLOSED VIOLATIONS
Except as provided in Section II.D.8 of the Policy, the Region will not impose gravity-
based penalties for violations voluntarily discovered if they are timely disclosed and
corrected, and provided that the applicable provisions of the Policy and this Agreement
are met. The Region will consider the least expensive means for coming into compliance
in calculating potential economic benefit penalties for any disclosed violations, provided
that such methods comply with regulatory requirements. Where any disclosed violations
entail economic benefits, and the potential economic benefit for such corrective actions
are calculated to be less than $10,000 for the sum total of all violations at a facility, the
penalties will be considered de minimus and will be waived by the Region.
VII. MISCELLANEOUS PROVISIONS
A. Notification and Certification of Disclosure Reports: [Hospital] designates as its
Formatted: Left, Tabs: Not at 540
pt + 576 pt + 612 pt + 648 pt +
684 pt + 720 pt + 756 pt + 792 pt
+ 828 pt + 864 pt + 900 pt + 936
Pt
responsible official, responsible for submitting disclosure reports to the
Region, the following individual:
Name of Responsible Official
Title
Name of Hospital
Address
City, State, Zip Code
Phone Number
Fax Number
Email Address
The responsible official shall certify that each disclosure report submitted to the
Region is true, accurate and complete in the form set forth in 40 C.F.R.
270.11(d).
[Hospital] designates as its contact person, to be the recipient of all
communications from the Region concerning this Agreement, the following
individual:
Name of Contact Person
Title
Name of Hospital
Page 6 of 13
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Address
City, State, Zip Code
Phone Number
Fax Number
Email Address
The Region designates the following individual as its contact person:
Charles Zafonte
Multimedia Enforcement Coordinator
DECA-CAPSB
U.S. Environmental Protection Agency, Region 2
290 Broadway (21ST Floor)
New York, New York 10007-1866
Phone:(212)637-3515
Fax: (212) 637-4086
zafonte.charles(@,epa.gov
The parties may redesignate their contact person and responsible official in
writing.
B. Compliance With Law and Regulation: Neither the existence of this Agreement,
nor compliance with this Agreement relieves [Hospital] of its obligation of
continued compliance with the regulations covered by this Agreement, and all
other federal, state and local laws and regulations.
C. Reservation of Right: The Region reserves its right to proceed against
[Hospital] for all violations outside the scope of the Audit, and violations within
the scope of the Audit that were not timely reported or timely corrected. In any
enforcement proceeding, the Region may enforce the provision of 40 C.F.R.
allegedly violated, or its authorized or approved state counterpart, if said
counterpart is federally enforceable as a matter of law.
D. Authority of Signatories: The signatories hereto represent that they have the
authority to bind the parties.
E. Modification: This Agreement may be modified by a writing signed by both
parties.
F. Coordination With the State Environmental Agency: The Region has informed
the New Jersey Department of Environmental Protection (NJDEP) of this
Agreement and shall provide a copy to the NJDEP. Nothing herein restricts the
NJDEP from acting as it deems appropriate.
Page 7 of 13
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G. Effective Date: This Agreement is effective on the date that it is signed by both
parties, or the last party if not signed on the same date.
WE, THE UNDERSIGNED, HEREBY AGREE TO BE BOUND BY THIS AGREEMENT:
For [Hospital]:
Name of Responsible Official
Title
Address
City, State, Zip Code
Date:
For EPA-Region 2:
Alan J. Steinberg, Regional Administrator
USEPA - Region 2
290 Broadway
New York, New York 10007
Date:
Page 8 of 13
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Appendix A
Covered Campuses and Off-Site Facilities Associated with Those Campuses
[List of Campuses and off-site facilities covered under the Audit Agreement goes here.]
Page 9 of 13
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Appendix B
SCOPE OF AUDIT PROGRAM
The following list provides the activities, areas, and/or shops that the review of the campus(es)
must cover. This list not meant to be all-inclusive. [Please select and include areas that exist at
your campus.]
Documents to Review (for the three years prior to the Program Period)
Verify EPA identification numbers and permits
Hazardous waste manifests
Training records
Land disposal restriction notifications
Exception reports
Lead disclosure statements in leases, or associated with leases of residential
housing let by the university in its capacity as a lessor, as defined in 40 C.F.R.
745.103
Contingency plans and annual reports (for contingency plans, only the current
plan will be reviewed)
Required certifications
Facilities Operation and Maintenance
Air conditioning/refrigeration service
Appliance and equipment repair, including medical equipment
Building cleaning and maintenance
Building renovation and construction
Cafeteria
Chemical storage areas
Drinking water treatment systems
Fabrication shops
Furniture repair
Heating and power plants (e.g., boilers, emergency generators)
House or architectural structure painting
Landscaping operations
Laundry
PCB transformers and switches
Pesticide storage facilities
Resource recovery/incinerator facilities
Waste disposal areas (landfills)
Wastewater treatment facilities
-------
Waste treatment facilities such as autoclaves
Fleet Maintenance
Automotive, truck, and ambulance servicing areas
Gasoline service stations
Garages
Hazardous Waste / Tanks / Wells
Aboveground and current operating underground storage tanks and their
containment areas/systems, and documentation concerning closures of regulated
tanks previously removed from service.
Dry wells, septic systems, cesspools, floor drains, sink drains, and disposal wells.
Facilities treating, storing or disposing of hazardous wastes.
Hazardous waste satellite accumulation areas.
Hazardous waste storage areas.
Tanks that have been permanently or temporarily closed.
Transformers and oil-containing electrical equipment (PCB and non-PCB).
Universal waste storage areas.
Laboratories
All clinical, pathology and dental laboratories
All teaching and research laboratories with regular chemical use.
Patient Care
Anesthesiology
Chemotherapy
Dentist Ms offices
Doctor
s offices
Floor Pharmacies
Histology
Intensive Care Units
Neonatal Areas
Nursing Stations
Operating Rooms
Pathology, microbiology
Patient
s Rooms
Patient treatment areas
-------
X-Ray/Radiology
Main Pharmacy
Storage areas
Outdated Pharmaceuticals
Sterile Supply and Materials Management
Autoclaving Units
Ethylene Oxide (EtO) Units
Glutaraldehyde
Use and disposal of disinfectants
Use and Disposal of Known Chemicals/Products of Concern
Computers/monitors, circuit boards, and other lead-bearing electronics
Ethanol and formaldehyde/ethanol solutions
Fluorescent light bulbs and other types of lamps, including high-intensity
discharge, neon, mercury vapor, high pressure sodium, and metal halide lamps
Formaldehyde/Formalin
Mercury and Mercury-containing devices and products
PVC-containing devices
Xylene
Batteries
Solvents
Photographic chemicals and scrap film
Other Services
Athletic and training facilities
Photo processing/publishing
Morgue/Crematorium
Animal care areas
-------
Appendix C
SCHEDULE OF AUDITS
[Insert a schedule of when audits will be done at each campus/location. Provide details as
necessary such as deadlines for submitting the disclosure report, the regulatory areas being
audited, and the names of campuses, buildings, or other location-specific info.]
Example:
Location
Campus A. e.g.:
Pharmacy
Physical Plant
Print Shop
Programs to be Audited
e.g., RCRA, CWA
Date Disclosure Report will be Submitted
-------
FACILITY AUDIT AGREEMENT
between the
ENVIRONMENTAL PROTECTION AGENCY
and
[Insert Name of Hospital]
INTRODUCTION
In recognition that environmental auditing plays a critical role in protecting human
health and the environment by identifying, correcting, and ultimately preventing
violations of environmental regulations, ["Hospital! and the United States
Environmental Protection Agency, Region 2 (the Region ) hereby agree that
A
["Hospital] shall conduct a self-audit program (the Audit Program ) for
compliance with the regulations promulgated or authorized by the United States
Environmental Protection Agency ( EPA ) set forth in Section II below. The
A
Agreement shall be governed by the terms of EPA
s Policy entitled
Incentives
for Self-Policing: Discovery, Disclosure, Correction and Prevention of
Violations, 65 Federal Register 19618 (4/11700, the
extent that those terms are explicitly modified below.
SCOPE OF THE AUDIT
Policy ), except to the
A. ["Hospital! shall conduct an audit (the Audit ) of its compliance with the
regulations cited below in subsections 1 - 6 of Section II.B. The Audit will
encompass all (enter number) campuses of ["Hospital! including any
associated off-site facilities such as (if applicable).
Appendix A attached hereto lists the campuses and other units associated
Page 1 of 13
-------
with each covered campus ( Covered Campuses ) that are covered by
A
this agreement.
B. Under the Audit Program, ["Hospital! will audit compliance with the
following federal regulatory programs:
1. Air Programs
Part 521 Section 21 Prevention of Significant Deterioration of Air Quality
Part 60 Standards of Performance for New Stationary Sources
Part 61 National Emission Standards for Hazardous Air Pollutants,
Subpart M, National Emission Standard for Asbestos
Part 62 Subpart HHH - Federal Plan Requirements for
Hospital/Medical/Infectious Waste Incinerators
Part 63 National Emission Standards for Hazardous Air Pollutants for
Source Categories (all applicable provisions)
Part 68 Chemical Accident Prevention Provisions
Part 70 State Operating Permit Programs
Part 82 Protection of Stratospheric Ozone
All applicable provisions of; and the New York State Implementation Plan
Regulations (promulgated pursuant to Section 110 of the Clean Air Act)
including the New Source Review regulations (Title 6NYCRR, Chapter III,
Part 200, et seq)
2. Water Programs
Part 112 Oil Pollution Prevention
Part 122 EPA Administered Permit Programs: The National Pollutant
Discharge Elimination System
Part 141 National Primary Drinking Water Regulations
Part 142 National Primary Drinking Water Regulations Implementation
1
The term
Part refers to the subdivisions of the subchapters of Title 40 Code of
Federal Regulations (I
Ic.F.R.
Page 2 of 13
-------
Part 143 National Secondary Drinking Water Regulations
Part 144 Underground Injection Control (
UIC ) Program
Part 145 State UIC Program Requirements
Part 146 UIC Program: Criteria and Standards
Part 147 State UIC Programs
Part 148 Hazardous Waste Injection Restrictions
Part 403 General Pretreatment Regulations for Existing and New
Sources of Pollution
3. Pesticide Programs
Part 160 Good Laboratory Practice Standards
Part 162 State Registration of Pesticide Products
Part 170 Worker Protection Standard
Part 171 Certification of Pesticide Applicators
Part 172 Experimental Use Permits
4. Solid and Hazardous Wastes
Part 260 Hazardous Waste Management System: General (Part 370, 6
New York Code of Rules and Regulations (
6 NYCRR )
Part 261 Identification and Listing of Hazardous Waste (Part 371, 6
NYCRR)
Part 262 Standards Applicable to Generators of Hazardous Waste (Part
372,6 NYCRR)
Part 263 Standards Applicable to Transporters of Hazardous Waste (Part
372,6 NYCRR)
Part 264 Standards for Owners and Operators of Hazardous Waste
Treatment, Storage, and Disposal Facilities (Subpart 373-2, 6
NYCRR)
Part 265 Interim Status Standards for Owners and Operators of
Hazardous Waste Treatment, Storage, and Disposal Facilities
(Subpart 373-3, 6 NYCRR)
Part 266 Standards for the Management of Specific Hazardous Wastes
and Specific Types of Hazardous Waste Management Facilities
(Subpart 374-1, 6 NYCRR)
Part 268 Land Disposal Restrictions (Part 376, 6 NYCRR)
Part 273 Standards for Universal Waste Management (Subpart 374-3, 6
NYCRR)
Part 279 Standards for the Management of Used Oil
Page 3 of 13
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Part 280 Technical Standards and Corrective Action Requirements for
Owners and Operators of Underground Storage Tanks
( USTs )
A
New York State has been authorized by the Region for many of the
federal regulations comprising Parts 260-266, 268 and 273 (New York is
not authorized for Parts 279 and 280). Once authorized, a state regulation
becomes the applicable regulation. [Resource Conservation and Recovery
Act(
A
RCRA ), as amended, 3006(b), 42 U.S.C. 6926(b)]. For
purposes of this Agreement, the institution will audit for compliance with
authorized New York State counterparts of the federal regulations, where
applicable, found at 6 NYCRR Parts 370 -373, 376 and Subpart 374-3.
5. Hazardous Substances and Chemicals, Environmental Response,
Emergency Planning, and Community Right-to-Know Programs
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
Part 745 Lead-Based Paint Poisoning Prevention in Certain Residential
Structures
Part 761 Polychlorinated Biphenyls (PCBs) Manufacturing, Processing,
Distribution in Commerce, and Use Prohibitions
Part 763 Asbestos
C. The types of facilities and documents to be audited on the Covered
Campuses are set forth in Appendix B. The benefits of this Agreement shall
extend to only those facilities within the Covered Campuses that are audited.
III. DISCLOSURE
[Hospital] shall disclose all EPA-enforceable regulatory violations discovered during the
Audit and eligible under the Audit Policy. [Hospital] will voluntarily disclose these
violations to the Region, in accordance with the Policy, in written disclosure reports to be
Page 4 of 13
-------
submitted in accordance with the schedule set forth below in Section IV. Each such
disclosure report shall contain, with reference to each violation disclosed, the following
additional information: the actions selected by [Hospital] to correct the violation within
60 days, or as otherwise approved pursuant to Section V below; the status of the
corrective action; and the means taken by [Hospital] to prevent recurrence of the
violation. All disclosure reports will be submitted by the scheduled date, and the Region
agrees to waive the 21-day disclosure requirement provided for in the Policy.
Once the action designed to correct a particular violation has been completed, and a
report submitted to the Region notifying it of the completion of the corrective action, no
further reporting on that violation, or the status of corrective action, is required. On
[Date of Termination of Agreement - usually sixty days after the scheduled
submittal of the last disclosure report], this Agreement shall terminate for all
purposes, except that [Hospital] shall remain obligated to complete the action necessary
to correct any disclosed violation, and to report to the Region in writing (1) the
completion of any corrective action, previously unreported, within thirty days after such
corrective action has been completed, and (2) the costs of coming into compliance for
each violation disclosed under this Audit Agreement, and the amount of pollutants no
longer released to the environment as a result of the corrective actions.
This Audit Agreement does not cover any pre-Agreement activities, including regulatory
compliance issues discovered by [Hospital] or its environmental consultant(s) prior to
the effective date of this Agreement.
IV. SCHEDULE
A. Within 10 days of the effective date of this agreement, [Hospital] will identify
suitable personnel or consultants (where appropriate) to perform each of the six
regulatory program audits identified in Section II above and shall further identify
the applicable criteria pursuant to which each such regulatory program audit shall
be conducted. [Hospital] shall submit to EPA the audit protocols and audit
checklists for each of the six regulatory program audits, tailored to the Hospital,
and shall provide copies of these audit instruments to the Region. [Hospital] is
willing to share any materials it develops with other institutions and the U.S.
Environmental Protection Agency.
B. Within 30 days of the signing of the agreement, the Audit shall commence.
C. [Hospital] shall complete the regulatory audits required by the Sections listed in
this agreement, and shall submit disclosure reports to the Region, in accordance
with the Policy and the Agreement, identifying all EPA-enforceable violations
discovered during the course of these audits according to the schedule set forth in
Appendix C.
Page 5 of 13
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V. CORRECTIVE ACTION
[Hospital] shall correct each violation identified during the Audit, and shall take steps
necessary to prevent the recurrence of each such violation. [Hospital] shall correct any
violations identified during the Audit as soon as possible, but within 60 days of
discovery. In those instances in which [Hospital] is unable to correct an identified
violation within the 60-day deadline, it shall request an extension of time from the
Region in writing and provide a correction schedule, accompanied by a justification of
the requested extension. Any extension of the 60-day correction period shall be subject to
the Region
s approval. Such approval will not be unreasonably withheld.
If [Hospital] discovers or otherwise becomes aware of a concern or concerns that may
present an imminent and substantial endangerment to human health or the environment,
and such concern(s) may exist at other [Hospital] campuses covered by this Agreement,
notwithstanding any other language herein to the contrary, [Hospital] agrees to address
such concern(s) at all covered campuses as expeditiously as possible and promptly take
such action as may be necessary at all covered campuses to protect human health and the
environment. [Hospital] shall notify EPA (initial notice may be by phone) of such
concern(s) within 24 hours of discovery or becoming aware of such concern(s) and shall
notify EPA in writing within five business days of such discovery of [Hospital]
proposed remedial action.
VI. CIVIL PENALTIES FOR DISCLOSED VIOLATIONS
Except as provided in Section II.D.8 of the Policy, the Region will not impose gravity-
based penalties for violations voluntarily discovered if they are timely disclosed and
corrected, and provided that the applicable provisions of the Policy and this Agreement
are met. The Region will consider the least expensive means for coming into compliance
in calculating potential economic benefit penalties for any disclosed violations, provided
that such methods comply with regulatory requirements. Where any disclosed violations
entail economic benefits, and the potential economic benefit for such corrective actions
are calculated to be less than $10,000 for the sum total of all violations at a facility, the
penalties will be considered de minimus and will be waived by the Region.
VII. MISCELLANEOUS PROVISIONS
Page 6 of 13
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A. Notification and Certification of Disclosure Reports: [Hospital] designates as its
responsible official, responsible for submitting disclosure reports to the
M
Region, the following individual:
Name of Responsible Official
Title
Name of Hospital
Address
City, State, Zip Code
Phone Number
Fax Number
Email Address
The responsible official shall certify that each disclosure report submitted to the
Region is true, accurate and complete in the form set forth in 40 C.F.R.
270.11(d).
[Hospital] designates as its contact person, to be the recipient of all
A
communications from the Region concerning this Agreement, the following
individual:
Name of Contact Person
Title
Name of Hospital
Address
City, State, Zip Code
Phone Number
Fax Number
Email Address
The Region designates the following individual as its contact person:
Charles Zafonte
Multimedia Enforcement Coordinator
DECA-CAPSB
U.S. Environmental Protection Agency, Region 2
290 Broadway (21ST Floor)
New York, New York 10007-1866
Page 7 of 13
-------
Phone: (212)637-3515
Fax: (212)637-4086
zafonte.charles@epa.gov
The parties may redesignate their contact person and responsible official in
writing.
B. Compliance With Law and Regulation: Neither the existence of this Agreement,
nor compliance with this Agreement relieves [Hospital] of its obligation of
continued compliance with the regulations covered by this Agreement, and all
other federal, state and local laws and regulations.
C. Reservation of Right: The Region reserves its right to proceed against
[Hospital] for all violations outside the scope of the Audit, and violations within
the scope of the Audit that were not timely reported or timely corrected. In any
enforcement proceeding, the Region may enforce the provision of 40 C.F.R.
allegedly violated, or its authorized or approved state counterpart, if said
counterpart is federally enforceable as a matter of law.
D. Authority of Signatories: The signatories hereto represent that they have the
authority to bind the parties.
E. Modification: This Agreement may be modified by a writing signed by both
parties.
F. Coordination With the State Environmental Agency: The Region has informed
the New York State Department of Environmental Conservation (NYSDEC) of
this Agreement and shall provide a copy to the NYSDEC. Nothing herein
restricts the NYSDEC from acting as it deems appropriate.
G. Effective Date: This Agreement is effective on the date that it is signed by both
parties, or the last party if not signed on the same date.
WE, THE UNDERSIGNED, HEREBY AGREE TO BE BOUND BY THIS AGREEMENT:
For [Hospital]:
Name of Responsible Official
Title
Address
City, State, Zip Code
Page 8 of 13
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Date:
For EPA-Region 2:
Alan J. Steinberg, Regional Administrator
USEPA - Region 2
290 Broadway
New York, New York 10007
Date:
Page 9 of 13
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Appendix A
Covered Campuses and Off-Site Facilities Associated with Those Campuses
[List of Campuses and off-site facilities covered under the Audit Agreement goes here.]
Page 10 of 13
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Appendix B
SCOPE OF AUDIT PROGRAM
The following list provides the activities, areas, and/or shops that the review of the campus(es)
must cover. This list not meant to be all-inclusive. [Please select and include areas that exist at
your campus.]
Documents to Review (for the three years prior to the Program Period)
Verify EPA identification numbers and permits
Hazardous waste manifests
Training records
Land disposal restriction notifications
Exception reports
Lead disclosure statements in leases, or associated with leases of residential
housing let by the university in its capacity as a lessor, as defined in 40 C.F.R.
745.103
Contingency plans and annual reports (for contingency plans, only the current
plan will be reviewed)
Required certifications
Facilities Operation and Maintenance
Air conditioning/refrigeration service
Appliance and equipment repair, including medical equipment
Building cleaning and maintenance
Building renovation and construction
Cafeteria
Chemical storage areas
Drinking water treatment systems
Fabrication shops
Furniture repair
Heating and power plants (e.g., boilers, emergency generators)
House or architectural structure painting
Landscaping operations
Laundry
PCB transformers and switches
Pesticide storage facilities
Resource recovery/incinerator facilities
Waste disposal areas (landfills)
Wastewater treatment facilities
-------
Waste treatment facilities such as autoclaves
Fleet Maintenance
Automotive, truck, and ambulance servicing areas
Gasoline service stations
Garages
Hazardous Waste / Tanks / Wells
Aboveground and current operating underground storage tanks and their
containment areas/systems, and documentation concerning closures of regulated
tanks previously removed from service.
Dry wells, septic systems, cesspools, floor drains, sink drains, and disposal wells.
Facilities treating, storing or disposing of hazardous wastes.
Hazardous waste satellite accumulation areas.
Hazardous waste storage areas.
Tanks that have been permanently or temporarily closed.
Transformers and oil-containing electrical equipment (PCB and non-PCB).
Universal waste storage areas.
Laboratories
All clinical, pathology and dental laboratories
All teaching and research laboratories with regular chemical use.
Patient
Care
Anesthesiology
Chemotherapy
II
Dentist
1
s offic*
Doctor
s offices
Floor Pharmacies
Histology
Intensive Care Units
Neonatal Areas
Nursing Stations
Operating Rooms
Pathology, microbiology
Patient
s Rooms
Patient treatment areas
-------
X-Ray/Radiology
Main Pharmacy
Storage areas
Outdated Pharmaceuticals
Sterile Supply and Materials Management
Autoclaving Units
Ethylene Oxide (EtO) Units
Glutaraldehyde
Use and disposal of disinfectants
Use and Disposal of Known Chemicals/Products of Concern
Computers/monitors, circuit boards, and other lead-bearing electronics
Ethanol and formaldehyde/ethanol solutions
Fluorescent light bulbs and other types of lamps, including high-intensity
discharge, neon, mercury vapor, high pressure sodium, and metal halide lamps
Formaldehyde/Formalin
Mercury and Mercury-containing devices and products
PVC-containing devices
Xylene
Batteries
Solvents
Photographic chemicals and scrap film
Other Services
Athletic and training facilities
Photo processing/publishing
Morgue/Crematorium
Animal care areas
-------
Appendix C
SCHEDULE OF AUDITS
[Insert a schedule of when audits will be done at each campus/location. Provide details as
necessary such as deadlines for submitting the disclosure report, the regulatory areas being
audited, and the names of campuses, buildings, or other location-specific info.]
Example:
Location
Campus A, e.s.:
Pharmacy
Physical Plant
Print Shop
Programs to be Audited
e.g., RCRA, CWA
Date Disclosure Report will be Submitted
-------
FACILITY AUDIT AGREEMENT
between the
ENVIRONMENTAL PROTECTION AGENCY
and
[Insert Name of Hospital!
INTRODUCTION
In recognition that environmental auditing plays a critical role in protecting human
health and the environment by identifying, correcting, and ultimately preventing
violations of environmental regulations, [Hospital] and the United States
Environmental Protection Agency, Region 2 (the
Region ) hereby agree that
[Hospital] shall conduct a self-audit program (the Audit Program ) for
A
compliance with the regulations promulgated or authorized by the United States
Environmental Protection Agency (I EPA ) set forth in Section II below. The
Agreement shall be governed by the terms of EPA Ms Policy entitled Incentives
A
for Self-Policing: Discovery, Disclosure, Correction and Prevention of
Violations, 65 Federal Register 19618 (4/11/00, the Policy ), exceptto the
A
extent that those terms are explicitly modified below.
SCOPE OF THE AUDIT
A. [Hospital] shall conduct an audit (the Audit ) of its compliance with the
A
regulations cited below in subsections 1 - 6 of Section II.B. The Audit will
encompass all (enter number) campuses of [Hospital], including any
associated off-site facilities such as (if applicable).
Appendix A attached hereto lists the campuses and other units associated
Page 1 of 13
-------
with each covered campus
this agreement.
Covered Campuses ) that are covered by
B. Under the Audit Program, [Hospital] will audit compliance with the
following federal regulatory programs:
1. Air Programs
Part 521 Section 21 Prevention of Significant Deterioration of Air Quality
Part 60 Standards of Performance for New Stationary Sources
Part 61 National Emission Standards for Hazardous Air Pollutants,
Subpart M, National Emission Standard for Asbestos
Part 62 Subpart HHH - Federal Plan Requirements for
Hospital/Medical/lnfectious Waste Incinerators
Part 63 National Emission Standards for Hazardous Air Pollutants for
Source Categories (all applicable provisions)
Part 68 Chemical Accident Prevention Provisions
Part 70 State Operating Permit Programs
Part 82 Protection of Stratospheric Ozone
All applicable provisions of, and the Commonwealth of Puerto Rico
Implementation Plan regulations (pursuant to Section 110 of the Clean Air
Act), including the New Source Review regulations. Part 52, Subpart
BBB.
2. Water Programs
Part 112 Oil Pollution Prevention
Part 122 EPA Administered Permit Programs: The National Pollutant
Discharge Elimination System 40CFR Part 122.
Part 141 National Primary Drinking Water Regulations
Part 142 National Primary Drinking Water Regulations Implementation
The term I iPart
A
refers to the subdivisions of the subchapters of Title 40 Code of
Federal Regulations (II IC.F.R.
Page 2 of 13
-------
Part 143 National Secondary Drinking Water Regulations
Part 144 Underground Injection Control
A
DIG ) Program
Part 145 State DIG Program Requirements
Part 146 DIG Program: Criteria and Standards
Part 147 State DIG Programs
Part 148 Hazardous Waste Injection Restrictions
Part 403 General Pretreatment Regulations for Existing and New
Sources of Pollution test
3. Pesticide Programs
Part 160 Good Laboratory Practice Standards
Part 162 State Registration of Pesticide Products
Part 170 Worker Protection Standard
Part 171 Certification of Pesticide Applicators
Part 172 Experimental Use Permits
4. Solid and Hazardous Wastes
Part 260 Hazardous Waste Management System: General
Part 261 Identification and Listing of Hazardous Waste
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
40CFR282.102.
5. Hazardous Substances and Chemicals, Environmental Response,
Emergency Planning, and Community Right-to-Know Programs
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
Page 3 of 13
-------
6. Toxic Substances
Part 745 Lead-Based Paint Poisoning Prevention in Certain Residential
Structures
Part 761 Polychlorinated Biphenyls (PCBs) Manufacturing, Processing,
Distribution in Commerce, and Use Prohibitions
Part 763 Asbestos
C. The types of facilities and documents to be audited on the Covered
Campuses are set forth in Appendix B. The benefits of this Agreement shall
extend to only those facilities within the Covered Campuses that are audited.
III. DISCLOSURE
[Hospital] shall disclose all EPA-enforceable regulatory violations discovered during the
Audit and eligible under the Audit Policy. [Hospital] will voluntarily disclose these
violations to the Region, in accordance with the Policy, in written disclosure reports to be
submitted in accordance with the schedule set forth below in Section IV. Each such
disclosure report shall contain, with reference to each violation disclosed, the following
additional information: the actions selected by [Hospital] to correct the violation within
60 days, or as otherwise approved pursuant to Section V below; the status of the
corrective action; and the means taken by [Hospital] to prevent recurrence of the
violation. All disclosure reports will be submitted by the scheduled date, and the Region
agrees to waive the 21-day disclosure requirement provided for in the Policy.
Once the action designed to correct a particular violation has been completed, and a
report submitted to the Region notifying it of the completion of the corrective action, no
further reporting on that violation, or the status of corrective action, is required. On
[Date of Termination of Agreement - usually sixty days after the scheduled
submittal of the last disclosure report], this Agreement shall terminate for all
purposes, except that [Hospital] shall remain obligated to complete the action necessary
to correct any disclosed violation, and to report to the Region in writing (1) the
completion of any corrective action, previously unreported, within thirty days after such
corrective action has been completed, and (2) the costs of coming into compliance for
each violation disclosed under this Audit Agreement, and the amount of pollutants no
longer released to the environment as a result of the corrective actions.
This Audit Agreement does not cover any pre-Agreement activities, including regulatory
compliance issues discovered by [Hospital] or its environmental consultant(s) prior to
the effective date of this Agreement.
Page 4 of 13
-------
IV. SCHEDULE
A. Within 10 days of the effective date of this agreement, [Hospital] will identify
suitable personnel or consultants (where appropriate) to perform each of the six
regulatory program audits identified in Section II above and shall further identify
the applicable criteria pursuant to which each such regulatory program audit shall
be conducted. [Hospital] shall submit to EPA the audit protocols and audit
checklists for each of the six regulatory program audits, tailored to the Hospital,
and shall provide copies of these audit instruments to the Region. [Hospital] is
willing to share any materials it develops with other institutions and the U.S.
Environmental Protection Agency.
B. Within 30 days of the signing of the agreement, the Audit shall commence.
C. [Hospital] shall complete the regulatory audits required by the Sections listed in
this agreement, and shall submit disclosure reports to the Region, in accordance
with the Policy and the Agreement, identifying all EPA-enforceable violations
discovered during the course of these audits according to the schedule set forth in
Appendix C.
4
V. CORRECTIVE ACTION
[Hospital] shall correct each violation identified during the Audit, and shall take steps
necessary to prevent the recurrence of each such violation. [Hospital] shall correct any
violations identified during the Audit as soon as possible, but within 60 days of
discovery. In those instances in which [Hospital] is unable to correct an identified
violation within the 60-day deadline, it shall request an extension of time from the
Region in writing and provide a correction schedule, accompanied by a justification of
the requested extension. Any extension of the 60-day correction period shall be subject to
the RegionlMIs approval. Such approval will not be unreasonably withheld.
T
If [Hospital] discovers or otherwise becomes aware of a concern or concerns that may
present an imminent and substantial endangerment to human health or the environment,
and such concern(s) may exist at other [Hospital] campuses covered by this Agreement,
notwithstanding any other language herein to the contrary, [Hospital] agrees to address
such concern(s) at all covered campuses as expeditiously as possible and promptly take
such action as may be necessary at all covered campuses to protect human health and the
environment. [Hospital] shall notify EPA (initial notice may be by phone) of such
concern(s) within 24 hours of discovery or becoming aware of such concern(s) and shall
Formatted: Left, Tabs: Not at 540
pt + 576 pt + 612 pt + 648 pt +
684 pt + 720 pt + 756 pt + 792 pt
+ 828 pt + 864 pt + 900 pt + 936
Pt
Deleted: '
Page 5 of 13
-------
notify EPA in writing within five business days of such discovery of [Hospital]
proposed remedial action.
VI. CIVIL PENALTIES FOR DISCLOSED VIOLATIONS
Except as provided in Section II.D.8 of the Policy, the Region will not impose gravity-
based penalties for violations voluntarily discovered if they are timely disclosed and
corrected, and provided that the applicable provisions of the Policy and this Agreement
are met. The Region will consider the least expensive means for coming into compliance
in calculating potential economic benefit penalties for any disclosed violations, provided
that such methods comply with regulatory requirements. Where any disclosed violations
entail economic benefits, and the potential economic benefit for such corrective actions
are calculated to be less than $10,000 for the sum total of all violations at a facility, the
penalties will be considered de minimus and will be waived by the Region.
VII. MISCELLANEOUS PROVISIONS
A. Notification and Certification of Disclosure Reports: [Hospital] designates as its
responsible official, responsible for submitting disclosure reports to the
M
Region, the following individual:
Name of Responsible Official
Title
Name of Hospital
Address
City, State, Zip Code
Phone Number
Fax Number
Email Address
The responsible official shall certify that each disclosure report submitted to the
Region is true, accurate and complete in the form set forth in 40 C.F.R.
270.11(d).
Page 6 of 13
-------
[Hospital] designates as its contact person, to be the recipient of all
communications from the Region concerning this Agreement, the following
individual:
Name of Contact Person
Title
Name of Hospital
Address
City, State, Zip Code
Phone Number
Fax Number
Email Address
The Region designates the following individual as its contact person:
Charles Zafonte
Multimedia Enforcement Coordinator
DECA-CAPSB
U.S. Environmental Protection Agency, Region 2
290 Broadway (21ST Floor)
New York, New York 10007-1866
Phone:(212)637-3515
Fax: (212) 637-4086
zafonte.charles(@,epa.gov
The parties may redesignate their contact person and responsible official in
writing.
B. Compliance With Law and Regulation: Neither the existence of this Agreement,
nor compliance with this Agreement relieves [Hospital] of its obligation of
continued compliance with the regulations covered by this Agreement, and all
other federal, state and local laws and regulations.
C. Reservation of Right: The Region reserves its right to proceed against
[Hospital] for all violations outside the scope of the Audit, and violations within
the scope of the Audit that were not timely reported or timely corrected. In any
enforcement proceeding, the Region may enforce the provision of 40 C.F.R.
allegedly violated, or its authorized or approved state counterpart, if said
counterpart is federally enforceable as a matter of law.
D. Authority of Signatories: The signatories hereto represent that they have the
authority to bind the parties.
Page 7 of 13
-------
E. Modification: This Agreement may be modified by a writing signed by both
parties.
F. Coordination With the Commonwealth Environmental Agency: The Region has
informed the Puerto Rico Environmental Quality Board (PREQB) of this
Agreement and shall provide a copy to the PREQB. Nothing herein restricts
PREQB from acting as it deems appropriate.
G. Effective Date: This Agreement is effective on the date that it is signed by both
parties, or the last party if not signed on the same date.
WE, THE UNDERSIGNED, HEREBY AGREE TO BE BOUND BY THIS AGREEMENT:
For [Hospital]:
Name of Responsible Official
Title
Address
City, State, Zip Code
Date:
For EPA-Region 2:
Alan J. Steinberg, Regional Administrator
USEPA - Region 2
290 Broadway
New York, New York 10007
Date:
Page 8 of 13
-------
Appendix A
Covered Campuses and Off-Site Facilities Associated with Those Campuses
[List of Campuses and off-site facilities covered under the Audit Agreement goes here.]
Page 9 of 13
-------
Appendix B
SCOPE OF AUDIT PROGRAM
The following list provides the activities, areas, and/or shops that the review of the campus(es)
must cover. This list not meant to be all-inclusive. [Please select and include areas that exist at
your campus.]
Documents to Review (for the three years prior to the Program Period)
Verify EPA identification numbers and permits
Hazardous waste manifests
Training records
Land disposal restriction notifications
Exception reports
Lead disclosure statements in leases, or associated with leases of residential
housing let by the university in its capacity as a lessor, as defined in 40 C.F.R.
745.103
Contingency plans and annual reports (for contingency plans, only the current
plan will be reviewed)
Required certifications
Facilities Operation and Maintenance
Air conditioning/refrigeration service
Appliance and equipment repair, including medical equipment
Building cleaning and maintenance
Building renovation and construction
Cafeteria
Chemical storage areas
Drinking water treatment systems
Fabrication shops
Furniture repair
Heating and power plants (e.g., boilers, emergency generators)
House or architectural structure painting
Landscaping operations
Laundry
PCB transformers and switches
Pesticide storage facilities
Resource recovery/incinerator facilities
Waste disposal areas (landfills)
Wastewater treatment facilities
-------
Waste treatment facilities such as autoclaves
Fleet Maintenance
Automotive, truck, and ambulance servicing areas
Gasoline service stations
Garages
Hazardous Waste / Tanks / Wells
Aboveground and current operating underground storage tanks and their
containment areas/systems, and documentation concerning closures of regulated
tanks previously removed from service.
Dry wells, septic systems, cesspools, floor drains, sink drains, and disposal wells.
Facilities treating, storing or disposing of hazardous wastes.
Hazardous waste satellite accumulation areas.
Hazardous waste storage areas.
Tanks that have been permanently or temporarily closed.
Transformers and oil-containing electrical equipment (PCB and non-PCB).
Universal waste storage areas.
Laboratories
All clinical, pathology and dental laboratories
All teaching and research laboratories with regular chemical use.
Patient Care
Anesthesiology
Chemotherapy
Dentist Ms offices
Doctor
s offices
Floor Pharmacies
Histology
Intensive Care Units
Neonatal Areas
Nursing Stations
Operating Rooms
Pathology, microbiology
Patient
s Rooms
Patient treatment areas
-------
X-Ray/Radiology
Main Pharmacy
Storage areas
Outdated Pharmaceuticals
Sterile Supply and Materials Management
Autoclaving Units
Ethylene Oxide (EtO) Units
Glutaraldehyde
Use and disposal of disinfectants
Use and Disposal of Known Chemicals/Products of Concern
Computers/monitors, circuit boards, and other lead-bearing electronics
Ethanol and formaldehyde/ethanol solutions
Fluorescent light bulbs and other types of lamps, including high-intensity
discharge, neon, mercury vapor, high pressure sodium, and metal halide lamps
Formaldehyde/Formalin
Mercury and Mercury-containing devices and products
PVC-containing devices
Xylene
Batteries
Solvents
Photographic chemicals and scrap film
Other Services
Athletic and training facilities
Photo processing/publishing
Morgue/Crematorium
Animal care areas
-------
Appendix C
SCHEDULE OF AUDITS
[Insert a schedule of when audits will be done at each campus/location. Provide details as
necessary such as deadlines for submitting the disclosure report, the regulatory areas being
audited, and the names of campuses, buildings, or other location-specific info.]
Example:
Location
Campus A. e.g.:
Pharmacy
Physical Plant
Print Shop
Programs to be Audited
e.g., RCRA, CWA
Date Disclosure Report will be Submitted
-------
FACILITY AUDIT AGREEMENT
between the
ENVIRONMENTAL PROTECTION AGENCY
and
[Insert Name of Hospital]
I. INTRODUCTION
In recognition that environmental auditing plays a critical role in protecting human health
and the environment by identifying, correcting, and ultimately preventing violations of
environmental regulations, [Hospital] and the United States Environmental Protection
Agency, Region 2 (the "Region") hereby agree that [Hospital] shall conduct a self-audit
program (the "Audit Program") for compliance with the regulations promulgated or
authorized by the United States Environmental Protection Agency ("EPA") set forth in
Section II below. The Agreement shall be governed by the terms of EPA's Policy
entitled "Incentives for Self-Policing: Discovery, Disclosure, Correction and Prevention
of Violations," 65 Federal Register 19618 (4/11/00, the "Policy"), except to the extent
that those terms are explicitly modified below.
II. SCOPE OF THE AUDIT
A. [Hospital] shall conduct an audit (the "Audit") of its compliance with the
regulations cited below in subsections 1 - 6 of Section II.B. The Audit will
encompass all / (enter number) campuses of [Hospital], including any
associated off-site facilities such as (if applicable). Appendix A
attached hereto lists the campuses and other units associated with each covered
campus ("Covered Campuses") that are covered by this agreement.
B. Under the Audit Program, [Hospital] will audit compliance with the following
federal regulatory programs:
1. Air Programs
Part 52l Section 21 Prevention of Significant Deterioration of Air Quality
Part 60 Standards of Performance for New Stationary Sources
Part 61 National Emission Standards for Hazardous Air Pollutants, Subpart M,
National Emission Standard for Asbestos
Part 62 Subpart HHH - Federal Plan Requirements for
Hospital/Medical/Infectious Waste Incinerators
Part 63 National Emission Standards for Hazardous Air Pollutants for Source
Categories (all applicable provisions)
1 The term "Part" refers to the subdivisions of the subchapters of Title 40 Code of Federal
Regulations ("C.F.R.").
Page 1 of 13
-------
Part 68 Chemical Accident Prevention Provisions
Part 70 State Operating Permit Programs
Part 82 Protect!on of Stratospheric Ozone
All applicable provisions of; and the New York State Implementation Plan
Regulations (promulgated pursuant to Section 110 of the Clean Air Act) including
the New Source Review regulations
2. Water Programs
Part 112 Oil Pollution Prevention
Part 122 EPA Administered Permit Programs: The National Pollutant Discharge
Elimination System
Part 141 National Primary Drinking Water Regulations
Part 142 National Primary Drinking Water Regulations Implementation
Part 143 National Secondary Drinking Water Regulations
Part 144 Underground Injection Control ("UIC") Program
Part 145 State UIC Program Requirements
Part 146 UIC Program: Criteria and Standards
Part 147 State UIC Programs
Part 148 Hazardous Waste Injection Restrictions
Part 403 General Pretreatment Regulations for Existing and New Sources of
Pollution
3. Pesticide Programs
Part 160 Good Laboratory Practice Standards
Part 162 State Registration of Pesticide Products
Part 170 Worker Protection Standard
Part 171 Certification of Pesticide Applicators
Part 172 Experimental Use Permits
4. Solid and Hazardous Wastes
Part 260 Hazardous Waste Management System: General (Part 370, 6 New York
Code of Rules and Regulations ("6 NYCRR")2
Part 261 Identification and Listing of Hazardous Waste (Part 371, 6 NYCRR)
Part 262 Standards Applicable to Generators of Hazardous Waste (Part 372, 6
NYCRR)
New York State has been authorized by the Region for many of the federal regulations
comprising Parts 260 - 280. Once authorized, a state regulation becomes the applicable regulation.
[Resource Conservation and Recovery Act ("RCRA"), as amended, §3006(b), 42 U.S.C. §6926(b)]. For
purposes of this Agreement [Hospital] will audit for compliance with authorized New York State
counterparts of the federal regulations, where applicable, found at 6 NYCRR Parts 370 -373 and Subpart
374-3.
Page 2 of 13
-------
Part 263 Standards Applicable to Transporters of Hazardous Waste (Part 372, 6
NYCRR)
Part 264 Standards for Owners and Operators of Hazardous Waste Treatment,
Storage, and Disposal Facilities (Subpart 373-2, 6 NYCRR)
Part 265 Interim Status Standards for Owners and Operators of Hazardous
Waste Treatment, Storage, and Disposal Facilities (Subpart 373-3, 6
NYCRR)
Part 266 Standards for the Management of Specific Hazardous Wastes and
Specific Types of Hazardous Waste Management Facilities (Subpart
3 74-1,6 NYCRR)
Part 268 Land Disposal Restrictions (Part 376, 6 NYCRR)
Part 273 Standards for Universal Waste Management (Subpart 374-3, 6
NYCRR)
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
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
Part 745 Lead-Based Paint Poisoning Prevention in Certain Residential
Structures
Part 761 Poly chlorinated Biphenyls (PCBs) Manufacturing, Processing,
Distribution in Commerce, and Use Prohibitions
Part 763 Asbestos
C. The facilities and documents to be audited on the Covered Campuses are set forth
in Appendix B. The benefits of this Agreement shall extend to only those
facilities within the Covered Campuses that are audited.
III. DISCLOSURE
[Hospital] shall disclose all regulatory violations discovered during the Audit.
[Hospital] will disclose these violations to the Region, in accordance with the Policy, in
written disclosure reports to be submitted in accordance with the schedule set forth below
in Section IV. Each such disclosure report shall contain, with reference to each violation
disclosed, the following additional information: the actions selected by [Hospital] to
correct the violation within 60 days, or as otherwise approved pursuant to Section V
below; the status of the corrective action; and the means taken by [Hospital] to prevent
Page 3 of 13
-------
recurrence of the violation. All disclosure reports will be submitted by the scheduled
date, and the Region agrees to waive the 21-day disclosure requirement provided for in
the Policy.
Once the action designed to correct a particular violation has been completed, and a
report submitted to the Region notifying it of the completion of the corrective action, no
further reporting on that violation, or the status of corrective action, is required. On
[Date of Termination of Agreement - usually sixty days after submittal of last
disclosure report], this Agreement shall terminate for all purposes, except that
[Hospital] shall remain obligated to complete the action necessary to correct any
disclosed violation, and to report to the Region in writing the completion of any
corrective action, previously unreported, within thirty days after such corrective action
has been completed.
This Audit Agreement does not cover any pre-Agreement activities, including regulatory
compliance issues discovered by [Hospital] or its environmental consultant(s) prior to
the effective date of this Agreement.
IV. SCHEDULE
A. Within 10 days of the effective date of this agreement, [Hospital] will identify
suitable personnel or consultants (where appropriate) to perform each of the six
regulatory program audits identified in Section II above and shall further identify
the applicable criteria pursuant to which each such regulatory program audit shall
be conducted. [Hospital] shall submit to EPA the audit protocols and audit
checklists for each of the six regulatory program audits, tailored to the Hospital,
and shall provide copies of these audit instruments to the Region. [Hospital] is
willing to share any materials it develops with other healthcare institutions and the
Region.
B. Within 30 days of the signing of the agreement, the Audit shall commence.
C. [Hospital] shall complete the regulatory audits required by the Sections listed in
this agreement, and shall submit disclosure reports to the Region, in accordance
with the Policy and the Agreement, identifying all violations discovered during
the course of these audits according to the schedule set forth in Appendix C.
V. CORRECTIVE ACTION
[Hospital] shall correct each violation identified during the Audit, and shall take steps
necessary to prevent the recurrence of each such violation. Wherever possible, [Hospital]
shall correct any violations identified during the Audit within 60 days of discovery. In
those instances in which [Hospital] is unable to correct an identified violation within the
60-day deadline, it shall request an extension of time from the Region in writing and
provide a correction schedule, accompanied by a justification of the requested extension.
Page 4 of 13
-------
Any extension of the 60-day correction period shall be subject to the Region's approval.
Such approval will not be unreasonably withheld.
If [Hospital] discovers or otherwise becomes aware of a concern or concerns that may
present an imminent and substantial endangerment to human health or the environment,
and such concern(s) may exist at other [Hospital] campuses covered by this Agreement,
notwithstanding any other language herein to the contrary, [Hospital] agrees to address
such concern(s) at all covered campuses as expeditiously as possible and promptly take
such action as may be necessary at all covered campuses to protect human health and the
environment. [Hospital] shall notify EPA (initial notice may be by phone) of such
concern(s) within 24 hours of discovery or becoming aware of such concern(s) and shall
notify EPA in writing within five business days of such discovery of [Hospital]'s
proposed remedial action.
VI. CIVIL PENALTIES FOR DISCLOSED VIOLATIONS
Except as provided in Section II.D.8 of the Policy, the Region will not impose gravity-
based penalties for violations discovered if they are timely disclosed and corrected, and
provided that the applicable provisions of the Policy and this Agreement are met. The
Region will consider the least expensive means for coming into compliance for
calculating potential economic benefit penalties for any disclosed violations, provided
that such methods comply with regulatory requirements.
VII. REGIONAL INSPECTIONS
The Region will assign a low priority for compliance inspections at the Covered
Campuses until after the completion of the Audit, except with respect to potential
violations of regulatory provisions, or at facilities, that are outside the scope of the Audit,
as defined in Section II above, or where: the Region has received a citizen's complaint;
the Region has reason to believe that circumstances exist that may pose a threat of actual
harm or an imminent and substantial endangerment to public health or the environment;
the Region has reason to believe that a criminal violation may, or has occurred; or where
[Hospital], pursuant to statute, has notified the National Response Center of a release.
Any civil violation discovered in a facility or unit within the scope of the Audit, that was
scheduled to be audited subsequent to such discovery, shall be treated as a disclosure by
[Hospital] and resolved under the terms of the Policy and this Agreement. Additionally,
the Region retains the right to conduct during the Audit the inspections set forth in
subsections A and B immediately below:
A. Oversight Inspections: Where [Hospital] has reported a violation that requires
corrective action in the nature of a clean-up of contaminated soil or water, the
Region shall have the right to conduct inspections at the corrective action site for
the purpose of overseeing or monitoring the clean-up, to assure correction of the
violation. No civil penalties shall be associated with or result from oversight
inspections, unless circumstances exist that may pose a threat of actual harm or an
imminent and substantial endangerment to public health or the environment.
Page 5 of 13
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B. Confirmation Inspections: Where [Hospital] has disclosed a violation, selected a
corrective action plan, and reported that the plan has been completed and the
violation cured, the Region shall have the right to inspect the relevant facility or
site to assure that the violation has in fact been corrected, or to require further
appropriate corrective action, if it has not. No civil penalties shall be associated
with or result from confirmation inspections, unless circumstances exist that may
pose a threat of actual harm or an imminent and substantial endangerment to
public health or the environment.
VIII. MISCELLANEOUS PROVISIONS
A. Notification and Certification of Disclosure Reports: [Hospital] designates as its
"responsible official," responsible for submitting disclosure reports to the Region,
the following individual:
Name of Responsible Official
Title
Name of Hospital
Address
City, State, Zip Code
Phone Number
Fax Number
The responsible official shall certify that each disclosure report submitted to the
Region is true, accurate and complete in the form set forth in 40 C.F.R.
§270.11(d).
[Hospital] designates as its "contact person," to be the recipient of all
communications from the Region concerning this Agreement, the following
individual:
Name of Contact Person
Name of Hospital
Address
City, State, Zip Code
Phone Number
Fax Number
Email Address
The Region designates the following individual as its contact person:
Charles Zafonte
Multimedia Enforcement Coordinator
DECA/CAPSB
U.S. Environmental Protection Agency, Region 2
290 Broadway (21ST Floor)
New York, New York 10007-1866
Page 6 of 13
-------
Phone:(212)637-3515
Fax: (212) 637-4086
zafonte. charles@epa. gov
The parties may redesignate their contact person and responsible official in
writing.
B. Compliance With Law and Regulation: Neither the existence of this Agreement,
nor compliance with this Agreement relieves [Hospital] of its obligation of
continued compliance with the regulations covered by this Agreement, and all
other federal, state and local laws and regulations.
C. Reservation of Right: The Region reserves its right to proceed against [Hospital]
for all violations outside the scope of the Audit, and violations within the scope of
the Audit that were not timely reported or timely corrected. In any enforcement
proceeding, the Region may enforce the provision of 40 C.F.R. allegedly violated,
or its New York State authorized or approved counterpart, if said state counterpart
is federally enforceable as a matter of law.
D. Authority of Signatories: The signatories hereto represent that they have the
authority to bind the parties.
E. Modification: This Agreement may be modified by a writing signed by both
parties.
F. Coordination With the State Environmental Agency: The Region has informed
NYSDEC of this Agreement and shall provide a copy to NYSDEC at each of the
following addresses:
Mr. James H. Ferreira, Esq.
Deputy Commissioner and General Counsel
NYS Department of Environmental Conservation
625 Broadway
Albany, NY 12233-1010
Name
Regional Director, Region ?
NYS Department of Environmental Conservation
Street
City, NY Zip
Nothing herein, however, restricts NYSDEC from acting as it deems appropriate.
Page 7 of 13
-------
WE, THE UNDERSIGNED, HEREBY AGREE TO BE BOUND BY THIS AGREEMENT:
For [Hospital]:
Name of Responsible Official
Title
Address
City, State, Zip Code
Date:
For EPA-Region 2:
Jane M. Kenny, Regional Administrator
USEPA - Region 2
290 Broadway
New York, New York 10007
Date:
Page 8 of 13
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Appendix A
Covered Campuses and Off-Site Facilities Associated with Those Campuses
[List of Campuses and off-site facilities covered under the Audit Agreement goes here.]
Page 9 of 13
-------
Appendix B
SCOPE OF AUDIT PROGRAM
The following list provides the activities, areas, and/or shops that the review of the campus(es)
must cover. This list not meant to be all-inclusive. [Please select and include areas that exist at
your campus.]
Documents to Review (for the three years prior to the Program Period)
• Verify EPA identification numbers and permits
• Hazardous waste manifests
• Training records
• Land disposal restriction notifications
• Exception reports
• Lead disclosure statements in leases, or associated with leases of residential housing let by
the university in its capacity as a lessor, as defined in 40 C.F.R. § 745.103
• Contingency plans and annual reports (for contingency plans, only the current plan will be
reviewed)
• Required certifications
Facilities Operation and Maintenance
• Air conditioning/refrigeration service
• Appliance and equipment repair, including medical equipment
• Building cleaning and maintenance
• Building renovation and construction
• Cafeteria
• Chemical storage areas
• Drinking water treatment systems
• Fabrication shops
• Furniture repair
• Heating and power plants (e.g., boilers, emergency generators)
• House or architectural structure painting
• Landscaping operations
• Laundry
• PCB transformers and switches
• Pesticide storage facilities
• Resource recovery/incinerator facilities
• Waste disposal areas (landfills)
• Wastewater treatment facilities
• Waste treatment facilities such as autoclaves
Fleet Maintenance
• Automotive, truck, and ambulance servicing areas
Page 10 of 13
-------
• Gasoline service stations
• Garages
Hazardous Waste / Tanks / Wells
• Aboveground and current operating underground storage tanks and their containment
areas/systems, and documentation concerning closures of regulated tanks previously
removed from service.
• Dry wells, septic systems, cesspools, floor drains, sink drains, and disposal wells.
• Facilities treating, storing or disposing of hazardous wastes.
• Hazardous waste satellite accumulation areas.
• Hazardous waste storage areas.
• Tanks that have been permanently or temporarily closed.
• Transformers and oil-containing electrical equipment (PCB and non-PCB).
• Universal waste storage areas.
Laboratories
• All clinical, pathology and dental laboratories
• All teaching and research laboratories with regular chemical use.
Patient Care
• Anesthesiology
• Chemotherapy
• Dentist's offices
• Doctor's offices
• Floor Pharmacies
• Histology
• Intensive Care Units
• Neonatal Areas
• Nursing Stations
• Operating Rooms
• Pathology, microbiology
• Patient's Rooms
• Patient treatment areas
• X-Ray/Radiology
Main Pharmacy
• Storage areas
• Outdated pharmaceuticals
Sterile Supply and Materials Management
• Autoclaving Units
• Ethylene Oxide (EtO) Units
• Glutaraldehyde
-------
• Use and disposal of disinfectants
Use and Disposal of Known Chemicals/Products of Concern
• Computers/monitors, circuit boards, and other lead-bearing electronics
• Ethanol and formaldehyde/ethanol solutions
• Fluorescent light bulbs and other types of lamps, including high-intensity discharge, neon,
mercury vapor, high pressure sodium, and metal halide lamps
• Formaldehyde/Formalin
• Mercury and Mercury-containing devices and products
• PVC-containing devices
• Xylene
• Batteries
• Solvents
• Photographic chemicals and scrap film
Other Services
• Athletic and training facilities
• Photo processing/publishing
• Morgue/Crematorium
• Animal care areas
-------
Appendix C
SCHEDULE OF AUDITS
[Insert a schedule of when audits will be done at each campus/location. Provide details as
necessary such as deadlines for submitting the disclosure report, the regulatory areas being
audited, and the names of campuses, buildings, or other location-specific info.]
Example:
Location
Campus A, e.s.:
Pharmacy
Physical Plant
Print Shop
Programs to be Audited
e.g., RCRA, CWA
Date Disclosure Report will be Submitted
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Operating Rooms
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Drug Preparation and
Administration
Generation of Regulated
Medical Waste
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Improper Disposal
Exposure to Biological
Contaminants
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination,
Employee Health
Disease
Transmission,
Environmental
Contamination
Employee/Patient
Exposure
Employee/Patient
Exposure
Compliance
1
1
1
0
1
2
1
0
Risk
1
1
1
0
1
O
2
2
Frequency
Of Activity
3
4
4
4
4
4
4
4
VAMC
Control
1
4
4
4
4
4
3
2
TOTAL
SCORE
6
10
10
8
10
13
10
8
-------
High Level Disinfection
Waste Anesthetic Gases
Radiography
Use of
Disposable/Reusable
Medical Supplies
Handling and Disposal
of Detergent
Disinfectants
Generation of Waste
Anesthetic Gases
Generation of Spent
Photo Processing
Fluids
Potential for Solid
Waste Generation or
Increased Sterilization
Activities
Employee Exposure
Potential
Employee/Patient
Health Effects
Environmental
Contamination,
Employee Exposure
to Hazardous
Chemicals
Increase of Solid
Waste Disposal or
Sterilization
Process
0
1
1
0
2
2
2
1
4
4
3
3
3
3
3
3
9
10
9
7
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Outpatient Clinics
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Drug Preparation and
Administration
Generation of Regulated
Medical Waste
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Aspect
Energy Consumption
Employee/Patient
Exposure and Waste
Disposal
Potential for Spills
Use of Paper
Improper Disposal
Exposure to Biological
Contaminants
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Disease
Transmission,
Environmental
Contamination
Employee/Patient
Exposure
Employee/Patient
Exposure
Compliance
1
1
1
0
0
2
1
1
Risk
1
1
1
0
1
3
2
2
Frequency
Of Activity
3
4
4
4
4
4
4
4
VAMC
Control
1
4
4
4
4
4
3
2
TOTAL
SCORE
6
10
10
8
9
13
10
9
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Pathology/Morgue
Date:
Activity or Service
Cleaning and
Disinfecting Surfaces and
Equipment
Generation of Regulated
Medical Waste
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Disposal of Human
Tissue
Autoclave Operation
Aspect
Handling of Detergent
Disinfectants
Exposure to Biological
Contaminants
Energy Consumption
Hazardous Waste
Disposal, Wastewater
Discharge
Potential for Spills
Use of Paper
Medical Waste
Generation
Sterilization of
Biological Waste,
Energy Consumption
Impact
Employee/Patient
Exposure
Disease
Transmission,
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Exposure to
Pathogens, Use of
Natural Resources
Compliance
2
2
1
2
1
0
1
1
Risk
2
3
1
2
O
0
4
2
Frequency
Of Activity
4
4
3
4
4
2
3
2
VAMC
Control
2
4
1
3
4
3
4
3
TOTAL
SCORE
10
13
6
11
12
5
12
8
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Pharmacy
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Compounding, Drug
Preparation and
Administration
Generation of
Pharmaceutical Waste
Cleaning and
Disinfecting Surfaces and
Equipment
Handling of Cardboard,
Plastics
Use of Fume Hoods
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Improper Disposal
Handling, Storage,
Labeling of Containers
Handling of Detergent
Disinfectants
Generation of Solid
Waste
Energy Consumption,
Air Emission
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Employee/Patient
Exposure
Generation of Solid
Waste or Potential
for Recycling
Use of Natural
Resources,
Environmental
Contamination
Compliance
1
0
0
0
1
0
1
0
1
Risk
1
2
2
0
1
O
2
0
3
Frequency
Of Activity
3
3
3
4
4
3
4
3
4
Local
Control
1
4
4
4
4
4
2
3
3
TOTAL
SCORE
6
9
9
8
10
10
9
6
11
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
VA Police
Date:
Activity or
Service
Automobile
Surveillance
Ammunition
Concerns
Report
Generation
Chemical Storage
Chemical Usage
Vest Replacement
Range Practice
Aspect
Oil and Exhaust
Storage, Handling and Usage
of Lead
Use of Paper
Potential for Spills
Oil, Lubricant and Solvent
Used for Gun Cleaning
Exporting Old Kevlar
Empty Brass Cartridge
Production
Impact
Contamination
Contamination
Natural Resource
Expense
Environmental
Contamination
Environmental
Contamination
Disposal Space
Usage
Disposal Space
Usage
Compliance
1
0
0
0
1
0
1
Risk
3
3
1
1
2
1
1
Frequency
Of Activity
4
1
2
1
1
1
2
VAMC
Control
2
3
3
3
3
2
2
TOTAL
SCORE
10
7
6
5
7
4
6
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Prosthetics
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Battery Consumption
Cleaning and
Disinfecting Surfaces and
Equipment
Assistive Device
Production and
Adjustment
Paint Spray Booth
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Replacement and
Disposal
Handling of Detergent
Disinfectants
Grinding, Welding,
Finishing, Heat
Treating (Oven Usage)
Air Emissions
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Employee/Patient
Exposure
Health Effects,
Environmental
Contamination,
Waste Production
Environmental
Contamination
Compliance
1
1
1
0
0
0
1
0
Risk
1
1
1
0
2
2
2
3
Frequency
Of Activity
3
2
4
4
1
4
3
2
VAMC
Control
1
4
4
4
4
2
3
3
TOTAL
SCORE
6
8
10
8
7
8
9
8
-------
Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
GEMS Quick Find Chart
(For Getting Started)
I NEED:
GO TO:
Help! I need a GEMS evaluation tool.
| \ Section 3, Enclosure 3-2,
^ GEMS Gap Analysis Tool;
and Section 7, E-SAFE
Criteria Statements
I need a sample GEMS Medical Center Policy.
Section 5B
How do I know if my GEMS program meets
requirements?
Where do I start?
I y Section 7, E-SAFE
Criteria Statements
| \ Section 3, Nine Steps for a
/ Successful GEMS
need electronic GEMS documents that I can modify. I ^ Section 5
I want to present an overview of the GEMS to my | \
VAMC Management. Where can I find training
materials?
See the GEMS
Awareness Training
PowerPoint in Section 6
I need a compliance audit guide.
What are some environmental impacts of
VA medical center operations?
Can I see an example of ranking of
significant aspects for a VAMC?
>=>
See Environmental
Compliance Guidebook,
Book 6B
See Section 4, Sample
Environmental Aspects
Templates
Section 4, Ranking of
Aspects
IX
-------
Geen Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Radiology and Nuclear Medicine
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Drug Preparation and
Administration
Generation of Regulated
Medical Waste
Changing Linen
Aspect
Energy Consumption
Film Processing
Potential for Spills
Use of Paper
Improper Disposal
Exposure to
Biological
Contaminants
Handling of
Contaminated
Laundry
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Disease
Transmission,
Environmental
Contamination
Employee/Patient
Exposure
Compliance
1
1
1
0
0
0
1
Risk
1
O
2
0
1
3
1
Frequency
Of Activity
3
4
4
4
3
4
4
VAMC
Control
1
4
4
4
3
4
3
TOTAL
SCORE
6
12
11
8
7
11
9
-------
Cleaning & Disinfecting
Surfaces and Equipment
Maintenance of
Equipment
X-ray Film Silver
Recovery Operation
X-ray Film Storage and
Disposal
High Level Disinfection
Nuclear Medicine
Scanning
Handling and Storage of
Radionucleotides
Handling of
Detergent
Disinfectants
Generation of
Batteries
Silver Recovery
Recycling or
Handling as
Hazardous Waste
Use of Cidex or
Other High Level
Disinfectants
Administration of
Radionucleotides,
Handling of Mixed
Wastes
Improper Disposal
and Handling of
Wastes
Employee/Patient
Exposure
Environmental
Contamination
Employee Health and
Wastewater
Contamination
Waste
Generation/Recycling
Employee Health
Effects
Employee Chemical
and Radiation
Exposure
Environmental
Contamination,
Human Health
Effects
0
1
2
0
0
1
1
2
1
3
2
2
3
3
4
2
4
4
3
4
4
2
2
3
3
3
3
3
8
6
12
9
8
11
11
-------
EPA/625/C-06/006
November 2007
Healthcare Environmental Assistance Resources
Pollution Prevention and Compliance Assistance
for Healthcare Facilities
U.S. Environmental Protection Agency
Office of Research and Development
National Risk Management Research Laboratory
Center for Environmental Research Information
Cincinnati, Ohio
-------
NOTICE
The U.S. Environmental Protection Agency through its Office of Research
and Development partially funded and managed the research described here
under Cooperative Agreement #R-83045301 -1 to the Kentucky Pollution
Prevention Center at the University of Louisville, Louisville, Kentucky. It has
been subjected to the Agency
s peer and administrative review and has been
approved for publication as an EPA document. Mention of trade names or
commercial products does not constitute endorsement or recommendation for
use.
The information provided on this CD ROM is intended to provide
compliance assistance to healthcare facilities. Please note that the information
for healthcare facilities may not be complete and should be relied upon only as
general guidance. This information should be used in conjunction with the
regulations, not in place of them. This document should not be considered
Agency guidance, policy, or any part of any rule-making effort, but is provided for
informational and discussion purposes only. It is not intended, nor can it be
relied upon, to create any rights enforceable by any party in litigation with the
United States. Any variation between applicable regulations and the information
provided on this CD ROM is unintentional and, in the case of such variations, the
requirements of the regulations govern. It is also important to note that this
document is based on the federal definition of hazardous waste and many states
have developed their own hazardous waste regulatory programs. This CD ROM
does not contain an exhaustive list or description of all federal, state or local
requirements, and other rules may apply. It is always advisable to check with
your local regulatory authority to ensure compliance.
Also note this CD ROM contains internet address and direct links to
internet sites. The links are active as of printing of this CD ROM. It is beyond
the control of the authors of this CD ROM to anticipate changes in addresses
and/or links.
-------
FOREWORD
The U.S. Environmental Protection Agency (EPA) is charged by Congress
with protecting the Nation Ms land, air, and water resources. Under a mandate of
national environmental laws, the Agency strives to formulate and implement actions
leading to a compatible balance between human activities and the ability of natural
systems to support and nurture life. To meet this mandate, EPAllls research
program is providing data and technical support for solving environmental problems
today and building a science knowledge base necessary to manage our ecological
resources wisely, understand how pollutants affect our health, and prevent or
reduce environmental risks in the future.
The National Risk Management Research Laboratory (NRMRL) is the
Agency 11 s center for investigation of technological and management approaches for
preventing and reducing risks from pollution that threaten human health and the
environment. The focus of the Laboratory Ms research program is on methods and
their cost-effectiveness for prevention and control of pollution to air, land, water, and
subsurface resources; protection of water quality in public water systems;
remediation of contaminated sites, sediments and ground water; prevention and
control of indoor air pollution; and restoration of ecosystems. NRMRL collaborates
with both public and private sector partners to foster technologies that reduce the
cost of compliance and to anticipate emerging problems. NRMRL Ms research
provides solutions to environmental problems by: developing and promoting
technologies that protect and improve the environment; advancing scientific and
engineering information to support regulatory and policy decisions; and providing the
technical support and information transfer to ensure implementation of
environmental regulations and strategies at the national, state, and community
levels.
-------
This publication has been produced as part of the Laboratory Ms strategic
long-term research plan. It is published and made available by EPA
s Office of
Research and Development to assist the user community and to link researchers
with their clients.
Sally C. Gutierrez, Director
National Risk Management Research Laboratory
ACKNOWLEDGMENTS
This CD ROM is a collection of healthcare resources and cooperation from U.S.
Environmental Protection Agency (EPA) including Office of Research &
Development (ORD), Office of Enforcement and Compliance Assurance (OECA),
Office of Pollution Prevention & Toxics (OPPT), Office of Policy Economics &
Innovation (OPEI), Office of Water (OW), Office of Solid Waste & Emergency
Response (OSWER), Office of Air and Radiation (OAR), several EPA Regions
(predominately EPA Region 2), the Veterans Health Administration, State
agencies, healthcare organizations, and working groups. Several key documents
on this CD ROM are a result of collaborative efforts between EPA and either the
Kentucky Pollution Prevention Center, or Hospitals for a Healthy Environment, or
healthcare facilities.
We'd like to offer special thanks to the many reviewers in the healthcare
community, State and Federal Agencies whose generous contributions of time
and expertise has greatly enhanced the quality of these products.
The actual collection of materials and layout of the CD ROM was made possible
by staff from EPA Region 2.
-------
ABSTRACT
This CD ROM is a result of several healthcare guidance documents coming into
existence around the same time and the need for one tool where healthcare
facilities could have access to these documents and other valuable healthcare
resources regardless of connection to the internet.
Through Regional EPA healthcare initiatives, namely Region's 1 and 2, it was
established that many healthcare facilities pose environmental and public health
concerns. Hospitals contribute to the presence of toxic chemicals such as
phthalates, mercury, and dioxin in the environment. In addition, hospitals are
also generators of a wide variety of hazardous wastes (e.g., chemotherapy and
antineoplastic chemicals, epinephrine, Pharmaceuticals, solvents, formaldehyde,
photographic chemicals, radionuclides, and waste anesthetic gases), which many
are mismanaged, and hospitals produce two million tons of solid waste which is
1 % of the total municipal solid waste in the U.S.
Many hospitals have only one person in charge of all health, safety and
environmental issues and it is very difficult for one person to manage all the
environmental aspects of a healthcare facility let alone the health and safety
issues as well. A hospital may have, for example, laboratories, operating rooms,
pharmacies, radiological facilities, cafeterias, housekeeping and laundry units,
fleet maintenance facilities, boilers, medical waste incinerators, emergency
generators, grounds and landscaping facilities, underground or above ground oil
and fuel storage tanks, air conditioning and refrigeration equipment, morgues,
lead-based paint, and asbestos. As a result, they are regulated by a myriad of
environmental statutes including the Resource Conservation and Recovery Act,
Clean Air Act, Clean Water Act, Safe Drinking Water Act, Oil Pollution Act and
the Emergency Planning and Community Right to Know Act, not to mention the
various state and local regulations that may be more stringent than the federal
laws.
This CD ROM is a tool that will help the user better understand the healthcare
sector's relationship to the environment and to help them come into compliance,
maintain compliance, and go beyond compliance.
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Rehabilitation/Occupational/Physical Therapy
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Activities to Include
Ceramics, Wood Shop,
Horticulture, etc.
Paint Spray Booth
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Use of Paints, Solvents,
Glazes, Pesticides,
Herbicides, etc.
Air Emissions
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Employee/Patient
Exposure
Employee/Patient
Exposure
Health Effects,
Environmental
Contamination
Air Pollution
Compliance
1
1
1
0
1
0
1
1
Risk
1
1
1
0
2
2
O
O
Frequency
Of Activity
3
4
4
4
2
4
3
2
VAMC
Control
1
4
4
4
2
2
4
4
TOTAL
SCORE
6
10
10
8
7
8
11
10
-------
Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Research Laboratory
Date:
Activity or Service
Operation of Electrical
Equipment
Chemical Usage
Chemical Storage
Report Generation
Use of Radioactive
Material
Use of Fume Hoods
Receive Specimens
Use of Refrigeration/
Freezer
Animal Testing
Aspect
Energy Consumption
Hazardous Waste
Disposal
Potential for Spills
Use of Paper
Hazardous Waste
Disposal
Energy Consumption,
Air Emissions
Biomedical Waste
Generation
Energy Consumption,
Waste Disposal
Disposal of Animal
Waste
Impact
Use of Natural
Resources
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination,
Employee Exposure
Use of Natural
Resources,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources,
Environmental
Contamination
Environmental
Contamination
Compliance
1
1
0
0
0
2
1
0
0
Risk
1
O
4
0
4
3
O
2
O
Frequency
Of Activity
3
2
4
2
4
4
4
3
2
VAMC
Control
1
4
4
3
4
3
4
2
4
TOTAL
SCORE
6
10
12
5
12
12
12
7
9
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Safety/Industrial Hygiene
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Disposal of Old
Calibration Gas
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Use of Storage Space,
Hazardous Waste
Disposal
Use of Paper
Hazardous Waste
Disposal
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Compliance
1
1
1
0
2
Risk
1
1
O
0
3
Frequency
Of Activity
3
4
3
4
1
VAMC
Control
2
4
3
3
3
TOTAL
SCORE
7
10
10
7
9
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Table of Contents
Section 1 - Introduction to the GEMS Program
Introduction
1.1 What is an Environmental Management System?
1.2 Code of Environmental Management Principles (CEMP)
1.3 ISO 14001 Environmental Management Systems - Specification with Guidance for Use
1.4 Summary
Enclosures
1-1 Discussion of EO 13148
1-2 EO 13148, Greening the Government Through Leadership in Environmental Management
1-3 VHA Directive, Veterans Health Administration Green Environmental Policy (Pending)
1-4 VHA Directive 2001-036, Pollution Prevention (P2) Program
1-5 FY '02 Waste Minimization and Compliance Report
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Green Environmental Management Systems (GEMS) Guidebook Introduction GEMS
Introduction
Federal government agencies are required by Executive Order 13148, entitled "Greening the
Government Through Leadership in Environmental Management," to develop and implement
by December 31, 2005, environmental management systems at all appropriate* agency
facilities. The text of Executive Order 13148 and a description of its sections are attached as
Enclosure 1-1 and Enclosure 1-2, respectively.
*Note: All VA Medical Centers are considered to be appropriate facilities.
Multi-campus VA Healthcare Systems are considered to be a single
appropriate facility. Other VHA facilities, such as Community Based
Outpatient Clinics, are considered part of their affiliated VAMCfor
the purpose of developing an environment management system.
This Guidebook is designed to help the Veterans Health Administration (VHA) facilities develop
and implement an environmental management system. VHA is naming their environmental
management system the Green Environmental Management System (GEMS). Properly
implemented, a GEMS program can improve productivity and advance environmental
protection and performance in a cost effective manner. It can elevate VHA environmental
management practices to the "best in class" in ways that will be recognized by stakeholders
inside and outside of VHA.
The most familiar form of an environmental management system is outlined in the 14001
Standard established by the International Organization for Standardization (ISO). This
standard, entitled "Environmental Management System Standard," states that environmental
management systems are "that part of the overall management system which includes
organizational structure, planning activities, responsibilities, practices, procedures, processes
and resources for developing, implementing, achieving, reviewing and maintaining the
environmental policy." Although there are other standards for environmental management
systems, such as the Environmental Protection Agency's (EPA's) CEMP (Code of
Environmental Management Principles), ISO 14001 is becoming widely adopted by the
private sector throughout the United States and internationally. Many federal agencies are
also considering the principles of ISO 14001 in the development of their environmental
management systems. More detailed information on ISO 14001 and CEMP will appear later
in this Introduction.
1.1 What is an Environmental Management System?
An environmental management system is a systematic approach to ensuring that a hospital's or a
facility's environmental activities are well managed in all organizations. Because an
environmental management system focuses on management practices, it can operate at
facilities of widely varying size, complexity and missions, whether they are offices,
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
laboratories, facilities or agencies. An environmental management system can provide
managers with a predictable structure for management, assessment and continual
improvement of the effectiveness and efficiency of their environmental activities. An
environmental management system approach builds in periodic review by top management
and emphasizes continual improvement instead of crisis management.
The systematic nature of the environmental management system allows an agency to focus on
management implementation and take a more inclusive and proactive view of environmental
protection. By demonstrating improved environmental performance, an environmental
management system can open the door to improved relations with regulators, stakeholders
and the public. By itself, an environmental management system does not guarantee
performance or compliance. Environmental management systems must be continually
reviewed and improved to ensure compliance and to advance environmental and mission
goals.
Each VA medical center needs to adapt its environmental management system to address its
particular goals, activities, budgets, missions, conditions and stakeholders; "one size does not
fit all." Developing an environmental management system rarely requires beginning from
scratch. Many VHA facilities will find they have many of the environmental management
system elements already in place. As facilities develop their environmental management
systems, they will undoubtedly note that their management of the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) Environment of Care requirements
follows a process very similar to that of an environmental management system. A formal
environmental management system can help draw together the numerous program elements
having environmental responsibilities that are typically found at VHA facilities. This will
help produce a clearly defined environmental program and an integrated framework for
environmental activities.
1.2 Code of Environmental Management Principles (CEMP)
The CEMP is a set of five broad environmental management principles developed by EPA to
address all areas of environmental responsibility. CEMP provides federal agencies with a
framework for developing environmental management systems at government facilities. The
principles and supporting performance objectives are intended to serve as guideposts for
organizations intending to implement environmental management programs or improve
existing ones. The organization is expected to create operational programs and procedures to
fulfill its commitment to the principles. EPA modeled the CEMP on common elements
found in a number of environmental management system standards but with a stronger
emphasis on sustainable development and regulatory compliance. The CEMP (published on
October 16, 1996, 61 Federal Register 54062) was developed in coordination with other
federal agencies, as required by Executive Order 12856, "Federal Compliance with Right-to-
Know Laws and Pollution Prevention Requirements."
The five CEMP Principles are as follows:
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Green Environmental Management Systems (GEMS) Guidebook Introduction GEMS
1. Management Commitment: The agency makes a written top-management commitment to
improve environmental performance by establishing policies that 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 ensures 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.
1.3 ISO 14001 Environmental Management Systems
— Specification with Guidance for Use
Increased interest in systematic management of environmental programs in the 1990s resulted in
the development of international consensus standards related to environmental management
systems. The ISO 14000 series has been developed under the auspices of the International
Organization for Standardization (ISO).
The ISO 14000 series includes Standard 14001 for environmental management systems. The
benefits of using the ISO 14001 standard as a model for environmental management systems
include:
• Increased efficiency and reduced costs.
• Reduced liabilities.
• Enhanced compliance.
• Enhanced reputation and public image.
The ISO 14001 approach to environmental management systems establishes procedures,
programs and operations that are designed to inspire environmental ethics in an organization.
The ISO 14001 standard is based on the Plan-Do-Check-Act model; it is operational and
process oriented, and addresses the following principles:
1. Continual Improvement. ISO 14001 establishes a framework that relies on process
management and continual improvement of processes. Continual improvement ensures
that processes do not stagnate - that they remain appropriate for continual use under the
changing circumstances of operation. Continual improvement should remain a
requirement of a facility's environmental management system even when the desired
level of environmental performance is reached. New opportunities for improvement can
be explored.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
2. Prevention of Pollution. ISO 14001 encourages facilities to avoid the creation of
pollution as a means of managing its environmental programs. Pollution prevention
strategies range from source reduction to product substitution and recycling. The
ultimate objective is to engineer pollution prevention features into products, design and
operational processes in the beginning that will result in decreased production of
pollutants and the attendant reduction in operating costs.
3. Employee Involvement. Maximizing the benefits accrued by an organization resulting
from implementation of an environmental management system depends to a significant
extent on employee involvement in the environmental management system process. To
promote the foregoing, the ISO standard states that the key elements of the environmental
management system must be implemented at "each relevant function and level of the
organization." For example, the expectation of ISO 14001 is that individual employees
have an in-depth understanding of their facility's operation as it relates to environmental
requirements.
4. Top Management Visibility and Leadership. ISO 14001 states that upper level
management visibility and leadership are essential elements of a facility's environmental
management system. The reason that this is an important part of an environmental
management system is that any attempt to change an organization's culture to embrace
environmental stewardship without strong leadership from the top would likely end in
failure. The high level of employee involvement that is required to successfully change
organizational culture will not happen unless management itself becomes involved,
committed and visible.
5. Integration. ISO 14001 states that the procedures, programs and operational controls that
are applied to the myriad risks and exposures (e.g., health and safety, security) that an
organization normally faces can be tailored as parts of one integrated system to include
environmental management. The process prescribed by ISO 14001 lends itself to the
creation of integrated programs to manage risks from different sources. This simplifies
the management of all risks, provides built-in efficiencies and can potentially reduce
costs. Behavioral change and improved operational techniques that deal with
environmental risks can also promote behavioral change in areas such as health and
safety.
An ISO 14001 environmental management system includes the following elements:
1. Policy Statement - Endorsed by top management. (Sample VA Medical Center policy,
Green Environmental Management Systems (GEMS), is located in Section 5B.)
2. Planning - Identifying how operations impact the environment, setting goals and targets
for reducing impacts, tracking legal and other requirements, and developing systems for
environmental management.
3. Implementation and Operation - Assigning roles and responsibilities, training,
communication, documentation and emergency preparedness.
4. Checking and Corrective Action - Establishing ways to monitor, identify and correct
environmental problems.
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Green Environmental Management Systems (GEMS) Guidebook Introduction GEMS
5. Management Review - Focused toward continual improvement.
1.4 Summary
This Guidebook is designed to assist VHA facilities in developing and implementing a Green
Environmental Management System (GEMS). By following the processes discussed in the
guidebook, VHA facilities will be able to develop a GEMS that meets the requirements of
EO 13148 and results in overall improvement in the management of operations. The pending
VHA policy (Enclosure 1-3) that will direct facilities to develop and implement GEMS will
be provided to facilities upon publication. All tools, samples and references to produce a
fully compliant GEMS are contained in this Guidebook. Additional references with abstracts
are provided in Section 6, Technical References, for use in developing facility specific
GEMS.
Enclosures
1-1 Discussion of EO 13148.
1-2 EO 13148, Greening the Government Through Leadership in Environmental
Management, dated April 21, 2000.
1-3 VHA Directive, Veterans Health Administration Environmental Policy (Pending).
1-4 VHA Directive 2001-036, Pollution Prevention (P2) Program, dated June 8, 2001.
1-5 FY '02 Waste Minimization and Compliance Report.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Table of Contents
Section 2 - Concepts of the GEMS Program
2.1 Environmental Policy
2.2 Environmental Aspects
2.3 Legal and Other Requirements
2.4 Objectives and Targets
2.5 Plan for Achieving Targets and Objectives
2.6 Structure and Responsibility
2.7 Training Awareness and Competence
2.8 Communication
2.9 GEMS Documentation
2.10 Document Control
2.11 Operational Control
2.12 Emergency Planning and Response
2.13 Monitoring and Measurement
2.14 Nonconformance, Corrective and Preventive Action
2.15 Records
2.16 Environmental Management System Gap Analysis
2.17 Management Review
Enclosure
2-1 The Aspect Identification and Prioritization Process
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Green Environmental Management Systems (GEMS) Guidebook Concepts of the GEMS Program
Concepts of the GEMS Program
In order to effectively implement and benefit from the Green Environmental Management
Systems (GEMS), it is important to have an understanding of the requirements, based on the
ISO 14001 Standard. A quick review of the ISO 14001 Standard shows that it is structured
to follow the Plan - Do - Check - Improve (Act) philosophy of the Total Quality Management
movement, as follows:
PLAN
4.2 Policy
4.3 Planning
DO
4.4 Implementation and Operation
CHECK
4.5 Checking and Corrective Action
IMPROVE (ACT)
4.6 Management Review
2.1 Environmental Policy
The organization must have a GEMS policy statement to drive the system. This statement tends
to be short, a one page or less document, and simply affirms the commitments. There is no
expectation that specific details be noted in the policy. For example, the commitment to
pollution prevention can simply be stated saying, "We are committed to the prevention of
pollution." The policy must be clearly endorsed by top management and be available to the
public and employees. Although the availability to the public can be rather passive (i.e., "it
is here if they want it"), there is an expectation that the employee awareness is more
proactive. Section 5B of this Guidebook provides a sample VA Medical Center policy.
2.2 Environmental Aspects
This element requires a procedure that not only identifies the aspects and impacts, but also
provides for determination of significance and keeping the information up-to-date. A GEMS
auditor does not prescribe what aspects should be significant or even how to determine
significance. However, the organization is expected to develop a consistent and verifiable
process to do so. See Section 3, Step 4, for further information.
Sample Environmental Aspects templates are available in Section 4 and should be completed for
each Operating Unit. Significant environmental aspects and impacts should then be
determined using the suggested format of Section 5, Document 5B1-1, "Procedure for
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Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
Determining Significant GEMS Environmental Aspects and Impacts" (see Section 2.11 for
Operational Controls).
2.3 Legal and Other Requirements
This is a requirement for a procedure that explains how the organization obtains information
regarding its legal and other requirements, and makes that information known to key
functions. This is not the assessment or compliance audit requirement, but rather a more up
front determination of requirements. See Section 3, Steps 4 and 8, for further information;
and Section 5, Document 5B1-2, "GEMS Procedure for Legal and Other Requirements" for a
written procedure.
2.4 Objectives and Targets
There is no requirement for a procedure in this element, only that objectives and targets be
documented. It does, however, require that certain items be considered in developing the
objectives, such as legal requirements and prevention of pollution. The objectives and
targets and these considerations may be documented in the minutes of the GEMS Committee
meetings. See Section 3, Step 6, for further discussion. A sample Objectives and Targets
procedure is available in Section 5, Document 5B1-3, "Establishing Objectives and Targets
for the GEMS Program." This procedure will define an environmental objective, the
associated operating units, target dates and methods. Form 5B1-3, "GEMS Objective and
Target Form" and Form 5B1-4, "GEMS Responsibility Matrix," may be used to outline
Objectives and Targets and organizational responsibilities.
PLAN - DO - CHECK - ACT
for Objectives and Targets
PLAN
Select Objectives & Targets
(Procedure for Objectives &
Targets)
ACT
Implement & Evaluate Corrective
Actions Discovered During
Monitoring & Measuring
(Procedure for Corrective Actions)
DO
Establish Operational Controls and
Measuring & Monitoring for
Objectives & Targets
(Procedure for Establishing Operational
Controls for Significant Aspects)
CHECK
Monitor & Measure Consistency with
Objectives & Targets
(Procedure for Monitoring & Measuring)
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Green Environmental Management Systems (GEMS) Guidebook Concepts of the GEMS Program
2.5 Plan for Achieving Targets and Objectives
This is the detailed plan explaining how the specific objectives and targets will be accomplished.
This plan usually notes responsible personnel, milestones, dates and measurements of
success. Noting monitoring and measurement parameters directly in the plan facilitates
conforming to the Monitoring and Measurement requirements discussed below. A sample
plan appears in Section 5B3.
2.6 Structure and Responsibility
The relevant management and accountability structure must be defined. This usually takes the
form of an organizational chart. Also, the organization must denote the GEMS Coordinator
who is responsible to oversee the GEMS and report to management on its operation. The
GEMS Coordinator's job description will reflect this responsibility (see Section 3, Enclosure
3-1). GEMS organizational structure and responsibility should be well defined in the VAMC
GEMS Policy, Section 5B.
2.7 Training Awareness and Competence
A procedure must address training in general knowledge of the GEMS (awareness) and
competence for the work involving significant environmental issues. Specific requirements
range from general facility-wide items, such as knowing the policy, to more function-specific
training on aspects and emergency response. The VAMC may respond to this element with a
training matrix, cross-referencing to training materials and records. See Section 3, Step 7. A
GEMS Training Program Policy is available in Section 5, Document 5B1-5. A training
program plan and attendance log is also provided. An additional program plan and needs
assessment are available in Section 3, Enclosures 3-4 and 3-5. A PowerPoint Awareness
Training Program is provided in Section 6, Enclosure 6 (on CD-ROM).
2.8 Communications
Procedures are required for both internal and external communications. Note that ISO 14001
requires procedures, but allows the organization to decide for itself the degree of openness
and disclosure of information. Whatever the decision in terms of disclosure, that decision
process must be recorded. A sample policy, "GEMS Communication to External and
Internal Parties" is provided in Section 5, Document 5B1-6.
2.9 GEMS Documentation
The organization must document GEMS in either electronic or paper form such that it addresses
the elements of the standard (ISO 14001) and provides direction to related documentation.
Not all GEMS procedures need to be documented, as long as the system requirements can be
verified (see Section 3, Step 5). A "GEMS Document and Record Control" sample policy is
available in Section 5, Document 5B1-7.
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Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
2.10 Document Control
Procedures are required to control documents, such as system procedures and work instructions;
they also need to ensure that current versions are distributed and obsolete versions are
removed from the system. See Section 3, Step 5. A document control worksheet is available
in Section 5, Document 5B1-7.
2.11 Operational Control
A procedure on operational controls for significant aspects connects the GEMS with the
organization as a whole. Here, the critical functions related to significant aspects and
objectives and targets are identified, and procedures and work instructions are created to
ensure the proper execution of activities. Requirements for communicating applicable
system requirements to contractors are also addressed (see Section 3, Step 5). A written
procedure for GEMS Operational Controls is available in Section 5, Document 5B1-8.
PLAN - DO - CHECK - ACT
for Operational Controls
PLAN
Identify Significant Aspects
(Procedure for Environmental Aspects)
ACT
Establish & Track Corrective Actions
For Non-Compliance/Non-Conformance
Discovered During Monitoring &
Measuring and Verify Effectiveness
(Procedure for Corrective Actions')
DO
Establish Operational Controls for
Significant Aspects
(Procedure for Establishing Operational
Controls for Significant Aspects)
CHECK
Monitor & Measure Activities for
Consistency with Operational Controls
(Procedure for Monitoring & Measuring)
2.12 Emergency Planning and Response
Although typically addressed through conventional emergency response plans, this element also
requires that a procedure be developed for the process of identifying the potential
emergencies, in addition to planning and mitigating them. A linkage to the aspect analysis,
where impacts are assessed, is appropriate. Emergency incidents include those that may not
be regulated, but may still cause significant impact as defined by the organization. The
VAMC's Emergency Management Plan should address controlling and preventing
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Green Environmental Management Systems (GEMS) Guidebook
Concepts of the GEMS Program
environmental consequences of emergency events (see Section 5, Document 5B1-9, "GEMS
Emergency Planning and Response").
2.13 Monitoring and Measurement
Procedures are required to describe how the organization will monitor and measure key
parameters of operations. These parameters relate to the significant aspects, objectives and
targets and legal and regulatory compliance. In order to properly manage the system,
measurements must be taken of the organization's performance to provide data for action.
Responses to this element usually cross-reference to many other specific procedures and
work instructions describing measurement and equipment calibration. Monitoring and
measurement of the success of the compliance program is measured in this element. This
requirement is commonly referred to as a compliance audit. Monitoring and measuring
procedures are addressed in "GEMS Monitoring and Measuring Procedure," Section 5,
Document 5B1-10, and "Biohazardous Waste Reduction Plan," Section 5, Document 5B3-1.
PLAN - DO - CHECK - ACT
for Compliance Assurance
PLAN
Identify Environmental Requirements
(Procedure for Legal & Other
Requirements)
ACT
Establish & Track Corrective Actions for
Non-Compliance/Non-Conformance
Discovered During Monitoring &
Measuring, Gap Analysis, &
Multi-Media Compliance Audit
(Procedure for Corrective Actions)
DO
Establish Operational Controls for
Regulated Activities/Materials
(Procedure for Establishing
Operational Controls for Significant
Aspects)
CHECK
Monitor & Measure Consistency with
Operational Controls
(Procedure for Monitoring & Measuring)
Conduct GEMS Gap Analysis
Annually
(Procedure for Gap Analysis)
Conduct Baseline Multi-Media
Compliance Audit at Least Every
3 Years
(Measuring and Monitoring Procedures)
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
2.14 Nonconformance, Corrective and Preventive Action
This element requires procedures for acting on nonconformances identified in the system,
including corrective and preventive action. Nonconformances may be identified through
audits, monitoring and measurement, and communications. The intent is to correct the
system flaws. Typically, Corrective Action Report (CAR) forms are the norm, noting the
nonconformance, the suggested fix and closure of the action when completed. Note that this
requirement does not imply in any way that the party identifying the nonconformance must
be the one to suggest the fix. Instead, it is expected that the system provide for the
information to be routed to the most appropriate party to address the concern. A corrective
action is not closed until verification of the effectiveness of the remedy. See Section 5,
Document 5B1-11, "GEMS Non-Conformance and Corrective & Preventive Action," for a
sample procedure.
2.15 Records
A procedure is required for record maintenance. Records are expected to exist to serve as
verification of the system operating. For example, records include audit reports and training
records. Unlike controlled documents, records are "once and done" documents, resulting
from the execution of some process or procedure. Procedures in this element are required for
the maintenance of records (see Section 3, Step 5).
2.16 Environmental Management System Gap Analysis
An internal audit procedure must be developed. This procedure will include methodologies,
schedules and processes to conduct the audits. Interestingly, the GEMS audit will in essence
audit the audit process itself! See Section 3, Step 3. A sample gap analysis policy and tool is
available in Section 3, Enclosure 3-2, and Section 5, Document 5B1-12.
2.17 Management Review
This element requires that top management periodically review the GEMS to ensure it is
operating as planned. If not, resources must be provided for corrective action. For areas
where there are no problems, the expectation is that with time, management will provide for
improvement programs. Usually there is no detailed procedure for this element; although
records of agendas, attendance and agreed-upon action items are maintained as verification.
A sample procedure for the review and sample report appear in Section 5, Document 5B1-13.
Enclosure
2-1 The Aspect Identification and Prioritizati on Process. (Courtesy of Edward Finer o, Office
of Federal Environmental Executive.)
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Table of Contents
Section 3 - Nine Steps to Establish a Successful
GEMS
3.1 Introduction
3.2 Nine Steps to a Successful GEMS
Step 1. Appoint GEMS Coordinator and Designate a GEMS Committee
Step 2. Train GEMS Committee
Step 3. Conduct GEMS Gap Analysis
Step 4. Identify Significant Environmental Aspects
Figure 3-1 - Process to Evaluate Environmental Aspects
Figure 3-2 - Some Useful Definitions
Figure 3-3 - Recommended Steps for Identifying Significant Aspects
Step 5. Establishing Operational Controls
(Develop, Publish and Distribute GEMS Policies and SOPs)
Step 6. Setting and Achieving Objectives and Targets
Step 7. Train Staff on GEMS Policies and SOPs
Step 8. Conduct Environmental Compliance Baseline Audit
Step 9. Annual Program Effectiveness Review and Report
Enclosures
3-1 Sample Position Description for GEMS Coordinator
3-2 GEMS Gap Analysis Tool
3-3 VHA Environmental Training Program Plan
3-4 GEMS Training Needs Assessment
3 -5 Green Environmental Management System Brochure
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Nine Steps to Establish a Successful GEMS Department of Veterans Affairs
Nine Steps to Establish a Successful
Green Environmental Management System
(GEMS)
3.1 Introduction
1. The nine steps presented below in Veterans Health Administration (VHA) language
represents a systematic approach to establishing a Green Environmental Management System
(GEMS) at VHA facilities. Because healthcare organizations are replete with management
systems, most of these steps will be very familiar to VHA management staff. Committee
work, audits, action plans, and continual improvement activities fill the days of most
healthcare managers. Only Steps 3 and 4 require activities that will be unfamiliar the first
year, and Step 8 will likely be accomplished by contract. The concepts supporting these
steps appear in Section 2.
2. Before describing the nine steps to establish a successful Green Environmental Management
System (GEMS), a clarification of roles and responsibilities may be useful:
Veterans Integrated Service Network (VISN) Director - The Network Director is
responsible for the development, coordination, implementation and evaluation of a
GEMS at each VHA facility.
VISN Safety Manager/Industrial Hygienist - The VISN Safely Manager/Industrial
Hygienist reviews and evaluates the GEMS at all VHA facilities within the Network.
Medical Center Director - The Medical Center Director is responsible for the development
and implementation of a GEMS program that addresses all VHA facilities under the
control of the Medical Center. The Director must:
• Appoint a GEMS Coordinator.
• Establish a GEMS Committee.
• Demonstrate commitment and provide resources and oversight necessary for an
effective GEMS program.
• Ensure that environmental responsibilities are contained in position descriptions and
performance measures developed for supervisors, managers and other appropriate
personnel.
• Ensure that a system is in place to identify all costs associated with GEMS.
Key Operations Managers - Key Operations Managers have broad control of systems and
operations of the facility (i.e., Chief of Safety/Industrial Hygienist, Chief of Engineering,
Chief of Acquisition and Materials Management, Chief of Environmental Management
Services, Chief of Facilities Management Service, Chief of VA Police/Security, etc.).
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Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
GEMS Coordinator - The GEMS Coordinator is responsible for coordinating with the VA
Medical Center (VAMC) staff, the community and regulatory agencies and ensuring that
GEMS addresses all applicable regulations and standards. This position is typically
assigned to the Chief Engineer, Facility Safety Officer, Industrial Hygienist or the Chief
of Safety.
Operating Unit Managers - The Operating Unit Managers are responsible for participating
in the GEMS, including planning, training and implementation.
3.2 Nine Steps to a Successful GEMS
Nine Steps to Establish a Successful
Green Environmental Management System (GEMS)
^-^
1
^— >
6
\
J Appoint GEMS
Coordinator
and Designate
GEMS
Committee
(
J Setting and
Achieving
Objectives and
Targets
f
~N
(L
/- — •
5
^1
(
V
\
) Train GEMS
Committee
(1
N 4 ^
J Conduct GEMS
Gap Analysis
V
J Establish Operational Controls
(Develop, Publish and Distribute
GEMS Policies and SOPs)
*•
\
J Train Staff on
GEMS Policies
and SOPs
(•
\
) Conduct
Environmental
Compliance
Baseline Audit
(•
— 1
4
>
-N,
^
>
\
} Identify
Significant
Environmental
Aspects
\
/ Annual
Program
Effectiveness
Review and
Report
—
Step 1 - Appoint GEMS Coordinator and Designate a GEMS Committee
The VA environmental policy should be reviewed as a guide in developing the GEMS program
(see Section 5B).
GEMS Coordinator - A GEMS Coordinator will be appointed at each VAMC to ensure
that the requirements of GEMS are established, implemented and periodically
reviewed in accordance with ISO 14001. The GEMS Coordinator participates in
most activities of the GEMS Committee, serving as technical consultant on ISO
14001 and environmental compliance. The VAMC will document this responsibility
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Nine Steps to Establish a Successful GEMS Department of Veterans Affairs
in a job description of the GEMS Coordinator (see sample position description,
Enclosure 3-1). The GEMS Coordinator is referred to as "Environmental
Representative" in ISO 14001.
GEMS Committee - The GEMS Committee is a multi-disciplinary committee established to
coordinate and oversee the GEMS.
a. GEMS Committee Membership - The membership of the GEMS Committee
should be specified in the VAMC GEMS Policy and should include:
• Chairperson (Senior management empowered to act on behalf of the facility.)
• GEMS Coordinator
• Representatives from:
Nursing
Infection Control
Facilities Engineering
Environmental Management Service
Safety/Industrial Hygiene
Acquisition and Material Management (Contracting and Logistics)
Laboratory
Research
Pharmacy
• Support services as needed/requested from:
VA Fire Department
Area Emergency Manager (if available)
Critical Operating Unit Managers
Public Affairs Officer
Nuclear Medicine (Radiation Safety Officer)
Fiscal
Education
b. The GEMS Committee should report to, or have a very close liaison with, the
facility Environment of Care Committee or Safety Committee.
c. Functions of the GEMS Committee include:
• Develop an action plan and timeline for establishment and implementation of
the GEMS, with the goal of full implementation by December 2005.
• Identify significant environmental aspects.
• Approve GEMS Implementing Procedures (Section 5B1) and Operational
Procedures (Section 5B2) that address significant aspects developed by the
Operating Units, Services or GEMS Committee.
• Assign roles and responsibilities of Operating Unit Managers and Key
Operators/Managers included in the GEMS.
• Oversee the development and maintenance of the GEMS.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
• Ensure that all employees have received appropriate training as required by
the GEMS.
• Establish and track the accomplishment of targets and objectives.
• Oversee an annual evaluation of the effectiveness of the GEMS, and report the
results to the facility director for approval and/or action.
Step 2 - Train GEMS Committee
While all the facility and VISN staff with GEMS responsibilities needs training, the GEMS
Committee will be trained first so they can develop, monitor and continually improve the
GEMS. The GEMS Committee training will include GEMS Awareness Training. The
competency training should also incorporate a GEMS implementation course that focuses on
the follow-through of the gap analysis process. A sample GEMS Awareness Training
Program PowerPoint presentation is provided on the CD-ROM (Section 6, Enclosure 6-6); it
can be modified as appropriate to meet the needs of a particular facility. A sample training
policy for GEMS appears in Section 5B1.
Step 3 - Conduct GEMS Gap Analysis
Note that this review is of the management system for conformance with the GEMS standards. It
is not a regulatory compliance audit; that will come later. For instance, in a GEMS review,
if an unlabeled hazardous waste container is discovered, the auditor will determine what
variance of GEMS element(s) led to that condition. It may be that the container labeling
Standard Operating Procedure (SOP) was not followed or was not appropriately written, or
the training program was not implemented as planned. Any of these findings will become
gaps to close in the corrective action plan. In a regulatory compliance audit, this same
unlabeled hazardous waste container will simply be an item on the list of deficiencies
(reference Section 2, Paragraph 2.16).
A review of the current environmental management system should be conducted initially to
determine any gaps in the program in relation to recognized environmental standards and
criteria. The GEMS review can be conducted by a trained GEMS auditor from outside the
facility, such as VISN staff or EPA staff conducting an Environmental Management Review,
or a contract ISO 14001 auditor. An internal audit team with training may also conduct a
review. The GEMS Gap Analysis Tool to conduct these reviews appears as Enclosure 3-2 to
this Section.
The purpose of the GEMS review is to produce a gap analysis to help the facility understand
what it is already doing in terms of the requirements for GEMS, and to identify ways to build
on existing programs and activities. VHA facilities will find that they are already performing
many of the GEMS activities, and they must only "fill in the gaps" between what they are
already doing and what needs to be done to establish their site-specific GEMS. The primary
purpose of GEMS is to bind together existing programs and activities so that efficiency,
effectiveness, performance and cost-effectiveness for the entire facility can be improved.
Building on existing programs becomes even more important when facilities are faced with
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Nine Steps to Establish a Successful GEMS
Department of Veterans Affairs
diminishing resources and being asked to "do more with less" (see GEMS Gap Analysis
Program Review, Section 5B1, Document 5B1-12).
The GEMS Committee will establish procedures to evaluate the effectiveness of the developing
environmental program using criteria consistent with the ISO 14001 model (reference
Enclosure 3-2, GEMS Gap Analysis Tool).
Once GEMS is implemented, many facilities are likely to realize a high return on their GEMS
investment through an improved "risk profile" that reduces the costs associated with
regulatory compliance, health and safety, incident response and cleanup of contaminated
sites. Improved public opinion and employee satisfaction can also be achieved. A gap
analysis is designed to answer the following questions:
• How well are the organization and its environmental programs performing?
• What standards of environmental performance does the organization hope to achieve?
• What are the gaps between objectives and performance?
• What existing programs and activities can serve as the best foundation for improved
environmental performance?
After the initial gap analysis, it should be repeated periodically to guide the GEMS Committee
toward full implementation. After GEMS is fully implemented, periodic gap analyses keep
GEMS on track and serves to document its status.
Step 4 — Identify Significant Environmental Aspects
Overview of the process:
There is a procedure describing how significant environmental aspects
are identified in order to determine where the organization can
focus its attention to accomplish the most with the least effort and
resources (see Section 5, Document 5B1-1). This involves a
process starting with identifying legal and other requirements (see
Section 5, Document 5B1-2) applicable to the activities of each
Operating Unit; then Operating Units identify and score the impacts
they have on the environment. The GEMS Committee reviews the
results of the scoring by the Operating Units and verifies that it is
consistent with significant aspects procedures. The Committee then
identifies significant aspects and asks the Operating Units to submit
operational controls (such as procedures) for all significant aspects.
The GEMS Committee then reviews all the operational controls for
each significant aspect to ensure there is agreement and consistency
within each program and across Operating Units (Step 5). This
process, as well as the gap analysis (Step 3), will determine if the
current SOPs reflect the actual practices. Finally, gaps between
written procedures and actual practice will be addressed as action
items for updates to the SOPs or changes in actual procedures,
possibly requiring retraining (Step 7).
SIGNIFICANT objectives
ASPECTS & Targets
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Green Environmental Management Systems (GEMS) Guidebook
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The GEMS aspect templates will be completed by Operating Units, and the Operating Units will
forward them to the GEMS Committee. The GEMS Committee will evaluate the reports
from the Operating Units to identify significant environmental aspects. A list of Operating
Units, along with sample environmental aspects templates, appear in Section 4 of this
Guidebook. These are examples only and should be edited to reflect the specific Operating
Units, environmental aspects and impacts at each medical center.
Figure 3-1: Process to Evaluate Environmental Aspects
No or yes
but want to
do more?
Objectives and
Targets
yes
Plan for meeting
Objectives and
Targets and
Operational
Control
No (still must have controls)
Deployed in
Environmental
Management System
Courtesy of Office of Federal
Environmental Executive.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Figure 3-2: Some Useful Definitions
Environmental Aspect - Element of the Operating Unit's activities and services that can
interact with the environment. An environmental aspect signifies the potential for an
environmental impact. Environmental impacts and aspects include both positive and
negative events, such as recycling paper and leaking drums.
Environmental Impact - Any change to the environment or to the health or safety of people,
whether adverse or beneficial, wholly or partially resulting from the operating unit's
activities or services.
Environmental Objective - Site-specific goal that the medical center sets for itself to
achieve. Objectives are selected from the significant aspects and are consistent with the
environmental policy. Example: Waste reduction.
Environmental Target - The measurable elements of the environmental plan, including a
measure of the objective (such as 10% reduction of waste) and a timeframe for
achievement (such as by the end of the fiscal year).
Significant Environmental Aspect - An environmental aspect that has or can have a
significant environmental impact.
Significant Environmental Impact - A significant actual or potential change to the
environment, wholly or partially resulting from the organization's activities or services.
Operating Unit Activity - A recurring activity or series of activities that is performed by the
Operating Unit in the accomplishment of its mission, including emergency
management.
See Section 2 for an in-depth discussion of these concepts.
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Green Environmental Management Systems (GEMS) Guidebook
Nine Steps to Establish a Successful GEMS
Figure 3-3: Recommended Steps for Identifying Significant Aspects
The GEMS Committee will distribute the appropriate sample environmental aspects template
from Section 4, along with instructions for completion and scoring guidelines (Section 4.2), to
each Operating Unit in the facility. The Operating Units will identify the environmental
aspects impacted by their operations and activities, and return the completed template to the
GEMS Committee. The sample below is from an Engineering Operating Unit.
Activity or
Service
Outdoor
Vehicle and
Equipment
Washing.
Parts Washing:
-Washer Fluid
-Washer Filter
Fertilizer
Applications.
Snow
Removal and
De-icing.
Aspect
Chemicals In
Runoff
Water.
Disposal of
Washer
Fluids.
Disposal of
Filter.
Use and
Disposal of
Fertilizers.
Application
of De-icing
Materials to
Icy Roads
and
Walkways.
Impact
Runoff Enters
the Storm
Water System.
Disposal of
Hazardous/
Regulated
Waste in
Municipal
Landfill.
Unnecessary
Use and
Improper
Disposal.
Runoff Enters
the Storm
Water System.
Compliance
2
3
1
3
Risk
2
0
0
0
Frequency of
Activity
2
4
1
2
VAMC
Control
4
4
2
2
TOTAL
SCORE
10
11
4
7
2. The GEMS Committee will evaluate the templates of all the Operating Units and identify
significant environmental aspects. A form like the one below will be useful to document the
decisions.
Operating Unit
ICU
ICU
Engineering
Aspect
Medical Waste
Isopropyl Alcohol Use
Fuel Storage
Aspect Evaluation Score
14
6
16
Significant Aspect
Yes No
X
X
X
See Section 5, Document 5B1-1, for a sample written procedure and Section 4 for sample
templates and scoring and ranking documents.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Step 5 - Establishing Operational Controls
(Develop, Publish and Distribute GEMS Policies andSOPs)
The GEMS Committee will develop the Medical Center Memorandum (see Section 5B) covering
GEMS policy, and the implementing procedures (see Section 5B1), and reference or attach
the supporting policies and standard operating procedures (SOPs) for significant aspects (see
Section 5B2). (Note that most of the GEMS implementing procedures [Section 5B1] are
discussed in one or more of the Nine Steps.)
SIGNIFICANT objectives
ASPECTS & Targets
The GEMS Committee will ask the Operating Units to develop the SOPs to maintain operational
control of the significant aspects identified by the GEMS Committee in Step 4. The GEMS
Committee will review all SOPs of significant aspects to ensure that they are consistent with
the GEMS policies and procedures. The GEMS Committee will oversee the elimination of
any discrepancies between the GEMS policies and procedures by coordinating the revision of
these documents or changing behavior. If there are existing Operating Unit SOPs that do
not score out as involving significant aspects, the Committee will determine that those
procedures will not be managed within the GEMS. For those aspects scored significant
where no operational controls exist, the Committee will task the Operating Units to
prepare it.
The GEMS Committee shall establish procedures for communication of GEMS policies (see
Section 5B1) throughout the organization. The GEMS Committee will also establish
procedures to review feedback from the Operating Units. Operating Unit managers should
regularly report the results of implementation to the GEMS Committee in accordance with
the monitoring and measuring procedure (see Section 5B1, Document 5B1-10). Reports
should include:
• Overall status of the GEMS implementation.
• Compliance with Environmental Regulations.
Corrective and Preventive Action Plans (Section 5B1, Document 5B1-11).
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Green Environmental Management Systems (GEMS) Guidebook
Nine Steps to Establish a Successful GEMS
The following format may be used for documenting the review and updating of the SOPs:
Operating Unit
Infection Control
Environmental
Mgmt. Service
EMS
Activity
Environmental
Rounds
Environmental
Collection and
Disposal of
Medical Waste
Significant
Aspect
Medical Waste
Disposal
Medical Waste
Disposal
Medical Waste
Disposal
SOP Title
and Number
Date of
Review
Date of Last
Update
Step 6-Setting and Achieving Objectives and Targets
From the list of significant aspects, the GEMS Committee selects a few for demonstrating
continual improvement. Continual improvement is determined by success in achieving the
objectives (a site-specific environmental goal, such as reducing hazardous waste) and
measurable targets (such as 10 percent reduction) by the target date (end of FY). A plan for
how to achieve the objectives and targets may include new or revised operational controls,
such as new procedures or the purchase of new equipment or materials. The targets,
objectives and plan for achieving them should appear in the GEMS Committee meeting
minutes. Results of periodic monitoring of the progress toward achieving the targets and
objectives will be reported in the GEMS Committee meeting minutes. The report of the
Annual Program Effectiveness Review that appears in the GEMS Committee meeting
minutes at the end of each year (Step 9) includes an evaluation of achievement of the targets
and objectives.
Objectives and targets should be meaningful and achievable. Occasionally, the GEMS
Committee may find that a target that was set cannot be achieved. As soon as that is
confirmed, the GEMS Committee should adjust the target or select a new one to
achieve. The goal is not perfection but rather continual improvement.
Two to five targets and objectives supporting the continual improvement of GEMS should be
developed by the GEMS Committee and reported to the facility Environment of Care
Council or Safety Committee where they will serve to monitor some aspects of the
Environment of Care (EOC) program as required by JCAHO EOC Standards. VHA medical
centers are accustomed to measuring and monitoring the hazardous materials management
program and reporting monthly, quarterly and annually to the facility EOC or Safety
IGN1FICANT Objectives
ASPECTS & Targets
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Committee. The GEMS targets and goals element will fit nicely into the existing monitoring
system, which can be expanded to cover not just hazardous materials management, but the
entire GEMS program. See a sample written plan for Setting and Achieving Target and
Objectives in Section 5B3.
The annual Waste Minimization and Compliance Reports submitted by each facility to
Environmental Programs Service (181C) provides the opportunity for tracking and trending
some features of its environmental performance. These reports should provide some ideas
for environmental objectives and targets at the facility level. To view the FY '02 Waste
Minimization and Compliance Report summarizing the national data, see Enclosure 1-5 in
Section 1.
Step 7- Train Staff on GEMS Policies andSOPs
The recommended training for all facility and VISN staff is outlined in Enclosure 3-3, VHA
Environmental Training Program Plan, and Enclosure 3-4, GEMS Training Needs
Assessment.
Training resources are identified in Section 5, Document 5B1-5, VHA Environmental Training
Program Plan, and include training programs that are being developed nationally by VHA
and will be announced as they become available. Other sources are Environmental
Protection Agency (EPA) Regional Offices, state environmental agencies and contractors.
Many of the training programs identified in the Enclosures are already being used at medical
centers for specific requirements such as those for underground storage tank (UST)
monitoring for operators, which is usually given by the manufacturer of the USTs.
JCAHO Environment of Care Standards, Occupational Safety and Health Administration
(OSHA), EPA regulations, and VHA Handbook 7701.1 address the requirements for
documenting training. Generally they require the training records to include date of training,
name and qualification of trainer, topics covered, names and social security numbers of
attendees. Some media-specific regulations of the federal EPA or state environmental
agencies have further requirements for training documentation, which should be confirmed
during the compliance audit.
The facility should develop a training program tailored to its particular needs. The training
program should provide sufficient education to the employees to ensure that the GEMS is
operating at the highest level. Training should include emphasis on the following:
• The importance of conformance to the policy.
• Recognition of significant aspects identified by the GEMS Committee.
• Individual roles and responsibilities regarding GEMS implementation and operation.
• Consequences of nonconformance.
• Environmental Awareness Training of Employees, including New Employee
Orientation.
• Annual reporting requirements.
Training status should be monitored, and refresher courses should be available periodically.
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Green Environmental Management Systems (GEMS) Guidebook Nine Steps to Establish a Successful GEMS
The Green Environmental Management Systems Brochure (included as a binder cover pocket
insert to this Guidebook and also as Enclosure 3-5) was designed to supplement the facility-
training program. It should be reproduced and given to all managers, so that the information
can be snared with all staff at monthly section/department meetings. As an additional tool,
GEMS should be added as an element in New Employee Orientation, and the GEMS
brochure reproduced and distributed to all incoming staff at that time. A sample GEMS
Awareness Training Program is in Section 6, Enclosure 6-6 (on CD-ROM).
Step 8 - Conduct Environmental Compliance Baseline Audit
Once the GEMS is designed and reviewed for gaps, medical center memoranda and SOPs
written, and training has been conducted, it is time to conduct a thorough multimedia
regulatory compliance audit addressing federal, state and local environmental regulations.
The purpose of this audit is to determine the compliance status of the facility and address any
non-compliance issues. The auditor will produce a report of non-compliance items
(violations), which the GEMS Committee will address with a corrective action plan for
immediate compliance and a tracking mechanism to report progress. The audit may instigate
the identification of additional significant aspects that require SOPs and targets or monitoring
by the GEMS Committee.
Compliance audits are usually conducted by external experts, which can include contractors and
experts from other federal agencies, but can be done by internal experts.
Scope: The regulatory compliance audit should cover all environmental regulations
impacting the medical center and include those promulgated by the federal EPA, state
environmental agencies and local regulatory entities.
Audit Tools: The Environmental Compliance Guidebook, Book 6B in the VHA Safety
Guidebook Series, published in 2003, is a multimedia guide to federal EPA regulations
affecting VHA medical centers. Some compliance assistance materials are available
from federal and state regulatory agencies.
(See Concepts, Section 2, paragraph 2.13; and Section 5, Document 5B1-10, Monitoring and
Measuring Compliance).
Step 9 —Annual Program Effectiveness Review and Report
The final step in developing your GEMS is the Annual Program Effectiveness Review, which
must cover at least these four elements:
• Status Report on the regulatory compliance program, specifically the completion of
previous corrective or preventive actions resulting from any compliance audits or
inspections.
• Status Report on GEMS implementation, specifically the completion of preventative
and corrective actions resulting from the GEMS gap analysis.
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Green Environmental Management Systems (GEMS) Guidebook
Department of Veterans Affairs
• Review of the accomplishments of the Targets and Objectives. This answers the
questions "Were the objectives and targets met? If not, why not? What corrective
actions were established?"
• Committee recommends adoption of new targets and objectives for the upcoming year
and proposes changes in the GEMS and/or improvements in the compliance program
based on findings of the GEMS gap analysis and compliance audit.
To maintain continual improvement, suitability and effectiveness of your environmental
management system, the Director is tasked to review and evaluate the environmental
management system at defined intervals. The GEMS Committee should carry out this
preliminary review with policy and program assessment and recommended changes to
objectives and targets. It will determine the suitability of the environmental management
system in relation to changing conditions and information. The GEMS Committee will
present their review, conclusions and recommendations to the Medical Center Director for
review, comment and approval. (See Section 5, Document 5B1-13, GEMS Procedure for
Annual Program Effectiveness Review and Report, for a sample procedure and sample
committee report.)
Congratulations on completing the Nine Steps of implementing GEMS! Now note that the
process of GEMS is cyclical and continual improvement requires revisiting Steps 3-9 of
GEMS on a regular basis.
Nine Steps to Establish a Successful
Green Environmental Management System (GEMS)
s~~^
1
^-^
6
\
J Appoint GEMS
Coordinator
and Designate
GEMS
Committee
(
J Setting and
Achieving
Objectives and
Targets
f
-N
(L
^ — -
5
^
(
\
\
) Train GEMS
Committee
(i
\ s
\
J Conduct GEMS
Gap Analysis
^
J Establish Operational Controls
(Develop, Publish and Distribute
GEMS Policies and SOPs)
*•
-}
J Train Staff on
GEMS Policies
and SOPs
(•
\
) Conduct
Environmental
Compliance
Baseline Audit
a
— i
4
>
-N
*s
>
\
) Identify
Significant
Environmental
Aspects
\
/ Annual
Program
Effectiveness
Review and
Report
^^H
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Green Environmental Management Systems (GEMS) Guidebook Nine Steps to Establish a Successful GEMS
The GEMS implementing procedures will specify the frequency of re-visiting each of these steps.
Enclosures
3-1 Sample Position Description for GEMS Coordinator.
3-2 GEMS Gap Analysis Tool.
3-3 VHA Environmental Training Program Plan.
3-4 GEMS Training Needs Assessment.
3-5 Green Environmental Management Systems Brochure.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Table of Contents
Section 4 - Operating Unit
Environmental Aspects Templates
4.1 Introduction
4.2 Instructions for Completing Templates
Figure 4-1 - Explanation of Aspects and Impacts Template Scoring
Enclosures
4-1 Sample Template with Explanation of Scoring Rationale
4-2 Blank GEMS Aspects Template
4-3 Operating Unit Templates
Administration
Blood Bank/Phlebotomy
Canteen
Cardiac Catheterization Laboratory
Clinical Laboratory
Dental Clinic/Laboratory
Dialysis
Domiciliary
Engineering
Above/Underground Storage Tanks
BMET Shop
Boiler/Chiller Plant
Carpentry/Lock Shop
Electrical Shop
HVAC Shop
Mason Shop
Motor Pool
Paint Shop
Pipe Shop
4-i
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Green Environmental Management Systems (GEMS) Guidebook Operating Unit Templates
Fire Department - Emergency Medical Service
Food and Nutrition
GI Procedure
Grounds Maintenance
Hematology/Oncology
Histology Laboratory
Housekeeping
Intensive Care Unit (ICU)
Inpatient Clinics
Interior Design
Information Resource Management (IRM)
Laundry Plant
Logistics, Contracting and Warehouse
Medical Media
Microbiology Laboratory
Operating Rooms
Outpatient Clinics
Pathology/Morgue
Pharmacy
Police
Prosthetics
Radiology and Nuclear Medicine
Rehabilitation (Occupational/Physical Therapy)
Research Laboratory
Safety/Industrial Hygiene
Specialty Care Clinics
Supply, Processing and Distribution (SPD)
4-4 GEMS Committee Ranking of Environmental Aspects
4-ii
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Operating Unit Environmental Aspects Templates
4.1 Introduction
Sample Operating Unit Templates have been developed as guides for the various Operating
Units to identify their particular environmental aspects. These samples have been developed
in a table format for easy customization and use. They are not intended to be comprehensive
or cover all the aspects at a particular location. Certain items in the samples may be specific
to a VA Medical Center (VAMC) while others may not.
Operating Unit managers should involve their staff members in completing the templates. This
will foster environmental awareness and ensure a more effective GEMS.
The Operating Unit templates may need revision as more information becomes available to
managers. As the templates evolve, feedback and coordination with the Green
Environmental Management Systems (GEMS) Committee will ensure consistency in the
GEMS Program.
On the sample templates in this Section, significant environmental aspects are identified in order
to determine where the organization can focus its attention to accomplish the most with the
least effort and resources. This starts with Operating Units identifying the impact(s) their
activities have on the environment, followed by the GEMS Committee determining which of
those impacts are significant aspects requiring operational controls.
The analysis of impacts will incorporate the following factors:
• The extent to which the aspect is regulated by law, regulation, Executive Order or
other requirement and how well the VAMC is complying with those regulations.
• The degree of risk to any exposed human population or exposed ecosystems.
• The frequency of the activity.
• The extent to which the aspect is under the control of the medical center.
The totals of the scores will determine which environmental aspects are significant and therefore
required to have operational controls. The GEMS Committee may select a cut off in the total
scores to identify significant aspects. The Committee may also review each aspect and set up
other criteria for selecting significant aspects, which must be reflected in their written
procedures.
Each year environmental targets and objectives are established for a few of the significant
aspects. This becomes the focus for continual improvement of the environmental program.
4.2 Instructions for Completing Templates
Operating Unit templates are divided into eight columns. The forms are designed to first look at
the routine processes within an Operating Unit (Column 1, Activity or Service); identify
those processes that have an environmental impact; evaluate each aspect to determine if it has
4-iii
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Green Environmental Management Systems (GEMS) Guidebook
Operating Unit Templates
or can produce a positive and/or negative effect (impact) on the environment. Once this is
completed for an Operating Unit, each aspect is ranked for Compliance, Risk, Frequency and
Control (see Figure 4-1, below for definitions and scoring). The Medical Center GEMS
Committee will then look at each Operating Unit's significant aspects as discussed in Section
3, Nine Steps.
Enclosure 4-1, Sample GEMS Aspects Rating Template, demonstrates how the rating for the
Blood Bank/Phlebotomy Laboratory was determined.
Figure 4-1
Explanation of Aspects and Impacts Template Scoring
Compliance
The extent to which the aspect is regulated by law, regulation,
Executive Order or other requirement
The aspect is not regulated or is in full compliance
Compliance activity has been initiated
Compliance activity has been scheduled
There is an awareness of non-compliance status, considering
compliance options
The aspect is out of compliance and has taken no compliance activity
to date
Score Assigned
0
1
2
3
4
Risk
The degree of risk to any exposed human populations or exposed
ecosystems
Minor risk to human population and/or ecosystems
Moderate risk to sensitive human populations and/or ecosystems
Moderate risk to general human populations and/or ecosystems
High risk to sensitive human populations and/or ecosystems
High risk to the general human population and/or ecosystems
Score Assigned
0
1
2
3
4
Frequency
Frequency that this activity occurs
< Once per calendar year
Bi-annually or less
Monthly
Weekly
Daily or more
Score Assigned
0
1
2
3
4
Control
The extent to which the aspect is under control of the Operating
Unit
Operating Unit has no control or influence
Operating Unit has some influence or control
Operating Unit has influence parity with other entities with some level
Score Assigned
0
1
2
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
of control
Operating Unit has significant influence
Operating Unit has total control over this aspect
3
4
This section contains sample forms showing how operating units list each impact, identify the
aspects, and rank their effect on the facility. A sample GEMS Committee Ranking is
included showing how the aspects rank as a whole. Also included is a blank form for facility
use.
Enclosures
4-1 Sample Template with Explanation of Scoring Rationale.
4-2 Blank GEMS Aspects Template.
4-3 Operating Unit Templates.
4-4 GEMS Committee Ranking of Environmental Aspects.
4-v
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Table of Contents
Section 5 - Sample GEMS Documents
5.1 Introduction
Figure 5-1 - GEMS Documentation Scheme
Tab A - VHA Environmental Policy
VHA Directive ## (Pending)
Tab B - VAMC GEMS Policy
Sample MCM, Green Environmental Management System (GEMS) Policy
Tab Bl - GEMS Implementation Procedures, Tools and Checklists
5B1 -1 Procedure for Determining Significant GEMS Aspects and Impacts
5B1 -2 GEMS Legal and Other Requirements
5B1-3 Establishing Objectives and Targets for GEMS Program
5B1 -4 GEMS Responsibility Matrix
5B1-5 GEMS Training Program
5B1-6 GEMS Communication to External and Internal Parties
5B1 -7 GEMS Document and Record Control
5B1-8 Procedures for GEMS Operational Controls
5B1-9 GEMS Emergency Planning and Response
5B1 -10 GEMS Monitoring and Measuring Procedure
5B1-11 GEMS Non-Conformance and Corrective and Preventive Action
5B1 -12 GEMS Gap Analysis Program Review
5B1-13 GEMS Procedure for Annual Program Effectiveness Review and Report
Tab B2 - Operational Procedures for Significant Aspects
5B2-1 Biohazardous Waste Management
5B2-2 Affirmative Procurement Program for Recycled-Content Products
5B2-3 Air Quality Management
5B2-4 Construction Waste Management
5B2-5 Disclosure of Known Lead-Based Paint in Residential Housing
5B2-6 Energy Management
5B2-7 Fuel Storage Tanks (Underground and Above Ground) and Piping Management
5B2-8 Hazardous Material and Waste
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
5B2-9 Management of Universal Hazardous Wastes
5B2-10 Mercury Pollution Prevention Program
5B2-11 Mercury Reduction Program
5B2-12 Notification of Environmental Incidents (Spills/Releases/Discharges)
5B2-13 Oil Spill Prevention Control and Countermeasure Plan
5B2-14 Pollution Prevention Plan
5B2-15 Pollution Prevention and Waste Minimization Plan
5B2-16 Precautions in Handling Carcinogenic Chemicals and/or Cytoxic Agents
5B2-17 Reclamation of Salvageable Material
5B2-18 Reporting of Environmental Incidents
5B2-19 Silver Recovery Program
5B2-20 Storm Water Prevention Plan
5B2-21 Underground Storage Tanks (USTs)
5B2-22 Waste Characterization Sampling and Analytical Work Plan
5B2-23 Waste Minimization Program
Tab B3 - Objectives, Targets and Plans for Meeting Objectives and Targets
5B3-1 Sample GEMS Committee Report of Annual Effectiveness Review
5B3-2 Sample Blank GEMS Objectives and Targets Form
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Department of Veterans Affairs
Sample GEMS Documents
The effective management of GEMS requires extensive documentation. Fortunately, most VHA
facilities will already have many of the required documents. The GEMS Committee must
review the existing documents and identify any required modifications and/or additions
needed. While updating the GEMS documents is an ongoing function of the GEMS
Committee, getting the required documents in place will likely take up the first year of the
GEMS program.
The design of the GEMS documentation program should be considered first, in order to create a
logical scheme that is understandable to all. For this purpose, one document organization
scheme is proposed in this Section (Figure 5-1); however, other schemes may be just as
appropriate.
Following is a listing of the categories of documents along with descriptions of their content.
Samples to illustrate the concepts, as well as serve as guidelines for evaluating existing
documents or creating new ones, are included in Tabs A through B3.
Tab A. As VA and VHA environmental policies become available, facility GEMS policies
should be updated to reflect the same commitment, language and targets.
Tab B. A medical center memorandum covering GEMS policy must be developed and signed
by the facility director. It can be a short document, as is this example (Tab B), with several
GEMS procedures as attachments (Tab Bl), or it can include the procedures within a larger
GEMS Medical Center Memorandum. VA Medical Center (VAMC) written policy should:
• Include a mission statement for development and implementation of VAMC policy that
meets EO 13148 and eliminates, minimizes and mitigates adverse environmental impacts.
• Comply with federal, state and local environmental laws and regulations.
• Evaluate VAMC operations to address the reduction of environmental vulnerabilities.
• Integrate pollution prevention, waste minimization, resource conservation and
environmental compliance into VAMC planning and decision making.
• Require training of VA staff to accomplish assigned environmental responsibilities.
• Designate the VAMC Director as the responsible person for the successful
implementation of a GEMS program.
• Assign responsibility to GEMS Coordinator and GEMS Committee to identify significant
aspects, set targets and objectives and approve action plans and program goals.
• Require annual review with recommendations be sent to VAMC Director for approval.
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Green Environmental Management Systems (GEMS) Guidebook Sample GEMS Documents
Tab Bl. There are 13 written procedures required in ISO 14001. These procedures describe the
steps required to implement and maintain an effective GEMS. The sample procedures in this
Section are provided to assist in developing a facility-specific implementation plan; however,
they will not work as written for all facilities. They should be revised to reflect the needs, the
culture and the activities at each facility. Procedures should be detailed enough to guide the
users to perform consistently. When writing these procedures, refer to Section 2 (Concepts)
and Section 3 (Nine Steps) of this Guidebook.
Tab B2. Sample operational procedures are provided as examples of operational controls of
significant aspects. Operational procedures do not need to repeat the regulatory requirements
or GEMS policies, but rather they must state how facility staff will conduct their activities in
order to meet the regulations, policies and objectives. For a hospital-wide objective, such as
biohazardous waste reduction, operational procedures must cover activities of all staff who
generate, handle and dispose of the waste. Therefore, there would be a need to have
operational procedure on waste reduction for Infection Control, Environmental Management
Service (Housekeeping), Safety/IH, Engineering, Contracting and clinical Operating Units.
Tab B3. Every year the GEMS Committee completes an annual report summarizing the year's
accomplishments. This report will also identify objectives and targets for the upcoming year.
The selection of new objectives and targets will be noted in the GEMS Committee minutes
and will be approved by the Director. A written plan for achieving the selected objectives
and targets should be included in or attached to the annual report. This Section contains a
sample annual report, along with the suggested forms for identifying new objectives and
targets and the written plan format.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Table of Contents
Section 6 - Technical Resources
6.1 Resources
a. Publication
b. Tools
6.2 WebSites
a. Environmental Management Systems Guides
b. Environmental Management Systems Standards
c. Site Specific Documentation Examples
d. Self Assessment/Environmental Audit Tools
e. Enforcement
f. General
g. Environmentally Preferable Cleaning Products
h. Chemical Cleaners and Disinfectants
i. Greening the VA
Enclosures
6-1 EPA Pamphlet 744-R-00-011, Integrated Environmental Management Systems
Implementation Guide
6-2 EPA Pamphlet 315-B-97-001, Implementation Guide for the
Code of Environmental Management Principles for Federal Agencies (CEMP)
6-3 US Army Environmental Management System Implementers Guide, Version 1.0
6-4 IL 049-02-11, Subject: Executive Order 13148
6-5 Federal Register 54061 - EPA Code of Environmental Principles
6-6 Green Environmental Management Systems (GEMS) Awareness Training PowerPoint
6-7 Sample Affirmative Procurement Program Facility-Level Audit Questions
6-8 OFEE Memorandum, Subject: EMS Self-Declaration Protocol
6-9 Checklist for Environmental Aspects
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Green Environmental Management Systems (GEMS) Guidebook Technical Resources
Technical Resources
This Section contains a list of the resources we have compiled, along with a summary paragraph
of each resource describing its contents to better help you select the best source of
information. The list is not all-inclusive but reflects the efforts of the Professional Advisory
Group (PAG) in providing the best information they have found to date. (Note: Reference
data and web site information was current at the time of publication of this Guidebook.)
Publications listed under Resources can be found on the accompanying CD-ROM only.
This Guidebook, as well as the entire Occupational Safety, Fire Protection and Industrial
Hygiene Guidebook series is available on the CEOSH web site:
vaww.ceosh.med.va.gov
Additional copies of this Guidebook may be obtained by contacting the CEOSH Administrative
Library at 314-543-6700.
6.1 Resources
a. Publications.
1) EPA Pamphlet 744-R-00-011, October 2000, Integrated Environmental
Management Systems Implementation Guide (Enclosure 6-1). Developed by the
Office of Pollution Prevention and Toxics, this brochure is intended to help
businesses integrate environmental concerns into their daily activities so they can
reduce cross media impacts, use energy and other resources efficiently, better
manage the risk associated with using hazardous chemicals, practice product and
process responsibility, and integrate environmental and worker safety and health
requirements.
2) EPA Pamphlet 315-B-97-001, March 1977, Implementation Guide for the Code
of Environmental Management Principles for Federal Agencies (CEMP)
(Enclosure 6-2). Developed by the Environmental Protection Agency (EPA) in
response to Executive Order 12856, CEMP is a collection of five broad principles
and underlying performance objectives that provide a basis for federal agencies to
move toward responsible environmental management. Adherence to the five
principles will help ensure environmental performance that is proactive, flexible,
cost-effective, integrated and sustainable. The CEMP is not a regulation; it is a
voluntary component of a program established to encourage federal agencies to
enhance their environmental performance through the creative use of management
tools. As such, the goal is to move agencies "beyond compliance" and the
traditional short-term focus on regulatory requirements to a broader, more
inclusive view of the inter-related nature of their environmental activities.
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3) US Army Environmental Management System Implementers Guide, Version
1.0, dated May 2003 (Enclosure 6-3). This guide provides Army personnel an
easy-to-use, step-by-step tool for implementing the Army's environmental
management system. It provides the information needed to establish and
implement an installation's environmental management system, while allowing
the flexibility to address differing installations' missions and operational readiness
requirements.
4) IL 049-02-11, Office of Acquisition and Materiel Management Information
Letter, Subject: Executive Order 13148, Greening the Government Through
Leadership in Environmental Management, dated July 5, 2002 (Enclosure 6-4).
This IL provides guidance to acquisition and procurement professionals regarding
Executive Order 13148, which requires federal agencies to integrate
environmental accountability into day-to-day decision-making and long-term
planning processes.
5) Federal Register 54061, Volume 61, No. 201, dated October 16, 1996, Notices,
Environmental Protection Agency Code of Environmental Principles (Enclosure
6-5). This is the public announcement of the issuance of the Code of
Environmental Management Principles developed by EPA in consultation with
other federal agencies as mandated by EO 12856, Federal Compliance With
Right-to-Know Laws and Pollution Prevention Requirements, August 3, 1993.
b. Tools.
1) Green Environmental Management Systems (GEMS) PowerPoint Presentation
developed by the Center for Engineering & Occupational Safety and Health
(CEOSH), Department of Veterans Affairs (Enclosure 6-6). This presentation can
be used by Medical Centers to provide training to staff on environmental
management roles, responsibilities, procedures and compliance.
2) Sample Affirmative Procurement Program (APP) Facility-Level Audit Questions
(Enclosure 6-7). A tool to assist procurement personnel in meeting the Facility
Affirmative Procurement Program.
3) Office of the Federal Environmental Executive to Agency Environmental
Executives, Subject: EMS Self-Declaration Protocol, dated January 27, 2004
(Enclosure 6-8).
4) Checklist for Environmental Aspects (Enclosure 6-9). A tool to assist managers
in identifying environmental aspects within their area of responsibility.
6.2 WebSites
a. Environmental Management Systems Guides.
http://www.epa.gov/ne/assistance/univ/index.html - DRAFT College and University
Environmental Management System Implementation Guide, US EPA, October,
2001. EPA Region 1 created this guide to help colleges and universities design
and implement an environmental management system in a streamlined, cost-
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Green Environmental Management Systems (GEMS) Guidebook Technical Resources
effective manner. This document provides an overview of the Guide content and
organization, and a road map for getting started, including form templates. Since
some federal agencies have functions similar to educational institutions, this guide
could be useful.
http://www.dep.state.pa.us/dep/deputate/pollprev/Isol4001/12elemnrl.pdf -
Guidance developed by EPA National Enforcement Investigation Center to assist
in developing enforcement documents requiring environmental management
systems. It gives an outline of many of the elements that should be considered
when developing an action directed at requiring an environmental management
system. The structure is somewhat different than that of an ISO 14001 type,
although the same concepts are incorporated. It is specifically designed to assist
facilities that have had compliance problems to develop a systematic approach to
compliance obligations.
http://www.epa.gov/dfe/pubs/iems/iems template/template-cover.pdf - EPA
Pamphlet 744-R-00-012, dated 2001, Integrated Environmental Management
Systems, Company Manual Template for Small Businesses. This contains
examples and samples of documents and procedures that may be adapted by or to
a particular company and its environmental management system. It will not be a
substitute for development of a specific environmental management system or
replace the implementation process, but it can help to facilitate the development
process and enhance the documentation. Caution is advised as this document
may invite over-simplification through cut-and-paste. While cut-and-paste can
be useful as a tool, it should not be substituted for facility specific evaluation and
system development.
http://www.nsf-isr.org/ - Environmental Management Systems: An Implementation
Guide for Small and Medium-Sized Organizations, Second Edition, NSF
International, Ann Arbor, MI, January 2001. Although developed for smaller
organizations, this guide is an excellent primer in environmental management
systems and can be of use to organizations of any size. It provides a step-by-step
approach to implementing environmental management systems at smaller
organizations and includes worksheets and examples to assist the implementer.
Contains an extensive appendix of sample documents and procedures. There is a
strong focus on organizational and management techniques for successful
implementation. (Also available at EPA web site http://www.epa.gov/ems).
b. Environmental Management Systems Standards.
ISO 14001, 14004 - Available in some libraries for reference, but they are
copyrighted by ANSI. ISO 14001 is the Environmental Management System
standards, and ISO 14004 is the implementation guidance. Standards are available
for purchase from:
• American National Standards Institute - http://www.ansi.org
• American Society for Quality -
http://qualitypress.asq.org/perl/catalog.cgi?category=Standards
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• NSF International Strategic Registrations -
http://www.techstreet.com/info/iso.html
• http://www.epa.gov/p2/programs/voluntary.htm - EPA Standards Network Fact
Sheets, ISO 14000 International Environmental Management Standards and the
Role of Voluntary Standards.
c. Site Specific Documentation Examples.
http://www.cityofseattle.net - Seattle, Washington's Environmental Management
Program web site provides background information regarding the City's approach
to their environmental management system. It consists of three parts: Part A
outlines the planning process and describes the management system for meeting
the environmental policy; Part B details the environmental policies and
performance indicators; and Part C identifies the specific work elements by
department planned for the next two years to implement this management
program. Also on this site is a benchmarking report developed from telephone
interviews and reviews of documentation from 23 municipal organizations.
Finally, this site contains a bibliography of environmental management resources.
http://www.ci.scottsdale.az.us/ecosystem - Scottsdale, Arizona's Environmental
Management System web site provides background information regarding the
City's environmental management system, as well as general information and
other applicable web sites.
http://pen.ci.santa-monica.ca.us/environment/policy/ - Santa Monica, California's
Sustainable City Program web site provides information on the City's approach to
a sustainable community. The program has been evolving since 1994; site
includes environmental policies, information on environmental programs to
implement those policies and indicators.
http://www.getf.org/proj ects/muni.cfm - The Global Environmental and Training
Foundation (GETF) provides training to the public sector by supplying
organizations with the information and tools they need to practice proactive
environmental management and to utilize this approach to identify and
successfully manage their environmental responsibilities and prevent new
environmental security risks. The Environmental Management System Pilot
Program for Local Government Entities is a detailed report on a pilot project that
the EPA Office of Wastewater Management sponsored in 1997-99 to implement
environment management systems at nine public agencies across the country.
The final report discusses the process, benefits and costs to the participants in a
fair amount of detail. Also there are case studies that describe each facility's
experiences, including benefits, resource commitments (labor, dollars, cost of
consultants if used) and the barriers encountered along the way.
http://www.dep.state.pa.us/dep/deputate/pollprev/Isol4001/emsrcemp.pdf - An
Environmental Management Systems Review of the National Park Service, EPA
Publication 300-R-00-006, Office of Enforcement and Compliance Assurance,
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August, 2000. Using the CEMP, a gap analysis was conducted of the NFS
management systems supporting their environmental program.
http://www.dep.state.pa.us/dep/deputate/pollprev/isol4001/Ford Manual/fordmanual.
htm - DOD EMS/ISO 14001 Pilot Study Sites and Points of Contact, Ford Motor
Company's ISO 14001 Environmental Management Systems Template. MS
Word documents downloadable as Section 3 of the Environment Management
System Workbook, December 1999.
http://www.epa.gov/ems - US Environmental Protection Agency's main
environmental management systems web site provides information and resources
related to environmental management systems for businesses, associations, the
public and state and federal agencies. Examples are EPA's internal
environmental management policy, 2001 Action Plan for incorporating
environmental management systems into the agency's programs and the revised
EPA position statement (2002).
d. Self Assessment/Environmental Audit Tools.
http://www.epa.gOv/compliance/resources/publications/incentives/ems/emstoolsmas.p
df. - Environmental Management System Tools: A Reference Guide, EPA
Publication 300-B-02-012. EPA Federal Facilities Enforcement Office, June
2001. Discusses use of CEMP and, for agencies that have adopted ISO 14001,
use of the Oregon Green Permits Program Guide ISO-based approach to conduct
an environmental management self-assessment.
Generic Protocol for Conducting Environmental Audits at Federal Facilities, 3rd
Edition, Federal Interagency Workgroup, 1998. Includes three sections: a very
detailed but now dated compliance auditing protocol, a section on auditing
environmental management systems within a media program, and a section on
auditing facility-wide environmental management systems. Available for
purchase from the Government Printing Office.
http://www.gemi.org - Exploring Pathways to a Sustainable Enterprise: SD Planner,
Global Environmental Management Initiative (GEMI), 2002. Their web site
states "this detailed and comprehensive self-assessment tool is designed to help
companies evaluate, plan for and integrate sustainable development into business
processes. The tool addresses all three aspects of development: environmental
impact, economic development and social equity as well as activities that can be
undertaken toward achieving those goals. Can assist companies in identifying the
critical sustainable development issues that are important to business activities."
http://www.c2e2.org/index.htm - The Campus Consortium for Environmental
Excellence is a not-for-profit corporation formed by several New England
colleges and universities. To help these colleges and universities move their
environmental management systems forward, the C2E2 has developed a self-
assessment tool (http://esf.uvm.edu/c2e2) designed to help a campus identify the
strengths and weaknesses of its current environmental management system.
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http://www.epa.gov/ortnisbol/pubs.httn - The Small Business Source Book on
Environmental Auditing, US EPA, May 2000. This is a comprehensive resource
guide that may be useful for organizations of all sizes. It describes publicly
available sources of information and training on environmental auditing.
e. Enforcement.
http://www.state.ma.us/dep/enf/enforce.htm - Massachusetts Department of
Environmental Protection (MADEP). New guidance from MADEP that provides
some slightly different insight than the NEIC document.
/ General.
https://www.denix.osd.mil/denix/Public/Library/EMS/ems.html - The Department of
Defense's (DoD's) DENIX web site provides environmental management systems
news, policy and guidance within DoD activities worldwide. Information
included on the site includes case studies, presentations and self-assessment tools.
http://www.p2pays.org/iso/ - North Carolina's Department of Natural Resources
Environmental Management Systems site provides case studies and design tools
to use when implementing an environmental management system and answers
frequently asked questions.
http://p21ibrarv.nfesc.navy.mil/ems/introduction.html - Navy Environmental
Management Systems Library. The primary purpose of the Joint Service P2
Library is to provide a source of information sharing throughout DoD. The
Library is designed as a clearinghouse for Joint Service environmental
management systems resources, including addressing issues and fostering
information sharing, success stories and lessons learned.
http://p2ric.org/TopicHubs/toc.cfm?hub=9&subsec=7&nav=7 - The Pollution
Prevention Regional Information Center's web site is intended as a quick guide to
environmental management systems, as well as a compilation of pertinent on-line
resources. The site offers general background information, including a lengthy
collection of documents on the overall impact of environmental management
systems.
http://www.peercenter.net/emsinplace/ and
http://www.peercenter.net/howtoimplement/sampledoc.cfm - EPA's PEER
Center acts as a clearinghouse of GEMS information. This includes a database of
environmental management systems implemented in the US. This database is
searchable by state, fenceline and government entity. The Center also has sample
documentation on various aspects of environmental management systems from
primarily local governments.
http://www.eli.org/isopilots.htm - The National Database on Environmental
Management Systems (NDEMS) is a collaborative effort between the EPA, the
University of North Carolina, the Environmental Law Institute and several states
to compile data to determine how the environmental and economic performance
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Green Environmental Management Systems (GEMS) Guidebook Technical Resources
of a range of corporate, military and municipal facilities is affected by the
implementation of environmental management systems.
http://tis.eh.doe.gov/oepa/ - This US Department of Energy (DOE) site provides
guidance documents created by DOE addressing environmental management
systems at federal facilities.
http://www.iwrc.org/programs/ems.cfm - The Iowa Waste Reduction EMS Service
Center provides small businesses with assistance regarding environmental actions.
The site contains environmental information specific to meat processors, soybean
growers, pork producers, automotive suppliers, food processors and die casters.
http://www.epa.gov/sbo/labguide.htm - Environmental Management Guide for
Small Laboratories, US EPA, July 1998. Prepared to assist those responsible for
administering or improving environmental management programs at small
laboratories, this includes a detailed section outlining requirements of federal
environmental regulatory programs that affect laboratories. It includes brief
section on P2 opportunities and an introduction to the concept of environmental
management systems. Not a comprehensive environmental management systems
guide.
http://www.epa.gov/compliance/resources/publications/incentives/ems/emsprimer.pdf
._ - Environmental Management Systems Primer for Federal Facilities. Office of
Environmental Policy and Assistance, US Department of Energy, and Federal
Facilities Enforcement Office, US EPA, 1998. The goal of this guide is to help
federal managers understand environmental management systems and how one
can help them improve environmental management at their facilities. It is not
intended to be a technical or detailed manual on implementation. Rather this
Primer outlines the elements of an environmental management system, offers tips
on how to make the case for an environmental management system to upper
management, explains how it will benefit an organization and places it in the
context of regulations, compliance issues, pollution prevention and other
government programs.
http://www.ofee.gov - Office of the Federal Environmental Executive. The OFEE's
mission is to promote sustainable environmental stewardship throughout the
federal government by encouraging sustainable practices; identifying and sharing
success stories, best practices and other tools to make sustainable practices easier
to adopt and maintain; providing training, awareness and outreach; assisting in
coordinating and advancing sustainability policies across agencies; publicly
advocating and supporting sustainable practices and policies; and measuring and
reporting on agencies' progress. Web site contains environmental information,
publications and links to additional environmental information.
http://www.dep.state.pa.us/dep/deputate/pollprev/isol4001/isol4000.htm. - ISO
14001 in Pennsylvania. Web site covering environmental happenings within
Pennsylvania. Repository for a variety of useful documents from around the
country, including EPA documents no longer available on the EPA web site.
Includes case studies and interesting articles.
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http://www.epa.gov/perfortnancetrack/ - National Environmental Performance Track
Program Description and Application Package. NEPT is EPA's national program
to promote environmental management and provide recognition for superior
environmental performance by facilities using an environmental management
system.
http://www.napawash.org - Third Party Auditing of Environmental Management
Systems: US Registration Practices for ISO 14001, National Academy of Public
Administration (NAPA), May 2001. An in-depth study done for the EPA about
the ISO 14001 registration process and how it functions.
http://www.eli.org/isopilots.htm - National Database on Environmental Management
Systems (NDEMS). Created by the University of North Carolina at Chapel Hill
(UNC) and the Environmental Law Institute (ELI), supported by US EPA, and
with cooperation of the Multi-State Working Group on Environmental
Management Systems (MSWG), the project is compiling data on the process and
nature of environmental management system implementation, the costs and
benefits realized and the economic benefits. The project seeks to determine how
the environmental and economic performance of a range of corporate, military
and municipal facilities is affected by the implementation of environmental
management systems.
http://www.eli.org/isopilots.htm - Drivers, Designs and Consequences of
Environmental Management Systems: A Research Compendium, March 12,
2001. This is a series of research papers on various issues related to
environmental management systems implementation and associated public policy
issues prepared by University of North Carolina and the Environmental Law
Institute in conjunction with the National Database on Environmental
Management Systems (NDEMS).
http://www.globalreporting.org - The Global Reporting Initiative is a multi-
stakeholder process and independent institution whose mission is to develop and
disseminate globally applicable guidelines for reporting on the economic,
environmental and social performance (initially for corporations and eventually
for any business, governmental or non-governmental organization). It is a
partnership between the Coalition for Environmentally Responsible Economies
(CERES) and the United Nations Environmental Program (UNEP) and seeks to
make sustainability reporting routine and credible in terms of comparability, rigor
and verifiability.
http: //www. natural step. org - The Natural Step is a non-profit advisory and think-
tank organization that helps businesses and government agencies integrate
sustainability into core strategy and operations.
http://www.rprogress.org - Redefining Progress (USA) is "a nonprofit public policy
organization that creates policies and tools to ... protect common social and
natural assets and to foster social and economic sustainability." It has a program
for calculating a personal ecological footprint, as well as links to national
footprints. Its Community Indicators Project links existing and emerging projects
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and facilitates the development of community indicator initiatives nationwide
through a series of tools, resources and technical support.
http://www.lewis.army.mil/envcaretakers - Fort Lewis, Washington, is the first
federal agency to achieve certification of its forestlands. Its forestry practices
were evaluated as related to environmental, industrial and social criteria.
Environmentally Preferable Cleaning Products. This is a revised list of green
cleaning/janitorial project web sites compiled by Dianne Thiel, Federal Facilities
Coordinator (8P-P3T), US EPA Region 8.
http://www.informinc.org/cleanforhealth.php - INFORM, Inc is a nonprofit group
that did a very informative report on changing to green janitorial products. Has a
large list of green cleaning products that have been reviewed by existing state or
local government green cleaning programs. Contains vendor information.
http://www.pnl.gov/esp/greenguide/custodialproducts - DOE Pacific Northwest
National Laboratory, Richland, WA case study of their switch to green janitorial
products. They use one company's cleaning products (at a very large site).
Sandra Cannon, Pacific Northwest National Laboratory, Environmentally
Preferable Purchasing Technical Assistance for the U.S. Department of Energy,
(509)529-1535
http://www.epa.gov/Region8/conservation recycling/yellowstone.html -
Yellowstone/Grand Teton National Parks faced special challenges in switching to
green janitorial products. Contains an interesting step-by-step case study, toxicity
and environmental information on common chemicals in cleaning products, and
discusses why chemicals in cleaning products are a concern. Contains the City of
Santa Monica's bid specifications for janitorial products.
http://www. newdream. org/procure/products/clean.html - Center for a New
American Dream is a nonprofit group working with state and local governments
on green janitorial products; participating governments have agreed to use the
Green Seal Standard 37 for Institutional and Industrial Cleaners.
http://www.ci.santa-monica.ca.us/environment/policy/purchasing/policies.htm -
Janitorial Products Purchasing Criteria, Santa Monica, California, was one of the
first to develop an environmentally preferable janitorial products purchasing
program. Custodial cleaning products were identified as the first category of
toxic products to be addressed under the program following a TUR assessment of
City operations. The goals of the cleaning product program are:
• To safeguard City custodial workers' health by minimizing workplace
exposure to hazardous materials.
• To minimize the environmental impacts incurred due to the manufacture, use
and disposal of custodial products used to clean City facilities.
• To increase workplace morale by allowing custodians to participate in
decisions about their work.
• To achieve a cost savings while maintaining or improving the level of service.
• To decrease liability for workers compensation claims.
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• To decrease custodial staff sick days due to exposure to toxic materials.
This program included a pilot-testing phase to evaluate the effectiveness of
various less toxic or non-toxic alternative custodial products. City custodians
were enlisted to test the products and provide feedback. The results of the pilot
contributed to the development of purchasing specifications for the evaluation of
bids from custodial product vendors. The specifications include environmental
and public health criteria as well as performance and cost criteria.
http ://www. greenseal. org - Goto product standards and look for Standard 37 on
Institutional and Industrial Cleaners, and Standard 34 on Degreasing Agents.
http://www.state.ma.us/osd/enviro/products/cleaning.htm - State of Massachusetts
used Standard 37 for a statewide procurement.
http://www.epa.gov/opptintr/epp/ - EPA's Environment + Price = Performance
(EPP) web site has information on green cleaning efforts around the country.
OSHA's Blood Borne Pathogen Regulation and Approved Disinfectants: When
implementing your green cleaning project, OSHA requires (29 CFR 1910.1030)
you to use an EPA registered tuberculocidal disinfectant (List B) or HIV
I/Hepatitis B disinfectant (List D) for cleaning up blood borne pathogens (i.e.,
bodily fluids or materials that have been in contact with liquid bodily fluids).
Most green cleaning products, even the disinfectants, aren't registered by EPA's
pesticide program as List B or List D disinfectants. This means that if the
University switches to green cleaning products, the janitorial staff still needs to
have access to an EPA registered tuberculocidal disinfectant for this special
need. One product on EPA's list whose active ingredient was listed as citric acid.
That would be a green product, if the inert ingredients were green. However,
most of the tuberculocidal disinfectants use chlorine bleach or similar serious
germ killers and would not be classified as environmentally preferable. The trick
in a green cleaning program is to limit the use of these products to the OSHA
blood borne pathogen situations. You could look for the registered product that
has the lowest bleach solution, as one approach.
EPA Disinfectant Web Site, http://www.epa.gov/oppad001/chemregindex.htm -
These strong disinfectants, used in hospital settings, do not need to be used all
the time, just for cleaning up blood or other bodily fluids. For disinfectant needs
other than in blood and bodily fluids covered by OSHA's regulations, a regular
environmentally preferable disinfectant can be used. The first set of numbers of
the EPA registration number refers to the registrant's identification number and
the second set of numbers represents the product identification number. A
distributor's product may use a different name, but must have the first two sets of
EPA Reg # of the primary registrant, plus a third set of numbers that represents
the Distributor/Relabeler Identification number, for example EPA Reg #001234-
000012-000567. An establishment number (EPA Est #) is the place where the
pesticide, formulation or device is produced and it is indicated by a set of codes
which consist of the registrant's number followed by the State where the product
is made and facility number.
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Green Environmental Management Systems (GEMS) Guidebook Technical Resources
h. Chemical Cleaners and Disinfectants. from Medical Industry Roundtable (MIRT)
Workshop: Clean Effectively and Reduce Chemical Hazards at Health Care Facilities
1) Selection and Use of Disinfectants:
http://www.mntap.umn.edu/health/disinfection.htm - Disinfection Best
Management Practices - Using best management practices for disinfecting
will help ensure that you are cleaning appropriately to kill the bugs - the
microbes - you need to kill. A side benefit is that you use only the amount of
disinfectant necessary to do the job. Ultimately, best management practices
protect patients, employees and the environment.
http://www.ehs.ucdavis.edu/sftynet/sn-51 .cfm - University of California Davis-
Selecting Chemical Disinfectants - The disinfectant table lists the disinfectants
most commonly used in laboratories, some commercially available products,
general use parameters, important characteristics, potential applications, and
general types of organisms they are effective against. This list should be used
as a general guide for selection in meeting your particular requirements.
http://www.apic.org/pdf/gddisinf.pdf - APIC Guideline For Selection and Use of
Disinfectants. The Association for Professionals in Infection Control and
Epidemiology (APIC) assists health-care professionals in their decisions in the
judicious selection and proper use of specific disinfectants.
2) Alternative Cleaning Products:
http://www.sustainablehospitals.org/cgi-bin/DB_Index.cgi - Sustainable
Hospitals Project Alternative Cleaning Products - Provides technical support
to the healthcare industry for selecting products and work practices that
reduce occupational and environmental hazards, maintain quality patient care
and contain costs.
http://www.ciwmb.ca.gov/wpie/healthcare - California Integrated Waste
Management Board -Waste Prevention Information Exchange Health Care
Waste: (Microfiber Mops; Replacing Ethylene Oxide and Glutaraldehyde) -
Comprehensive list of publications, fact sheets and web links to information
on healthcare waste.
http://www.zerowaste.org/ugca.htm - Zero Waste Alliance Unified Green
Cleaning Alliance - Promotes credible and reliable criteria to distinguish
cleaning product formulations that perform and are preferable with respect to
human and environmental health. We refer to those products as sustainable or
"eco-effective."
http://www.newdream.org/procure/products/clean.html - Center for New
American Dream Green Cleaners Product List - The Center for a New
American Dream helps Americans consume responsibly to protect the
environment, enhance quality of life and promote social justice. The Center
works with individuals, institutions, communities and businesses to conserve
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
natural resources and promote positive changes in the way goods are produced
and consumed.
3) Miscellaneous:
http://www.greenseal.org/standards.htm - Green Seal is a labeling standard for
industrial and institutional cleaning products. The standard helps users and
purchasers of cleaning chemicals select products that clean effectively while
minimizing negative health and environmental effects.
http://eerc.ra.utk.edu/ccpct/pdfs/EnvPrefCleaners-wholedoc.pdf - Green Seal
Standard and Environmental Evaluation for General-Purpose Bathroom and
Glass Cleaners Used for Industrial and Institutional Purposes - This report was
prepared by the University of Tennessee Center for Clean Products and Clean
Technologies for Green Seal to evaluate three classes of industrial and
institutional cleaners: general-purpose cleaners, bathroom cleaners, and glass
cleaners. Green Seal focused on these three cleaners because they are
frequently used with annual sales of $2.38 billion.
www.epa.gov/pesticides/factsheets/antimic.htm - US EPA Information on
Antimicrobial Pesticide Products - More than 8000 antimicrobial products are
currently registered with the US Environmental Protection Agency (EPA) and
sold in the marketplace. Nearly 50% of antimicrobial products are registered
to control infectious microorganisms in hospitals and other healthcare
environments. However, public health antimicrobial products tend to be low-
volume products, and thus constitute less than 5% of the estimated total
market for antimicrobial products.
4) The following resources were contributed by Philip Dickey, Washington Toxics
Coalition:
http ://www. wrppn. org/Janitorial/jp4.cfm - Janitorial Products Pollution
Prevention Project - Risks of janitorial products and ingredients,
recommended alternatives (Sponsored by US EPA, Cal/EPA Department of
Toxic Substance Control, Santa Clara County Pollution Prevention Program,
City of Los Angeles, City of Richmond, City of Santa Barbara, Local
Government Commission).
http://www.informinc.org/cleanforhealth.php - Excellent Report on Cleaning
Products from INFORM - Cleaning for Health: Products and Practices for a
Safer Indoor Environment, Alicia Culver, Marian Feinberg, David Klebenov,
Judy Muskinow, Lara Sutherland (86 pp. $30; $15 for government/nonprofit;
contact below for bulk rate) ISBN 0-918780-79-9 (August 2002).
http://www.epa.gov/opptintr/dfe/ - The Design for the Environment (DfE)
Program is one of EPA's premier partnership programs, working with
individual industry sectors to compare and improve performance, human
health, environmental risks, costs of existing and alternative products,
processes and practices. DfE partnership projects promote integrating cleaner,
cheaper and smarter solutions into everyday business practices.
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Green Environmental Management Systems (GEMS) Guidebook Technical Resources
EPA also supports using "benign by design" principles in the design,
manufacture, and use of chemicals and chemical processes—a concept known
as "green chemistry." EPA's Green Chemistry Program promotes the
research, development, and implementation of innovative chemical
technologies that prevent pollution in both a scientifically sound and cost-
effective manner. In addition, EPA's emerging Green Engineering Program
strives to help academia introduce a "green" philosophy into undergraduate
chemical engineering curricula. The DfE Program works with these and other
related programs.
http://www.watoxics.org/pages/root.aspx - Scientific Report on APE Surfactants
- Troubling Bubbles: The Case for Replacing Alkylphenol Ethoxylate
Surfactants, Philip Dickey, Washington Toxics Coalition, 1997. This 88-page
report documents the scientific evidence that APEs are poor environmental
performers. Includes a summary of research on biodegradability, endocrine
disruption and toxicity, as well as recommendations for replacing APEs with
alternative surfactants. Contains a list of 477 products found to contain one or
more APEs. (Prices: $5.00 individuals and non-profits; $10.00 government
agencies; $25.00 businesses.) Available by mail at Washington Toxics
Coalition web site.
5) Other Links, Organizations and Associations:
http://atsdr 1.atsdr.cdc.gov/toxfaq.html - Agency for Toxic Substances and
Disease Registry (ATSDR) ToxFAQs - This is a series of summaries about
hazardous substances developed by the ATSDR Division of Toxicology.
Information for this series is excerpted from the ATSDR Toxicological
Profiles and Public Health Statements. Each fact sheet serves as a quick and
easy to understand guide. Answers are provided to the most frequently asked
questions (FAQs) about exposure to hazardous substances found around
hazardous waste sites and the effects of exposure on human health.
http://www.epa.gov/tri/chemical/appendixcl999pdr.pdf - OSHA Basis of
Carcinogen Listing of Individual Chemicals - This table shows the specific
bases for which the individual chemical was designated as a known or suspect
carcinogen.
http://www.osha.gov/SLTC/etools/hospital/mainpage.html - Hospital E-Tool -
US Department of Labor, Occupational Safety and Health Administration
(OSHA) - The OSH Act of 1970 strives to "assure safe and healthful
working conditions" for today's workers and mandates that employers provide
a safe work environment for employees. There are many occupational health
and safety hazards throughout the hospital. This E-Tool focuses on some of
the hazards and controls found in the hospital setting, and describes standard
requirements as well as recommended safe work practices for employee safety
and health.
http://www.lni.wa.gov/Safety/Rules/default.htm - Workplace Safety and Health
Rules (WISHA), Washington State Department of Labor and Industries -
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Here are the WISHA Safety and Health rules for Washington State employers.
There may be other local, state and federal safety and health rules that apply
to your business.
http://www.noharm.org - Health Care Without Harm is an international coalition
of hospitals and healthcare systems, medical professionals, community
groups, health-affected constituencies, labor unions, environmental and
environmental health organizations and religious groups. Its mission is to
transform the healthcare industry worldwide, without compromising patient
safety or care, so that it is ecologically sustainable and no longer a source of
harm to public health and the environment.
http://www.state.ma.us/ota/otapubs.htmtfeppnet - Heath Care Environmentally
Preferable Purchasing (EPP) Network Information Exchange Bulletin -
Massachusetts Executive Office of Environmental Affairs Office of Technical
Assistance, October 1999 - March 2001. This bi-monthly newsletter provides
updates on health care environmental purchasing innovations from across the
country.
www.h2e-online.org/ - Hospitals for a Healthy Environment (H2E) is a
voluntary program designed to help healthcare facilities enhance work place
safety, reduce waste and waste disposal costs and become better
environmental stewards and neighbors.
www.ewg.org/pub/home/reports/greening/greenpr.html - Greening Hospitals
Report - A first of its kind environmental survey of 50 major U.S. hospitals
uncovered widespread failure on the part of medical facilities to take steps to
halt contamination of milk, meats and fish by dioxins and mercury pollutants
that cause a wide range of health impacts.
/'. Greening the VA.
wwwl .va.gov/oamm/recycle/ - The Department of Veterans Affairs, Office of
Acquisition and Materiel Management's (VA OA&MM) Environmental
Affairs - Greening VA web site. VA is committed to the health of the
environment and promotes pollution prevention, energy efficiency, acquisition
of environmentally preferable products and services, and the "Three R's" of
waste prevention and management: Reducing, Reusing, Recycling. The VA
intranet URL is vawwl .va.gov/oamm/recycle/.
Enclosures
6-1 EPA Pamphlet 744-R-00-011, Integrated Environmental Management Systems
Implementation Guide.
6-2 EPA Pamphlet 315-B-97-001, Implementation Guide for the Code of Environmental
Management Principles for Federal Agencies (CEMP).
6-3 US Army Environmental Management System Implementers Guide, Version 1.0.
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Green Environmental Management Systems (GEMS) Guidebook Technical Resources
6-4 IL 049-02-11, Subject: Executive Order 13148.
6-5 Federal Register 54061 - EPA Code of Environmental Principles.
6-6 Green Environmental Management Systems (GEMS) Awareness Training PowerPoint.
6-7 Sample Affirmative Procurement Program Facility-Level Audit Questions.
6-8 OFEE Memorandum, Subject: EMS Self-Declaration Protocol.
6-9 Checklist for Environmental Aspects.
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
Table of Contents
Section 7 - Environmental Safety Automated
Facility Evaluation (E-SAFE)
7.1 Introduction
7.2 Criteria Statements
Category 1 - Environmental Policy
Category 2 - Planning
Category 3 - Implementation and Operation
Category 4 - Checking and Corrective Action
Category 5 - Management Review
7.3 Questions to Ask During E-SAFE
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Green Environmental Management Systems (GEMS) Guidebook E-SAFE
Environmental Safety Automated Facility
Evaluation (E-SAFE)
7.1 Introduction
Environmental Safety Automated Facility Evaluation (E-SAFE) is a new evaluation software
program developed at Center for Engineering & Occupational Safety and Health (CEOSH).
It is the Green Environmental Management Systems (GEMS) addition to the Safety
Automated Facility Evaluation (SAFE) Program, which for several years has been used for
conducting the Annual Workplace Evaluations (AWE) at Medical Centers, required by the
Occupational Safety and Health Administration (OSHA) regulations.
The management system of GEMS is periodically evaluated to identify conformance with the
ISO 14001 Environmental Management Standard and gaps between the Standard and the
facility practice.
This gap analysis serves as a snapshot-in-time review of the degree to which the GEMS has been
developed and implemented. It is an essential component of an environmental management
system, which is required by EO 13148. The E-SAFE criteria statements that follow will be
used to evaluate the facility GEMS. The citations in parentheses refer the reader to relevant
sections in the ISO 14001 Standard and in this Guidebook.
Evaluations of the GEMS can be conducted by staff from within or from outside of the facility.
Evaluation by persons external to the operations of the facility GEMS is considered to be the
more objective approach. Regardless, the person doing the evaluation must have completed
an ISO 14001 accredited Internal or Lead Auditor course. An annual evaluation is
recommended and may be conducted all at once or completed over several months to a year.
Reports of the gap analysis should be submitted to the GEMS Committee for review and
corrective action. The corrective actions should be tracked to completion (with effectiveness
verified) and noted in the GEMS Committee minutes.
Note: The following Criteria Statements were updated January 10, 2005;
therefore, they will vary from the printed version of the Guidebook.
7.2 Criteria Statements
1. Category 1 - Environmental Policy (ISO 14001-2004, Section 4.2; VA Directive 0057,
paragraph 2.k; VHA GEMS Guidebook, Sections 2.1 and 5B (Sample MCM).
a. Policy. Is there a published environmental policy in place that supports pollution
prevention, regulatory compliance and continual environmental improvement?
b. Policy. Is the policy communicated to the employees and available to the public?
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
2. Category 2 - Planning
a. Environmental Aspects and Impacts. (ISO 14001-2004, Section 4.3.1; VA Directive
0057, paragraph 2e; VHA GEMS Guidebook, Sections 2.2, 3.2 (Step 4) and 4.2 and
Documents 5B1-1, 5B1-2 and 5B1-3).
1) Aspects and Impacts. Has the facility established a written procedure to identify the
environmental aspects and impacts of its activities, products and services?
2) Aspects and Impacts. Have significant environmental aspects been determined and
considered in setting environmental objectives and targets?
b. Legal Requirements. (ISO 14001-2004, Section 4.3.2; VHA GEMS Guidebook, Sections
2.3 (Step 4) and Document 5B1-2).
Legal. Is there a written procedure to identify, access and evaluate federal, state and local
legal requirements?
c. Objectives and Targets. (ISO 14001-2004, Section 4.3.3; VHA GEMS Guidebook,
Sections 2.4, 2.5 and 3.2 (Step 6) and Documents 5B1-3, 5B1-4, 5B2 and 5B3).
1) Setting Objectives and Targets. Is there a written procedure to achieve objectives and
targets. Identify and document environmental objects and targets for each relevant
function and level? Consider legal requirements and significant aspects and other
operational requirements. Identify the means and acceptable time frames for
accomplishment. Designate responsibility at each relevant function and level.
3. Category 3 - Implementation and Operation
a Accountability (Structure and Responsibility). (ISO 14001-2004, Section 441; VA
Directive 0057, paragraph 2.b, and 2.c; EO 13148, Section 404(b); VHA GEMS
Guidebook, Sections 2.6, 3.2 (Step 1) and Document 5B1-4).
1) Accountability. Has top management provided adequate resources? Has top
management appointed a GEMS Committee to oversee, track and report GEMS status
and performance?
2) Accountability. Have roles, responsibilities and authorities been defined, documented
and communicated to facility staff to ensure effective environmental management?
b. Training. (ISO 14001-2004, Section 4.4.2; VA Directive 0057, paragraph 2.j; VHA
GEMS Guidebook, Sections 2.7 and 3.2 (Steps 2 and 7) and Document 5B1-5, Enclosure
6-6).
1) Training. Has GEMS awareness been conducted for all employees?
2) Training. Does New Employee Orientation include GEMS awareness training?
3) Training. Has the organization identified training needs for those workers who may
create a significant impact on the environment?
4) Training. Are employees aware of environmental aspects/impacts associated with
their work activities?
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Green Environmental Management Systems (GEMS) Guidebook E-SAFE
5) Training. Does the worksite specific GEMS training include significant
environmental impacts, emergency response procedures and environmental
consequences of nonconformance with standard operating procedures?
c. Communications. (ISO 14001-2004, Section 4.4.3; VHA GEMS Guidebook, Section 2.8
and Document 5B1-6).
1) Communications. Is there a written procedure for internal communication between
the various levels/functions of the facility, the GEMS Coordinator and the GEMS
Committee?
2) Communications. Is there a written procedure in place to coordinate and document
inquiries from external public, private and regulatory organizations?
d. GEMS Documentation and Record Keeping. (ISO 14001-2004, Section 4.4.4 and 4.4.5;
VA Directive 0057, paragraph 2.f; VHA GEMS Guidebook, Sections 2.9, 2.10, 2.15 and
3.2 (Step 5) and Documents 5B1-5 and 5B1-7).
1) GEMS Documentation. Is there a written procedure to ensure all GEMS policies and
procedures are fully integrated and consistent with all other VAMC policies and
procedures?
2) Record Keeping. The written GEMS document control procedure specifies:
1. approval of documents for adequacy prior to issue
2. review and update as necessary and re-approval of documents
3. ensuring that changes and all the current revision status of documents are
identified
4. ensuring that relevant versions of applicable documents are available at points of
use
5. ensuring that documents remain legible and readily identifiable
6. ensuring that documents of external origin, determined by the VAMC to be
necessary for the planning and operation of the GEMS, are identified and their
distribution controlled and
7. preventing the unintended use of obsolete documents and apply suitable
identification to them if they are retained for any purpose.
3) Record Keeping. Is there a written procedure to identify, maintain and dispose of
environmental, training audit records?
4) Record Keeping. Are environmental records identifiable, legible, readily retrievable
and traceable to activity, product and service?
e. Operational Control. (ISO 14001-2004, Section 4.4.6; VA Directive 0057, paragraph 2.f;
VHA GEMS Guidebook, Sections 2.11 and 3.2 (Step 5) and Documents 5B1-7 and 5B1-
8; Construction Safety Guidebook, Chapter 1).
1) Operational Control. Are the VAMC environmental operations aligned with
significant environmental aspects and objectives?
2) Operational Control. Are procedures in place to communicate the GEMS
requirements to suppliers and contractors?
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Green Environmental Management Systems (GEMS) Guidebook Department of Veterans Affairs
f. Emergency Response. (ISO 14001-2004, Section 4.4.7; VHA GEMS Guidebook, Section
2.12 and Document 5B1-9; VHA Emergency Management Guidebook).
Emergency Response. Is there an emergency preparedness and response procedure to
recognize and mitigate potential environmental impacts?
4. Category 4 - Checking and Corrective Action.
a. Monitoring and Measurement. (ISO 14001-2004, Section 4.5.land 4.5.2.1; VHA GEMS
Guidebook, Sections 2.13 and 3.2 (Steps 8 and 9) and Document 5B1-10).
1) Monitoring and Measurement. Is there a written monitoring and measuring
procedure for operations and activities related to significant environmental aspects?
2) Monitoring and Measurement. Does the monitoring and measuring procedure
include requirements for calibration and recording of information to track
performance, operational controls and conformance objectives and targets?
3) Monitoring and Measurement. Has a periodic (every 3 years) and/or baseline
environmental compliance audit been conducted?
b. Corrective and Preventive Action. (ISO 14001-2004, Section 4.5.3; VHA GEMS
Guidebook, Sections 2.14 and Documents 5B1-4 and 5B1-11).
1) Action Plans. Is there a written procedure covering the definition of roles and
responsibilities for investigating and determining a cause of nonconformance?
2) Action Plans. Does the preventive and corrective action procedure include action
needed to mitigate impact and necessary preventive action?
3) Action Plans. Do corrective and preventive action plans address the causes of the
deficiency?
4) Action Plans. Is the effectiveness of corrective and preventive actions verified before
considered completed?
c. Gap Analysis. (ISO 14001-2004, Section 4.5.5; VA Directive 0057, paragraph 2.c; VHA
GEMS Guidebook, Sections 2.16 and 3.2 (Step 3 and Documents 5B1-11 and 5B1-12).
1) Gap Analysis. Does the program have procedures for conducting annual gap analyses
of GEMS?
2) Gap Analysis. Is the scope based on the environmental importance of the activity and
the results of the previous GEMS gap analysis?
3) Gap Analysis. Are the results of the GEMS gap analysis reviewed by the GEMS
Committee and the recommendations forwarded to top management for review?
4) Action Plans. Are resources assigned to corrective and preventive actions in order to
complete them in a reasonable timeframe?
5) Action Plans. Are corrective and preventive actions tracked to completion in the
GEMS committee?
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Green Environmental Management Systems (GEMS) Guidebook E-SAFE
5. Category 5 - Management Review.
a.) Annual Review. (ISO 14001-2004, Section 4.6; VHA GEMS Guidebook, Sections 2.17
and 3.2 (Step 9) and Document 5B1-13).
1) Annual Review. Is the management review conducted and documented on an annual
basis and reported in the GEMS Committee?
2) Annual Review. Does the GEMS Committee use the gap analysis results to address
the need for changes to policy, objectives and other GEMS elements?
3) Annual Review. Is there evidence that the facility director (top management)
participates in the annual review (for instance, by signing annual review report)?
7.3 Questions to Ask During E-SAFE
1. Does the management review include questions for employees, such as:
a. Are you adequately involved in the development of the Standard Operating Procedures
(SOPs)?
b. Do you have responsibilities under GEMS?
c. Do you know the potential environmental consequences of not following GEMS
procedures?
d. Do you believe that you have had satisfactory training to conform to GEMS procedures?
e. Do you have the ability to communicate ideas/suggestions to upper management on how
to improve VAMC environmental performance?
2. Does the management review include questions for top managers, such as:
a. What was your role in the GEMS policy?
b. How do you determine the appropriate human resources, financial resources, specialized
skills and technological resources needed to implement and control GEMS?
c. How do you determine GEMS' continued suitability, adequacy and effectiveness?
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT: Supply, Processing and Distribution
Date:
Activity or
Service
Chemical Usage
Chemical Usage
Chemical Usage
Chemical Usage
Chemical Storage
Operation of
Sterilization
Machinery
Report
Generation
Aspect
Ethylene Oxide Sterilization
Cidex Sterilization
Steris Sterilization
Bleach
Potential for Spills
Energy Consumption, Noise,
Heat
Use of Paper
Impact
Air
Contamination
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination
Environmental
Contamination
Natural Resource
Expense
Natural Resource
Expense
Compliance
0
0
0
1
1
1
1
Risk
4
3
2
1
1
1
1
Frequency
Of Activity
3
2
2
4
1
4
2
VAMC
Control
3
3
3
2
3
1
3
TOTAL
SCORE
10
8
7
8
6
7
7
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Green Environmental Management Systems (GEMS) Aspects Template
OPERATING UNIT:
Specialty Care Clinics
Date:
Activity or Service
Operation of Equipment
Chemical Usage
Chemical Storage
Report Generation
Drug Preparation and
Administration
Generation of Regulated
Medical Waste
Changing Linen
Cleaning and
Disinfecting Surfaces and
Equipment
Maintenance of
Equipment
Aspect
Energy Consumption
Employee/Patient
Exposure, Waste
Disposal
Potential for Spills
Use of Paper
Improper Disposal
Exposure to Biological
Contaminants
Handling of
Contaminated Laundry
Handling of Detergent
Disinfectants
Generation of Batteries
Impact
Use of Natural
Resources
Health Effects,
Environmental
Contamination
Environmental
Contamination
Use of Natural
Resources
Environmental
Contamination
Disease
Transmission,
Environmental
Contamination
Employee/Patient
Exposure
Employee/Patient
Exposure
Environmental
Contamination
Compliance
1
1
1
0
0
1
1
0
1
Risk
1
2
1
0
1
O
1
2
1
Frequency
Of Activity
3
4
4
4
4
4
4
4
2
VAMC
Control
1
4
4
4
4
4
3
2
2
TOTAL
SCORE
6
11
10
8
9
12
9
8
6
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Sample GEMS Documents
Department of Veterans Affairs
Veterans Health Administration
Environmental Policy
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Green Environmental Management System (GEMS) Guidebook Sample GEMS Documents
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