Healthcare Environmental Assistance Resource Pollution Prevention and Compliance Assistance for Healthcare Facilities Volume 16 of 19


v>EPA
United Stales
Environmental Protector
   Healthcare Environmental Assistance Resources
   Pollution Prevention and Compliance Assistance
   for Healthcare Facilities

-------
United States
Environmental Protection
Agency	
Enforcement and    EPA305-B-01-003
Compliance Assurance  June 2001
(2224-A)	
Protocol for Conducting
Environmental Compliance
Audits for Hazardous
Waste Generators under
RCRA
         EPA Office of Compliance

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Notice

U.S. EPA's Office of Compliance prepared this document to aid regulated entities in developing programs at
individual facilities to evaluate their compliance with environmental requirements arising under federal law. The
statements in this document are intended solely as guidance to you in this effort. Among other things, the
information provided in this document describes existing requirements for regulated entities under the Resource
Conservation and Recovery Act (RCRA) and their implementing regulations at 40 CFR 260 through 268. While the
Agency has made every effort to ensure the accuracy of the statements in this document, the regulated entity's legal
obligations are determined by the terms of its applicable environmental facility-specific permits, and underlying
statutes and applicable state and local law. Nothing in this document alters any statutory, regulatory or permit
requirement. In the event of a conflict between statements in this document and either the permit or the regulations,
the document would not be controlling. U.S. EPA may decide to revise this document without notice to reflect
changes in EPA's regulations or to clarify and update the text. To determine whether U.S. EPA has revised this
document and/or to obtain additional copies, contact EPA's National Center for Environmental Publications at (1-
800-490-9198). The contents of this document reflect regulations issued as of April 30,2001.

Acknowledgments

U.S. EPA would like to gratefully acknowledge the support of the U.S. Army Corps of Engineers Construction
Engineering Research Laboratory (CERL) for providing suggestions for overall format of this document. The Office
of Compliance at U.S. EPA gratefully acknowledges the contribution of U.S. EPA's program offices and the U.S.
EPA's Office of Counsel in reviewing and providing comment on this document.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Table of Contents

Notice	inside cover
Acknowledgment	inside cover

Section 1: Introduction
Background	ii
Who Should Use These Protocols?	ii
U.S. EPA's Public Policies that Support Environmental Auditing	iii
How To Use the Protocols	iv
The Relationship of Auditing to Environmental Management Systems	vi

Section II: Audit Protocol
Applicability	1
Review of Federal Legislation	1
State and Local Regulations	2
Key Compliance Requirements	2
Key Terms and Definitions  	6
Typical Records to Review	 16
Typical Physical Features to Inspect	 17
List of Acronyms and Abbreviations	 17
Index for Checklist Users	 19
Checklist	21

Appendices
Appendix A: Hazardous Waste from Non-Specific Sources and From Specific Sources	Al
Appendix B: Commercial Chemical Products or Manufacturing Chemical Intermediates Identified
             as Toxic Wastes	Bl
Appendix C: Toxicity Characteristics Constituents and Regulatory Levels	Cl
Appendix D: Commercial Chemical Products or Manufacturing Chemical Intermediates Identified
             as Acute Hazardous Wastes	Dl
Appendix E: Hazardous Waste Storage Incompatibility Chart	El
Appendix F: User Satisfaction Questionnaire and Comment Form	Fl
   This document is intended solely for guidance.
   No statutory or regulatory requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


                                                  Section I
                                               Introduction


Background

The Environmental Protection Agency (EPA) is responsible for ensuring that businesses and organizations comply with
federal laws that protect the public health and the environment. EPA's Office of Enforcement and Compliance Assurance
(OECA) has begun combining traditional enforcement activities with more innovative compliance approaches including the
provision of compliance assistance to the general public. EPA's Office of Compliance Assistance was established in 1994 to
focus on compliance assistance-related activities. EPA is also encouraging the development of self-assessment programs at
individual facilities. Voluntary audit programs play an important role in helping companies meet their obligation to comply
with environmental requirements. Such assessments can be a critical link, not only to improved compliance, but also to
improvements in other aspects of an organization's performance. For example, environmental audits may identify pollution
prevention opportunities that can substantially reduce an organization's operating costs.  Environmental audits can also serve
as an important diagnostic tool in evaluating a facility's overall environmental management system or EMS.

EPA is developing 13 multi-media Environmental Audit Protocols to assist and encourage businesses and organizations to
perform environmental audits and disclose violations in accordance with OECA's Audit and Small Business Policies. The
audit protocols are also intended to promote consistency among regulated entities when conducting environmental audits and
to ensure that audits are conducted in a thorough and comprehensive manner. The protocols provide detailed regulatory
checklists that can be customized to  meet specific needs  under the following primary environmental management areas:

     •   Generation of RCRA            •   Treatment Storage and           •   EPCRA
         Hazardous Waste                    Disposal of RCRA
                                            Hazardous Waste

     •   CERCLA                      •   Clean Air Act                   •   Clean Water Act

     •   Safe Drinking Water Act         •   TSCA                          •   Universal Waste and Used Oil

     •   Managing Nonhazardous         •   Pesticides Management          •   Management of Toxic
         Solid Waste                         (FIFRA)                            Substances (e.g., PCBs, lead-
                                                                               based paint, and asbestos)
                                        •   RCRA Regulated Storage
                                            Tanks
Who Should Use These Protocols?

EPA has developed these audit protocols to provide regulated entities with specific guidance in periodically evaluating their
compliance with federal environmental requirements. The specific application of this particular protocol, in terms of which
media or functional area it applies to, is described in Section II under "Applicability".

The Audit Protocols are designed for use by individuals who are already familiar with the federal regulations but require an
updated comprehensive regulatory checklist to conduct environmental compliance audits at regulated facilities.  Typically,
compliance audits are performed by persons who are not necessarily media or legal experts but instead possess a working
knowledge of the regulations and a familiarity with the operations and practices of the facility to be audited.  These two basic
skills are a prerequisite for adequately identifying areas at the facility subject to environmental regulations and potential
regulatory violations that subtract from the organizations environmental performance. With these basic skills, audits can be
successfully conducted by persons with various educational backgrounds (e.g., engineers, scientists, lawyers, business owners
or operators). These protocols are not intended to be a substitute for the regulations nor are they intended to be instructional
   This document is intended solely for guidance.
   No statutory or regulatory requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


to an audience seeking a primer on the requirements under Title 40, however, they are designed to be sufficiently detailed to
support the auditor's efforts.

The term "Protocol" has evolved over the years as a term of art among the professional practices of auditing and refers to the
actual working document used by auditors to evaluate facility conditions against a given set of criteria (in this case the federal
regulations). Therefore these documents describe "what" to audit a facility for rather than "how" to conduct an audit. To
optimize the effective use of these documents, you should become familiar with basic environmental auditing practices. For
more guidance on how to conduct environmental audits, EPA refers interested parties to two well known organizations: The
Environmental Auditing Roundtable (EAR) and the Institute for Environmental Auditing (IEA).

Environmental Health and Safety Auditing Roundtable       The Institute for Environmental Auditing
35888 Mildred Avenue                                   Box 23686
North Ridgeville, Ohio 44039                             L'Enfant Plaza Station
(216) 327-6605                                          Washington, DC 20026-3686

U.S. EPA's Public Policies that Support Environmental Auditing

In 1986, in an effort to encourage the use of environmental auditing, EPA published its "Environmental Auditing Policy
Statement" (see 51 FR 25004).  The 1986 audit policy states that "it is EPA policy to encourage the use of environmental
auditing by regulated industries to help achieve and maintain compliance with environmental laws and regulation, as well as
to help identify and correct unregulated environmental hazards."  In addition, EPA defined environmental auditing as "a
systematic, documented, periodic, and objective review of facility operations and practices related to meeting environmental
requirements." The policy also identified several objectives for environmental audits:
          •   verifying compliance with environmental requirements,
          •   evaluating the effectiveness of in-place environmental management systems, and
          •   assessing risks from regulated and unregulated materials and practices.

In 1995, EPA published "Incentives for Serf-Policing: Discovery, Disclosure, Correction and Prevention of Violations" -
commonly known as the EPA Audit Policy - which both reaffirmed and expanded the Agency's  1986 audit policy (see 60 FR
66706 December 22, 1995). The 1995  audit policy offered major incentives for entities to discover, disclose and correct
environmental violations.  On April 11, 2000, EPA issued a revised final Audit Policy that replaces the 1995 Audit Policy (65
FR 19,617). The April 11, 2000 revision maintains the basic structure and terms of the 1995 Audit Policy while lengthening
the prompt disclosure period to 21 days, clarifying some of its language (including the applicability of the Policy in the
acquisitions context), and conforming its provisions to actual EPA practices. The revised audit policy continues the Agency's
general practice of waiving or substantially  mitigating gravity-based civil penalties for violations discovered through an
environmental audit or through a compliance management system, provided the violations are promptly disclosed and
corrected and that all of the Policy conditions are met. On the criminal side, the revised policy continues the Agency's
general practice of not recommending that criminal charges be brought against entities that disclose violations that are
potentially criminal in nature, provided the entity meets all of the policy's conditions.  The policy safeguards human health
and the environment by precluding relief for violations that cause serious environmental harm or may have presented an
imminent and substantial endangerment. The audit policy is available on the Internet at www.epa.gov/auditpol.html.

In 1996, EPA issued its "Policy on Compliance Incentives for Small Businesses" which is commonly called the "Small
Business Policy" (see 61 FR 27984 June 3,  1996). The Small Business Policy was intended to promote environmental
compliance among small businesses by providing them with special incentives to participate in government sponsored on-site
compliance assistance programs or conduct environmental audits. EPA will eliminate or reduce penalties for small businesses
that voluntarily discover, promptly disclose, and correct violations in a timely manner.

On April 11, 2000, EPA issued its revised final Small Business Policy (see 65 FR 19630) to expand the options allowed
under the 1996 policy for discovering violations and to establish a time period for disclosure. The major changes contained in
the April 11, 2000 Small Business Policy revision include lengthening the prompt disclosure period from 10 to 21 calendar
days and broadening the applicability of the Policy to violations uncovered by small businesses through any means of
voluntary discovery. This broadening of the Policy takes advantage of the wide range of training, checklists, mentoring, and
other activities now available to small businesses through regulatory agencies, private organizations, and the Internet.
   This document is intended solely for guidance.                                                                   iii
   No statutory or regulatory requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
More information on EPA's Small Business and Audit/Self-Disclosure Policies are available by contacting EPA's
Enforcement and Compliance Docket and Information Center at (202) 564-2614 or visiting the EPA web site at:
http://es.epa.gov/oeca/main/strategy/crossp.html
How to Use The Protocols

Each protocol provides guidance on key requirements, defines regulatory terms, and gives an overview of the federal laws
affecting a particular environmental management area. They also include a checklist containing detailed procedures for
conducting a review of facility conditions. The audit protocols are designed to support a wide range of environmental
auditing needs; therefore several of the protocols in this set or sections of an individual protocol may not be applicable to a
particular facility. To provide greater flexibility, each audit protocol can be obtained electronically from the EPA Website
(www.epa.gov/oeca/ccsmd/profile.html). The EPA Website offers the protocols in a word processing format which allows
the user to custom-tailor the checklists to more specific environmental aspects associated with the facility to be audited.

The protocols are not intended to be an exhaustive set of procedures; rather they are meant to inform the auditor, about the
degree and quality of evaluation essential to a thorough environmental audit. EPA is aware that other audit approaches may
also provide an effective means of identifying and assessing facility environmental status and in developing corrective actions.

It is important to understand that there can be significant overlap within the realm of the federal regulations. For example,
the Department of Transportation (DOT) has established regulations governing the transportation of hazardous materials.
Similarly, the Occupational Safety and Health Administration (OSHA) under the U.S. Department of Labor has promulgated
regulations governing the protection of workers who are exposed to hazardous chemicals. There can also be significant
overlap between federal and state environmental regulations. In fact, state programs that implement federally mandated
programs may contain more stringent requirements that are not included in these protocols. There can also be multiple state
agencies regulating the areas covered in these protocols. The auditor also should determine which regulatory agency has
authority for implementing an environmental program so that the proper set of regulations is consulted. Prior to conducting
the audit, the auditor should review federal, state and local environmental requirements and expand the protocol, as required,
to include other applicable requirements not included in these documents.

Review of Federal Legislation and Key Compliance Requirements:

These sections are intended to provide only supplementary information or a "thumbnail sketch" of the regulations and
statutes. These sections are not intended to function as the main tool of the protocol (this is the purpose of the checklist).
Instead, they serve to remind the auditor of the general thrust of the regulation and to scope out facility requirements covered
by that particular regulation. For example, a brief paragraph describing record keeping and reporting requirements and the
associated subpart citations will identify and remind the auditor of a specific area of focus at the facility. This allows the
auditor to plan the audit properly and to identify key areas and documents requiring review and analysis.

State and Local Regulations:

Each EPA Audit Protocols contains a section alerting the auditor to typical issues addressed in state and local regulations
concerning a given topic area (e.g., RCRA and used oil). From a practical standpoint, EPA cannot present individual state
and local requirements in the protocols. However, this section does provide general guidance to the auditor regarding the
division of statutory authority between EPA and the states over a specific media. This section also describes circumstances
where states and local governments may enact more stringent requirements that go beyond the federal requirements.
This document is intended solely for guidance.
No statutory or regulatory requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

EPA cannot overemphasize how important it is for the auditor to take under consideration the impact of state and local
regulations on facility compliance. EPA has delegated various levels of authority to a majority of the states for most of the
federal regulatory programs including enforcement. For example, most facilities regulated under RCRA, and/or CWA have
been issued permits written by the states to ensure compliance with federal and state regulations. In turn, many states may
have delegated various levels of authority to local jurisdictions. Similarly, local governments (e.g., counties, townships) may
issue permits for air emissions from the facility. Therefore, auditors are advised to review local and state regulations in
addition to the federal regulations in order to perform a comprehensive audit.

Key Terms and Definitions:

This section of the protocol identifies terms of art used in the regulations and the checklists that are listed in the "Definitions"
sections of the Code of Federal Regulations (CFR). It is important to note that not alldefinitions from the CFR may be
contained in this section, however; those definitions which are commonly repeated in the checklists or are otherwise critical to
an audit process are included. Wherever possible, we have attempted to list these definitions as they are written in the CFR
and not to interpret their meaning outside of the regulations.

The Checklists:

The checklists delineate what should be evaluated during an audit. The left column states either a requirement mandated by
regulation or a good management practice that exceeds the requirements of the federal regulations. The right column gives
instructions to help conduct the evaluation. These instructions are performance objectives that should be accomplished by the
auditor. Some of the performance objectives may be simple documentation checks that take only a few minutes; others may
require a time-intensive physical inspection of a facility. The checklists contained in these protocols are (and must be)
sufficiently detailed to identify any area of the company or organization that would potentially receive a notice of violation if
compliance is not achieved. For this reason, the checklists often get to a level of detail such that a specific paragraph of the
subpart (e.g., 40 CFR 262.34(a)(l)(i)) contained in the CFR is identified for verification by the auditor. The checklists
contain the following components:

• "Regulatory Requirement or Management Practice Column"
The "Regulatory Requirement or Management Practice Column" states either a requirement mandated by regulation
or a good management practice that exceeds the requirements of the federal regulations. The regulatory citation is
given in parentheses after the stated requirement. Good management practices are distinguished from regulatory
requirements in the checklist by the acronym (MP) and are printed in italics.

• "Reviewer Checks" Column:
The items under the "Reviewer Checks:" column identify requirements that must be verified to accomplish the
auditor's performance objectives. (The key to successful compliance auditing is to verify and document site
observations and other data.) The checklists follow very closely with the text in the CFR in order to provide the
service they are intended to fulfill (i.e., to be used for compliance auditing). However, they are not a direct recitation
of the CFR. Instead they are organized into more of a functional arrangement (e.g., record keeping and reporting
requirements vs. technical controls) to accommodate an auditor's likely sequence of review during the site visit.
Wherever possible, the statements or items under the "Reviewer Checks" column, will follow the same sequence or
order of the citations listed at the end of the statement in the "Regulatory Requirement" column.

• "NOTE:" Statements
"Note:" statements contained in the checklists serve several purposes. They usually are distinguished from "Verify"
statements to alert the auditor to exceptions or conditions that may affect requirements or to referenced standards that
are not part of Title 40 (e.g., American Society for Testing and Materials (ASTM) standards). They also may be used
to identify options that the regulatory agency may choose in interacting with the facility (e.g., permit reviews) or
options the facility may employ to comply with a given requirement.
This document is intended solely for guidance.
No statutory or regulatory requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

• Checklist Numbering System:
The checklists also have a unique numbering system that allows the protocols to be more easily updated by topic area
(e.g., RCRA Small Quantity Generator). Each topic area in turn is divided into control breaks to allow the protocol to
be divided and assigned to different teams during the audit. This is why blank pages may appear in the middle of the
checklists. Because of these control breaks, there is intentional repetition of text (particularly "Note" Statements)
under the "Reviewer Checks" column to prevent oversight of key items by the audit team members who may be using
only a portion of the checklist for their assigned area.
Environmental regulations are continually changing both at the federal and state level. For this reason, it is important for
environmental auditors to determine if any new regulations have been issued since the publication of each protocol document
and, if so, amend the checklists to reflect the new regulations. Auditors may become aware of new federal regulations through
periodic review of Federal Register notices as well as public information bulletins from trade associations and other
compliance assistance providers. In addition, EPA offers information on new regulations, policies and compliance incentives
through several Agency Websites. Each protocol provides specific information regarding EPA program office websites and
hotlines that can be accessed for regulatory and policy updates.

The Relationship of Auditing to Environmental Management Systems

An environmental auditing program is an integral part of any organization's environmental management system (EMS). Audit
findings generated from the use of these protocols can be used as a basis to implement, upgrade, or benchmark environmental
management systems. Regular environmental auditing can be the key element to a high quality environmental management
program and will function best when an organization identifies the "root causes" of each audit finding. Root causes are the
primary factors that lead to noncompliance events. For example a violation of a facility's wastewater discharge permit may be
traced back to breakdowns in management oversight, information exchange, or inadequate evaluations by untrained facility
personnel.

As shown in Figure 1, a typical approach to auditing involves three basic steps: conducting the audit, identifying problems
(audit findings), and fixing identified deficiencies. When the audit process is expanded, to identify and correct root causes to
noncompliance, the organization's corrective action part of its EMS becomes more effective. In the expanded model, audit
findings (exceptions) undergo a root cause analysis to identify underlying causes to noncompliance events. Management
actions are then taken to correct the underlying causes behind the audit findings and improvements are made to the
organizations overall EMS before another audit is conducted on the facility. Expanding the audit process allows the
organization to successfully correct problems, sustain compliance, and prevent discovery of the same findings again during
subsequent audits.

Furthermore, identifying the root cause of an audit finding can mean identifying not only the failures that require correction but
also successful practices that promote compliance and prevent violations. In each case a root cause analysis should uncover
the failures while promoting the successes so that an organization can make continual progress toward environmental
excellence.
This document is intended solely for guidance.
No statutory or regulatory requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                             Figure 1 - Expanded Corrective Action Model
                           Improve
                           Environmental
                           Mgmt. System
                           Effectiveness
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                                                    vn

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                  This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                  vui
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

Section II
Audit Protocols

Applicability

This protocol is intended to help inform facilities that generate hazardous waste, and it includes requirements for waste
minimization and export of hazardous waste. There is a separate booklet that applies to treatment, storage, and disposal
facilities (TSDFs).

The following pages and checklist items contained in the December 1998 document (Protocol for Conducting
Environmental Compliance Audits of Hazardous Waste Generators under the Resource Conservation and Recovery
Act (EPA 300-B-98-005)) have been added/revised in this edition:

- Definitions for the terms Aquifer, Battery, Closure Device, Cover, Dike, Equipment, Exempted Hazardous Waste
Containers and Surface Impoundments, Exempted Hazardous Waste Management Unit, Hazardous Debris, New
Hazardous Waste Management Facility, On-site, Open-end Valve or Line, Qualified Groundwater Scientist, Soil,
Treatment, and Used Oil (see pages 6 through 16 of this document)
- HW.10.1
- HW.80.2
- HW. 130.7 through HW. 130.12
- HW.200.2
- Appendix A

Not all checklist items will be applicable to a particular facility. Guidance is provided on the checklists to direct the auditor to
the regulations typically applicable to the type of hazardous waste activities/facilities on the site.

There are numerous environmental regulatory requirements administered by federal, state, and local governments. Each level
of government may have a major impact on areas at the facility that are subject to the audit. Therefore, auditors are advised to
review federal, state, and location regulations in order to perform a comprehensive audit.

Review of Federal Legislation

The Resource Conservation and Recovery Act, Subtitle C (1976)
The Resource, Conservation and Recovery Act (RCRA) of 1976, which amended the Solid Waste Disposal Act of 1965,
addresses hazardous (Subtitle C) and solid (Subtitle D) waste management activities. Subtitle C of RCRA, 42 U.S. Code
(USC) sections 6921-693 9b, establishes standards and procedures for the handling, storage, treatment, and disposal of
hazardous waste. For example, RCRA prohibits the placement of bulk or noncontainerized liquid hazardous waste or free
liquids containing hazardous waste into a landfill. It also prohibits the "land disposal" of specified wastes and disposal of
hazardous waste through underground injection within 1/4 mile (0.40 km) of an underground source of drinking water.
Pursuant to Subtitle C of RCRA, the United States Environmental Protection Agency (U.S. EPA) promulgated regulations at
40 CFR Parts 260-299, establishing a "cradle-to-grave" system that governs hazardous waste from the point of generation to
its treatment or disposal.

The 1984 Hazardous and Solid Wastes Amendments (HSWA) greatly expanded the requirements and coverage of RCRA.
Perhaps the most significant provision of HSWA is the prohibition on the land disposal of hazardous waste. The land disposal
restrictions (LDRs) promulgated by U.S. EPA essentially ban the disposal of untreated liquid hazardous waste or hazardous
waste containing free liquids in landfills and establish treatment standards for these wastes. In addition to the new statutory
and regulatory requirements imposed by HSWA, a new subtitle to the act was created to govern underground storage tanks
(USTs). This document does not provide audit guidance for underground or above ground storage tanks regulated
under RCRA. Audit guidance and technical information on above and underground storage tanks is provided by U.S. EPA in
a separate protocol titled Protocol for Conducting Environmental Compliance Audits of Storage Tanks under the Resource
Conservation and Recovery Act, EPA Document Number 300-B-00-006.

This document is intended solely for guidance. No statutory or regulatory \
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
After assessing air emissions at TSDFs, the U.S. EPA ascertained that volatile organic chemicals (VOCs) adversely affect
human health and welfare. In response, U.S. EPA promulgated three subparts of RCRA rules designed to control VOCs. In
1990, U.S. EPA issued Subparts AA and BB, which amended 40 CFR Parts 264 and 265. Subpart AA governs organic
chemical emissions from certain hazardous waste treatment processes, while Subpart BB governs equipment that contains or
contacts hazardous waste with at least 10% organic chemicals by weight. Subpart CC includes requirements for controlling
VOC emissions from tanks, surface impoundments, containers, and certain miscellaneous "Subpart X" units. The Subpart CC
Final Rule was signed on December 6, 1994, and the Final Rule Amendments were signed on October 4, 1996.

State/Local Regulations

RCRA encourages states to develop their own parallel regulatory programs for hazardous waste management. This includes
enacting statutory authority and operating hazardous waste regulatory programs. Many states have met the requirements
established by U.S. EPA in 40 CFR 271 (Requirements for Authorization of state Hazardous Waste Programs) and have been
approved to manage their own state programs. Many states have adopted the U.S. EPA regulations by reference or have
promulgated regulations that are identical to the U.S. EPA regulations, while other states have promulgated regulations
stricter than the federal RCRA. These differences between individual state regulations and the federal program require that
auditors check the status of their state's authorization and then determine which regulations apply. For example, some states
have listed additional waste as hazardous waste (used oil, PCBs, asbestos). Since the section checklists are based exclusively
on the requirements of the federal RCRA program, the auditor should determine in what ways the applicable state program
differs from the federal program.

Key Compliance Requirements

Identification of Hazardous Waste
Proper identification of hazardous wastes is a complex task that is fundamental to determining which materials at a facility are
subject to RCRA Subtitle C requirements. To determine whether or not a material is a hazardous waste, a facility must answer
four questions about each waste stream. First, is the material a "solid waste," as defined by the RCRA regulations? The
regulatory framework for distinguishing solid and hazardous wastes can be found at 40 CFR §§261.2 and 261.3. Second, does
it fit one of the exclusions from the definition of solid or hazardous waste? Materials that have been excluded are listed in 40
CFR §261.4. Third, is it a listed or characteristic hazardous waste? Listed and characteristic wastes are defined in 40 CFR
§261, Subparts B, C, and D. And finally, has the waste been delisted?

Waste Analysis
A solid waste is a hazardous waste if it is a listed hazardous waste (defined at 40 CFR §261, Subpart D) or if it exhibits any of
the characteristics defined in 40 CFR §261, Subpart C. In order to determine whether the waste exhibits any of the
characteristics, the generator generally must use analytical methods capable of quantitatively identifying the contaminants in
question. Unlike characteristic wastes, listed wastes are generally determined based on the generator's knowledge of its
manufacturing process or the chemicals used.

A generator can meet waste analysis requirements using several methods or combinations of methods. Wherever feasible, the
preferred method is to conduct sampling and laboratory analysis because it is more accurate than other options. However,
generators can also apply "acceptable knowledge," which includes (1) process knowledge; (2) waste analysis data obtained
from facilities that send their waste off-site for treatment, storage, or disposal; or (3) records of analysis performed before the
effective date of RCRA regulations, assuming the information is current and accurate.

Process knowledge involves obtaining detailed information on a waste from existing published or documented waste analysis
data or studies conducted on hazardous waste generated by processes similar to that which generated the waste.

When using process descriptions and existing data, a facility must carefully scrutinize whether (1) there are any differences
between the processes documented and the actual processes and (2) the data used are accurate and current, including (a)
whether any wastes are newly regulated as hazardous wastes, (b) whether existing data are sufficient to identify any new
constituent concentration limits, and (c) the information is based on currently valid analytical techniques.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


Generator Requirements
The responsibilities of any particular facility are based on the amount of hazardous waste being generated in one calendar
month. Typical hazardous wastes include solvents, paint, contaminated antifreeze or oil, and sludges. In some states, waste oil
and other substances have been classified as a hazardous waste and therefore need to be included in the total amount of waste
generated. Under federal regulations there are three classifications of generators:


1.   A Conditionally Exempt Small Quantity Generator (CESQG) generates no more than 100 kg (220.46 Ib.) of hazardous
    waste or 1 kg (2.20 Ib.) of acutely hazardous waste in a calendar month. A CESQG also may not accumulate  on-site more
    than 1,000 kg (2,204.62 Ib.) of hazardous waste at any one time. When either the volume of hazardous waste produced in
    one calendar month exceeds 100 kg (220.46 Ib.) or more than 1,000 kg (2,204.62 Ib.) of hazardous waste have
    accumulated on-site, the facility is required to comply with the more stringent standards applicable to a Small Quantity
    Generator (SQG). When the volume of acutely hazardous waste exceeds 1 kg of spill residue, contaminated  soil, waste
    or other debris exceeds 100 kg, then the waste is subject to standards applicable to  large quantity generators (LQGs);

2.   An SQG generates between 100 kg (220.46 Ib.) and 1,000 kg (2,204.62 Ib.) of hazardous waste in a calendar month. The
    hazardous waste cannot accumulate on-site for more than 180 days unless the waste is transported more than 200 miles
    (321.87 km) to a treatment, storage and disposal facility (TSDF). If the hazardous  waste must be transported more than
    200 miles, it can accumulate for up to 270 days. At no time is there to be more than 6,000 kg (13,227.73 Ib.) of
    hazardous waste accumulated at the facility. When the volume of hazardous waste generated in 1 mo exceeds 1,000 kg
    (2,204.62 Ib.) of nonacutely hazardous  waste or 1 kg (2.20 Ib.) of acutely hazardous waste or the accumulation time limit
    is exceeded, the facility is required to comply with the standards for an LQG. When more than 6,000 kg (13,227.73 Ib.)
    of hazardous waste is stored on-site, the SQG is required to obtain a storage permit and comply with  the requirements of
    40 CFR 264 and 40 CFR 265;

3.   An LQG generates more than 1,000 kg (2,204.62 Ib.) of hazardous waste in a calendar month. (NOTE:  Usingwater,
    which weighs approximately 8.34 Ibs./gal (3.78 kg/gal or 1 kg/L) as a basis of measurement, 100 kg (220.46  Ib.) would
    equal about 26.4 gallons (100 L) (almost one-half of a 55-gal. (208.2 L) drum); 1,000 kg (2,204.62 Ib.) would equal
    about 264 gallons (1000 L) (almost five 55-gal. drums)).

Whether the facility is a CESQG, SQG, or a LQG determines whether and how the RCRA regulations apply to that facility.
Storage areas connected with generation points are often referred to as 90 day storage areas. Regardless of the amount of
hazardous waste generated, the regulations require every facility to test or use knowledge of materials or processes used to
determine if its waste is a listed hazardous waste or exhibits one of four hazardous characteristics (ignitability, corrosivity,
toxicity, reactivity).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                          Comparison of RCRA Generator Requirements
Requirement
Determine Whether Solid
Waste is Hazardous
Quantity Limits
Acute Waste Limits
Facility Receiving Waste
EPA ID Number
RCRA Personnel Training
Exception Report
Biennial Report
On-site Accumulation
Limits (without permit)
Accumulation Time Limits
(without permit)
Storage Requirements for
Accumulated Hazardous
Waste
Use Manifests
Contingency Plan
CESQG
Yes
<100 kg/mo (220.46
Ib./mo)
<1 kg/mo (2.20 Ib./mo)
State approved, RCRA
permitted, interim status,
or exempt recycling
facility
Not required
Not required
Not required
Not required
1,000 kg (2,204.62 Ib.)
None
None
No
No
SQG
Yes
100 kg/mo (220.46 Ib.) to
1,000 kg/mo (2,204.62
Ib.)
<1 kg/mo (2.20 Ib./mo)
RCRA permitted, interim
status, or exempt
recycling facility
Required
Basic training required
Required within 60 days
of hazardous waste being
accepted by initial
transporter
Not required
6,000 kg (13,227.73 Ib.)
180 days [or 270 days if
transported more than 200
mi. (321. 87 km)] U.S. EPA
may grant 30 days for
unforeseen, temporary, and
uncontrollable
circumstances.
Basic requirements with
technical standards for
containers or tanks
Yes, unless the waste is
reclaimed under
contractual agreement in
accordance with the
requirements of 40 CFR
262.20 (e).
No
LQG
Yes
>1,000 kg/mo (2,204.62
Ib./mo)
None
RCRA permitted, interim
status, or exempt
recycling facility
Required
Required
Required within 45 days
of hazardous waste being
accepted by initial
transporter
Required
Any quantity
90 days +
U.S. EPA may grant 30 days
for unforeseen, temporary,
and uncontrollable
circumstances.
Full compliance with
management of containers
or tanks
Yes, unless the waste is
reclaimed under
contractual agreement in
accordance with the
requirements of 40 CFR
262.20 (e).
Required
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

Pre-Transport Requirements
Hazardous waste shipped off-site must be packaged, labeled and marked. The vehicles used to transport the waste must be
placarded in accordance with DOT regulations.

90 Day Storage
90 day storage is an area in or near the place where hazardous waste is accumulated or stored before being sent off-site for
disposal. Storage in these areas is temporary, and the permissible length of time for accumulation depends on whether the
facility is classified as an LQG, SQG, or CESQG.

Satellite Accumulation Point Management
A satellite accumulation point is an area at or near the point of generation where no more than 55 gal. (208.20 L) of a
hazardous waste or one qt. (0.95 L) of acutely hazardous waste is accumulated. The satellite accumulation point is to remain
under the control of a single operator. When the 55 gal. (208.20 L) limit is reached, the operator has three days to move the
waste to a 90 day storage area or a permitted TSDF. These standards apply to SQGs and LQGs only.

Waste Minimization/Pollution Prevention
Waste minimization and pollution prevention programs are being increasingly discussed and implemented by both
environmental managers and environmental policy makers. Usually defined as a reduction in the volume and toxicity of waste,
waste minimization often pays for itself through reduced disposal costs, operating costs, and liability. While these cost savings
are often enough to justify a program, there are an increasing number of voluntary and mandatory programs that drive waste
minimization/pollution prevention.

Under RCRA, LQGs are required to sign a certification on each manifest stating that they have a program in place to reduce
waste to the degree that is economically feasible and to select a disposal method that minimizes threats to human health and
the environment. SQGs must show a "good faith effort" to minimize waste and to select the best waste management method
available.

U.S. EPA has also developed guidelines on a waste minimization program for generators. Issued in 58 Federal Register (FR)
31114 on May 28, 1993, the Interim Final Guidance to Hazardous Waste Generators on the Elements of a Waste
Minimization Program is intended to provide guidance to generators of regulated hazardous wastes. The program includes:
• Provisions for top management assurance that waste minimization is a company-wide effort;
• Characterization of waste generation and waste management costs;
• Periodic waste minimization assessments;
• A cost allocation system;
• Encouragement of technology transfer; and
• Program implementation and evaluation.
For further information regarding the RCRA regulations, contact U.S. EPA's RCRA/UST, Superfund and EPCRA Hotline at
800-424-9346 (or 703-412-9810 in the D.C. area) from 9 a.m. to 6 p.m., Monday through Friday.

This U.S. EPA hotline provides up-to-date information on regulations developed under RCRA, CERCLA (Superfund), and
the Oil Pollution Act. The hotline can assist with Section 112(r) of the Clean Air Act (CAA) and Spill Prevention, Control
and Countermeasures (SPCC) regulations. The hotline also responds to requests for relevant documents and can direct the
caller to additional tools that provide a more detailed discussion of specific regulatory requirements.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Key Terms and Definitions

Acknowledgement of Consent
The cable sent to the U.S. EPA from the U.S. Embassy in a receiving country that acknowledges the written consent of the
receiving country to accept the hazardous waste and describes the terms and conditions of the receiving country's consent to
the shipment (40 CFR 262.51).

Acute Hazardous Waste
Any waste listed under 40 CFR 261.31 through 261.33(c) with a hazard code of H. These also include U.S. EPA hazardous
waste numbers F020, F021, F022, F023, F026, and F027 (40 CFR 261.31) and the P listed wastes in 40 CFR 261.33(e) (40
CFR 261.31 through 261.33).

Approved State Program
A RCRA program administered by a state that has been approved by U.S. EPA according to 40 CFR 271.

Aquifer
A geologic formation or group of formations, or part of a formation capable of yielding a significant amount of groundwater
to wells or springs (40 CFR 260.10).

Average Volatile Organic (VO) Concentration
The mass-weighted average VO concentration of a hazardous waste (40 CFR 265.1081).

Battery
A device consisting of one or more electrically connected electrochemical cells which is designed to receive, store, and
deliver electric energy. An electrochemical cell is a system consisting of an anode, cathode, and an electrolyte, plus such
connections (electrical and mechanical) as may be needed to allow the cell to deliver or receive electrical energy. The term
battery also includes an intact, unbroken battery from which the electrolyte has been removed (40 CFR 260.10 and 273.9).

Boiler
An enclosed device using controlled flame combustion and having the following characteristics (40 CFR 260.10):
1. The unit has physical provisions for recovering and exporting thermal energy in the form of steam, heated fluids, or
heated gases; and
2. The unit's combustion chamber and primary energy recovery section(s) must be of integral design; and
3. While in operation the unit maintains a thermal energy recovery efficiency of at least 60 percent; and
4. The unit has been approved by the Administrator of U.S. EPA; and
5. The unit must export and utilize at least 75% of the recovered energy (40 CFR 260.10).
U.S. EPA may also decide on a case-by-case basis that certain enclosed devices using controlled flame combustion are boilers
even though they may not otherwise meet the definition of boiler.

Certification
A statement of professional opinion based upon knowledge and belief (40 CFR 260.10).

Characteristics of Hazardous Waste
The characteristics of ignitibility, corrosivity, reactivity, and toxicity that identify hazardous waste (40 CFR 261.20 through
261.24).

Closure Device
A cap, hatch, lid, plug, seal, valve, or other type of fitting that blocks an opening in a cover such that when the device is
secured in the closed position it prevents or reduces air pollutant emissions to the atmosphere. Closure devices include
devices that are detachable from the cover (e.g., a sampling port cap), manually operated (e.g., hinged access lid or hatch), or
automatically operated (e.g., a spring loaded pressure relief valve) (40 CFR 265.1081).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

Competent Authorities
The regulatory authorities of concerned countries having jurisdiction over transfrontier movements of wastes destined for
recovery operations (40 CFR 262.81).

Consignee
The ultimate treatment, storage, or disposal facility in a receiving country to which the hazardous waste will be sent (40 CFR
262.51).

Container
Any portable device in which a material is stored, transported, treated, disposed of, or otherwise handled (40 CFR 260.10).

Containment Building
A hazardous waste management unit that is used to store or treat hazardous waste under 40 CFR 264.1100 through 264.1102
and 40 CFR 265.1100 through 265.1102 (40 CFR 260.10).

Contingency Plan
A document setting out an organized, planned, and coordinated course of action to be followed in case of a fire, explosion, or
release of hazardous waste or hazardous waste constituents which could threaten human health or the environment (40 CFR
260.10).

Cover
A device that provides a continuous barrier over the hazardous waste managed in a unit to prevent or reduce air pollutant
emissions to the atmosphere. A cover may have openings (such as access hatches, sampling ports, gauge wells) that are
necessary for operation, inspection, maintenance, and repair of the unit on which the cover is used. A cover may be a separate
piece of equipment which can be detached and removed from the unit or a cover may be formed by structural features
permanently integrated into the design of the unit (40 CFR 265.1081).

Debris
Solid material exceeding a 60 mm particle size that is intended for disposal and that is a manufactured object, plant or animal
matter, or natural geologic material. The following materials are not debris: any material for which a specific treatment
standard is provided; process residuals such as smelter slag and residues from the treatment of waste, wastewater, sludges, or
air emissions residues; and intact containers of hazardous waste that are not ruptured and retain at least 75 percent of their
original volume (40 CFR 268.2).

Dike
An embankment or ridge of either natural or man-made materials used to prevent the movement of liquids, sludges, solids, or
other materials (40 CFR 260.10).

Discharge or Hazardous Waste Discharge
The accidental or intentional spilling, leaking, pumping, pouring, emitting, emptying, or dumping of hazardous waste into or
on any land or water (40 CFR 260.10).

Disposal
The discharge, deposit, injection, dumping, spilling, leaking, or placing of any solid waste or hazardous waste into or on any
land or water so that such solid waste or hazardous waste or any constituent thereof may enter the environment or be emitted
into the air or discharged into any waters, including groundwaters (40 CFR 260.10).

Disposal Facility
A facility or part of a facility at which hazardous waste is intentionally placed into or on any land or water, and at which waste
will remain after closure. The term disposal facility does not include a corrective action management unit into which
remediation wastes are placed (40 CFR 260.10).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


Elementary Neutralization Unit
A device which is used for neutralizing hazardous wastes that are hazardous only because they exhibit corrosivity (as defined
in 40 CFR 261.22) or are listed in Subpart D of 40 CFR 261 and that meets the definition of tank, tank system container,
transport vehicle, or vessel (40 CFR 260.10).

Enclosure
A structure that surrounds a tank or container, captures organic vapors emitted from the tank or container, and vents the
captured vapors through a closed-vent system to a control device (40 CFR 265.1081).

EPA Hazardous Waste Number
The number assigned by U.S. EPA to each listed hazardous waste under Subpart D and to each characteristic waste under
Subpart C (40 CFR 260.10).

EPA Identification Number
The number assigned by U.S. EPA to each generator, transporter, and treatment, storage, or disposal facility (40 CFR
260.10).

Equipment
Each valve, pump, compressor, pressure relief device, sampling connection system, open-ended valve or line, or flange or
other connector, and any control devices or systems required by this subpart (40  CFR 264.1031) [Added April 1999].

Exempted Hazardous Waste Containers and Surface Impoundments
Containers and surface impoundments are exempt from these air emission control requirements (specified under 40 CFR
264.1084 through 264.1087 or under 40 CFR 265.1085 through 265.1088) if the waste management unit is one of the
following (40 CFR 264.1082(c) and 265.1083(b)):
1.  containers and surface impoundments for which all hazardous wastes entering the unit have an average VO concentration
    at the point of waste origination of less than 500 ppmw as determined by using the procedures specified under 40 CFR
    264.1083(a) and 40 CFR 265.1084(a). This determination is updated at least every  12 months
2.  containers and surface impoundments for which the organic content of all hazardous wastes entering the unit has been
    reduced by an organic destruction or removal process that achieves any of the following conditions:
        a.   a process that removes or destroys the organics to a level such that the average VO concentration of the
            hazardous waste at the point of waste treatment is less than the exit concentration limit established for the
            process as determined by using the procedures specified under 40 CFR 264.1083(a) and 265.1084(b)
        b.   a process that removes or destroys the organics contained in the hazardous  waste to such a level that the organic
            reduction efficiency for the process is equal to or greater than 95 percent, and the average VO concentration of
            the hazardous waste at the point of waste treatment is less than 100 ppmw as determined by using the procedures
            specified under 40 CFR 264.1083(a) and 265.1084(b)
        c.   a process that removes or destroys the organics contained in the hazardous  waste to such a level that the actual
            organic mass removal rate for the process is greater than the required organic mass removal rate established for
            the process as determined by using the procedures specified under 40 CFR 264.1083(a) and 265.1084(b)
        d.   a biological process that destroys or degrades the organics contained in the hazardous waste such that either of
            the following is met:
               (i)  the organic reduction efficiency for the process is equal to or greater than 95 percent and the organic
                   biodegradation efficiency for the process is equal to or greater than 95 percent as determined by using
                   the procedures specified under 40 CFR 264.1083(a) and 265.1084(b)
               (ii) the total actual organic mass biodegradation rate for all hazardous waste treated by the process is  equal
                   to or greater than the  required organic mass removal rate as determined by using the procedures
                   specified under 40 CFR 264.1083(a) and 265.1084(b)
        e.   a process that removes or destroys the organics contained in the hazardous  waste and meets all the following
            conditions:
               (i)  from the point of waste origination through the point where the hazardous waste enters the treatment
                   process, the hazardous waste is continuously managed in waste management units which use air
                   emissions controls as specified in 40 CFR 264.1084 through 264.2087 or in 40 CFR 265.1085 through
                   265.1088, as applicable to the waste management unit

This document is intended solely for guidance. No statutory or regulatory                                        8
requirements are in any  way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


               (ii) from the point of waste origination through the point where the hazardous waste enters the process, any
                   transfer of the hazardous waste is accomplished through continuous hard-piping or other closed system
                   transfer that does not allow exposure of the waste to the atmosphere
               (iii) the average VO concentration of the hazardous waste at the point of waste treatment is less than the
                   lowest average VO concentration at the point of waste origination determined for each of the individual
                   hazardous waste streams entering the process or 500 ppmw, whichever value is lower (The average VO
                   concentration of each individual waste stream at the point of waste origination shall be determined using
                   the procedures specified under 40 CFR 264.1083(a) and 265.1084(b))
        f.   a process that removes or destroys the organics contained in the hazardous waste to a level such that the organic
            reduction efficiency for the process is equal to or greater than 95 percent and the owner/operator certifies that
            the average VO concentration at the point of waste origination for each of the individual waste streams entering
            the process is less than 10,000 ppmw, as determined by using the procedures specified under 40 CFR
            264.1083(a)  and 265.1084(b))
        g.   a hazardous waste incinerator for which the owner/operator has been issued a final permit under 40 CFR Part
            270, or has designed and operated the incinerator in compliance with 40 CFR 264, Subpart O
        h.   a boiler or industrial furnace for which the owner or operator has been issued a final permit under 40 CFR 270,
            or has designed and operated the unit in compliance with 40 CFR 266, Subpart H.
3.   a tank, container, or surface impoundment for which all hazardous waste placed in the unit either:
        a.   meets the numerical concentrations limits for organic hazardous constituents as specified in 40 CFR 268, or
        b.   the organic hazardous constituents in the waste have been treated by the treatment technology established by the
            U.S. EPA for the waste listed under 40 CFR 268.42(a) or have been removed or destroyed by an equivalent
            method of treatment approved by the U.S. EPA.

Exempted Hazardous Waste Management Unit
The air emission standards specified under Subpart CC of 40 CFR 264 and 265 do not apply to the  following waste
management units (40 CFR 264.1080(b) and 265.1080(b)):
1.   a waste management unit that holds hazardous waste placed in the unit before December 6, 1996, and in which no
    hazardous waste is added to the unit on or after December 6, 1996
2.   a container that has a design capacity less than or equal to 0.1 m3
3.   a tank in which an owner/operator has stopped adding hazardous waste and the owner/operator has begun implementing
    or completed closure pursuant to an approved closure plan
4.   a surface impoundment in which an owner/operator has stopped adding hazardous waste (except to  implement an
    approved closure plan) and the owner/operator has begun implementing or completed closure pursuant to an approved
    closure plan
5.   a waste management unit that is used solely for on-site treatment or storage of hazardous waste that is placed in the unit
    as a result of implementing remedial activities required under the corrective action authorities of RCRA Sect 3004(u),
    3004(v), or 3008(h); CERCLA authorities; or similar federal or state authorities
6.   a waste management unit that is used solely for the management of radioactive mixed waste in  accordance with all
    applicable regulations under the Atomic Energy Act and the Nuclear Waste Policy Act
7.   a waste management unit that the owner or operator certifies is equipped with and operating air emissions controls in
    accordance with the requirements of an applicable Clean Air Act (CAA) regulation codified under 40 CFR 60, 61, and 63
8.   a tank that has a process vent as defined in 40 CFR 264.1031.

Existing Hazardous Waste Management Facility or Existing Facility
A facility which was in operation or for which construction commenced on or before November 19, 1980 (40 CFR 260.10).

Facility
All contiguous land and structures, other appurtenances, and improvements on the land, used for treating, storing, or disposing
of hazardous waste. A facility may consist of several treatment, storage or disposal operational units (e.g., one or more
landfills, surface impoundments, or combination of them) (40 CFR 260.10).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


Fixed Roof
A cover that is mounted on a unit in a stationary position and does not move with fluctuations in the level of the material
managed in the unit (40 CFR 265.1081).

Food-Chain Crops
Tobacco, crops grown for human consumption, and crops grown for feed for animals whose products are consumed by
humans (40 CFR 260.10).

Free Liquids
Liquids which readily separate from the solid portion of a waste under ambient temperature and pressure (40 CFR 260.10).

Generator
Any person, by site, whose act or process produces hazardous waste identified or listed in 40 CFR Part 261, or whose act first
causes a hazardous waste to become subject to regulation (40 CFR 260.10).

Groundwater
Water below the land surface in a zone of saturation (40 CFR 260.10).

Halogenated Organic Compounds (HOC)
Those compounds having a carbon-halogen bond which are listed in Appendix III (40 CFR 268.2).

Hazardous Debris
Debris that contains a hazardous waste listed in subpart D of 40 CFR 261, or that exhibits a characteristic of hazardous waste
identified in subpart C of 40 CFR 26. Any deliberate mixing of prohibited hazardous waste with debris that changes its
treatment classification (i.e., from waste to hazardous debris) is not allowed under the dilution prohibition in 40 CFR 268.3
(40 CFR 268.2)

Hazardous Waste
A solid waste identified as a characteristic or listed hazardous waste in 40 CFR 261.3 (40 CFR 260.10).

Hazardous Waste Constituent
A constituent that caused the hazardous waste to be listed in 40 CFR Part 261, Subpart D (lists of hazardous wastes from non-
specific and specific sources, and listed hazardous wastes), or a constituent listed in the table of maximum concentrations of
contaminants  for the toxicity characteristic) (40 CFR 260.10).

Hazardous Waste Management Unit
A contiguous area of land on or in which hazardous waste is placed, or the largest area in which there is significant likelihood
of mixing hazardous waste constituents in the same area. Examples are a surface impoundment, a waste pile, a treatment area,
a landfill cell, an incinerator, a tank and its associated piping and underlying containment system, and a container storage
area. A container alone does not constitute a unit; the unit includes containers and the land or pad upon which they are placed
(40 CFR 260.10).

In Light Liquid Service
The piece of equipment  contains or contacts a waste  stream where  the vapor pressure of one or more of the organic
components in the stream is greater than 0.3 kPa at 20 degrees Celsius, the total concentration of the pure organic components
having a vapor pressure greater than 0.3 kPa at 20 degrees Celsius is equal to or greater than 20 percent by weight, and the
fluid is a liquid at operating conditions (40 CFR 264.1031).

In Light Material Service
The container is used to manage material for which both of the following conditions apply:
1.  The vapor pressure of one or more of the organic constituents in the material is greater than 0.3 kPa at 20 ° C , and
This document is intended solely for guidance. No statutory or regulatory                                        19
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

2. The total concentration of the pure organic constituents having a vapor pressure greater than 0.3 kPa at 20 °C is equal to
or greater than 20 percent by weight (40 CFR 265.1081).

Incompatible Waste
A hazardous waste that is unsuitable for:
1. Placement in a particular device or facility because it may cause corrosion or decay of containment materials (e.g.,
container liners or tank walls); or
2. Commingling with another waste or material under uncontrolled conditions because the commingling conditions produce
heat or pressure, fire or explosion, violent reaction, toxic dusts, mist, fumes, or gases, or flammable fumes or gases (40
CFR 260.10).

Individual Generation Site
The contiguous site at or on which one or more hazardous wastes are generated. An individual generation site, such as a large
manufacturing plant, may have one or more sources of hazardous waste, but is considered a single or individual generation
site if the site or property is contiguous (40 CFR 260.10).

Industrial Furnace
Any of the following enclosed devices that are integral components of manufacturing processes and that use thermal treatment
to accomplish recovery of materials or energy:
1. cement kilns
2. lime kilns
3. aggregate kilns
4. phosphate kilns
5. coke ovens
6. blast furnaces;
7. smelting, melting and refining furnaces;
8. titanium dioxide chloride process oxidation reactors
9. methane reforming furnaces
10. pulping liquor recovery furnaces
11. combustion devices used in the recovery of sulfur values from spent sulfuric acid; certain halogen acid furnaces, and
12. other devices designated by the Administrator of U. S. EPA (40 CFR 260.10).

Injection Wells
A well into which fluids are injected (40 CFR 260.10).

Inner Liner
A continuous layer of material placed inside a tank or container which protects the construction materials of the tank or
container from the contained waste or reagents used to treat the waste (40 CFR 260.10).

International Shipment
The transportation of hazardous waste into or out of the jurisdiction of the United States (40 CFR 260.10).

Land Disposal
Placement of hazardous waste in a landfill, surface impoundment, waste pile, injection well, land treatment facility, salt dome
formation, salt bed formation, underground mine or cave, or placement in a concrete vault or bunker intended for disposal
purposes (40 CFR 268.2).

Land Treatment Facility
A facility or part of a facility at which hazardous waste is applied onto or incorporated into the soil surface; such facilities are
disposal facilities if the waste will remain after closure (40 CFR 260.10).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

Landfill
A disposal facility or part of a facility where hazardous waste is placed in or on land and which is not a pile, a land treatment
facility, a surface impoundment, an underground injection well, a salt dome formation, a salt bed formation, an underground
mine, a cave, or a corrective action management unit (40 CFR 260.10).

Large Quantity Generator
A facility generating hazardous waste in quantities greater than 1000 kg (2,204.62 Ibs.) per calendar month or greater than 1
kg of acutely hazardous waste per calendar month (40 CFR 260.10).

Leachate
Any liquid, including any suspended components in the liquid, that has percolated through or drained from hazardous waste
(40 CFR 260.10).

Leak Detection System
A system capable of detecting the failure of either the primary or secondary containment structure or the presence of a release
of hazardous waste or accumulated liquid in the secondary structure. Such a system must employ operational controls (e.g.,
daily visible containment for releases into the secondary containment system of aboveground tanks) or consist of an interstitial
monitoring device designed to detect continuously and automatically the failure of the primary or secondary containment
structure or the presence of a release of hazardous waste into the secondary containment structure (40 CFR 260.10).

Malfunction
Any sudden, infrequent, and not reasonably preventable failure of air pollution control equipment, process equipment, or a
process to operate in a normal or usual manner. Failures that are caused in part by poor maintenance or careless operations
are not malfunctions (40 CFR 265.1081).

Management or Hazardous Waste Management
The systematic control of the collection, source separation, storage, transportation, processing, treatment, recovery, and
disposal of hazardous waste (40 CFR 260.10).

Management Practice (MP)
Practices which, although not mandated by law, are encouraged to promote safe operating procedures.

Manifest
The shipping document originated and signed by the generator containing the information required by 40 CFR 262, Subpart B
(40 CFR 260.10).

Manifest Document Number
The U.S. EPA 12-digit identification number assigned to the generator plus a unique 5-digit number assigned to the manifest
by the generator for recording and reporting purposes (40 CFR 260.10).

Movement
That hazardous waste transported to a facility in an individual vehicle (40 CFR 260.10).

New Hazardous Waste Management Facility
A facility that began operation, or for which construction commenced after October 21, 1976 (40 CFR 260.10).

No Detectable Organic Emissions
No escape of organics to the atmosphere as determined by using the procedures specified in 40 CFR 265.1084(d) (40 CFR
265.1081).

Nonwastewaters
Wastes that do not meet the criteria for wastewaters (40 CFR 268.2). (See definition of wastewater.)

This document is intended solely for guidance. No statutory or regulatory 12
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


Notifier
The person under jurisdiction of the exporting country who has, or will have at the time the planned transfrontier movement
commences, possession or other forms of legal control of the wastes and who proposes their transfrontier movement for the
ultimate purpose of submitting them to recovery operations. When the United States (U.S.) is the exporting country, notifier
is interpreted to mean a person domiciled in the United States (40 CFR 262.81).

OECD Country
Designated member countries of the Organization for Economic Coordination and Development (OECD) consisting of
Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Japan, Luxembourg, Netherlands,
New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, Turkey, United Kingdom, and the United States.  Canada and
Mexico are considered OECD member countries under the RCRA regulations only for the purpose of transit (40 CFR
262.58).

On-site
The same or geographically contiguous property which may be divided by a public or private right-of-way, provided the
entrance and exit between the properties is at a crossroads intersection, and access is by crossing as opposed to going along
the right-of-way. Non-contiguous properties owned by the same person but connected by a right-of-way which he controls
and to which the public does not have access is also considered onsite property (40 CFR 260.10)

Open Burning
The combustion of any material without the following characteristics:
1.   Control of combustion air to maintain adequate temperature for efficient combustion,
2.   Containment of the combustion-reaction in an enclosed device to provide sufficient residence time and mixing for
    complete combustion,
3.   Control of emission of the gaseous combustion products (40 CFR 260.10).

Open-ended Valve or Line
Any valve, except pressure relief valves, having one side of the valve seat in contact with hazardous waste and one side open
to the atmosphere, either directly or through open piping (40 CFR 264.1031)

Pile
Any non-containerized accumulation of solid, nonflowing hazardous waste that is used for treatment or storage that is not a
containment building (40 CFR 260.10).

Point Source
Any discernible, confined, and discrete conveyance, including but not limited to  any pipe, ditch, channel, tunnel, conduit,
well, discrete fissure, container, rolling stock, concentrated animal feeding operation, vessel or floating craft, from which
pollutants are or may be discharged. This term does not include return flows from irrigated agriculture (40 CFR 260.10).

Point of Waste Treatment
The point where a hazardous waste exits a waste management unit used to destroy, degrade, or remove organics in the
hazardous waste (40 CFR 265.1081).

Pollution Prevention
The use of materials, processes, or practices that reduce or eliminate the creation of pollutants or waste at the source.  It
includes practices that reduce the use of hazardous materials, energy, water or other resources and practices that protect
natural resources through conservation and more efficient use.

Primary Exporter
Any person who is required to originate the manifest for a shipment of hazardous waste in accordance with 40 CFR 262,
Subpart B or an equivalent state provision, that specifies a treatment, storage, or disposal facility in a receiving country as the
facility to which the hazardous waste will be sent and any intermediate arranging for the export (40 CFR 262.51).
This document is intended solely for guidance.  No statutory or regulatory                                         13
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


Prohibited Wastes
A subset of restricted wastes (under the land disposal restriction (LDR) regulations) that have established treatment standards,
are not subject to variances or waiver, and do not meet the respective treatment standard.

Publicly Owned Treatment Works (POTW)
Any device or system used in the treatment (including recycling and reclamation) of municipal sewage or industrial wastes of
a liquid nature which is owned by a state or municipality (as defined by section 502(4) of the CWA). This definition includes
sewers, pipes, or other conveyances only if they convey wastewater to a POTW providing treatment (40 CFR 260.10).

Qualified Groundwater Scientist
A scientist or engineer who has received a baccalaureate or post- graduate degree in the natural sciences or engineering and
has sufficient training and experience in groundwater hydrology and related fields as may be demonstrated by state
registration, professional certification, or completion of accredited university courses that enable the individual to make sound
professional judgments regarding groundwater monitoring and contaminant fate and transport (40 CFR 260.10).

Receiving Country
A foreign country to which a hazardous waste is sent for the purpose of treatment, storage, or disposal (except short-term
storage incidental to transportation) (40 CFR 262.51).

Representative Sample
A sample  of a universe or whole (e.g., waste pile, lagoon, groundwater) which can be expected to exhibit the average
properties of the universe or whole (40 CFR 260.10).

Restricted Wastes
The RCRA hazardous wastes that are subject to the LDR program. A waste is restricted if U.S. EPA has established a
treatment  standard for it, or if it has been specifically designated by Congress as ineligible for land disposal.

Runoff
Any rainwater, leachate, or other liquid that drains over land from any part of a facility (40 CFR 260.10).

Run-on
Any rainwater, leachate, or other liquid that drains over land onto any part of a facility (40 CFR 260.10).

Sludge
Any solid, semi-solid, or liquid waste generated from a municipal, commercial, or industrial wastewater treatment plant, water
supply treatment plant, or air pollution control facility exclusive of the treated effluent from a wastewater treatment plant (40
CFR 260.10).

Small Quantity Generator
A generator who generates less than 1,000 kg (2,204.62 Ib.) of hazardous waste but more than 100 kg (220.46 Ib.) in a
calendar month (40 CFR 260.10).

Soil
Unconsolidated earth material composing the superficial geologic strata (material overlying bedrock), consisting of clay, silt,
sand, or gravel size particles as classified by the U.S. Natural Resources Conservation Service, or a mixture of such materials
with liquids, sludges or solids which is inseparable by simple mechanical removal processes and is made up primarily of soil
by volume based on visual inspection. Any deliberate mixing of prohibited hazardous waste with soil that changes its
treatment classification (i.e., from waste to contaminated soil) is not allowed under the dilution prohibition in 40 CFR 268.3
(40 CFR 268.2)
This document is intended solely for guidance. No statutory or regulatory                                         14
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA

Storage
The holding of hazardous wastes for a temporary period, at the end of which the hazardous wastes are treated, disposed of, or
stored elsewhere (40 CFR 260.10).

Sump
Any pit or reservoir that meets the definition of tank and those troughs/trenches connected to it that serve to collect hazardous
waste for transport to hazardous waste TSDF except that as used in the landfill, surface impoundment, and waste pile rules,
sump means any lined pit or reservoir that serves to collect liquids drained from a leachate collection and removal system or
leak detection system for subsequent removal from the system (40 CFR 260.10).

Transfer Facility
Any transportation-related facility including loading docks, parking areas, storage areas and other similar areas where
shipments of hazardous wastes are kept during the normal course of transportation (40 CFR 260.10). (NOTE: Transfer
facilities are regulated under 40 CFR 263.12.)

Transfrontier Movement
Any shipment of hazardous wastes destined for recovery operations from an area under the national jurisdiction of one OECD
member country to an area under the national jurisdiction of another OECD country (40 CFR 262.81).

Transit Country
Any foreign country, other than a receiving country, through which a hazardous waste is transported (40 CFR 260.10).

Transport Vehicle
A motor vehicle or rail car used for the transportation of cargo by any mode. Each cargo-carrying body (trailer, railroad
freight car, etc.) is a separate transport vehicle (40 CFR 260.10).

Transporter
A person engaged in the off-site transportation of hazardous wastes by air, rail, highway, or water (40 CFR 260.10).

Treatability Study
A study in which a hazardous waste is subjected to a treatment process to determine:
1. Whether the waste is amenable to the treatment process,
2. What pretreatment (if any) is required,
3. The optimal process conditions needed to achieve the desired treatment,
4. The efficiency of a treatment process for a specific waste or wastes, or
5. The characteristics and volumes of residuals from a particular treatment process (40 CFR 260.10).

Also included in this definition for the purpose of the 40 CFR 261.4(e) and (f) exemptions are liner compatibility, corrosion,
and other material compatibility studies and lexicological and health effects studies. A treatability study is not a means to
commercially treat or dispose of hazardous waste.

Treatment
Any method, technique, or process, including neutralization, designed to change the physical, chemical, or biological
character or composition of any hazardous waste so as to neutralize the waste, or so as to recover energy or material resources
from the waste, or so as to render the waste nonhazardous or less hazardous; safer to transport, store, or dispose of; or
amenable for recovery, amenable for storage, or reduced in volume (40 CFR 260.10).

Unsaturated Zone or Zone of Aeration
The zone between the land surface and the water table (40 CFR 260.10).
This document is intended solely for guidance. No statutory or regulatory 15
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


United States
The 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the US Virgin Islands, Guam, American Samoa,
and the Commonwealth of the Northern Mariana Islands (40 CFR 260.10).

Uppermost Aquifer
The geologic formation nearest the natural ground surface that is an aquifer, as well as lower aquifers that are hydraulically
interconnected with this aquifer within the facility's property boundary (40 CFR 260.10).

Used Oil
Any oil that has been refined from crude oil, or any synthetic oil, that has been used and as a result of such use is
contaminated by physical or chemical impurities (40 CFR 260.10).

Volatile Organic (VO) Concentration
The fraction by weight of the volatile organic compounds in a hazardous waste expressed in terms of ppmw as determined by
direct measurement or by knowledge of the waste (40 CFR 265.1081)

Waste Stabilization Process
Any physical or chemical process used to  either reduce the mobility of hazardous constituents in a hazardous waste or
eliminate free liquids (40 CFR 265.1081).

Wastewater Treatment Unit
A device that (1) is part of a wastewater treatment facility subj ect to regulation under section 402 or 3 07 of the CWA; and (2)
receives and treats or stores an influent wastewater that is a hazardous waste (as defined in 40 CFR 261.3), or that generates
and accumulates a wastewater treatment sludge that is a hazardous waste, or treats or stores a wastewater treatment sludge;
and (3) meets the definition of tank or tank system (40 CFR 260.10).

Wastewaters
Wastes that contain less than one percent by weight total organic compounds and one percent by weight total suspended solids
(40 CFR 268.2).

Zone of Engineering Control
An area under the control of the owner/operator that upon detection of a hazardous waste release, can be readily cleaned up
before the release of hazardous waste or hazardous constituents to groundwater or surface water (40 CFR 260.10).

Typical Records to Review

•   Notification of Hazardous Waste Activity (EPA ID No.);
•   Hazardous waste manifests;
•   Manifest exception reports;
•   Biennial reports;
•   Inspection logs;
•   Delistings;
•   Speculative accumulation records;
•   Land disposal restriction certifications;
•   Employee training documentation;
•   Hazardous substance spill control and contingency plan;
•   Notifications of hazardous waste oil fuel marketing or blending activity;
.   Material Safety Data Sheets (MSDSs);
•   Inventory records;
•   Shipping papers;
•   Hazardous Communication Plan;
•   Chemical Hygiene Plan (labs); and
•   Spill records.


This document is intended solely for guidance. No statutory or regulatory                                         15
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Typical Physical Features to Inspect

•   Hazardous waste generations sites (e.g., production and manufacturing areas);
•   Waste storage areas;
•   Satellite accumulation points;
•   Vehicles used for transport;
•   Container storage areas;
•   Generation points;
•   Shipping and receiving areas; and
•   Shop activities.

List of Acronyms and Abbreviations

AST       Aboveground storage tank
BTU       British thermal unit
CAA       Clean Air Act
CAMU     Corrective action management unit
CERCLA   Comprehensive Environmental Response, Compensation, and Liability Act (or Superfund)
CESQG    Conditionally exempt small quantity generator
CFC       Chlorofluorocarbon
CFR       Code of Federal Regulations
CSD       Contaminated soil and debris
CWA      Clean Water Act
DOT       Department of Transportation
EPA       Environmental Protection Agency
FR        Federal Register
ft.         Feet
gal.        Gallon
h          Hour
HOC       Halogenated organic compound
hp         Horsepower
HSWA     Hazardous and Solid Waste Amendments
HWM      Hazardous waste management
ID         Identification
kg         Kilogram
km        Kilometer
L          Liter
Ib.         Pound
LDR       Land disposal restriction
LQG       Large quantity generator
OECD      Organization for Economic Coordination and Development
m         Meter
Mg        Megagram
MJ        Megajoule
mm       Millimeter
mo        Month
MP        Management practice
MSDS      Material Data Safety Sheet
MW       Megawatt
NOV       Notice of violation
NRC       National Response Center
PCB       Polychlorinated biphenyl
PL        Public Law
POTW     Publicly owned treatment works
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
17

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
ppm        Part per million
ppmw       Part per million by weight
qt.          Quart
RCRA      Resource Conservation and Recovery Act
scf         Standard cubic foot
scm        Standard cubic meter
SDWA      Safe Drinking Water Act
SPCC       Spill prevention, control, and countermeasure
SQG        Small quantity generator
TSCA       Toxic Substances Control Act
TSDF       Treatment, storage, and disposal facility
UIC        Underground injection control
U.S.        United States
U.S. EPA    United States Environmental Protection Agency
USC        United States Code
UST        Underground storage tank
VO         Volatile organic
VOC        Volatile organic compound
yr          Year
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
18

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Index for Checklist Users

Category
All Facilities
All Sizes of Generators
Conditionally Exempt Small Quantity Generators (CESQG)
Small Quantity Generators (SQG)
General
Personnel Training
Containers
Satellite Accumulation Points
Container Storage Areas
Disposal of Restricted Wastes
Large Quantity Generators (LQG)
General
Personnel Training
Contingency Plans and Emergency Coordinators
Containers
Emissions from Process Vents
Air Emissions Standards for Equipment Leaks
Satellite Accumulation Points
Container Storage Areas
Containment Buildings
Disposal of Restricted Waste
Transportation of Hazardous Waste
Export/Import of Hazardous Waste
Exports of Hazardous Waste for Recovery Within the
OECD Member Countries
Exports of Hazardous Waste (Except to the OECD
Member Countries) for Recovery
Imports of Hazardous Waste for Recovery Within the
OECD Member Countries
Imports of Hazardous Waste (Except from the OECD
Member Countries) for Recovery
Waste Minimization/Pollution Prevention
Refer To:

Checklist Items:
HW. 1.1 through HW. 1.4
HW.10.1 through HW. 10.4
HW.20.1 through HW.20.6

HW.30.1 through HW.30.6
HW.40.1andHW.40.2
HW.50.1 through HW.50.6
HW.60.1
HW.70.1 through HW.70.3
HW.80.1 through HW.80.5

HW. 100.1 through HW. 100.7
HW. 1 10.1 and HW. 110.2
HW. 120.1 through HW. 120.4
HW. 130.1 through HW. 130. 12
HW. 140.1 through HW. 140.6
HW. 150.1 through HW. 150. 10
HW. 160.1
HW. 170.1 through HW. 170.3
HW. 190.1 through HW. 190.7
HW.200.1 through HW.200.6
HW.300.1 through HW.300.5

HW.400.1 through HW.400.7

HW.420.1 through HW.420.8

HW.440.1 through HW.440.6

HW.460.1andHW.460.2

HW.500.1
Page
Numbers:
21
23
27

31
35
37
39
41
43

47
51
53
57
69
77
85
87
89
93
97

101

107

111

115

117
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
19

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       20
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Checklist
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     ALL FACILITIES
     HW.l
     HW.1.1.  The  current status
     of any ongoing or unresolved
     Consent Orders,  Compliance
     Agreements,   Notices   of
     Violation     (NOV),     or
     equivalent state enforcement
     actions pertaining to RCRA
     or   corresponding    state
     regulations     should    be
     examined.
Determine if noncompliance issues have been resolved by reviewing a copy of the
previous report,  Consent Orders, Compliance Agreements, NOVs, Interagency
agreements or equivalent state enforcement actions.

Determine and indicate, for those open items, what corrective action is planned
and milestones established to correct problems.
     HW.1.2.    Facilities    are
     required to comply with state
     and    local     regulations
     concerning  hazardous  waste
     management.
Determine  state authorization  status.   In authorized states,  compare state
regulations to federal requirements outlined in this document and annotate this
checklist accordingly.

Verify that the facility is abiding by state and local hazardous waste requirements.

Verify that the facility is operating according to hazardous waste permits issued
by the state or local agencies where approved.

(NOTE: Issues typically regulated by state and local agencies include:
   - additional manifesting requirements
   - more frequent reporting requirements
   - transportation
   - identification of special waste or waste categories
   -regulation  of specific  substances  as  hazardous  waste  such as:  medical,
     pathological, and infectious waste; used oil; explosives; used batteries
   - small and conditionally exempt small quantity generator requirements
   - RCRA permitting of oil/water separators
   - disposal requirements
   - construction and operation of storage and disposal facilities
   - satellite accumulation point requirements
   - container marking and labeling requirements.)

Verify that the  actions detailed  in  compliance  agreements are being taken
according to the schedule established in the agreements.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       21

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW.1.3. Facilities are
required to comply with all
applicable federal regulatory
requirements not identified in
this checklist
Determine if any new hazardous waste regulations have been issued since the
finalization of the guide. If so, annotate checklist to include new standards.

Determine if the facility has hazardous waste activities or facilities that are
federally regulated, but not addressed in this checklist.

Verify that the facility is in compliance with all applicable and newly issued
hazardous waste regulations.
HW.1.4. Specific persons
should be designated
responsible for hazardous
waste storage areas, and the
precise nature of their
responsibilities should be
specified (MP).
Verify that specific individuals have been designated responsible for hazardous
waste storage areas.

Verify that the individuals designated responsible for hazardous waste storage
areas are aware of the precise nature of their responsibilities.

Verify that required training for hazardous waste handling is in personnel file.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
22

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     ALL SIZES OF
     GENERATORS

     HW.10
     HW.10.1.   Facilities   that
     generate solid wastes  must
     determine  if the wastes are
     hazardous  wastes (40  CFR
     262.11, 261.3, 261.4(b), and
     261.21   through   261.24)
     [Revised January 2001].
(NOTE:  Determination of whether or not a waste is a hazardous waste can be
done through one of the following:

   -knowledge of all the constituents of the waste (MSDSs) and whether it is
     listed in 40 CFR 261
   - laboratory analysis
   -knowledge of materials and processes used.)

(NOTE:  Unidentified waste materials and spilled hazardous materials may have
to be  disposed  of as hazardous waste depending on their  constituents or
characteristics.)

(NOTE:  Some batteries, pesticides, thermostats, and mercury lamps may be
considered universal wastes instead of hazardous wastes and need to be handled
according to the requirements in 40 CFR 273.)

Discuss with staff how  wastes generated on the facility  were  identified and
classified.

Determine  if  the  facility  followed  U.S.  EPA  criteria  for  identifying  the
characteristics  of hazardous waste and U.S. EPA's listed wastes in 40  CFR 261
(see Appendices A, B, C, and D of this document).

Determine whether the facility generates, transports, treats, stores, or disposes of
any hazardous waste and the quantity (see Appendices  A,  B, C, and D of this
document for guidance, note that the listings  reflected in these appendices  are
frequently revised in the Federal Register).

(NOTE:  When making quantity determinations, all hazardous waste generated
must be included except hazardous waste that is:
   -exempt  from  regulation under  40  CFR  261.4(c) through  261.4(f),
     261.6(a)(3), 261.7(a)(l), or 261.8
   -managed   immediately  upon  generation  only  in  on-site  elementary
     neutralization  units,  wastewater treatment  units,  or  totally  enclosed
     treatment facilities
   - recycled,  without prior storage or accumulation, only in an on-site process
     subject to regulation under 40 CRR 261.6(c)(2)
   -used oil managed under 40 CFR 261.6(a)(4) and 40 CFR 279
   - spent lead-acid batteries managed under the requirements of 40 CFR 266,
     Subpart G	
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      23

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                      -universal waste managed under 40 CFR 261.9 and 40 CFR 273.)

                                  (NOTE: The following are examples of solid wastes which are not considered
                                  hazardous wastes (40 CFR 261.3 and 261.4(b)):
                                      - household waste
                                      - solid wastes that are generated by any of the following and are returned to
                                       the soils as fertilizers:
                                           - growing and harvesting of agricultural crops
                                           - raising of animals, including animal manures
                                           - mining overburden returned to the mine site
                                      - fly ash waste,  bottom ash waste, slag waste,  and flue gas emission control
                                       waste generated primarily from the combustion of coal or other fossil fuels
                                       except for facilities that burn hazardous waste
                                      -drilling  fluids, produced waters  and   other wastes  affiliated with  the
                                       explorations,  development, or production of crude oil,  natural gas, or
                                       geothermal energy
                                      - wastes  that fail the test for the toxicity characteristic because chromium is
                                       present or are listed in Subpart D because of the presence of chromium, that
                                       do not fail the  test for toxicity characteristics for any other constituent or are
                                       not listed due  to the presence of any other constituent, and that do not fail
                                       the test  for other characteristics (see 40 CFR 261.4(b)(6)(i) for a listing of
                                       types of industries generating this type of waste that receive exclusions)
                                      - solid waste from  the extraction, beneficiation, and processing of ores and
                                       minerals (including coal,  phosphate rock, and overburden) from the mining
                                       of uranium ore (NOTE:  There is an exception to this for facilities that burn
                                       or process hazardous waste, see 40 CFR 266.112.)
                                      - cement kiln dust waste, except for facilities that burn or process hazardous
                                       waste
                                      -solid  waste which  consists of discarded arsenic-treated wood or wood
                                       products which fails the test for Toxicity Characteristics for hazardous waste
                                       codes D004 through DO 17 and which is  not a hazardous waste for any other
                                       reason if the waste  is generated by persons  who utilize the arsenic-treated
                                       wood and wood products for those materials intended end use
                                      -petroleum contaminated  media and debris that fail the  test for  Toxicity
                                       Characteristic  of 40 CFR 261.24 (Hazardous Waste Codes DO 18 through
                                       D043 only) and are required to meet the corrective action regulations under
                                       40 CFR280
                                      -injected groundwater that is hazardous only because it exhibits the Toxicity
                                       Characteristic  (Hazardous Waste Codes DO 18 through D043 only) in 40
                                       CFR  261.24  that is reinjected through an underground injection  well
                                       pursuant to free  phase  hydrocarbon recovery operations undertaken at
                                       petroleum refineries, petroleum marketing terminals, petroleum bulk plants,
                                       petroleum pipelines, and petroleum transportation spill sites  until January
                                       25, 1993. This extension applies to recovery operations in existence, or for
                                       which contracts have been issued, on or  before March 25, 1991. For
                                       groundwater returned through infiltration galleries from such operations at
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              24

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                       petroleum refineries, marketing terminals, and bulk plants. New operations
                                       involving injection wells (beginning after March 25, 1991) will qualify for
                                       this compliance date extension (until January 25, 1993) only if:
                                          - operations are performed pursuant to a written state agreement that
                                            includes a provision to assess the groundwater and the need for further
                                            remediation once the free phase recovery is completed; and
                                          - a copy of the written agreement has been submitted to: Characteristics
                                            Section  (OS-333),  U.S.  Environmental Protection Agency, 401  M
                                            Street, SW., Washington, DC 20460
                                     -used chlorofluorocarbon refrigerants  from totally enclosed  heat transfer
                                       equipment, including mobile air conditioning systems,  mobile  refrigeration
                                       and commercial and  industrial air conditioning and refrigeration systems
                                       that use chlorofluorocarbons as the  heat transfer fluid  in a  refrigeration
                                       cycle, provided that the refrigerant is reclaimed for further use
                                     - non-terne plated used oil filters that are not mixed with  a listed hazardous
                                       waste if these oil  filters have been gravity hot-drained using one of the
                                       following methods:
                                          - puncturing the filter anti-drain back valve or the  filter dome end and
                                            hot-draining
                                          - hot-draining and crushing
                                          - dismantling and hot-draining, or
                                          - any other equivalent hot-draining method that will  remove used oil
                                     -used oil  re-refining  distillation  bottoms  that  are  used as  feedstock  to
                                       manufacture asphalt products
                                     -leachate or gas condensate collected from landfills  where  certain solid
                                       wastes have been disposed, provided that:
                                          -the solid wastes disposed would meet one or  more of the listing
                                            descriptions  for Hazardous Waste Codes  K169, K170, K171, and
                                            K172 if these wastes had been generated after February 8,  1999
                                          - the solid wastes were disposed prior to  the effective date of the listing
                                          -the leachate  or  gas  condensate  do not exhibit any characteristic  of
                                            hazardous waste nor are derived from any other listed hazardous waste
                                          - discharge of the leachate or gas condensate, including leachate or gas
                                            condensate transferred from the landfill to a POTW by truck, rail,  or
                                            dedicated pipe, is subject to regulation under sections 307(b)  or 402 of
                                            the CWA.

                                  (NOTE:  After  February 13, 2001, leachate or gas condensate will no longer  be
                                  exempt if it is stored or managed in a surface impoundment prior to discharge.
                                  There is one exception:  if the surface impoundment is used to temporarily store
                                  leachate or gas condensate in response to an emergency situation (e.g., shutdown
                                  of wastewater treatment system),  provided the impoundment has a double liner,
                                  and provided the leachate or gas condensate is removed from the impoundment
                                  and  continues to be managed in compliance with  40 CFR 261.4(b)  after the
                                  emergency ends.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              25

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
Verify that wastes are tested for toxicity characteristics or are previously
identified as toxic.

Verify that all data used for determination, including quality assurance data, is
maintained and kept available for reference or inspection.
HW.10.2. Facilities which
claim that a particular
material is not a solid waste
or is conditionally exempt
from regulation as a
hazardous waste should be
prepared to provide specific
documentation in the event of
an enforcement action (40
CFR261.2(f)).
Determine if the facility has any wastes that are typically handled as hazardous
wastes that it claims are exempt.

Verify that for these wastes, the facility can demonstrate that there is a known
market or distribution for the material (if relevant) and that they meet the terms of
the exclusion or exemption.

Verify that documentation is provided that indicates the material is not a waste or
is exempt from regulation.

(NOTE: One example of documentation is contracts showing that a second
person uses the material as an ingredient in a production process.)

Verify that if the facility is claiming to recycle material, the equipment for the
recycling is actually at the facility and in working order.
HW.10.3. Areas where
containers of hazardous
waste are stored should have
secondary containment
(MP).
Verify that the areas where containers of hazardous waste are stored have
secondary containment.
HW.10.4. Generators must
not offer their waste to
transporters or TSDFs that
have not received an EPA
identification number (40
CFR262.12(c)).
Verify that all transporters of hazardous wastes and TSDFs used by the generator
have an EPA identification number by examining facility records pertaining to
these services. Examples of such records could include sales agreements or
vendor contracts. Auditors could also contact the state regulatory agency or local
U.S. EPA regional office to confirm that these vendors have the appropriate EPA
identification number.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
26

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     CONDITIONALLY
     EXEMPT SMALL
     QUANTITY
     GENERATORS (CESQG)

     HW.20
     HW.20.1.  Generators of no
     more   than   100   kg/mo
     (220.46 Ib/mo) of hazardous
     waste  or  1 kg  of acutely
     hazardous waste may qualify
     as CESQGs when they meet
     specific   requirements   (40
     CFR    261.5)     [Revised
     January 2001].
Verify that the following quantity and storage limitations are met:

   -no more than 100 kg  (220.46 Ib.) of hazardous waste is generated in a
     calendar month
   -total on-site accumulation does  not exceed 1,000 kg (2,204.62 Ib.) of
     hazardous waste
   -no more than 1 kg (2.2 Ib.) of acute hazardous waste (see Appendix D) is
     generated in a calendar month
   -no more than a total of 100 kg (220.46 Ib.) of any residue or contaminated
     soil, waste, or other debris resulting from the cleanup of any acute wastes in
     a calendar month is generated.

Verify that wastes are either  treated  or  disposed of in an on-site facility or
delivered to an off-site TSDF, which is one of the following:

   - permitted under 40 CFR 270
   - operating under interim status
   -authorized  to manage hazardous waste  by a  state  with an approved
     hazardous waste management program under 40 CFR 271
   - permitted, licensed, or registered by a state to manage solid waste
   - a facility which does one of the following:
        -beneficially uses  or  reuses, or legitimately  recycles or  reclaims its
         waste
        - treats it waste prior to beneficial use or reuse, or legitimate recycling
         or reclamation
   - a universal waste handler or destination facility for universal  waste if the
     waste is to be disposed of is universal waste regulated under 40 CFR 273.

(NOTE:  If a hazardous waste generator meets the requirements  for being a
CESQG, it is not required to meet any of the standards outlined in 40 CFR 262
through 266, (except 262.11), 268, and 270.)

(NOTE:  If a facility mixes its waste with used oil, the mixture is subject to  the
requirements in Subpart G of 40 CFR 279 if it is destined to be burned for energy
recovery.)

(NOTE:  Quantities of hazardous and acutely hazardous waste greater than  the
threshold quantities listed above become subject to the standards for LQGs.)	
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      27

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  (NOTE:  Even though a CESQG is not legally required to use a manifest or
                                  obtain a hazardous waste identification number, many hazardous waste haulers
                                  will not transport hazardous waste from a facility without a manifest or ID
                                  number.)
     HW.20.2.     Environmental
     management  at the facility
     may be enhanced  if CESQG
     personnel    who     handle
     hazardous   waste  receive
     training in certain key areas
     of waste management (MP).
Verify that the facility personnel complete  classroom instruction or on-the-job
training as set forth below:

Verify that the training program is directed by a person trained in hazardous
waste management procedures and that the program includes instruction which
teaches facility personnel hazardous waste  management procedures relevant to
positions in which they are employed.

(NOTE: Although not specified by the regulations, examples of training topics for
hazardous  waste management procedures could include (but would not  be
limited to) the following:
   - waste turn in procedures
   - identification of hazardous wastes
   — container use, marking, labeling and on-site transportation
   — manifesting and off-site transportation
   - 90 day storage area management
   -personal health and safety and fire safety.)

Verify that the training program includes contingency plan implementation and
is designed to ensure that facility personnel are able to respond to emergencies
including (where applicable):

   — key parameters for automatic waste feed cut-off systems
   —procedures for using, inspecting, repairing, and replacing emergency and
     monitoring equipment
   — operation of communications and alarm systems
   — response to fire or explosion
   - response to  groundwater contamination incidents
   - response to  leaks or spills
   — shutdown of operations.

Verify that new employee training is completed within six months of employment/
assignment.

Verify that an annual review of initial training is provided.

Verify that employees do not work unsupervised until training is completed.

Verify specifically that waste storage  area  managers and hazardous waste
handlers have been trained.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      28

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW.20.3. Training records
should be maintained for all
CESQG staff who manage
hazardous waste (MP).
Verify that training records include the following:

—job title and description for each employee by name
— written description of how much training each position will obtain
- documentation of training received by name.

Determine if training records are retained for 3 yr after employment at the
facility.
HW.20.4. Empty containers
at CESQGs previously
holding hazardous wastes
must meet the regulatory
definition of empty before
they are exempted from
hazardous waste
requirements (40 CFR
261.7).
Verify that for containers or inner liners holding hazardous wastes:

-wastes are removed that can be removed using practices commonly
employed to remove materials from that type of container (e.g., pouring,
pumping, and aspirating) and,
- no more than 2.5 cm (1 in.) of residue remains, or
-if the container is less than or equal to 110 gal. (416.40 L), no more than 3
percent by weight of total container capacity remains, or
-when the container is greater than 110 gal. (416.40 L), no more than 0.3
percent by weight of the total container capacity remains.

Verify that for containers that hold a compressed gas, the pressure in the
container approaches atmosphere.

Verify that for a container or inner liner that held an acute hazardous waste listed
in Appendix D, one of the following is done:

- it is triple rinsed
- it is cleaned by another method identified through the literature or testing as
achieving equivalent removal
- the inner liner is removed.
HW.20.5. Containers at
CESQGs should be managed
in accordance with specific
management practices (MP).
Verify the following by inspecting storage areas:

— containers are not stored more than two high and have pallets between
them
-containers of highly flammable wastes are electrically grounded (check for
clips and wires and make sure wires lead to ground rod or system)
- at least 3 ft. (0.91 m) of aisle space is provided between rows of containers.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
29

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                       COMPLIANCE CATEGORY:
                                  HAZARDOUS WASTE MANAGEMENT
         REGULATORY
       REQUIREMENT OR
         MANAGEMENT
           PRACTICE
                        REVIEWER CHECKS
     HW.20.6.   Containers   of
     hazardous waste should be
     kept in  designated storage
     areas at CESQGs (UP).
Verify  that all hazardous waste containers  are  identified and  stored in
appropriate areas.

(NOTE: Any unidentified contents of solid waste containers and/or containers
not in designated storage areas must be tested to determine if solid or hazardous
waste requirements apply.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                   30

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     SMALL QUANTITY
     GENERATORS (SQGs)

     HW.30

     General
     HW.30.1.     SQGs    that
     generate, transport, or handle
     hazardous wastes must obtain
     an    EPA    identification
     number (40  CFR 262.12(a)
     and  262.12(b);   40  CFR
     265.11).
Determine  the  facility's  generator   identification  number  by  examining
documentation from U.S. EPA.

Verify that correct identification number is used on all appropriate documentation
(i.e., manifests).
     HW.30.2.   Generators   of
     more than  100 kg  (220.46
     Ib.) but less than 1,000 kg
     (2,204.62 Ib.)  of  hazardous
     waste per month may qualify
     as   an  SQG   which  can
     accumulate  hazardous  waste
     on-site  for 180 days (or 270
     days)  without  a  permit  if
     specific conditions are met
     (40    CFR    262.34(d)(l),
     262.34(d)(4), 262.34(e) and
     262.34(f)).
Verify that containers, storage, and records have been inspected.

Verify that no more than 1,000 kg (2,204.62 Ib.) of hazardous waste is generated
in any calendar month.

Verify that the on-site accumulation time does not exceed 180 days.

(NOTE:  For an SQG the accumulation start date begins when the first waste is
poured/placed into the waste container, except at satellite accumulation points.)

(NOTE:  The 180 day time period is extended to 270 days if the waste must be
transported more than 200 miles to a TSDF. This extension does not apply if a
TSDF is available within 200 miles and the facility chooses to transport the waste
to a more distant TSDF.)

Verify that no more than 6,000 kg (13,227.73 Ib.) is allowed to accumulate at the
facility.

Verify that containers are marked with the date that accumulation began and the
words HAZARDOUS WASTE.

Verify that the containers and the areas where  containers are  stored meet the
requirements outlined in the subsections pertaining to SQG.

(NOTE:  Quantities  of hazardous and acutely  hazardous waste greater than the
threshold quantities listed above become subject to the standards for LQGs.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                     31

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW.30.3. An SQG must not
offer its hazardous waste to
transporters or to TSDFs that
have not received an EPA
identification number (40
CFR262.12(c)).
Verify that all transporters of hazardous waste and TSDFs utilized by the facility
have an EPA identification number by examining facility records pertaining to
these services. Examples of such records could include vendor contracts or sales
agreements. Auditors could also contact the state regulatory agency or the local
U.S. EPA regional office to confirm that these vendors have the appropriate EPA
identification number.
HW.30.4. SQGs of
hazardous waste are required
to use manifests and keep
records of hazardous waste
activity (40 CFR 262.20,
262.42(b) and 262.44).
Verify that signed copies of returned manifests are kept for three years from the
date the waste was accepted by the initial transporter.

Verify that exception reports were submitted to the regulatory agency when a
signed manifest copy was not received within 60 days of the waste being accepted
by the initial transporter.

Verify that exception reports are kept for at least three years.

(NOTE: The requirement to prepare a manifest does not apply if:
- the waste is reclaimed under contractual agreement and:
-the type of waste and frequency of shipments are specified in the
agreement;
- the vehicle used to transport the waste to the recycling facility and to
deliver regenerated material back to the generator is owned and
operated by the reclaimer; and
- the generator maintains a copy of the reclamation agreement for at
least three years after termination of the agreement.)

(NOTE: Period of retention of records is extended automatically during the
course of any unresolved enforcement action or as requested by the regulatory
agency.)
HW.30.5. SQGs are required
to keep records of waste
analyses, tests, and waste
determinations (40 CFR
262.40(c)).
Verify that appropriate records are kept for at least three years from the date the
waste was last sent to an on-site or off-site TSDF.

(NOTE: Period of retention of records is extended automatically during the
course of any unresolved enforcement action or as requested by the regulatory
agency.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
32

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                       COMPLIANCE CATEGORY:
                                  HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
           PRACTICE
                        REVIEWER CHECKS
     HW.30.6. SQGs are required
     to   have   an  emergency
     coordinator  and emergency
     response planning  (40  CFR
     262.34(d)(5)).
Verify that the facility has at least one emergency coordinator who is either on the
premises or on call.

Verify that the following emergency information is posted next to the telephone:

   - name and telephone number of emergency coordinator
   - location of fire extinguishers and spill control materials
   - location of fire alarms (if present)
   -telephone number of fire department.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                   33

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       34
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                       COMPLIANCE CATEGORY:
                                  HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                        REVIEWER CHECKS
     SMALL QUANTITY
     GENERATORS

     HW.40

     Personnel Training
     HW.40.1.   SQG personnel
     are required to be thoroughly
     familiar  with  proper  waste
     handling   and  emergency
     procedures    (40     CFR
     262.34(d)(5)(iii)).
Verify that personnel are thoroughly familiar with waste handling and emergency
procedures relevant to their responsibilities during normal facility operation and
emergencies.
     HW.40.2.  Training records
     should be maintained for all
     SQG  staff  who   manage
     hazardous waste (MP).
Verify that training records include the following:

   -job title and description for each employee by name
   - written description of how much training each position will obtain
   — documentation of training received by name.

Determine if training records are retained for three years after employment at
the facility.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                    35

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       35
requirements are in any way altered by any statement(s) contained herein.

HW.50

Containers
HW.50.1. Empty containers
at SQGs previously holding
hazardous wastes must meet
the regulatory definition of
empty before they are
exempted from hazardous
waste requirements (40 CFR
261.7).
Verify that for containers or inner liners holding hazardous wastes:

-wastes are removed that can be removed using practices commonly
employed to remove materials from that type of container (e.g., pouring,
pumping, and aspirating), and
- no more than 2.5 cm (1 in.) of residue remains, or
-if the container is less than or equal to 110 gal. (416.40 L), no more than 3
percent by weight of total container capacity remains, or
-when the container is greater than 110 gal. (416.40 L), no more than 0.3
percent by weight of the total container capacity remains.

Verify that for containers that held a compressed gas, the pressure in the container
approaches atmosphere.

Verify that for a container or inner liner that held an acute hazardous waste listed
in Appendix D, one of the following is done:

- it is triple rinsed
- it is cleaned by another method identified through the literature or testing as
achieving equivalent removal
- the inner liner is removed.
HW.50.2. Containers used to
store hazardous waste at
SQGs must be in good
condition and not leaking (40
CFR 262.34 (d)(2) and 40
CFR 265.171).
Verify that containers are not leaking, bulging, rusting, damaged or dented.

Verify that waste in leaking containers is transferred to a new container or
managed in another appropriate manner when necessary.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
37

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW.50.3. Containers used at
SQGs must be made of or
lined with materials
compatible with the waste
stored in them (40 CFR
262.34(d)(2) and 40 CFR
265.172).
Verify that containers are compatible with waste; for example, check that strong
caustics and acids are not stored in metal drums.
HW.50.4. Containers of
hazardous waste at SQGs
must be closed during
storage and handled in a safe
manner (40 CFR
262.34(d)(2) and 40 CFR
265.173).
Verify that containers are closed except when it is necessary to add or remove
waste (check bungs on drums, look for funnels).

Verify that handling and storage practices do not cause damage to the containers
or cause them to leak.
HW.50.5. The handling of
incompatible wastes or
incompatible wastes and
materials in containers at
SQGs must comply with safe
management practices (40
CFR 262.34(d)(2) and 40
CFR 265.177).
Verify that incompatible wastes or incompatible wastes and materials are not
placed in the same containers unless it is done so that it does not:

- generate extreme heat or pressure, fire, explosion, or violent reaction
-produce uncontrolled toxic mists, fumes, dusts, or gases in sufficient
quantities to threaten human health
-produce uncontrolled flammable fumes or gases in sufficient quantities to
pose a risk of fire or explosions
- damage the structural integrity of the device or facility
- threaten human health by any other like means.

(NOTE: Incompatible wastes as listed in Appendix E of this document should
not be placed in the same drum.)

Verify that hazardous wastes are not placed in an unwashed container that
previously held an incompatible waste or material.

Verify that containers holding hazardous wastes incompatible with wastes stored
nearby in other containers, open tanks, piles, or surface impoundments are
separated or protected from each other by a dike, berm, wall or other device.
HW.50.6. Containers of
hazardous waste at SQGs
should be managed in
accordance with specific
management practices (MP).
Determine the following by inspecting containers and storage areas:

- containers are not stored more than two high and have pallets between
them
-containers of highly flammable wastes are electrically grounded (check for
clips and wires and make sure wires lead to ground rod or system)
— at least 3 ft. (0.91 m) of aisle space is provided between rows of containers.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
38

HW.60

Satellite Accumulation
Points
HW.60.1. All SQGs may
accumulate as much as 55
gal. of hazardous waste or 1
qt. of acutely hazardous
waste in containers at or near
any point of initial generation
without complying with the
requirements for on-site
storage if specific standards
are met (40 CFR 262.34(c)).
(NOTE: This type of storage area is often referred to as a satellite accumulation
point.)

Verify that the satellite accumulation point is at or near any point of generation
where wastes initially accumulate and is under the control of the operator of the
waste generating process.

Verify that the containers are in good condition and are compatible with the waste
stored in them and that the containers are kept closed except when waste is being
added or removed.

Verify that the containers are marked HAZARDOUS WASTE or other
appropriate identification.

(NOTE: See ices A, B, C, and D for a guidance list of hazardous and acute
wastes. Note that the listings reflected in these appendices are frequently revised
in the Federal Register)

Verify that shop managers are interviewed, in order to identify when waste is
accumulated in excess of quantity limitations, and when such findings are made
the following actions are taken:

-the excess container is marked with the date the excess amount began
accumulating
- the waste is transferred to a storage area within three days where it will be
stored for 180 days or less.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
39

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       40
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     SMALL QUANTITY
     GENERATORS

     HW.70

     Container Storage Areas
     HW.70.1.    Containers   of
     hazardous  waste  at  SQGs
     should be  kept in  storage
     areas   designated   in  the
     management plan (MP).
Verify that all containers are identified and stored in appropriate areas.

(NOTE:  Any unidentified contents of solid waste containers and/or containers
not in designated storage areas must be tested to determine if solid or hazardous
waste requirements apply.)
     HW.70.2. SQG storage areas
     must     be      designed,
     constructed,  maintained,  and
     operated  to  minimize  the
     possibility   of    a   fire,
     explosion, or any unplanned
     release of hazardous waste or
     constituents   which  could
     threaten human health or the
     environment    (40    CFR
     262.34(d)(4)  and  40  CFR
     265.30 through 265.37).
Determine if the following required equipment is easily accessible and in working
condition by inspecting the SQG storage areas (unless none of the hazards posed
by  the  waste  managed  at  the  facility would  require the particular kind of
equipment):

   - internal communications or alarm system capable of providing immediate
     emergency instruction to facility personnel
   - a telephone or hand-held two way radio capable of contacting local and
     emergency responders
   -portable fire extinguishers and fire control equipment, including special
     extinguishing equipment (foam, inert gas, or dry chemicals)
   - spill control equipment
   - decontamination equipment
   -fire hydrants or other  source of water (reservoir, storage tank,  etc.) with
     adequate  volume and  pressure, foam producing equipment, or  automatic
     sprinklers, or water spray systems.

Determine if equipment is tested and maintained as necessary to insure proper
operation in an emergency.

Verify that sufficient aisle space is maintained to allow unobstructed movement
of  personnel,  fire  protection  equipment,  spill  control  equipment,  and
decontamination equipment to any area of the operation.

Verify that police, fire departments, and emergency response teams are familiar
with the layout of the facility, properties of the waste being handled, and general
operations as appropriate for the type of waste and potential need for such
services, by reviewing  with  them  the  procedures employed  by  facility
management.

Verify that local hospitals are familiar with the site and types  of injuries that
could result in an emergency as appropriate for the type of waste and potential
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      41

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                       COMPLIANCE CATEGORY:
                                  HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                        REVIEWER CHECKS
                                 need for such services by reviewing with them the procedures employed by
                                 facility management.

                                 (NOTE: Where state or local authorities decline to enter into arrangements, the
                                 facility must document this refusal in the operating record.)
     HW.70.3.    SQGs    must
     conduct  weekly inspections
     of container storage areas (40
     CFR   262.34(d)(2)    and
     265.174).
Verify  that inspections are  conducted  at  least  weekly to look for leaking
containers and signs of deterioration of containers.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                   42

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     SMALL QUANTITY
     GENERATORS

     HW.80

     Disposal of Restricted
     Waste
     HW.80.1.  SQGs  must  test
     their wastes or use process
     knowledge  to  determine if
     they are restricted from land
     disposal      (40       CFR
     268.7(a)(l)).
Determine whether the generator determines if wastes have to be treated prior to
disposal.

Determine if the facility generates restricted wastes (see Appendix VII to 40 CFR
Part 268) by reviewing test results or reviewing procedures employed by facility
management  where process  knowledge  was applied  in  making  the  waste
determinations.
     HW.80.2.  When an SQG is
     managing a restricted waste,
     a  written notice  must be
     issued to the TSDF of the
     appropriate        treatment
     standards  and   prohibition
     levels (40 CFR 268.7(a)(2)
     through         268.7(a)(4),
     268.7(a)(10))       [Revised
     January 2001].
(NOTE: The notification requirement under 40 CFR 268.7 has changed to a one-
time notification and certification if the composition of the wastes, the process
generating the wastes, and the treatment facility receiving the wastes  do not
change (See FR Vol 62, No. 91, May 12, 1997, pg 26004).)

Verify that, for waste or contaminated soil which does not meet the applicable
treatment standards or exceeds the applicable prohibition levels, the notice is
issued and includes:

   -U.S. EPA hazardous waste numbers and manifest number of first shipment
   -the waste is subject to the LDRs (NOTE:  The  notice must also include
     constituents of concern for F001-F005, and F039, and underlying hazardous
     constituents in characteristic wastes, unless the waste will be treated and
     monitored for all  constituents.  If all constituents will  be  treated  and
     monitored, there is no need to put them all on the LDR notice.)
   -the applicable wastewater/nonwastewater category  (see 40 CFR 268.2(d)
     and 268.2(f)) and subdivisions made within a waste code  based on waste-
     specific criteria (such as D003 reactive cyanide)
   - waste analysis data (when available)
   -for  hazardous  debris, when  treating  with  the   alternative treatment
     technologies provided by 40 CFR 268.45:
        -the  contaminants subject to  treatment, as described  in 40  CFR
          268.45(b)
        - an indication that these contaminants are being treated to comply with
          40 CFR 268.45
   -for contaminated soil subject to LDRs as provided in 40 CFR 268.49(a), the
     constituents subject to treatment as described in 40 CFR 268.49(d), and the
     following statement: "This contaminated soil [does/does not] contain listed
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      43

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                       hazardous waste and [does/does not] exhibit a characteristic of hazardous
                                       waste and  [is subject to/complies with]  the soil treatment standards  as
                                       provided by 40 CFR 268.49(c) or the universal treatment standards."

                                  Verify that, for waste or contaminated soil which meets the treatment standard at
                                  the original point of generation, the notice includes:

                                     -U.S. EPA hazardous waste numbers and manifest number of first shipment
                                     -the waste is subject to the LDRs (NOTE:  The notice must also include
                                       constituents of concern for F001-F005, and F039, and underlying hazardous
                                       constituents in characteristic  wastes, unless  the waste will be treated and
                                       monitored  for all constituents.  If all  constituents  will be treated and
                                       monitored, there is no need to put them all on the LDR notice.)
                                     -the applicable wastewater/nonwastewater  category (see 40  CFR 268.2(d)
                                       and 268.2(f)) and subdivisions made within a waste code based on waste-
                                       specific criteria (such as D003 reactive cyanide)
                                     - waste analysis data
                                     -for contaminated soil subject to LDRs as provided in 40 CFR 268.49(a), the
                                       constituents subject to treatment as described in 40 CFR 268.49(d), and the
                                       following statement: "This contaminated soil [does/does not]  contain listed
                                       hazardous waste and [does/does not] exhibit a characteristic of hazardous
                                       waste and  [is subject to/complies with  the soil treatment standards  as
                                       provided by 40 CFR 268.49(c) or the universal treatment standards"
                                     -the signature of  an authorized  representative certifying that  the  waste
                                       complies with the treatment  standards  of 40 CFR  268  (the text of the
                                       required certification statement can be found in 40 CFR 268.7(a)(3)(i).)

                                  Verify that, for waste or contaminated soil that meets the treatment standard at the
                                  original point  of generation, if the waste changes, the generator sends a new
                                  notice and certification to the receiving facility and placed a copy in their files.

                                  (NOTE:   Generators  of  hazardous debris  excluded from the  definition  of
                                  hazardous waste under 40 CFR 261.3(f) are not subject to the  requirements for
                                  waste or contaminated soil which  meets the  treatment standard at the original
                                  point of generation.)

                                  Verify that, for restricted waste  subject to an exemption from a prohibition of the
                                  type of land disposal used, the notice states that the waste is not prohibited from
                                  land disposal and includes:

                                     -U.S. EPA hazardous waste numbers and manifest number of first shipment
                                     - statement: this waste is not prohibited from land disposal
                                     - waste analysis data, when available
                                     - date the waste is subject to the prohibition
                                     -for  hazardous  debris,  when  treating  with the  alternative  treatment
                                       technologies  provided by 40  CFR 268.45: the  contaminants  subject  to
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              44

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                          REVIEWER CHECKS
                                        treatment, as described in 40 CFR 268.45(b); and an indication that these
                                        contaminants are being treated to comply with 40 CFR 268.45.

                                   (NOTE:  SQGs with tolling agreements are required to comply with notification
                                   and certification requirements for the initial shipment  of waste subject to the
                                   agreement.  The  SQG  will  retain  an on-site  copy of the notification and
                                   certification along with the tolling agreement for at least three years after the
                                   termination or expiration of the agreement.)
     HW.80.3.  SQGs  that  are
     managing prohibited  wastes
     in  tanks,   containers,   or
     containment  buildings  and
     treating the waste  to meet
     applicable         treatment
     standards, must develop and
     follow   a   written   waste
     analysis   plan  (40   CFR
     268.7(a)(5)             and
     268.7(a)(10)).
Verify that the plan describes the procedures that the generator will follow in
order to comply with treatment standards.

(NOTE:    SQGs treating  hazardous debris under  the alternative  treatment
standards are not required to conduct waste analysis.)

Verify that the plan is kept on-site and:

   -the plan  is based on a  detailed chemical and physical  analysis  of
     representative sample of the prohibited waste being treated
   - the plan contains all information necessary to treat the wastes in accordance
     with regulatory requirements including the selected testing frequency
   -the plan must  be kept in the facility's on-site files and made available to
     regulatory inspectors.

(NOTE:  SQGs with tolling agreements are required to comply with notification
and certification requirements for the initial shipment  of waste subject to the
agreement.   The SQG will retain  an on-site  copy of the  notification and
certification along with the tolling agreement for at least three years after the
termination or expiration of the agreement.)
     HW.80.4. SQGs are required
     to keep  specific documents
     pertaining    to    restricted
     wastes  on-site   (40  CFR
     268.7(a)(4)          through
     268.7(a)(7)             and
     268.7(a)(10)).
Verify that if the facility is using generator knowledge to determine whether a
waste or contaminated  soil meets  land  disposal restriction requirements,  the
supporting  data  used in making  this determination  is retained  on-site in  the
facility operating files.

Verify that if the  facility has determined whether a waste  is restricted using
appropriate test methods, the waste analysis data is retained on-site in the files.

Verify that if the facility has determined that it is managing a restricted waste that
is excluded from the definition of a hazardous waste or solid waste or exempt
from RCRA Subtitle C,  a one-time notice is placed in the facility's files stating
that the generated waste is excluded.

Verify that a copy of all notices, certifications, waste analysis data and other
documentation is kept for at least three years from the  date that the waste was last
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                        45

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  sent to on-site or off-site treatment, storage, or disposal.

                                  Verify that SQGs with tolling agreement retain the agreement and copies of
                                  notification and certification for at least three years after the agreement expires.
     HW.80.5.   The  storage  of
     hazardous   waste   that  is
     restricted from land disposal
     is not allowed unless specific
     conditions are  met (40 CFR
     268.50).
Verify that land disposal restricted waste is not stored at the facility unless the
SQG is  storing the wastes in tanks, containers, or containment buildings on-site
only for the purpose of accumulating enough quantity  of hazardous waste to
facilitate proper recovery, treatment, or disposal and all appropriate standards for
containers, tanks, and containment buildings are met.

(NOTE:  The prohibition on storage does not apply to hazardous wastes that have
met treatment standards.)

Verify that liquid hazardous wastes containing PCBs  at concentrations greater
than 50 ppm are stored at a site that meets the requirements of 40 CFR 761.65(b)
(see Toxic Substances Control Act (TSCA)) and is removed from  storage within
one year of the date it was first placed into storage.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      46

HW.100

General
HW.100.1. A generator that
generates, transports, or
handles hazardous wastes
must obtain an EPA
identification number (40
CFR 262.12(a) and
262.12(b)).
Determine the facility's generator identification number by examining
documentation from U.S. EPA.

Verify that the correct identification number is used on all appropriate
documentation (i.e., manifests).
HW. 100.2. Generators may
accumulate hazardous waste
on-site for 90 days or less
without a permit or interim
status provided they meet
certain conditions (40 CFR
262.34(a)(2), 262.34(a)(3)
and 262.34(b)).
Verify that each 90 day storage area is inspected and the storage manager is
interviewed so as to verify the following:

- the date upon which accumulation begins is clearly marked and visible for
inspection
- the recorded start date indicates no container or tank has been accumulating
a hazardous waste longer than 90 days (unless granted a 30 day extension)
-each container and tank is labeled or marked clearly with the words
HAZARDOUS WASTE.

(NOTE: For a generator the accumulation start date begins when the first waste
is poured/placed into the waste container, except at satellite accumulation points.)

(NOTE: A generator who meets these standards is exempt from meeting the
closure requirements outlined in 40 CFR 265.110 through 265.156, except for
265.111 and 265.114.)

(NOTE: A generator who accumulates hazardous waste for more than 90 days
(without an extension), is subject to all TSDF and permitting requirements.)
HW. 100.3. Generators must
not offer their waste to
transporters or TSDFs that
have not received an EPA
identification number (40
CFR262.12(c)).
Verify that all transporters of hazardous wastes and TSDFs used by the generator
have an EPA identification number by examining facility records pertaining to
these services. Examples of such records could include sales agreements or
vendor contracts. Auditors could also contact the state regulatory agency or local
U.S. EPA regional office to confirm that these vendors have the appropriate EPA
identification number.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
47

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW. 100.4. Generators who
shipped hazardous waste off-
site to a TSDF must submit a
biennial report to the
regulatory agency by 1
March of even numbered
years (40 CFR 262.40(b) and
262.41(a)).
Verify that the biennial report (EPA Form 8700-13 A) is complete and was
submitted in a timely manner.

Verify that copies are kept for three years.

(NOTE: Reporting for exports of hazardous waste is covered under the
import/export section of this protocol.)

(NOTE: Periods of retention of records may be extended automatically during
the course of any unresolved enforcement action or at the request of the
regulatory agency.)
HW. 100.5. Generators are
required to use manifests, file
manifest exception reports,
and maintain records (40
CFR 262.20, 262.40(a),
262.40(b), 262.40(d), and
262.42(a)).
Verify that manifests are used when shipping the waste off-site.

Verify that exception reports were filed with the regulatory agency when a copy
of the manifest was not received within 45 days of the waste being accepted by
the initial transporter.

Verify that manifests and exception reports are kept for three years.

(NOTE: Periods of retention for reports may be extended automatically during
the course of any unresolved enforcement action.)
HW. 100.6. Generators are
required to keep records of
waste analyses, tests, and
waste determinations (40
CFR 262.40(c)).
Verify that the appropriate records are kept for three years from the date the
waste was last sent to the on-site or off-site TSDF.

(NOTE: Periods of retention for reports may be extended automatically during
the course of any unresolved enforcement action or at the request of the
regulatory agency.)
HW. 100.7. Generator
storage areas must be
designed, constructed,
maintained, and operated to
minimize the possibility of a
fire, explosion, or any
unplanned release of
hazardous waste or
constituents which could
threaten human health or the
environment (40 CFR
262.34(a)(4) and 40 CFR
265.30 through 265.37).
Determine if the following required equipment is easily accessible and in working
condition at the storage area (unless none of the hazards posed by the waste
managed at the facility would require the particular kind of equipment):

- internal communications or alarm system capable of providing immediate
emergency instruction to facility personnel
- a telephone or hand-held two way radio capable of summoning emergency
assistance
-portable fire extinguishers and fire control equipment, including special
extinguishing equipment (foam, inert gas, or dry chemicals)
- spill control equipment
- decontamination equipment
-fire hydrants or other source of water (reservoir, storage tank, etc.) with
adequate volume and pressure, foam producing equipment, or automatic
sprinklers, or water spray systems.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
48

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                 Determine if equipment is tested and maintained as necessary to insure proper
                                 operation in an emergency.

                                 Verify that sufficient aisle space is maintained to allow unobstructed movement
                                 of  personnel,  fire  protection  equipment,  spill   control  equipment,  and
                                 decontamination equipment to any area of the operation.

                                 Verify that police, fire departments, and emergency response teams are familiar
                                 with the layout of the facility, properties of the waste being handled, and general
                                 operations  as appropriate for the type of waste  and potential  need  for  such
                                 services, by  reviewing  with them  the  procedures employed by facility
                                 management.

                                 Verify that local  hospitals are familiar with the site and  types of injuries that
                                 could result in an emergency as appropriate for the type of waste and potential
                                 need  for such services by reviewing with them the procedures employed by
                                 facility management.

                                 (NOTE: Where state or local authorities decline to enter into arrangements, the
                                 facility must document this refusal in the operating record.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                             49

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       50
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     LARGE QUANTITY
     GENERATORS

     HW.110

     Personnel Training
     HW.110.1.    All   facility
     personnel    who    handle
     hazardous  waste must meet
     certain training  requirements
     (40 CFR  262.34(a)(4);  40
     CFR   265.16(a)   through
     265.16 (c)).
Verify that the facility personnel has completed classroom instruction or on-the-
job training as set forth below.

Verify that the training program is directed by a person trained in hazardous
waste management procedures and that the program includes instruction which
teaches facility personnel hazardous waste  management procedures relevant to
positions in which they are employed.

(NOTE: Although not specified by the regulations, examples of training topics for
hazardous waste management procedures could include (but would not be limited
to) the following:
   - waste turn in procedures
   - identification of hazardous wastes
   - container use, marking, labeling and on-site transportation
   - manifesting and off-site transportation
   - 90 day storage area management
   - personal health and safety and fire  safety.)

Verify that the training program includes contingency plan implementation and is
designed to ensure that facility personnel are able to respond to  emergencies
including (where applicable):

   - key parameters for automatic waste feed cut-off systems
   -procedures for using, inspecting,  repairing, and replacing emergency and
     monitoring equipment
   - operation of communications and alarm systems
   - response to fire or explosion
   - response to groundwater contamination incidents
   - response to leaks  or spills
   - shutdown of operations.

Verify  that  new  employee  training  is  completed  within  six  months  of
employment/ assignment.
                                  Verify that an annual review of initial training is provided.

                                  Verify that employees do not work unsupervised until training is completed.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      51

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
Verify specifically that waste storage area managers and hazardous waste
handlers have been trained.
Verify that training records include the following by examination:

-job title and description for each employee by name
- written description of how much training each position will obtain
- documentation of training received by name.

Determine if training records are retained for three years for former employees.

Determine if training records on current employees are maintained. (NOTE:
Training records on current employees must be maintained until the closure of the
facility.)
HW. 110.2. Training records
must be maintained for all
facility staff who manage
hazardous waste (40 CFR
262.34(a)(4); 40 CFR
265.16(d) and 265.16(e)).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
52

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     LARGE QUANTITY
     GENERATORS

     HW.120

     Contingency Plans and
     Emergency Coordinators
     HW.120.1. Generators  must
     have a contingency plan (40
     CFR  262.34(a)(4)  and  40
     CFR 265.50 through 265.54).
(NOTE:  Generating activities may be addressed in the facility's SPCC plan or
other emergency plan, or if none exists, in a separate contingency plan.)

Verify that the contingency plan is designed to minimize hazards to human health
or the environment from fires, explosions, or any unplanned sudden or non-
sudden release of hazardous waste or hazardous waste constituents.

Verify that the plan includes the following:

   - a description of actions to be taken during an emergency
   -a description of arrangements made with  local police  departments,  fire
     departments, hospitals, contractors, and state and local emergency response
     teams as appropriate
   -names,  addresses, and phone  numbers of all persons qualified to act as
     emergency coordinator  (if  more than one  name is  listed, the plan must
     identify  one person as  the  primary  emergency coordinator with other
     persons listed in the order in which they will assume responsibility as an
     alternate)
   - a list of all emergency equipment at the facility and where this equipment is
     required, located, and what it looks like
   -an evacuation plan  for facility  personnel where  there  is  a possibility
     evacuation would be needed.

Verify that copies of the contingency plan and all revisions are maintained at the
facility and also have been submitted to organizations which may be called upon
to provide emergency services.

Verify that the  contingency plan is routinely  reviewed and updated, especially
when:

   - the applicable regulations are revised
   - the plan fails in an emergency
   -the facility changes (e.g., in its design, construction, operation, maintenance)
     in a  way that materially increases the potential for fires, explosions, or
     releases of hazardous constituents or changes the response necessary in an
     emergency	
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      53

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                          REVIEWER CHECKS
                                       - the list of emergency coordinators changes
                                       - the list of emergency equipment changes.
     HW. 120.2.  Each  generator
     must  have   an  emergency
     coordinator  on  the  facility
     premises or  on call at all
     times  (40 CFR 262.34(a)(4)
     and 40 CFR 265.55).
Verify that, at all times, there is at least one employee at the facility or on call
with responsibility for coordinating all emergency response measures.

Verify that the emergency coordinator is thoroughly familiar with the facility,
including all operations and activities  at the facility, the location of all records
within the facility, the facility layout, the characteristics of the waste handled, and
the provisions of the contingency plan.  In  addition, verify  the  emergency
coordinator has the authority to commit the resources needed to carry out the
contingency plan.
     HW. 120.3.      Emergency
     coordinators  at  generators
     must     follow     certain
     emergency       procedures
     whenever   there    is   an
     imminent     or     actual
     emergency situation (40 CFR
     262.34(a)(4)  and  40  CFR
     265.56(a) through 265.56(1)).
Verify that the emergency coordinator is required to follow these emergency
procedures:

   -immediately activate facility alarms or communication systems and notify
     appropriate facility, state, and local response parties
   -identify the character, exact source,  amount, and  a real  extent of any
     released materials
   - assess possible hazards to human health or the environment, including direct
     and indirect effects (e.g.,  release of gases, surface  runoff  from water  or
     chemicals used to control fire or explosions, etc.)
   - take all reasonable measures necessary to ensure that fires, explosions and
     releases do  not  occur, recur, or spread to other hazardous waste at the
     facility. These measures must include where applicable:
        - stop processes and operations at the facility when necessary to prevent
          fires, explosions, or further releases
        - collect and contain the released waste
        - remove or isolate containers when necessary
   - monitor for leaks, pressure buildup, gas generation,  or ruptures in valves,
     pipes, or other equipment whenever appropriate
   - provide for treatment, storage, or disposal of recovered waste, contaminated
     soil, or surface water, or other material  immediately after emergency
   - ensure that no waste that may be incompatible with the released material is
     treated, stored, or disposed of until cleanup is completed
   - ensure that all emergency equipment is cleaned and fit for its intended use
     before operations are resumed
   -notify U.S. EPA, and appropriate state and local authorities that the facility
     is in compliance with 40 CFR 265.56(h) before operation resumes.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                        54

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                       COMPLIANCE CATEGORY:
                                  HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                        REVIEWER CHECKS
     HW. 120.4.       Generator
     operators  must  record  the
     time, date, and details of any
     incident    that     requires
     implementing           the
     contingency plan (40  CFR
     262.34(a)(4)  and  40  CFR
     265.560)).
Determine if  incidents have been  recorded and corrective actions taken by
reviewing facility operating records.

Verify that written reports have been submitted to the regulatory agency within 15
days after the incident.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                   55

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       55
requirements are in any way altered by any statement(s) contained herein.

HW.130

Containers
HW.130.1. Empty containers
at generators previously
holding hazardous wastes
must meet the regulatory
definition of empty before
they are exempted from
hazardous waste
requirements (40 CFR
261.7).
Verify that for containers or inner liners holding hazardous wastes:

Verify that for containers that held a compressed gas, the pressure in the container
approaches atmosphere.

Verify that for a container or inner liner that held an acute hazardous waste listed
in Appendix D, one of the following is done:

- it is triple rinsed
- it is cleaned by another method identified through the literature or testing as
achieving equivalent removal
- the inner liner is removed.

Verify that the rinse water has been tested.
HW. 130.2. Containers used
to store hazardous waste at
generators must be in good
condition and not leaking (40
CFR 262.34(a)(l)(i) and
265.171).
Verify that containers are not leaking, bulging, rusting, damaged or dented.

Verify that waste is transferred to a new container or managed in another
appropriate manner when necessary
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
57

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW. 130.3. Containers used
at generators must be made
of or lined with materials
compatible with the waste
stored in them (40 CFR
262.34(a)(l)(i)and265.172).
Verify that containers are compatible with waste. For example, check that strong
caustics and acids are not stored in metal drums.
HW. 130.4. Containers must
be closed during storage and
handled in a safe manner at
generators (40 CFR
262.34(a)(l)(i)and265.173).
Verify that containers are closed except when it is necessary to add or remove
waste (check bungs on drums, look for funnels).

Verify that handling and storage practices do not cause damage to the containers
or cause them to leak.
HW. 130.5. The handling of
incompatible wastes, or
incompatible wastes and
materials in containers at
generators must comply with
safe management practices
(40 CFR 262.34(a)(l)(i) and
265.177).
Verify that incompatible wastes or incompatible wastes and materials are not
placed in the same containers unless it is done so that it does not:

- generate extreme heat or pressure, fire, or explosion, or violent reaction
-produce uncontrolled toxic mists, fumes, dusts, or gases in sufficient
quantities to threaten human health
-produce uncontrolled flammable fumes or gases in sufficient quantities to
pose a risk of fire or explosions
- damage the structural integrity of the device or facility
-by any other like means threaten human health or the environment.

(NOTE: Incompatible wastes, as listed in Appendix E, should not be placed in
the same drum.)

Verify that hazardous wastes are not placed in an unwashed container that
previously held an incompatible waste or material.

Verify that containers holding hazardous wastes incompatible with wastes stored
nearby in other containers, open tanks, piles, or surface impoundments are
separated or protected from each other by a dike, berm, wall, or other device.
HW. 130.6. Containers used
to store hazardous waste at
generators should be
managed in accordance with
specific management
practices (MP).
Verify the following by inspecting container storage areas:

— containers are not stored more than 2 high and have pallets between them
-containers of highly flammable wastes are electrically grounded (check for
clips and wires and make sure wires lead to ground rod or system)
— at least 3 ft. (0.91 m) of aisle space is provided between rows of containers.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
58

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                          REVIEWER CHECKS
     HW. 130.7.  Containers with
     design capacities greater than
     0.1  m3  [-26 gal.]  and less
     than or  equal  to  0.46 m3
     [-122   gal.]   into   which
     hazardous waste is placed are
     required   to  meet   specific
     design    and     operating
     standards      (40      CFR
     262.34(a)(l)(i),     265.178,
     265.1087(a)         through
     265.1087(b)(l)(i),       and
     265.1087(c)).
 (NOTE:  These requirements  do not apply to a container  that has a design
 capacity less than or equal to 0.1 m3 [-26 gal.] (40 CFR 265.1080(b)(2)) or to
 containers of any size  at satellite accumulation points.  See the  definition of
 Exempted Hazardous  Waste  Containers  and Surface  Impoundments  and
 Exempted Hazardous Waste Management Units as listed on page 8 and 9 of this
 document.)

 (NOTE:  Standards for  containers used in waste stabilization processes (40 CFR
 265.1087(b)(2)) are in checklist item HW.HW. 130.9.)

 Verify that, for containers with a design capacity greater than 0.1 m3 [-26 gal.]
 and less  than or equal to  0.46  m3  [-122 gal.], air emissions are controlled
 according to the following Container Level 1 standards:

    - a container that meets applicable U.S. DOT regulations on the packaging of
     hazardous materials for transportation
    - a container that is equipped with a cover and closure devices that form a
     continuous barrier over the container openings so that when the cover and
     closure devices are secured in the closed position there  are not visible holes,
     gaps or other open spaces into the interior of the container
    -an open-top container in which an organic vapor suppressing barrier is
     placed on or over the hazardous waste in the container  so that no hazardous
     waste is exposed to the atmosphere.

 Verify that when a container using Level 1 standards, other than DOT approved
 containers, is  used, it is equipped with covers and closure devices  composed of
 suitable materials to  minimize exposure of the hazardous waste to the atmosphere
 and to maintain the equipment integrity for as long as it is in service.

 Verify that, whenever waste is in a container using Level 1  controls, covers and
 closure devices are installed and closure devices are secured and maintained in
 the closed position except as follows:

    - opening  of a closure device or cover is allowed for adding waste or other
     material to the container as follows:
         -when  the  container is filled  to the intended  final  level in one
          continuous operation,  the  closure  device is secured in the closed
          position and the  cover is  installed  at the conclusion of the  filling
          operation
         - when discrete batches or quantities of material are added intermittently
          to the container over a period of time, the closure devices are secured
          in the closed position and covers installed upon either the container
          being  filled  to the intended  final level, the completion of a batch
          loading after which no  additional  material will  be added  to the
          container  within  15  minutes, the person  performing the loading
	operation  leaving the  immediate vicinity of the  container,  or the
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                        59

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                            shutdown of the process generating the  material being added to the
                                            container, whichever condition occurs first.
                                      - opening of a closure device or cover is allowed for removing the hazardous
                                       waste as follows:
                                          - in order to meet the requirements for an empty container
                                          - when discrete  quantities or batches of material are removed from the
                                            container but  the container is not empty,  the  closure devices will
                                            promptly be returned  to the closed position and the covers installed
                                            upon completion of batch removal after which no additional material
                                            will  be removed within 15  minutes or the  person performing the
                                            unloading leaves the immediate vicinity, whichever condition occurs
                                            first
                                      -opening of a  closure device or cover  is allowed when access inside the
                                       container  is needed to  perform routine activities  other than  transfer of
                                       hazardous waste
                                      -opening of a spring  loaded,  pressure vacuum relief valve, conservation vent,
                                       or similar type of pressure  relief device which vents to the atmosphere is
                                       allowed during normal operations  for the purpose  of maintaining internal
                                       container pressure
                                      - opening of a safety device to avoid unsafe conditions.
     HW. 130.8.  Containers with
     design capacities greater than
     0.46  m3  [-122  gal.]  into
     which  hazardous  waste  is
     placed are required to meet
     specific design and operating
     standards      (40     CFR
     262.34(a)(l)(i), 265.178, and
     265.1087(a)        through
     265.1087(b)(l)(ii),
     265.1087(b)(l)(iii),
     265.1087(c),            and
     265.1087(d)).
(NOTE:   These requirements do not apply to a container that has a design
capacity less than or equal to 0.1  m3 [-26 gal.] (40 CFR 265.1080(b)(2)) or to
containers of any size at satellite accumulation points.  See the  definition of
Exempted Hazardous Waste  Containers  and Surface  Impoundments  and
Exempted Hazardous  Waste Management Units as listed on page 8 and 9 of this
document.)

(NOTE:  Standards for containers  used in waste stabilization processes (40 CFR
265.1087(b)(2)) are in checklist item HW.HW. 130.9.)

Verify that, for containers with a design capacity greater than 0.46 m3 [-122 gal.]
that are not in light material service, air emissions are controlled according to the
following Container Level 1 standards:

   - a container that meets applicable U.S. DOT regulations on the packaging of
     hazardous materials for transportation
   - a container that is equipped  with a cover and closure  devices that form a
     continuous barrier over the container openings so that when the cover and
     closure devices are secured in the closed position there  are not visible holes,
     gaps or other open spaces into the interior of the container
   -an open-top container in which an organic vapor suppressing barrier is
     placed on or over the hazardous waste in the container  so that no hazardous
     waste is exposed to the atmosphere.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       60

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                   Verify that, for containers with a design capacity greater than 0.46 m3 [-122 gal.]
                                   that are in  light material service, air emissions are controlled according to the
                                   following Container Level 2 standards:

                                      -a  container is used that meets applicable U.S. DOT regulations on the
                                       packaging of hazardous materials for transportation
                                      - a container is used that operates with no detectable organic emissions
                                      -a container is used that has been demonstrated within the preceding 12 mo
                                       to be air tight.

                                   (NOTE:  Level 2 standards apply only to containers that are in light material
                                   service.  For the containers that are not in light material service, Level 1 standards
                                   apply. (See  40 CFR 265.1087(b)(ii) and (iii).)

                                   Verify that  when a container using Level 1 standards, other than DOT approved
                                   containers,  is used it is equipped with covers and closure devices composed of
                                   suitable materials to minimize  exposure of the hazardous waste to the atmosphere
                                   and to maintain the equipment  integrity for as long as it is in service.

                                   Verify that  whenever waste is in a container using Level 1 or Level 2 controls,
                                   covers  and closure devices are installed and closure devices are secured and
                                   maintained in a closed position except as follows:

                                      - opening of a closure  device or cover  is allowed for adding waste or other
                                       material to the container as follows:
                                           -when the  container is filled to  the  intended  final  level  in  one
                                            continuous operation, the closure devices are secured in the closed
                                            position and  the covers  installed at  the conclusion  of the filling
                                            operation
                                           - when discrete batches or quantities of material are added intermittently
                                            to the container over a period of time, the closure devices are promptly
                                            secured in the closed position and covers installed upon either:
                                               - the container being filled to  the intended final level
                                               -the completion of a batch loading  after which  no   additional
                                                 material will be added to the container within 15 minutes
                                               -the  person performing  the   loading  operation  leaving  the
                                                 immediate vicinity of the container
                                               - the shutdown of the process generating the material being added
                                                 to the container, whichever condition occurs first
                                      - opening of a closure device or cover is allowed for removing the hazardous
                                       waste as follows:
                                           - in order to meet the  requirements for an empty container
                                           - when discreet quantities or batches of material are removed from the
                                            container but the container is  not  empty, the closure devices are
                                            promptly secured in the closed position and the covers installed either:
                                  	-upon completion of batch removal  after which  no  additional
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              61

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                                 material will be removed within 15 min
                                               -the  person performing  the  unloading leaves the immediate
                                                 vicinity, whichever condition occurs first
                                     -opening of a closure  device or cover is  allowed when access inside the
                                       container  is needed  to perform routine activities other than transfer of
                                       hazardous waste
                                     -opening of a spring loaded, pressure vacuum relief valve, conservation vent,
                                       or similar type of pressure relief device which vents to the atmosphere and is
                                       allowed during normal operations for the purpose of maintaining internal
                                       container pressure
                                     - opening of a safety device to avoid unsafe conditions.

                                  Verify that  the transfer of hazardous  waste  in or out of containers  meeting
                                  Container Level 2 controls is  done in a manner to minimize exposure of the
                                  hazardous waste to the atmosphere (i.e., a submerged fill pipe, a vapor balancing
                                  system, a vapor recovery  system, a fitted opening in  the top of the container
                                  through which the hazardous waste is filled and subsequently purge the transfer
                                  line before removing it).
     HW. 130.9.  Containers with
     design capacities greater than
     0.1 m3 [-26 gal.] used for the
     treatment  of  a  hazardous
     waste  by a waste stabilization
     process are required to meet
     specific design and operating
     standards      (40      CFR
     262.34(a)(l)(i),    265.178,
     265.1087(a)         through
     265.1087(b)(2),         and
     265.1087(e)(l)      through
     265.1087(e)(3)).
(NOTE:   These requirements  do not apply to a container that has a design
capacity less than or equal to 0.1 m3 [-26 gal.] (40 CFR 265.1080(b)(2)) or to
containers of any size at satellite accumulation points.  See the definition of
Exempted Hazardous Waste  Containers  and  Surface  Impoundments  and
Exempted Hazardous Waste Management Units as listed on page 8 and 9 of this
document.)

(NOTE: Safety devices may be installed and operated as necessary.)

Verify that containers with design capacities greater than 0.1  m3 [-26 gal.] used
for the  treatment of  a hazardous waste by a stabilization process meet  the
following Container  Level  3  standards at those   times  during  the waste
stabilization process when the hazardous waste in the container is exposed to the
atmosphere:

   -a container is  vented directly  through a closed-vent system to a control
     device
   -a container is  vented  inside an  enclosure which is  exhausted through a
     closed-vent system to a control device
   -the  container closure  is  designed  and operated in  accordance with  the
     criteria for a permanent total enclosure under 40 CFR 52.741
   -the  closed-vent system and control device  is designed and operated in
     accordance with 265.1088 (see checklist item HW. 130.12).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       62

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     HW.130.10.   Facilities  are
     required  to  have  a written
     plan   and   schedule   for
     inspection  and  monitoring
     requirements  for containers
     and meet specific inspection
     requirements     (40    CFR
     262.34(a)(l)(i),     265.178,
     265.1087(c)(4),
     265.1087(d)(4),         and
     265.1089).
(NOTE:   These requirements do not apply to a container  that has a design
capacity less than or equal to 0.1  m3 [-26 gal.] (40 CFR 265.1080(b)(2))  or to
containers of any size at satellite accumulation points.  See the definition of
Exempted Hazardous Waste Containers  and Surface  Impoundments  and
Exempted Hazardous  Waste Management Units as listed on page 8 and 9 of this
document.)

Verify that the facility has a written plan and schedule for performing inspections
and monitoring.

Verify that the plan and schedule are being met.

Verify that inspections of the containers and their covers and closure devices for
containers using Container Level 1 or Level 2 controls are done as follows:

   - when a hazardous waste  is already in the container when it is first accepted
     and the container is not  emptied within 24 hours after it is accepted, it is
     visually inspected within 24 hours after acceptance for cracks, holes,  gaps,
     or other open spaces
   - when a container is used for managing hazardous waste for 1 yr or more, it
     is visually inspected at least once every  12 mo for visible cracks, holes,
     gaps, or other open spaces when the cover and closure devices are secured
     in the closed position.

Verify that when a  defect is  detected, the first efforts at repairs are within 24
hours after detection, and repair is completed as  soon as possible but no later than
5 calendar days after detection.

(NOTE:   If repair cannot be  completed within 5 calendar days, the hazardous
waste must be removed from the container.)
     HW.130.11.   Facilities  are
     required       to       meet
     documentation  requirements
     for   containers   (40   CFR
     262.34(a)(l)(i),    265.178,
     265.1087(c)(5), 265.1090(a),
     and   265.1090(d)  through
     265.1090(1).
(NOTE:   These requirements do not apply to a container  that has a design
capacity less than or equal to 0.1  m3 [-26 gal.] (40 CFR 265.1080(b)(2))  or to
containers of any size at satellite accumulation points.  See the definition of
Exempted Hazardous Waste Containers  and Surface  Impoundments  and
Exempted Hazardous  Waste Management Units as listed on page 8 and 9 of this
document.)

Verify that a copy is available of the procedure used to determine that containers
with a capacity of 0.46  m3  [-122  gal.] or greater which do not  meet DOT
standards are not managing hazardous waste in light material service.

Verify that if using Container Level 3 air emissions controls, the facility prepares
and maintains records that:

   - include the most recent set of calculations and measurements performed by
     the  owner/operator to verify that  the  enclosure meets  the criteria  of a
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       63

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                       permanent total enclosure as specified in 40 CFR 52.741, Appendix B
                                     - The same records as required for closed-vent systems.

                                  Verify that if using a closed-vent system and control device, the following records
                                  are maintained:

                                     - certification that is signed and dated by the owner/operator stating that the
                                       control device  is designed to operate at the performance level documented
                                       by a design analysis or by performance tests when the container is operating
                                       at capacity or the highest level reasonably expected to occur
                                     - design documents  if design analysis is used, including certification that the
                                       equipment meets the applicable specification
                                     - a performance test plan if performance tests are used and all test results
                                     - description and date of each modification, as applicable
                                     - identification of operating  parameters, description of monitoring devices,
                                       and diagrams of monitoring sensor locations, as applicable
                                     - semiannual records of the following for those planned routine maintenance
                                       operations that would require the control device to exceed limitations:
                                          - a description of the planned  routine maintenance that is  anticipated to
                                            be performed for the  control device during the  next  6-mo period,
                                            including the type of maintenance  needed,  planned frequency, and
                                            lengths of maintenance periods.
                                          - a description of the planned routine maintenance that was performed
                                            for the control device during the previous 6-mo period,  including the
                                            type of maintenance performed and the total number of hours during
                                            those  6-mo  that  the  control  device did  not  meet applicable
                                            requirements
                                     -records  of the following  for  those  unexpected  control device system
                                       malfunctions that would cause the  control device to not meet specifications:
                                          - the occurrence and duration  of each malfunction of the control device
                                            system
                                          - the duration of each period during a malfunction when gases, vapors,
                                            or fumes are vented  from the waste management  unit through the
                                            closed-vent system to the control device while the control device is not
                                            properly functioning
                                          - actions taken during periods of malfunction to restore a malfunctioning
                                            control device to its normal or usual manner of operation
                                          -records of the management of the  carbon removed from a carbon
                                            adsorption system.

                                  Verify that, for  exempted containers,  the following records are  prepared and
                                  maintained as applicable:

                                     -if  exempted  under  the   hazardous  waste  concentration conditions,
                                       information used for  the waste determination in the facility  operating log
                                       and/or the date, time, and location of each waste sample if analysis results
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                             64

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                       for samples are used
                                     -if exempted under incinerator  use  or  process  destruction  use,  the
                                       identification number for the incinerator, boiler, or industrial furnace in
                                       which the hazardous waste is treated.

                                  Verify that covers designated as unsafe to monitor are listed in a log kept in the
                                  facility operating record with an explanation of why they are unsafe to inspect and
                                  monitor and a plan and schedule of inspection and monitoring is recorded.

                                  Verify that, for containers not using the air emissions controls specified in  40
                                  CFR  265.1085  through 265.1088  (see checklist  items  HW. 130.7  through
                                  HW.130.12), the following information is maintained:

                                     - a list of the individual organic peroxide compounds  manufactured at the
                                       facility if it produces more than one functional family of organic peroxides
                                       or multiple organic peroxides within one functional family, and one or more
                                       of these organic peroxides  could  potentially undergo serf-accelerating
                                       thermal decomposition at or below ambient temperatures
                                     - a description of how the hazardous waste containing the organic peroxide
                                       compounds identified in the  above list are managed, including:
                                          - a facility identification number for the container or group of containers
                                          - the purpose and placement of this container or group of containers in
                                            the management train of this hazardous waste
                                          -the procedures used  to  ultimately  dispose  of the hazardous waste
                                            handled in the containers
                                     -explanations why managing these containers would  be an undue safety
                                       hazard.

                                  Verify that all records, except design information records, are kept for at least 3
                                  years.

                                  Verify that design information records are  maintained in the operating record
                                  until the air emissions control equipment is replaced or otherwise no longer in
                                  service.

                                  (NOTE: See  also the recordkeeping requirements for carbon adsorption units in
                                  checklist item HW. 130.)
     HW.130.12.   Facilities are
     required  to  meet  specific
     requirements for closed-vent
     systems and control devices
     used to achieve compliance
     (40  CFR  262.34(a)(l)(i),
     265.178, and 265.1088).
(NOTE:   These requirements  do not apply to a container that has a design
capacity less than or equal to 0.1 m3 [-26 gal.] (40 CFR 265.1080(b)(2)) or to
containers of any size at satellite accumulation points.  See the definition of
Exempted Hazardous Waste  Containers  and  Surface Impoundments   and
Exempted Hazardous  Waste Management Units as listed on page 8 and 9 of this
document.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       65

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                  Verify that closed-vent systems meet the following:

                                      - it routes the gases, vapors and fumes emitted from the hazardous waste in
                                       the waste management unit to a control device
                                      -it is designed and operated in accordance with 40 CFR 265.1033(j) (see
                                       checklist item HW. 140.2)
                                      - if it includes bypass devices that could be used to divert the gas or vapor
                                       stream to  the atmosphere before  entering the  control device, one of the
                                       following  equipment requirements is met for each type of bypass device
                                       (NOTE: low leg drains, high point bleeds, analyzer vents, open-ended valve
                                       or lines,  spring loaded pressure relief valves,  and  other fittings used for
                                       safety purposes are not considered bypass devices):
                                          - a flow indicator is installed, calibrated, maintained, and operated at the
                                            inlet to the bypass line used to divert gases  and vapors from the closed-
                                            vent  system to the atmosphere at a point upstream of the control device
                                            inlet
                                          -a seal or locking device is placed on the mechanism by which the
                                            bypass device position is controlled when the bypass valve is in the
                                            closed  position so that the bypass device  cannot be opened without
                                            breaking the seal  or removing the lock.

                                  Verify that the seal or closure mechanism is visually inspected at least once every
                                  month.

                                  Verify that one  of the following control devices are used:

                                      - a device designed and operated to reduce the  total organic content of the
                                       inlet vapor stream vented to the control device by at least 95 percent by
                                       weight
                                      - an enclosed combustion device designed and operated in accordance with
                                       265.1033(c) (see checklist item HW. 140.2)
                                      -a flare designed and operated in accordance with 40 CFR 265.1033(d) (see
                                       checklist item HW. 140.2).

                                  Verify that, when a closed-vent system  and control device is used, the  following
                                  are met:

                                      - periods of planned routine maintenance of the control device during which
                                       the device does not meet specifications do not exceed 240 hours per year
                                      - control device system malfunctions are corrected as soon as practicable
                                      - it is operated such that gases, vapors, and/or fumes are not actively vented to
                                       the control device during periods of planned maintenance or control device
                                       system malfunction, except in cases where it is necessary to do so in order to
                                       avoid an unsafe condition or to implement malfunction corrective  actions or
                                       planned maintenance actions.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              66

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                  Verify that, if a carbon absorption system is used, the following requirements are
                                  met:

                                     -all activated carbon is replaced with fresh carbon on a regular basis as
                                       outlined in 40  CFR 265.1033(g) and  265.1033(h)  (see  checklist  item
                                       HW. 140.2)
                                     - all carbon removed from the devices is managed in a correct manner.

                                  Verify  that,  if a control device other than a thermal vapor incinerator, flare,
                                  boiler,  process  heater,  condenser, or carbon absorption system is used, the
                                  requirements in 40 CFR 265.1033(i) are met (see checklist item HW. 140.2).

                                  Verify that, for control devices, it is demonstrated by either a performance test or
                                  a design analysis that the device achieves compliance except for the following:

                                     - a flare
                                     -boiler or process heater with a design heat input capacity of 44 MW or
                                       greater
                                     - a boiler or process heater into which the vent stream is introduced with the
                                       primary fuel
                                     - a boiler or process heater burning hazardous waste for which the owner or
                                       operator has been issued a final permit under 40 CFR 270 and has designed
                                       and  operates the unit  in accordance with the requirements of 40 CFR 266,
                                       subpart H
                                     -a  boiler or industrial furnace burning hazardous waste for the owner or
                                       operator has certified compliance with the interim status requirements of 40
                                       CFR 266, subpart H.

                                  Verify that the readings from each control device are inspected at least once each
                                  operating day to check control device operation.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                             67

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       68
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     LARGE QUANTITY
     GENERATORS

     HW.140

     Emissions from Process
     Vents
     HW.140.1.  Generators with
     process vents associated with
     distillation,    fractionation,
     thin-film evaporation, solvent
     extraction,  or  air  or steam
     stripping   operations,   that
     manage   hazardous  wastes
     with organic concentrations
     of at least 10  ppmw,  are
     required  to  meet   specific
     standards      (40      CFR
     262.34(a)(l)(  i),  265.178,
     265.1030(b),    265.1030(e)
     and 265.1032).
(NOTE:   This applies  only if the  operations are conducted in one  of the
following:
   - a unit that is subject to the permitting requirements of 40 CFR 270
   - a unit (including a hazardous waste recycling unit) that is not exempt from
     permitting under the provisions of 40  CFR 262.34(a)  (i.e., a hazardous
     waste recycling unit that is  not a 90-day tank  or container) and  that is
     located at a hazardous waste management facility that is otherwise subject to
     the permitting requirements of 40 CFR 270
   -a unit that is  exempt from  permitting  under the  provisions of 40 CFR
     262.34(a) (i.e., a 90-day tank or container).)

Verify that one of the following is met:

   -total organic emissions from the process vents do not exceed 1.4 kg/h (3
     Ib/h) and 2.8 Mg/yr (3.1 tons/yr)
   -total organic emissions are reduced by use of a control device from all
     process vents by 95 weight percent.

(NOTE:   A  process vent is not subject to  these  standards if the  facility
owner/operator certifies  that all the regulated process vents  at the facility are
equipped  with and  operating air emission  controls in accordance  with  the
requirements of the Clean Air Act (CAA) 40 CFR Parts 60, 61, and 63.)
     HW. 140.2.       When   a
     generator uses a closed-vent
     system and control device to
     meet the standards for total
     organic    emissions,    the
     closed-vent    system    and
     control  device  must  meet
     certain            minimum
     requirements    (40    CFR
     262.34(a)(l)(i),    265.178,
     265.1033(b)        through
     265.1033(k)).
(NOTE:    This  applies  to generators  with  process  vents  associated  with
distillation, fractionation, thin-film evaporation, solvent extraction, or air or steam
stripping operations, that  manage hazardous wastes with organic concentrations
of at least 10 ppmw, if the operations are conducted in one of the following:
   - a unit that is subject to the permitting requirements of 40 CFR 270
   - a unit (including a hazardous waste  recycling unit)  that is not exempt from
     permitting under the provisions of 40  CFR 262.34(a) (i.e.,  a hazardous
     waste recycling unit that is not a  90-day tank or container) and that is
     located at a hazardous waste management facility that is otherwise subject to
     the permitting requirements of 40 CFR 270
   -a unit that is exempt from permitting under the  provisions of 40  CFR
     262.34(a) (i.e., a 90-day tank or container).)

Verify that control devices involving vapor recovery are designed and operated to
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       69

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                   recover organic vapors vented to the air with an efficiency of 95 weight percent
                                   or greater, unless the total organic emission limit can be attained at an efficiency
                                   of less than 95 weight percent.

                                   Verify that, if an enclosed combustion device is used (i.e., vapor incinerator,
                                   boiler, or process heater), it  is designed and  operated to reduce the organic
                                   emissions vented to it by 95 weight percent or greater, to achieve a total organic
                                   compound concentration  of 20  ppmv expressed  as  the  sum  of the actual
                                   compounds, not carbon equivalents, on a dry basis corrected to 3 percent oxygen,
                                   or  to  provide a  minimum residence time of 0.50 seconds  at  a minimum
                                   temperature of 760 degrees Celsius [1400 degrees Fahrenheit].

                                   Verify that, if a boiler or process heater is used as  the control device, the vent
                                   stream is introduced into the flame zone of the boiler  or process heater.

                                   Verify that, if flares are used:

                                      - they are designed and operated with no visible emissions except for periods
                                       not in excess of 5 minutes during any 2 consecutive hours
                                      - they are operated with a flame present at all times
                                      - they are  used only if the net heating value of  the gas being combusted is
                                       11.2 MJ/scm (300 Btu/scf) or greater if  the flare is  steam assisted or air
                                       assisted
                                      -if nonassisted, the net heating value of the  gas being combusted is  7.45
                                       MJ/scm (200 Btu/scf) or greater
                                      - if nonassisted or steam assisted, have an exit velocity less than 18.3 m/s (60
                                       ft/s) except when the net heating value of the gas being combusted is greater
                                       than 37.3 MJ/scm (1000 Btu/scf) and the exit velocity is equal to or greater
                                       than 18.3 m/s (60 ft/s) but less than 122 m/s (400 ft/s).

                                   Verify that each monitor and control device is inspected on a routine basis.

                                   Verify that each  required control device is installed, calibrated, monitored and
                                   inspected as follows:

                                      - a flow indicator is installed in the vent stream at the nearest feasible point to
                                       the control device inlet, but before being combined with other streams, and
                                       provides a record of vent stream flow from each affected process vent to the
                                       control device at least once every hour
                                      -a control device to  continuously monitor control device operations  as
                                       specified:
                                          - a temperature monitoring device equipped with a continuous recorder
                                            for a thermal vapor incinerator
                                          - a temperature monitoring device equipped with a continuous recorder
                                            for a catalytic vapor incinerator
                                  	- a heat sensing monitor with a continuous recorder for flares	
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              70

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                          - a temperature monitoring device equipped with a continuous recorder
                                            to  measure  parameters  that  indicate good combustion operating
                                            practices are being used for a boiler or process heater having a design
                                            heat input capacity less than 44 MW
                                          -for a condenser, one of the following:
                                               - a monitoring device  with a continuous recorder to measure the
                                                concentration level of the organic compound in the exhaust vent
                                                stream from the condenser
                                               -a temperature monitoring device equipped with a  continuous
                                                recorder capable  of monitoring temperature in the exhaust vent
                                                stream from the condenser with an accuracy of +/- 1 percent of
                                                the temperature being monitored in  Celsius  or in +/-0.5  °C,
                                                whichever is greater
                                          - for a carbon absorption system such as a fixed carbon bed absorber
                                            that regenerates the carbon bed directly in the control device, one of
                                            the following:
                                               -a monitoring device equipped with a continuous  recorder to
                                                measure the concentration levels of the organic compounds in the
                                                exhaust vent stream from the carbon bed
                                               -a monitoring device equipped with a continuous  recorder to
                                                measure a parameter that indicates the  carbon bed is regenerated
                                                on a regular, predetermined time cycle.

                                  Verify that readings from monitoring devices are checked at least once a day.

                                  Verify that, if a carbon  absorption system is being used that regenerates the
                                  carbon bed directly on-site, the existing carbon in the control device is replaced
                                  with fresh carbon at a regular, predetermined time interval.

                                  (NOTE:  The predetermined time  interval is based on the design analysis required
                                  under 40 CFR 265.1035(b)(4)(iii)(F).)

                                  Verify that if a carbon absorption system is being used that does not regenerate
                                  the carbon bed directly on-site in the control device, the existing carbon in the
                                  control device is replaced on a regular basis.

                                  (NOTE:   When to replace  the carbon is determined by one of the following
                                  procedures:
                                     - monitoring the concentration level of the organic compound in the exhaust
                                       vent stream from  the carbon absorption system daily or at an  interval no
                                       greater than 20 percent of the  time required to consume the total carbon
                                       working capacity, whichever is longer
                                     - replace the carbon at a regular predetermined time interval that  is less than
                                       the design carbon replacement interval.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                             71

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  Verify that closed-vent systems meet one of the following:

                                      - are designed and operated with no detectable emissions as indicated by an
                                       instrument reading of less than 500 ppm above background as determined
                                       by the procedures in 40 CFR 265.1034(b) and by visual inspection
                                      - are designed to operate at a pressure below atmospheric pressure and are
                                       equipped with at least  one pressure gauge or other pressure measurement
                                       device that can be read from a readily accessible location.
     HW. 140.3.   Generators are
     required to maintain specific
     records pertaining to process
     vent  emissions   (40   CFR
     262.34(a)(l)(i), 265.178, and
     265.1035).
Verify that the following information is kept in the operating record:

   - an implementation schedule
   - up-to-date documentation of compliance with process vents and with closed-
     vent systems and control devices
   - the test plan if test data is used to determine the organic removal efficiency
     or total organic compound concentration achieved by a control device
   - documentation of compliance with 40 CFR 265.1033, including:
        - a list of all information, references and sources  used in preparing the
          documentation
        - records, including the dates  of required compliance tests
        -design  analysis, specifications, drawing,  schematics,  and piping and
          instrumentation diagrams if engineering calculations are used
   - a statement signed and dated by the operator or owner certifying that the
     operating parameters used in the design analysis reasonably represent the
     conditions which exist when the hazardous waste  management unit is or
     would be operating at the highest load or capacity level reasonably expected
   - a statement signed and dated by the owner or operator certifying that the
     control device is  designed to operate at an efficiency of 95 percent or
     greater unless the total  organic concentration limit is achieved at  an
     efficiency of less  than 95 weight percent,  or the total organic emissions
     limits for affected  process vents  can be  attained  by  a control device
     involving vapor recovery at an efficiency less than 95 weight percent
   - all performance test results if used to demonstrate compliance
   - design documentation
   - monitoring and  inspection results for each  closed-vent system and control
     device
   - notations of exceedance of control device parameter design value
   - explanation for each period of exceedance
   - for carbon absorption systems:
        - when the carbon is replaced in carbon absorption systems
        -date  and  time when  a control  device  is  monitored for carbon
          breakthrough
   - the date of each control device startup and shutdown.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       72

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  Verify that records of monitoring operations and inspection information are kept
                                  for 3  years.
     HW. 140.4.     Closed-vent
     systems are required  to  be
     monitored,   inspected,   and
     leaks   repaired   (40   CFR
     262.34(a)(l)(i),     265.178,
     265.1033(k)            and
     265.1033(n)).
(NOTE:    This  applies  to generators  with process  vents  associated with
distillation, fractionation, thin-film evaporation, solvent extraction, or air or steam
stripping operations, that  manage hazardous wastes with organic concentrations
of at least 10 ppmw, if the operations are conducted in one of the following:
   - a unit that is subject to the permitting requirements of 40 CFR 270
   - a unit (including a hazardous waste  recycling unit)  that is not exempt from
     permitting under the provisions of 40  CFR 262.34(a) (i.e.,  a hazardous
     waste recycling unit that is not a  90-day  tank  or container) and  that is
     located at a hazardous waste management facility that is otherwise subject to
     the permitting requirements of 40 CFR 270
   -a unit that is exempt from permitting under the  provisions of 40 CFR
     262.34(a) (i.e., a 90-day tank or container).)

Verify that closed-vent  systems  designed and  operated with no detectable
emissions,  as indicated by an  instrument reading of less than 500 ppm above
background, are monitored as follows:

   -an initial leak detection monitoring of the closed-vent  system using  the
     procedures  specified in 40 CFR 265.1034(b) on  or before the  date  the
     system became subject to this section of the CFR
   - after initial leak detection monitoring:
        -visual inspection at  least once a year for closed-vent system joints,
          seams, or other connections that are permanently or semi-permanently
          sealed (e.g., a welded joint between two sections of hard piping or a
         bolted and  gasketed ducting flange)
        - whenever a component is repaired or  replaced, monitor according to
         40CFR265.1034(b)
        - annually and at times required by the  regulatory agency  for all other
         parts of the  system using the  procedures  specified  in 40 CFR
         265.1034(b).

Verify that closed-vent systems designed to operate at no  detectable emissions, as
indicated by an instrument reading of less than 500 ppmv above background,  are
monitored as follows:

   - annual visual inspection to check for defects that could result in air pollutant
     emissions
   -initial inspection on or before the date the  system becomes subject to this
     section of the CFR.

(NOTE:  For closed-vent  systems designed to operate at no detectable emissions,
as indicated by an instrument reading  of less than 500 ppmv above  background,
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       73

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                          REVIEWER CHECKS
                                  portions of the system designated as unsafe to monitor are exempt from the visual
                                  monitoring if:
                                     - the components are unsafe to monitor because monitoring personnel would
                                       be exposed to an immediate danger
                                     - a written plan that requires monitoring as practicable during safe to monitor
                                       periods is in place and followed.)

                                  Verify that detectable  emissions,  as indicated by visual inspection or by  an
                                  instrument reading of greater than 500 ppmv above background, are controlled as
                                  soon as practicable but not later than 15 days after the emissions are detected.

                                  Verify that a first attempt at repair is made no later than 5 calendar days after the
                                  emission is detected.

                                  (NOTE:   Delay of repair of a closed-vent system for  which leaks have been
                                  detected is allowed if the repair is  technically infeasible without a  process unit
                                  shutdown, or if it is determined that the emissions resulting from the immediate
                                  repair would be greater than the fugitive emissions likely to result from delay of
                                  repair.)
     HW. 140.5.      Closed-vent
     systems and control devices
     used  to  comply  with the
     provisions   of   40   CFR
     265.1030  through 265.1035
     are required to be operated at
     all times when emissions may
     be vented to  them (40 CFR
     262.34(a)(l)(i), 265.178, and
     265.1033(1)).
 (NOTE:   This  applies  to  generators  with process vents  associated with
 distillation, fractionation, thin-film evaporation, solvent extraction, or air or steam
 stripping operations, that manage hazardous wastes with organic concentrations
 of at least 10 ppmw, if the operations are conducted in one of the following:
    - a unit that is subject to the permitting requirements of 40 CFR 270
    - a unit (including a hazardous waste recycling unit) that is not exempt from
     permitting under the provisions of 40 CFR 262.34(a) (i.e., a hazardous
     waste recycling unit that is not a 90-day tank or container) and that  is
     located at a hazardous waste management facility that is otherwise subject to
     the permitting requirements of 40 CFR 270
    -a  unit that is exempt from permitting under  the provisions of  40 CFR
     262.34(a) (i.e., a 90-day tank or container).)

 Verify that closed-vent systems and control devices are operated at all times when
 emissions may be vented to them.
     HW. 140.6.   When  carbon
     absorption systems are used,
     operators  are  required  to
     manage  all carbon that is a
     hazardous waste according to
     specific  parameters (40 CFR
     262.34(a)(l)(i), 265.178, and
     265.1033(m)).
 (NOTE:   This  applies  to  generators  with process vents  associated with
 distillation, fractionation, thin-film evaporation, solvent extraction, or air or steam
 stripping operations, that manage hazardous wastes with organic concentrations
 of at least 10 ppmw, if the operations are conducted in one of the following:
    - a unit that is subject to the permitting requirements of 40 CFR 270
    - a unit (including a hazardous waste recycling unit) that is not exempt from
     permitting under the provisions of 40 CFR 262.34(a) (i.e., a hazardous
     waste recycling unit that is not a 90-day tank  or container) and that  is
     located at a hazardous waste management facility that is otherwise subject to
	the permitting requirements of 40 CFR 270	
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       74

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                    -a unit that is exempt from permitting under the provisions of 40 CFR
                                      262.34(a) (i.e., a 90-day tank or container).)

                                 Verify that carbon removed from control devices that is a hazardous waste is
                                 managed in one of the  following manners, regardless of the  average VOC
                                 concentration of the carbon:

                                    - regenerated or reactivated in a thermal treatment unit that meets one of the
                                      following:
                                         - the unit has a final permit under 40 CFR 270 which implements the
                                          requirements of 40 CFR 264, subpart X
                                         -the unit is equipped with and operating air emission controls in
                                          accordance with applicable requirements
                                    - incinerated in a hazardous waste incinerator for which the operator either:
                                         -has a  final permit  under 40 CFR  270 which  implements  the
                                          requirements of 40 CFR 264, subpart O
                                         -has designed and operates the incinerator in accordance  with the
                                          interim status required in 40 CFR 265, subpart O
                                    -burned in a boiler or industrial furnace for which the operator either:
                                         -has been issued a final permit  under 40 CFR 270 implementing 40
                                          CFR 266
                                         -has designed  and operates  the boiler  or  industrial furnace  in
                                          accordance with the  interim status requirements of  40 CFR 266,
                                          subpart H.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                            75

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       75
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     LARGE QUANTITY
     GENERATORS

     HW.150

     Air Emission Standards for
     Equipment Leaks
(NOTE:  This section applies to equipment that contains or contacts hazardous
waste with organic concentrations of at  least 10 percent by weight that  are
managed in one of the following (40 CFR 265.1050(b):
   - a unit that is subject to the permitting requirements of 40 CFR 270
   - a unit (including a hazardous waste recycling unit) that is not exempt from
     permitting under the provisions of 40 CFR 262.34(a) (i.e., a hazardous
     waste recycling unit that is  not a 90-day  tank or container) and that is
     located at a hazardous waste management facility that is otherwise subject to
     the permitting requirements of 40 CFR 270
   -a unit that  is exempt from  permitting under  the  provisions of 40 CFR
     262.34(a) (i.e., a 90-day tank or container) and is not a recycling unit under
     the provisions of 40 CFR 261.6.)

(NOTE:  This section does not apply to (40 CFR 265.1050(d) and 265.1050(e)):
   - equipment that is in vacuum service and is identified as such on the required
     list
   -equipment that  contains  or  contacts hazardous  waste  with an  organic
     concentration of at least 10 percent by weight for less than 300  hours  per
     calendar year and is identified as such.)
     HW.150.1.  Generators with
     pumps in light liquid service,
     that   contain   or  contact
     hazardous   wastes    with
     organic  concentrations of at
     least 10  percent by weight,
     are required to meet specific
     standards     (40      CFR
     262.34(a)(l)(i),     265.178,
     265.1052).
Verify that pumps in light liquid service are  monitored monthly according to
designated reference methods and inspected visually weekly.

(NOTE:  A leak is detected if there is an instrument reading of 10,000 ppm or
greater or if there is an indication of liquid dripping from the pump seal.)

Verify that, when a leak is detected, the first attempt at repair is made within 5
calendar days and repair is completed within 15 calendar days.

(NOTE:   Pumps equipped with dual mechanical  seal systems  and pumps
designated for no detectable emissions that meet standards outlined here do not
have to be monitored monthly or visually checked weekly.)

Verify that pumps equipped with a dual mechanical seal system which do not
have to be  monitored monthly or visually checked weekly, meet the following
design and operation requirements:

   - the dual mechanical seal system is operated with barrier fluid at a pressure
     that is at all times greater than the pump stuffing box, or equipped with a
     barrier fluid degassing reservoir that is connected by a closed-vent system to
     a control device, or equipped with a system that purges the barrier fluid into
     a hazardous waste stream with no detectable emission to the atmosphere
   - the barrier fluid system has no hazardous waste with organic concentrations
     10 percent or greater by weight
   - the barrier fluid system is equipped with a sensor that will detect failure if
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       77

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                       the seal is broken
                                     - pumps are checked by visual inspection weekly
                                     - sensors are checked daily or equipped with an audible alarm that is checked
                                       monthly.

                                  (NOTE: Each owner or operator must determine, based on design considerations
                                  and  operating experience, criteria that  indicate failure of the seal  system, the
                                  barrier fluid system, or both.)

                                  Verify that pumps designated for no detectable emissions meet the following:

                                     -they are  operated  with no  detectable emissions,  as indicated by  an
                                       instrument reading of 500 ppm above background or less
                                     - they are tested for compliance as indicated by an instrument reading of 500
                                       ppm above background or less initially upon designation, annually, and at
                                       other times as requested by the regulatory agency
                                     - no externally actuated shaft penetrates the pump housing.

                                  (NOTE:  Any pump that is equipped with a closed-vent  system capable  of
                                  capturing and transporting any leakage from the seal or seals to a control device is
                                  exempt from all above requirements.)
     HW. 150.2.  Generators with
     compressors that  contain or
     contact   hazardous  wastes
     with organic concentrations
     of at least 10  percent  by
     weight are required to  meet
     specific  standards  (40  CFR
     262.34(a)(l)(i), 265.178, and
     265.1053).
Verify that each compressor is equipped with a seal system which includes  a
barrier fluid  system and prevents leakage of total organic emissions to the
atmosphere except if:

   -it  is  equipped with  a  closed-vent system  capable  of capturing and
     transporting any leakage from the seal to a control device, and
   - it is designated for no detectable emissions as indicated by an instrument
     reading of less than 500 ppm above background, and
   - it is tested for compliance initially upon designation, annually, and at times
     as requested by the regulatory agency.

Verify that the compressor seal systems meet one of the following:

   - it is operated  with the barrier fluid at a pressure that is at all times greater
     than the compressor stuffing box pressure
   - it is equipped with a barrier fluid system  that is connected to a closed-vent
     system or a control device
   - it is equipped with a system that purges  the barrier fluid into a hazardous
     waste stream with  no detectable emissions to the atmosphere.

Verify that the barrier fluid is not a hazardous waste with organic concentrations
10 percent or greater by weight.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       78

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  Verify that each barrier system is equipped with a sensor which will detect failure
                                  of the seal system, barrier fluid system, or both.

                                  Verify that each sensor is checked daily or it is equipped with an audible alarm
                                  that is checked monthly.

                                  (NOTE: Sensors on compressors located within the boundary of an unmanned
                                  site must be checked daily.)

                                  (NOTE: Each owner or operator must determine, based on design considerations
                                  and operating experience, criteria that indicate failure of  the seal system, the
                                  barrier fluid system, or both.)

                                  Verify that, when a leak is detected, the first attempt at repair is made within 5
                                  calendar days and the repair is made within 15 calendar days.
     HW. 150.3.  Generators with
     pressure  relief  devices   in
     gas/vapor service that contain
     or contact  hazardous waste
     with organic concentrations
     of at  least 10  percent  by
     weight are  required to meet
     specific standards  (40 CFR
     262.34(a)(l)(i), 265.178, and
     265.1054).
Verify that, except during pressure releases, each pressure relief device in
gas/vapor service is operated with no detectable emissions as indicated by an
instrument reading of less than 500 ppm above background.

Verify that if there is a pressure release, the device is returned to a no detectable
emission status within 5 calendar days and the device is monitored to ensure
compliance.

(NOTE:  Any  pressure relief device that is equipped with a closed-vent system
capable of capturing and transporting leakage from the pressure relief device to a
control device is exempt from these requirements.)
     HW. 150.4.  Generators with
     sampling connecting systems
     that   contain   or   contact
     hazardous   wastes    with
     organic  concentrations  of at
     least  10 percent  by weight
     are required to meet specific
     standards      (40     CFR
     262.34(a)(l)(i), 265.178, and
     265.1055).
Verify that each sampling connection system is equipped with a closed-purge,
closed loop system or closed-vent system.

Verify that each system collects the sample purge for return to the processing or
for routing to the appropriate treatment system.

(NOTE:  Gases displaced through filling of the sample container are not required
to be collected or captured.)

Verify that each closed-purge, closed-loop system or closed-vent system does one
of the following:

   - returns the purged process fluid directly to the process line
   - collects and recycles the purged process fluid
   -is designed and operated to capture and transport all the purged process
     fluid to a waste management unit that is in compliance or  a control device
     that is in compliance,	
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       79

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  (NOTE:  In-situ sampling systems are exempt from these requirements.)
     HW. 150.5.  Generators with
     open-ended  valves  or lines
     that   contain   or   contact
     hazardous   wastes    with
     organic  concentrations of at
     least  10 percent  by weight
     are required to meet specific
     standards      (40     CFR
     262.34(a)(l)(i), 265.178, and
     265.1056).
Verify that each open-ended valve or line is equipped with a cap, blind flange,
plug or second valve.

Verify that the cap, blind flange, plug, or second valve seals the open end at all
times,  except during operations requiring hazardous waste stream flow through
the open-ended valve or line.

Verify that each open-ended valve or line equipped with a second valve is
operated so the valve on the hazardous  waste stream end is closed before the
second valve is closed.

Verify that, when a double block and bleed system is being used, the bleed valve
is shut or plugged except during operations that require venting the line between
the block valves.
     HW. 150.6.  Generators with
     valves in gas/vapor service or
     light  liquid   service,   that
     contain or contact hazardous
     wastes      with     organic
     concentrations of at least 10
     percent   by   weight,    are
     required  to  meet   specific
     monitoring    and    repair
     standards      (40      CFR
     262.34(a)(l)(i),    265.178,
     265.1057, and 265.1062).
Verify that valves in gas/vapor service or light liquid service  are  monitored
monthly to detect leaks.

(NOTE:  A leak is detected if an instrument reading of 10,000 ppm or greater is
measured. If a leak is not detected for 2 consecutive months, monitoring may be
cut back to quarterly until a leak is detected.)

(NOTE:  Valves that are designated for no detectable emissions, as indicated by
an instrument reading of less than 500 ppm above background, do not have to be
monitored monthly if:
   - the valve has no external actuating mechanism in contact with the hazardous
     waste stream
   - the valve is operated with emissions less than 500 ppm above background
   - the valve is tested initially upon designation, annually, and at the request of
     the regulatory agency.)

(NOTE:  Valves that are designated as unsafe to monitor are exempt from the
requirement for monthly monitoring if:
   -the  valve  is unsafe to monitor because monitoring personnel would be
     exposed to an immediate danger
   - a written monitoring plan is followed that requires monitoring as often as is
     reasonably practicable during safe to monitor times.)

(NOTE:  The generator may elect to have all valves within a hazardous waste
management unit comply with an alternative standard of no greater than 2 percent
of the valves to leak; see checklist item HW. 150.10.)

(NOTE: Valves that are designated as difficult to monitor are exempt from the
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       80

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                          REVIEWER CHECKS
                                   requirement for monthly monitoring if:
                                      - the valve cannot be monitored without elevating the monitoring personnel
                                       more than 2 m above a support surface
                                      - the hazardous waste management unit within which the valve is located was
                                       in operation before 21 June 1990
                                      - a written monitoring plan is followed that requires the monitoring of the
                                       valve at least once per calendar year.)

                                   (NOTE:  The  following are alternatives to the prescribed monitoring schedule
                                   which can be used until the percentage of valves leaking is greater than 2 percent:
                                      - after 2 consecutive quarterly leak detection periods  with the percentage of
                                       valves leaking equal to or less than 2 percent, an owner or operator may
                                       begin to  skip one of the quarterly leak detection periods for the valves
                                       subject to 40 CFR 265.1057
                                      - after 5 consecutive quarterly leak detection periods  with the percentage of
                                       valves leaking equal to or less than 2 percent, an owner or operator may
                                       begin to  skip three of the  quarterly leak detection  periods for the valves
                                       subject to 40 CFR 265.1057.)

                                   Verify that the first attempt at repairing a leak is done within 5 calendar days after
                                   detection and leak repair is completed within 15 calendar days after detection.

                                   (NOTE: First attempts at repair include but are not limited to:
                                      - tightening of bonnet bolts
                                      - replacement of bonnet bolts
                                      -tightening of packing gland nuts
                                      - injection of lubricant into lubricated packaging.)
     HW. 150.7. Generators with
     pumps and valves in heavy
     liquid service, pressure relief
     devices in light liquid service
     or heavy liquid service, and
     other connectors that contain
     or contact hazardous wastes
     with organic concentrations
     of at least   10  percent  by
     weight are required to meet
     specific    monitoring   and
     repair  standards  (40  CFR
     262.34(a)(l)(i),  265.178, and
     265.1058).
Verify that pumps and valves in heavy liquid service, pressure relief devices in
light liquid service or heavy liquid service, and other connectors are monitored
within 5 days if evidence of a potential leak is found by visual, olfactory, audible,
or other detection method.

(NOTE:  Any connector that is inaccessible  or is ceramic or ceramic-lined is
exempt from the monitoring requirements.)

(NOTE:  A leak is detected if an instrument reading of 10,000 ppm or greater is
measured.)

Verify that, when a leak is detected, the first attempt at repair occurs within 5
days and repair is done within 15 days after discovery.

(NOTE:  First attempts at repair include, but are not limited to:
   - tightening of bonnet bolts
   - replacement of bonnet bolts	
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                        81

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                          REVIEWER CHECKS
                                     -tightening of packing gland nuts
                                     - injection of lubricant into lubricated packaging.)
     HW. 150.8.  Generators are
     required  to  keep  specific
     records  pertaining  to  the
     valves, pumps, pressure relief
     devices,    and   connecting
     systems being monitored for
     leaks  and  to  submit certain
     reports      (40       CFR
     262.34(a)(l)(i),     265.178,
     265.1058(e) and 265.1064).
 Verify that the following information is maintained in the generator's operating
 record:

    -equipment  identification   number  and   hazardous   management  unit
     identification
    - approximate locations
    - type of equipment
    - percent-by-weight total  organics in the hazardous waste  stream  at the
     equipment
    - hazardous waste state at the equipment (gas, liquid, vapor)
    - method of compliance
    - implementation schedule if needed
    - a performance plan for control devices if needed
    - documentation of compliance
    - documentation of repair, including:
        - the  instrument and operator identification numbers and the equipment
          identification number
        - the  date evidence of a potential leak was found
        - the  date the leak was detected and the date of each attempt to repair the
          leak
        - repair methods applied in each attempt
        - "Above 10,000" if the maximum instrument reading after each repair
          attempt is greater than 10,000 ppm
        - "Repair Delayed" and  the reason for delay if the leak is not repaired
          within 15 calendar days after discovery
        - documentation supporting the delay of repair of a valve
        - signature of the  owner or operator whose decision it was that the repair
          could not be effected without a hazardous  waste management unit
          shutdown
        -the  expected date  of  successful repair of the leak when it  is not
          repaired within 15 calendar days
        -the  date of the successful repair of the leak
    - design documentation and monitoring, operating, and inspection information
     for each closed-vent system control device required  to comply with the
     provisions of 40 CFR 265.1060
    -monitoring and inspection  information indicating  proper operation and
     maintenance of the control device for a control device other than a thermal
     vapor incinerator, catalytic vapor incinerator, flare, boiler, process heater,
     condenser, or carbon  absorption system
    -the following information for all equipment subject to 40 CFR 265.1052
     through 40 CFR 265.1060:
	- a list of identification numbers for equipment (except welded fittings)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       82

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                          -a list  of identification numbers  for  equipment that  the  owner or
                                            operator elects to designate for no detectable emissions
                                          - a list of equipment identification numbers for pressure relief devices
                                          -the  dates  of required compliance  tests,  background  levels,  and
                                            maximum instrument reading measured during the compliance test
                                          - a list of identification numbers for equipment in vacuum service
                                          - identification either by list or location (area or group) of equipment
                                            that  contains   or  contacts  hazardous  waste with  an  organic
                                            concentration of at least 10 percent by weight  for less than  300 hours
                                            per calendar year.

                                  Verify that the following information is kept for all valves subject to 40 CFR
                                  265.1057(g)and(h):

                                     - a list of identification numbers for valves listed as unsafe to monitor, an
                                       explanation for each valve stating why it is difficult to monitor, and the plan
                                       for monitoring each valve
                                     - a list of identification numbers for valves that are designated as difficult to
                                       monitor, an explanation for each valve stating why it is difficult to monitor,
                                       and the plan for monitoring each valve
                                     - the following for all valves complying with 40 CFR 265.1062:
                                          - a schedule of monitoring
                                          - the percent of valves found leaking in each monitoring period.

                                  Verify that the following information is kept for use in determining exemptions:

                                     - an analysis determining the design capacity of the unit
                                     - a statement listing the hazardous waste influent to  and effluent from each
                                       unit  subject to 40  CFR  265.1052  through 265.1060  and  an analysis
                                       determining whether these hazardous wastes are heavy liquids
                                     -an up-to-date analysis and the supporting information and  data used to
                                       determine if equipment is subject to the requirements.

                                  (NOTE:  Any connector that  is inaccessible or is  ceramic or  ceramic lined is
                                  exempt from the recordkeeping requirements.)
     HW. 150.9.  Each piece of
     equipment  subject  to  the
     requirements  in  40   CFR
     265.1050  through 265.1064
     is required to be marked so
     that it  can be distinguished
     from  other  equipment  (40
     CFR        262.34(a)(l)(i),
     265.178, and 265.1050(c)).
Verify that each piece of equipment subject to the requirements in 40 CFR
265.1050 through 265.1064 (see checklist items HW. 150.1 through HW.150.10)
is marked so that it can be distinguished from other equipment.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      83

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     HW.150.10.      When   a
     generator  has  elected  to
     comply   with    alternative
     standards,   specific   actions
     are   required  (40    CFR
     262.34(a)(l)(i)          and
     265.1061).
Determine if the owner/operator subject to 40 CFR 265.1057 (see checklist item
HW. 150.6) has elected to have all valves within a hazardous waste management
unit comply with an alternative standard  of allowing 2 percent of the valves to
leak.

Verify that the  following actions  have  been taken if the owner/operator has
decided to comply with the 2 percent alternative:

   - the regulatory agency has been notified of the choice to comply with the
    alternative standards
   - a performance test was conducted initially upon designation, annually, and
    at other times as required by the regulatory agency
   - if a valve leak is detected, first attempt at repair is within five calendar days
    and leak repair is completed within 15 days after detection.

Verify that if the  owner/operator has decided to no longer comply with the 2
percent rule, the regulatory agency has been notified.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      84

HW.160

Satellite Accumulation
Points
HW.160.1. Generators may
accumulate as much as 55
gal. of hazardous waste or 1
qt. of acutely hazardous
waste in containers at or near
any point of initial generation
without complying with the
requirements for on-site
storage if specific standards
are met (40 CFR 262.34(c)).
(NOTE: This type of storage area is often referred to as a satellite accumulation
point.)

Verify that the satellite accumulation point is at or near the point of generation
and is under the control of the operator of the waste generating process.

Verify that the containers are in good condition and are compatible with the waste
stored in them and the containers are kept closed except when waste is being
added or removed.

Verify that the containers are marked HAZARDOUS WASTE or other
appropriate identification.

(NOTE: See Appendices A, B, C, and D for a guidance list of hazardous and
acutely hazardous wastes.)

Verify by interviewing the shop managers that when waste is accumulated in
excess of quantity limitations, the following actions are taken:

-the excess container is marked with the date the excess amount began
accumulating
- the waste is transferred to a 90 day or permitted storage area within three
days.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
85

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       86
requirements are in any way altered by any statement(s) contained herein.

HW.170

Container Storage Areas
HW.170.1. At generators,
containers of hazardous
waste should be kept in
designated storage areas
(MP).
Verify that all containers are identified and stored in appropriate areas.

(NOTE: Any unidentified contents of solid waste containers and/or containers
not in designated storage areas must be tested to determine if solid or hazardous
waste requirements apply.)
HW.170.2. Containers
holding ignitable or reactive
waste must be located 15 m
(50 ft.) from the property line
of the facility (40 CFR
262.34(a)(l)(i)and265.176).
Determine the distance from storage containers holding ignitable or reactive
waste to the property line.
HW.170.3. Generator
personnel must conduct
weekly inspections of
container storage areas (40
CFR 262.34(a)(l)(i) and
265.174).
Verify that inspections are conducted at least weekly to look for leaking
containers and signs of deterioration of containers.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
87

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                                REVIEWER CHECKS
     LARGE QUANTITY
     GENERATORS

     HW.190

     Containment Buildings
      (NOTE:  According to the 'Background Information' published on page 37221 of
      the  August 18,  1992,  edition  of the Federal Register, a  hazardous waste
      containment building involves "the management of a hazardous waste inside a
      unit designed and operated to contain the hazardous waste within the unit". This
      is not a building that holds drums  or tanks filled with hazardous waste, but a
      building that holds the hazardous waste itself.)
     HW.190.1. Generators with
     containment  buildings  that
     are  in compliance  are not
     subject to  the definition of
     land  disposal   if  specific
     requirements  are  met  (40
     CFR  262.34(a)(l)(iv)  and
     265.1100).
      Verify that the containment building meets the following:

          -it is a completely enclosed,  serf-supporting structure that is designed and
           constructed of man-made materials of sufficient strength and thickness to
           support themselves,  the  waste contents, and any  personnel and heavy
           equipment that operate within the unit
          -it is  designed  to prevent failure due  to pressure  gradients, settlement,
           compression, or uplift, physical contact with the hazardous wastes, climatic
           conditions, and the stress of daily operations
          -it has a primary barrier that is  designed  to be sufficiently durable to
           withstand the movement of personnel, wastes, and handling of equipment
           within the unit
          - if the unit is used to manage liquids:
              -there is a primary barrier designed and constructed of materials to
                prevent migration of hazardous constituents into  the barrier
              -there  is  a liquid  collection system  designed and constructed of
                materials to minimize the accumulation of liquid on the primary barrier
              - there is a secondary containment system designed and constructed of
                materials  to prevent migration of  hazardous  constituents  into the
                barrier, with a leak detection and liquid  collection system capable of
                detecting, collecting, and removing leaks of hazardous constituents at
                the earliest practicable time
          - it has controls sufficient to prevent fugitive dust emissions
          - it is designed and operated to ensure containment and prevent the tracking
           of materials from the unit by personnel and equipment.
     HW. 190.2.     Containment
     buildings are required to be
     designed    according    to
     specific standards  (40  CFR
     262.34(a)(l)(iv),
and
     265.1101(a)(2),
     265.1 10 l(a)(4),
     265.1101(b)).
Verify that containment buildings meet the following design standards:

   - it is completely enclosed with a floor, walls, and a roof to prevent exposure
     to the elements and to assure containment of wastes
   -the  floor and containment  walls,  including  any  required  secondary
     containment system, are designed and constructed of man-made materials of
     sufficient strength and thickness to support themselves, the waste contents,
     and any personnel and heavy equipment that operate within the unit
   -it is designed to prevent failure due  to pressure gradients,  settlement,
     compression, or uplift, physical contact with the hazardous wastes, climatic
     conditions, and the stress of daily operations
   - it has sufficient structural strength to prevent collapse or other failure	
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                              89

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                      - all surfaces in contact with hazardous wastes are compatible with the wastes
                                      -it has a primary  barrier that  is designed to be sufficiently durable to
                                       withstand the movement of personnel, wastes, and handling of equipment
                                       within  the   unit  and  is  appropriate  for  the  chemical  and   physical
                                       characteristics of the waste.

                                   Verify that if the containment building is going to manage hazardous wastes with
                                   free liquids or treated with free liquids, the following design requirements are also
                                   met:

                                      - there is a primary barrier designed and constructed of materials to prevent
                                       migration of hazardous constituents into the barrier (e.g.,  a  geomembrane
                                       covered by a concrete wear surface)
                                      - there is a liquid collection and removal system designed and constructed of
                                       materials to minimize the accumulation of liquid on the primary barrier
                                          -the primary  barrier  is sloped  to  drain  liquids to the associated
                                            collection system
                                          - liquids and wastes are collected and removed to minimized  hydraulic
                                            head on the  containment system at the earliest practicable time
                                      -there is a secondary containment system, including a secondary barrier,
                                       designed and constructed of materials to prevent migration of hazardous
                                       constituents into  the barrier, with a leak detection and  liquid collection
                                       system  capable of detecting, collecting, and removing leaks of hazardous
                                       constituents at the earliest practicable time
                                      - the leak detection component of the secondary  containment system meets
                                       the following:
                                          - it is constructed with a bottom slope of 1 percent or more
                                          -it  is constructed  of  granular drainage materials  with a  hydraulic
                                            conductivity of 1  x 10~2 cm/sec or more and a thickness  of 12 in (30.5
                                            cm) or more, or constructed of synthetic or geonet drainage materials
                                            with a transmissivity of 3 x 10~5 m2/sec or more
                                      - if treatment is to be conducted in the building, the treatment area is designed
                                       to prevent the release of liquids, wet materials,  or liquid  aerosols to other
                                       portions of the building
                                      -the  secondary  containment system is constructed  of materials  that are
                                       chemically resistant to the waste and liquids managed in the building  and of
                                       sufficient strength and thickness to prevent collapse under pressure exerted
                                       by overlaying materials and by any equipment used.

                                   (NOTE: An  exception to the structural strength requirement may be  made for
                                   lightweight doors  and windows  based  on the nature of the waste management
                                   operations if the following criteria are met:
                                      -the doors and  windows provide  an effective barrier again fugitive dust
                                       emissions
                                      - the unit is designed and operated in a manner that ensures that the waste will
                                       not come in contact with the doors or windows.)	
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              90

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  (NOTE: A containment building can serve as secondary containment systems for
                                  tanks within the building if it meets the requirements of 40  CFR 264.193(b),
                                  264.193(c)(l) and (2), and 264.193(d).)
     HW. 190.3.     Containment
     buildings are required to be
     operated     according    to
     specific standards  (40  CFR
     262.34(a)(l)(iv),
     265.1101(a)(3),
     265.1101(c)(l),         and
     265.1101(c)(4)).
Verify that  incompatible wastes or treatment reagents are not placed in the
building or its secondary containment system if they could cause the unit or the
secondary containment system to leak, corrode, or otherwise fail.

Verify that the following operational procedures are done:

   - controls and practices are used to ensure the containment of the waste within
     the building
   - the primary barrier is maintained so that it is free of significant cracks, gaps,
     corrosion, or other deterioration that could cause hazardous waste to  be
     released from the primary barrier
   - the  level of the stored/treated hazardous waste is maintained so that the
     height of any containment wall is not exceeded
   - measures are implemented to prevent the tracking of hazardous waste out of
     the unit by personnel or equipment used in the handling of the waste
   -there  is  a  designated area for  the  decontamination of equipment and
     collection of rinsate
   - any collected rinsate is managed as needed according to its constituents
   -measures are implemented to control fugitive dust emissions so that  no
     openings exhibit visible emissions
   -paniculate  collection devices are maintained and operated according to
     sound air pollution control practices.

Verify that  data is gathered from monitoring equipment and  leak  detection
equipment and the site is inspected at least once every seven days and the results
recorded in the operating record.

Verify that there is a written description of procedures to ensure that waste does
not remain in the building for more than 90 days.

Verify that there is documentation that the waste does not remain for more than
90 days.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       91

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW. 190.4. Containment
buildings are required to be
certified by a registered
professional engineer (40
CFR 262.34(a)(l)(iv) and
265.1101(c)(2)).
Verify by reviewing the documentation that the building has been certified.
HW. 190.5. Leaks in
containment buildings must
be repaired and reported (40
CFR 262.34(a)(l)(iv) and
265.1101(c)(3)).
Verify that if a condition is detected that could lead to a leak or has already
caused a leak, it is repaired promptly.

Verify that when a leak is discovered:

- the discovery is recorded in the facility operating record
- the portion of the containment building that is affected is removed from
service
- a cleanup and repair schedule is established
-within seven days the regulatory agency is notified and within 14 working
days written notice is provided to the regulatory agency
-the regulatory agency is notified upon the completion of all repairs, and
certification from a registered professional engineer is also submitted.
HW. 190.6. Containment
buildings that contain both
areas with and without
secondary containment must
meet specific requirements
(40 CFR 262.34(a)(l)(iv),
264.1101(d), and
265.1101(d)).
Verify that each area is designed and operated according to the appropriate
requirements.

Verify that measures are taken to prevent the release of liquids or wet materials
into areas without secondary containment.

Verify that a written description is maintained in the facilities operating log of
operating procedures used to maintain the integrity of areas without secondary
containment.
HW. 190.7. When a
containment building is
closed, specific requirements
must be met (40 CFR
262.34(a)(l)(iv), 264.1102,
and 265.1102).
Determine if the facility has closed a containment building recently.

Verify that at closure, all waste residues, contaminated containment system
components, contaminated subsoils, and structures and equipment contaminated
with waste and leachate were removed or decontaminated.

Verify that the containment building is closed in accordance with closure and
post-closure requirements for TSDFs.

Verify that if it is found that not all contaminated subsoils can be practicably
removed or decontaminated, the site is closed and landfill post-closure
requirements are implemented.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
92

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     LARGE QUANTITY
     GENERATORS

     HW.200

     Disposal of Restricted
     Waste
     HW.200.1.  Facilities   that
     generate  hazardous  wastes
     must test their wastes or use
     process     knowledge    to
     determine   if   they   are
     restricted from land disposal
     (40CFR268.7(a)(l)).
Determine whether the generator tests for restricted wastes.

Determine if the facility generates restricted wastes (see Appendix VII of 40 CFR
Part 268) by reviewing test results or reviewing procedures employed by facility
management  where  process  knowledge  was applied  in making  the  waste
determination.
     HW.200.2.     When     a
     generator  is  managing  a
     waste or  contaminated  soil
     that does not meet treatment
     standards,  a  written  notice
     must be issued to the  TSDF
     stating    the    appropriate
     treatment   standards    and
     prohibition levels  (40  CFR
     268.7(a)(2), and 268.7(a)(3))
     [Revised January 2001].
(NOTE: The notification requirement under 40 CFR 268.7 has changed to a one-
time notification and certification if the composition of the wastes, the process
generating the wastes,  and the  treatment facility receiving the wastes do not
change (See FR Vol 62, No. 91, May 12, 1997, pg 26004).)

Verify that, for waste or contaminated soil which does not meet the applicable
treatment standards or  exceeds  the applicable prohibition levels,  the notice  is
issued and includes:

   -U.S. EPA hazardous waste numbers and manifest number of first shipment
   -the waste is subject to the LDRs (NOTE:  The notice must also include
     constituents of concern for F001-F005, and F039, and underlying hazardous
     constituents in characteristic wastes, unless the waste will be treated and
     monitored for all  constituents.  If all constituents will  be  treated and
     monitored, there is no need to put them all on the LDR notice.)
   -the applicable wastewater/nonwastewater category (see 40 CFR 268.2(d)
     and 268.2(f)) and  subdivisions made within a waste code  based on  waste-
     specific criteria (such as D003 reactive cyanide)
   - waste analysis data (when available)
   -for  hazardous  debris, when  treating  with  the  alternative  treatment
     technologies provided by 40 CFR 268.45:
        -the  contaminants subject to  treatment,  as described  in 40 CFR
          268.45(b)
        - an indication that these contaminants are being treated to comply with
          40 CFR 268.45
   -for contaminated soil subject to LDRs as provided in 40 CFR 268.49(a), the
     constituents subject to  treatment as described in 40 CFR 268.49(d), and the
     following statement: "This contaminated soil [does/does not] contain listed
     hazardous waste and  [does/does not] exhibit a characteristic  of hazardous
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       93

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
REVIEWER CHECKS
                                       waste and [is subject to/complies with] the soil treatment standards as
                                       provided by 40 CFR 268.49(c) or the universal treatment standards."

                                  Verify that, for waste or contaminated soil which meets the treatment standard at
                                  the original point of generation, the notice includes:

                                      -U.S. EPA hazardous waste numbers and manifest number of first shipment
                                      -the waste is subject to the LDRs (NOTE:  The notice must also include
                                       constituents of concern for F001-F005, and F039, and underlying hazardous
                                       constituents in characteristic wastes, unless the waste  will be treated and
                                       monitored for all constituents.  If all  constituents will be  treated and
                                       monitored, there is no need to put them all on the LDR notice.)
                                      -the applicable wastewater/nonwastewater category  (see 40  CFR  268.2(d)
                                       and 268.2(f)) and subdivisions made within a waste code based on waste-
                                       specific criteria (such as D003 reactive  cyanide)
                                      - waste analysis data
                                      -for contaminated soil subject to LDRs as provided in 40 CFR 268.49(a), the
                                       constituents subject to treatment as described in 40 CFR 268.49(d), and the
                                       following statement: "This contaminated soil  [does/does not] contain  listed
                                       hazardous waste and [does/does  not] exhibit a characteristic of hazardous
                                       waste and [is subject to/complies  with the  soil treatment standards as
                                       provided by 40 CFR 268.49(c) or the universal treatment standards"
                                      -the signature  of  an authorized  representative certifying that the waste
                                       complies  with the treatment standards  of 40  CFR 268  (the text of the
                                       required certification statement can be found in 40 CFR 268.7(a)(3)(i).)

                                  Verify that, for waste or contaminated soil that meets the treatment standard  at the
                                  original point of generation, if the waste changes,  the generator sends a new
                                  notice and certification to the receiving facility and placed a copy in their files.

                                  (NOTE:    Generators  of  hazardous  debris  excluded from the definition of
                                  hazardous waste under 40 CFR 261.3(f) are not subject to the requirements for
                                  waste or contaminated soil  which meets the  treatment standard at the original
                                  point of generation.)

                                  Verify that, for restricted waste subject to an exemption from a prohibition of the
                                  type of land disposal used, the notice states that the waste is not prohibited from
                                  land disposal and includes:

                                      -U.S. EPA hazardous waste numbers and manifest number of first shipment
                                      - statement: this waste is not prohibited from land disposal
                                      - waste analysis data, when available
                                      - date the waste is subject to the prohibition
                                      -for  hazardous debris, when  treating with  the   alternative  treatment
                                       technologies  provided by 40  CFR 268.45:  the contaminants subject to
                                       treatment, as described in 40 CFR 268.45(b); and an indication that  these
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                              94

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                          COMPLIANCE CATEGORY:
                                     HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                          REVIEWER CHECKS
                                        contaminants are being treated to comply with 40 CFR 268.45.
     HW.200.3.  Generators that
     are   managing   prohibited
     wastes in tanks,  containers,
     or containment buildings and
     treating the waste  to  meet
     applicable         treatment
     standards, must develop and
     follow   a  written   waste
     analysis   plan   (40    CFR
     268.7(a)(5)             and
     268.7(a)(10)).
Verify that the plan describes the procedures that the generator will carry out to
comply with treatment standards.

(NOTE:   Generators treating hazardous debris under the alternative treatment
standards are not required to conduct waste analysis.)

Verify that the plan is kept on-site and:

   -the  plan  is  based  on a detailed  chemical  and physical analysis  of
     representative sample of the prohibited waste being treated
   -contains all information necessary to treat the waste in accordance  with
     regulatory requirements including the selected testing frequency
   -the  plan is kept in the on-site files  and made available  to  regulatory
     inspectors.
     HW.200.4.  Generators  are
     required  to  keep  specific
     documents    pertaining   to
     restricted wastes on-site  (40
     CFR   268.7(a)(6)   through
     268.7(a)(8)).
Verify that if the facility is using generator knowledge to determine whether a
waste or contaminated soil is restricted from land disposal, the supporting data
used in making this determination is retained on-site in the generator's files.

Verify that if the facility has determined whether a waste or contaminated soil is
restricted using appropriate test methods, the waste analysis data is retained on-
site.

Verify that if the facility has determined that they are managing a restricted waste
that is excluded from the definition of a hazardous waste or solid waste or exempt
from RCRA Subtitle C, a one-time notice is placed in the facility's files stating
that the generated waste is excluded.

Verify that a copy  of all notices, certifications, waste analysis data and other
documentation is kept for at least three years from the date that the waste was last
sent to an on-site or off-site TSDF.
     HW.200.5.  Generators  who
     first  claim  that  hazardous
     debris  is excluded from the
     definition of hazardous waste
     are required to meet specific
     notification and  certification
     requirements     (40     CFR
     268.7(d)).
Verify that a one-time notification is submitted to the regulatory agency including
the following:

   -the name and address of the facility receiving the treated waste
   - a description of the hazardous debris as  initially generated, including the
     applicable EPA hazardous waste codes, treatability groups, and underlying
     hazardous constituents
   - for excluded debris, the technology used to treat the debris.

Verify that the notification is updated if the  debris is shipped to a different
facility.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                        95

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                  Verify that for debris that is excluded, if a different type of debris is treated or if a
                                  different technology is used to treat the debris, the notification is updated.
     HW.200.6. The storage  of
     hazardous   waste   that  is
     restricted from land disposal
     is not allowed unless specific
     conditions are  met (40 CFR
     268.50).
Verify that land disposal restricted waste is not stored at the facility unless the
generator is storing the wastes in tanks, containers, or containment buildings on-
site only for the purpose of accumulating enough quantity of hazardous waste to
facilitate proper recovery, treatment, or disposal and all appropriate standards for
containers, tanks, and containment buildings are met.

(NOTE: If the 90 day storage period is exceeded, the generator is required to be
permitted as a TSDF.)

(NOTE: The prohibition on storage does not apply to hazardous wastes that have
met treatment standards.)

Verify that liquid hazardous wastes  containing PCBs at concentrations  greater
than 50 ppm are stored at a site that meets the requirements of 40  CFR 761.65(b)
(see the Toxic Substances Control Act (TSCA)) and is removed from  storage
within one year of the date it was first placed into storage.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      96

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     TRANSPORTATION OF
     HAZARDOUS WASTE

     HW.300
     HW.300.1. Transporters of
     hazardous  waste   that  is
     required  to be manifested
     must    have    an    EPA
     identification   number  and
     must comply with  manifest
     management    requirements
     (40     CFR     263.10(a),
     263.10(b), 263.11, 263.20(a)
     through  263.20(d),  263.21
     and263.22(a)).
(NOTE:   These requirements do  not  apply to the  on-site transportation  of
hazardous waste.)

Determine if the facility transports  hazardous waste off-site by using their own
vehicles or a contractor.

Verify that the transporter has an EPA identification number.

Verify that  all waste  accepted,  transported,  or  offered  for transport  is
accompanied by a manifest.

Verify that prior to transport, the transporter signs and dates the manifest and
returns a copy to the generator prior to leaving the facility.

Verify that the transporter retains a copy of the manifest after delivery.

Verify that all wastes accepted by the transporter are delivered to the designated
facility listed on the manifest, or the alternate designated facility if an emergency
prevents delivery,  or the next designated transporter or the place outside the
United States designated by the generator.

(NOTE: If the transporter cannot deliver the hazardous waste to the facilities or
transporters designated on the manifest, the transporter must contact the generator
for further directions and  revise  the  manifest  according  to  the  generator's
instructions.)

Verify that manifests are kept on file for three years.

(NOTE:  Special issues involved in the transportation of hazardous waste by air,
rail or water are not addressed in this guide.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       97

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW.300.2. Before
transporting hazardous waste
or offering hazardous waste
for transportation off-site in
the United States, the facility
must package and label the
waste in accordance with
DOT regulations contained in
49 CFR 172, 173, 178, and
179 (40 CFR 262.30 through
262.33).
Determine what pretransport procedures for hazardous waste are used.

Verify that containers are properly constructed and exhibit no leaks, corrosion, or
bulges by inspecting a sample of containers awaiting transport.

Verify that there are no indications of drum failure by examining end-seams for
minor weeping.

Verify that labeling and marking on each container is compatible with the
manifests.

Verify that the following information is displayed on a random sample of
containers of 110 gal. (416.40 L) or less in accordance with 49 CFR 172.304:

- "HAZARDOUS WASTE - Federal Law Prohibits Improper Disposal. If
found, contact the nearest police or public safety authority or the U.S.
Environmental Protection Agency."
- generator's name and address
- Manifest Document Number.

Verify that proper DOT placarding is available for the transporter.
HW.300.3. Transporters of
waste off-site must take
immediate notification and
clean-up action if a discharge
occurs during transport (40
CFR 263.30 and 263.31).
Verify that transport operators have instructions to notify local authorities and
take clean-up action so that the discharge does not present a hazard.

Verify that transporters give notice to the NRC and report in writing as required
by 49 CFR 171.15 and 49 CFR 171.16.
HW.300.4. The facility
should ensure that
transportation of hazardous
wastes between buildings is
accomplished in accordance
with good management
practices to help prevent
spills, releases, and
accidents (MP).
Determine if procedures exist to manage movement of hazardous wastes
throughout the facility.

Determine if drivers are trained in spill control procedures.

Determine if provisions have been made for securing wastes in vehicles during
transport.
HW.300.5. Transporters
must not store manifested
shipments in containers
meeting DOT packaging
requirements for more than
10 days at a transfer facility
(40 CFR 263.12).
Determine if the facility has a transfer facility.

Verify the following:

- transfer facility storage is for 10 days or less
- DOT packaging requirements are met
- shipments are manifested and manifests accompany shipments
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
98

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      COMPLIANCE CATEGORY:
                                 HAZARDOUS WASTE MANAGEMENT
         REGULATORY
       REQUIREMENT OR
         MANAGEMENT
           PRACTICE
REVIEWER CHECKS
                                   - storage is consistent with good management practices.

                                (NOTE:  Storage for more than 10 days will require a TSDF permit.)

                                Verify that  transporters do  not  store manifested  shipments of land disposal
                                restricted wastes for more than 10 days (40 CFR 268.50(a)(3)).
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                          99

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
    EXPORT/IMPORT OF
    HAZARDOUS WASTE

    HW.400

    Exports of Hazardous
    Waste for Recovery Within
    the OECD Member
    Countries
    HW.400.1.  A U.S.  Notifier
    that exports amber list or red
    list hazardous waste  (see 40
    CFR   262.89   and  262.82)
    destined    for    recovery
    operations   (see   40   CFR
    262.81(k))   in  an   OECD
    member country  (40   CFR
    262.58(a))  must comply with
    notification requirements (40
    CFR 262.83).
Determine whether the importing country is  an Organization  for Economic
Coordination  and Development  (OECD) member country [Australia, Austria,
Belgium, Denmark, Finland,  France, Germany, Greece, Iceland, Ireland,  Italy,
Japan,  Luxembourg,  Netherlands,  New Zealand,  Norway,  Portugal,  Spain,
Sweden, Switzerland, Turkey, United Kingdom, and United States].

(NOTE: The  following countries have become OECD member countries since
U.S. EPA promulgated its  OECD  regulations in 1996:  South  Korea,  Czech
Republic, Poland, and Hungary.  U.S.  EPA plans to amend its regulations to
reflect these new OECD countries. In the interim, U.S. EPA strongly recommends
that U.S. exports to these new OECD countries comply with the applicable OECD
regulations,  since  these  countries  would  expect  compliance with OECD
requirements for shipments they receive from the U.S.)

Determine whether the waste is destined  for recovery operations,  including
resource recovery, recycling, reclamation, direct re-use or alternative uses.

Verify that 45 days prior to shipment of hazardous waste, the facility has notified
U.S. EPA (in writing) of the following:

   - serial number or other accepted identifier of the notification form
   - name, address, telephone and telefax numbers, and EPA ID number of the
     notifier
   - name, address, telephone and telefax numbers of any consignee (other than
     the owner or operator of the recovery facility) and whether the consignee
     will exchange or store the waste before delivery to the final recovery facility
   - Intended transporters and any agents
   - country of export and point of departure
   - countries of transit, relevant competent authority, and point of entry and
     departure
   - country of import, relevant competent authority, and point of entry
   - statement of whether the notification is for a single or multiple shipments
     and, for multiple shipments,  period of validity requested
   - date foreseen for shipments to begin
   - designation of waste types from the  appropriate list (amber or red and waste
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                     101

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                       list code), descriptions of each waste type, estimated total quantity of each,
                                       RCRA waste code, and United Nations number for each waste type
                                     - signed certification that states the following:
                                          - "I certify that the above information is complete and correct to the best
                                           of  my  knowledge.  I  also certify that legally-enforceable written
                                           contractual obligations  have been entered into, and that any applicable
                                           insurance or other financial guarantees are or shall be in force covering
                                           the transfrontier movement."

                                  (NOTE: The U.S. does not currently require financial assurance; however,  U.S.
                                  exporters may be asked by other governments to provide and certify to  such
                                  assurance as a condition of obtaining consent to a proposed movement.)

                                  (NOTE: If  wastes with similar physical and chemical characteristics,  the same
                                  United Nations classification, and the same RCRA waste codes are to be sent to
                                  the  same recovery facility  by the same notifier, the notifier may submit one
                                  notification of intent to export these wastes in multiple shipments during a period
                                  of up to one year.)

                                  (NOTE: For amber list wastes to be shipped to a recovery facility pre-approved by
                                  the  competent authority of the receiving country, the notifier must provide the
                                  above information to U.S. EPA at least  10 days prior to shipment. Waste may be
                                  shipped as soon as the notification has been received by the competent authorities
                                  in the  exporting,  importing, and transit countries unless the notifier receives
                                  information indicating that any country objects to the shipment.)

                                  Verify  that, for amber list  wastes, either (1) no  objection was lodged by any
                                  exporting, importing, or transit countries  within  30  days after  issuance  of the
                                  Acknowledgment of Receipt of notification by the competent authority  of the
                                  importing country or (2) the competent authorities of all importing and transit
                                  countries provided written consent within 30 days.

                                  Verify  that, for red list wastes, written  consent was received  from the importing
                                  country and any transit countries prior to export.
     HW.400.2.   A  U.S.  notifier
     must execute  a  valid written
     contract or chain of contracts
     with the recovery facility that
     specifies  the  responsibilities
     of each (40 CFR 262.85).
Verify that contracts specify the name and EPA ID number, where available, of:

   - the generator of each type of waste
   - each person who will have physical custody of the waste
   - each person who will have legal control of the waste
   - the recovery facility.

Verify that contracts specify:

   -which party will assume responsibility for  alternate  management of the
     wastes if it cannot be carried out as described in the notification of intent to
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       102

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                       export
                                      - that the person with actual possession or physical control over the waste will
                                       immediately notify the notifier and the competent authorities of the exporting
                                       and importing countries and transit country if wastes are located in a country
                                       of transit
                                      - the person specified in the contract who will assume responsibility for the
                                       adequate management of the wastes including, if necessary, arranging for
                                       their return to the original country of export
                                      - notification prior to re-export to a third country
                                      - provisions for financial guarantees.
     HW.400.3.   A U.S. notifier
     must ensure that  a tracking
     document accompanies each
     shipment of amber or red list
     wastes  until it reaches the
     final recovery  facility  (40
     CFR 262.84).
Verify that a copy of the tracking document is attached to the shipment.

Verify that  the tracking  document  includes all  information contained  in  the
notification and the following:

   - the date shipment commenced
   -name,  address,  telephone  and telefax  numbers of primary  exporter, if
     different than the notifier
   - name and EPA ID number of all transporters
   - any special precautions to be taken by transporters
   - signed certification that states the following:
        - "I certify that the above information is complete and correct to the best
         of my knowledge.    I also certify that legally-enforceable written
         contractual obligations have been entered into, and that any applicable
         insurance or other financial guarantees are or shall be in force covering
         the transfrontier movement, and that:
             - 1. All necessary consents have been received; OR
             - 2. The shipment is directed at a recovery facility within the OECD
              area and  no  objection has  been received from  any of  the
              concerned countries within the 30 day tacit consent period; OR
             -3. The shipment is directed at a recovery facility pre-authorized
              for  that  type  of waste  within  the  OECD  area;   such  an
              authorization has not been revoked, and no objection  has been
              received from any of the concerned countries."
             -(NOTE:  The   notifier  may delete   sentences  that  are   not
              applicable.)
   - appropriate signatures for each custody transfer.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       103

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
     HW.400.4.   A  U.S.  notifier
     must  comply  with  special
     manifest  requirements  (40
     CFR 262.84(c) and 262.54(a),
Verify that the tracking documents contain the following:

   - the name and address of the foreign consignee (and any alternate consignee)
     in place of the designated facility's name, address, and EPA ID number
   -the  point of departure from the United  States indicated in the Special
     Handling Instructions and Additional Information section.

Verify that  a copy of the manifest is provided for delivery to  the U.S. Customs
official at the point of departure from the U.S.
     HW.400.5.      A  primary
     exporter must file an annual
     report  with U.S.  EPA  by
     March   1   of   each  year
     regarding  hazardous  waste
     exported for recovery during
     the  previous year (40  CFR
     262.87(a)).
Verify that an annual report has been submitted by March 1 of every year for
hazardous waste exported for recovery during the previous calendar year.

Determine  whether annual reports contain the following information for all
hazardous waste exported for recovery during the previous year by randomly
checking several of them:

   - the EPA ID number, name, mailing and site address of the notifier filing the
     report
   - calendar year covered by the report
   - the name and address of each final recovery facility
   - for each final recovery facility and each waste exported: a description of the
     waste, the EPA hazardous waste number, the OECD  waste type and code,
     the  DOT hazard class, the EPA ID number for each transporter used, the
     total amount of waste shipped, and the number of shipments
   -under certain circumstances,  the efforts  used  to reduce the  volume and
     toxicity of the waste and the change achieved  during the previous year in
     comparison to earlier years
   - certification signed by the primary exporter that states the following:
        - "I certify under penalty of law that I  have personally examined and am
         familiar  with the information submitted in this  and  all attached
         documents, and  that based on  my  inquiry  of  those  individuals
         immediately responsible for obtaining the  information, I believe that
         the submitted information is true, accurate, and complete.  I am aware
         that there  are  significant  penalties  for submitting false information
         including the possibility of fine and imprisonment."
     HW.400.6.      A  primary
     exporter   must    file   an
     exception  report  with U.S.
     EPA     under      certain
     circumstances    (40    CFR
     262.87(b)).
Verify that an exception report is filed with U.S.  EPA each time any of the
following occurs:

   - the notifier does not receive a copy of the tracking document signed by the
     transporter stating  point of  departure  from the U.S. within 45  days  of
     acceptance by the initial transporter
   -within  90 days  from the date the waste  was  accepted  by the initial
     transporter, the notifier  does not  receive written confirmation from the
     recovery facility that the waste was received or	
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       104

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA


COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE

HW.400.7. A primary
exporter must maintain
records that relate to export
activities (40 CFR 262.87(c)).
REVIEWER CHECKS
-the waste is returned to the U.S.
Verify that the following records are kept for the appropriate period of time:
- each notification of intent to export and all written consents obtained (at
least three years from the date the hazardous waste was accepted by the
initial transporter)
- each annual report (at least three years from the due date of the report)
- any exception reports and each confirmation of delivery received from the
recovery facility (at least three years from the date the initial waste was
received from the recovery facility).

This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
105

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       195
requirements are in any way altered by any statement(s) contained herein.

HW.420

Exports of Hazardous
Waste (Except to the OECD
Member Countries) for
Recovery
HW.420.1. A primary
exporter of hazardous waste
must comply with notification
requirements (40 CFR
262.53(a) and 262.53(b)).
Determine if the facility imports/exports hazardous waste.

Verify that 60 days prior to the initial shipment of hazardous waste to each
country in each calendar year, the facility has notified the U.S. EPA (in writing) of
the following:

- name, mailing address, telephone number, and EPA identification number of
the primary exporter
-by consignee, for each hazardous waste type:
- identification of the hazardous waste shipped by EPA identification
number
- DOT shipping name, hazard class, and importer for the waste
- estimated frequency/rate at which such wastes(s) is to be exported
- estimated total quantity (in units)
- all points of entry to and departure from each foreign country the waste
will pass through
- a description of the approximate length of time the waste will remain in
each country, and how it will be handled there
- the mode of transportation used to transport the waste and type(s) of
containers used
- description of the treatment, storage, or disposal method to be used in
the receiving country
- name and address of the foreign consignee.
HW.420.2. The primary
exporter must attach a copy of
an U.S. EPA
Acknowledgment of Consent
(that confirms the consent of
the foreign country to receive
the waste) to the shipment of
hazardous waste to a foreign
country (40 CFR 262.52(c),
262.53(f) and 262.54(h)).
Verify that a copy of the U.S. EPA Acknowledgment of Consent is on file by
checking the records.

Verify that a copy of this document was attached to the shipment.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
107

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW.420.3. Primary exporters
of hazardous waste must
require confirmation of the
delivery of the hazardous
waste and a description of any
significant discrepancies
between the manifest and the
shipment (40 CFR 262.54(f)).
Verify that the facility has been receiving confirmation of delivery.

Determine if there are any notations of discrepancies.
HW.420.4. Primary exporters
of hazardous waste are
required to comply with
general manifest requirements
with certain modifications (40
CFR 262.54(a) through
262.54(e) and 262.54(1)).
Verify that the manifest copies comply with the general manifest requirements of
40 CFR 262.20 through 262.23.

Determine if the following modifications are made by reviewing the manifest
copies:

- the name and address of the foreign consignee (and any alternate consignee)
is put in the place of the designated facility's name, address, and EPA
number.
-the point of departure from the United States is indicated in the Special
Instructions and Additional Information sections.
-this statement, "and conform to the terms of the attached U.S. EPA
Acknowledgment of Consent," is added to the end of the first sentence of the
certification in Item 16.

Verify that a copy of the manifest is provided for delivery to the U.S. Customs
official at the U.S. point of departure.
HW.420.5. Primary exporters
of hazardous waste are
required to follow specific
procedures when a shipment
cannot be delivered to the
designated or alternate
consignee (40 CFR
262.54(g)).
Verify that when a shipment cannot be delivered, the primary exporter does one of
the following:

-notifies the U.S. EPA of a change in the conditions of the original
notification to allow shipment to a new consignee and obtains an U.S. EPA
Acknowledgment of Consent prior to delivery, or
- instructs the transporter to return the waste to the primary exporter in the
United States or designates another facility within the United States.

Verify that the facility instructs the transporter to revise the manifest to reflect
changes made.
HW.420.6. Primary exporters
of hazardous waste are
required to file an exception
report under certain
conditions (40 CFR 262.55).
Verify that an exception report was filed if:

- a signed copy of the manifest from the transporter containing the following
information was not received within 45 days from the day it was accepted by
the initial transporter:
- date of departure of the waste from the United States
-place of departure of the waste from the United States
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
108

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                         COMPLIANCE CATEGORY:
                                    HAZARDOUS WASTE MANAGEMENT
          REGULATORY
        REQUIREMENT OR
          MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
                                     -within  90 days  from the date the waste  was  accepted  by the initial
                                       transporter,  the facility has not received a written confirmation from the
                                       foreign consignee stating that the hazardous waste was received
                                     - the waste is returned to the United States.
     HW.420.7.    The   primary
     exporter must file an Annual
     Report with  the  regulatory
     agency by March 1 of each
     year   regarding   hazardous
     waste  exported  during  the
     previous   year   (40   CFR
     262.56).
Verify that an Annual Report has been submitted by March 1 of every calendar
year.

Verify that the Annual Reports contain the following information for all hazardous
waste exported during the previous calendar year:

   -type, EPA hazardous waste number,  DOT hazard class and name for each
     hazardous waste(s) exported
   - EPA identification number for each transporter (where applicable)
   - quantity of hazardous waste(s) exported
   - frequency (dates) of hazardous waste(s) exported
   - ultimate destination for all hazardous waste(s) exported
   - efforts used to reduce the volume and toxicity of the waste (and the changes
     achieved during the year in comparison to previous years)
   - a certification signed by the primary exporter that states:
        - "I certify under penalty of law that I have personally examined and am
          familiar  with the information submitted in  this and  all attached
          documents, and  that  based on my inquiry  of  those  individuals
          immediately responsible for obtaining the information, I believe that
          the submitted information is true, accurate, and complete.  I am aware
          that there  are  significant  penalties for submitting false information
          including the possibility of fine and imprisonment."
     HW.420.8. Primary exporters
     of hazardous  wastes  must
     maintain  additional  records
     that  relate  to  their  export
     activities (40 CFR 262.57).
Verify that the following are kept for at least three years:

   - a copy of each notification of intent to export
   - a copy of each U.S. EPA Acknowledgment of Consent
   - a copy of each confirmation of delivery (signed manifests) of the waste
   - annual reports.

(NOTE: Periods of retention are automatically extended during the course of any
unresolved enforcement action.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                       109

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       119
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                   HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                         REVIEWER CHECKS
    EXPORT/IMPORT OF
    HAZARDOUS WASTE

    HW.440

    Imports of Hazardous
    Waste for Recovery Within
    the OECD Member
    Countries
    HW.440.1.  A U.S. importer
    of  amber  list  or red  list
    hazardous waste  (see 40 CFR
    262.89  and 262.82) destined
    for recovery operations (see
    40  CFR 262.81(k)) from an
    OECD  member  country  (40
    CFR 262.58(a)) must execute
    a  valid  written contract or
    chain of contracts with the
    recovery facility that specifies
    the responsibilities of  each
    (40 CFR 262.85).
Determine whether the exporting country is an OECD member country [Australia,
Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland,
Italy, Japan, Luxembourg, Netherlands, New Zealand, Norway, Portugal,  Spain,
Sweden, Switzerland, Turkey, United Kingdom, and United States].

(NOTE: The following countries  have become OECD member countries since
U.S. EPA promulgated its regulations in 1996:  South Korea,  Czech Republic,
Poland, and Hungary. U.S. EPA plans to amend its regulations to reflect these
new OECD countries. In the interim, U.S. EPA strongly recommends that exports
to these new OECD countries  comply with applicable OECD regulations, since
these countries would expect compliance with OECD requirements for shipments
they receive from the U.S.)

Determine  whether the waste  is for recovery  operations, including resource
recovery, recycling, reclamation, direct re-use or alternative uses.

Verify that contracts specify the name and EPA ID number, where available, of:

   - the generator of each type of waste
   - each person who will have physical custody of the waste
   - each person who will have legal control of the waste
   - the recovery facility.

Verify that contracts specify:

   -which party  will assume  responsibility for alternate management  of  the
     wastes if it cannot be carried out as described in the notification of intent to
     export
   - that the person with actual possession or physical control over the waste will
     immediately notify the notifier and the competent authorities of the exporting
     and importing countries and transit country if wastes are located in a country
     of transit
   - that the person specified  in the  contract will  assume responsibility for  the
     adequate management of the wastes including, if necessary, arranging their
     return to the original country of export	
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                      Ill

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
- notification prior to re-export to a third country
- provisions for financial guarantees.
HW.440.2. A U.S. importer
must ensure that a tracking
document accompanies each
shipment of amber or red list
wastes until it reaches the
final recovery facility (40
CFR 262.84).
Verify that a copy of the tracking document was attached to the shipment.

Verify that the tracking document included all information contained in the
notification and the following:

- the date shipment commenced
-name, address, telephone and telefax numbers of primary exporter, if
different than the notifier
- name and EPA ID number of all transporters
- identification of means of transport, including types of packaging
- any special precautions to be taken by transporters
- signed certification required by 40 CFR 262.84(b)(6)
- appropriate signatures for each custody transfer.
HW.440.3. A consignee
must comply with general
manifest requirements with
certain modifications (40
CFR 262.84(c) and 262.60).
Verify that the manifest copies comply with the general manifest requirements of
40 CFR 262.20.

Determine if the following modifications are made by reviewing the manifest
copies:

-the name and address of the foreign generator and the importer's name,
address and EPA identification number are put in place of the generator's
name, address and EPA identification number
-the U.S. importer (or his agent) must sign and date the certification statement
in place of the generator's signature and obtain the signature of the initial
transporter.
HW.440.4. Each person in
the U.S. that has physical
custody of the waste until it
arrives at the recovery facility
must sign the tracking
document (40 CFR
262.84(d)).
Verify that the U.S. transporter, consignee, and owner or operator of the recovery
facility have signed the manifest.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
112

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
COMPLIANCE CATEGORY:
HAZARDOUS WASTE MANAGEMENT
REGULATORY
REQUIREMENT OR
MANAGEMENT
PRACTICE
REVIEWER CHECKS
HW.440.5. An
owner/operator of a U.S.
recovery facility must send
signed copies of the tracking
document to the notifier, to
U.S. EPA, and to the
competent authorities of the
exporting and transit
countries within three days of
receipt of imports (40 CFR
262.84(e)).
Verify that the facility sends signed copies of the tracking document to the
notifier, to U.S. EPA, and to the competent authorities of the exporting and transit
countries within the three days.
HW.440.6. A facility that
has arranged to receive
hazardous waste from a
foreign source must notify
U.S. EPA (40 CFR
264.12(a)(l) and
265.12(a)(l)).
Verify that the facility notifies the appropriate U.S. EPA Regional Administrator
in writing at least four weeks prior to the date the waste is expected to arrive at the
facility.

(NOTE: Notice of subsequent shipments of the same waste from the same foreign
source is not required.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
113

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       114
requirements are in any way altered by any statement(s) contained herein.

HW.460

Imports of Hazardous
Waste (Except from the
OECD Member Countries)
for Recovery
HW.460.1. Any person who
imports hazardous waste must
comply with general manifest
requirements with certain
modifications (40 CFR
262.60).
Verify that the manifest copies comply with the general manifest requirements of
40 CFR 262.20.

Determine if the following modifications are made by reviewing the manifest
copies:

-the name and address of the foreign generator and the importer's name,
address and EPA identification number are put in place of the generator's
name, address and EPA identification number
-the U.S. importer (or his agent) must sign and date the certification statement
in place of the generator's signature and obtain the signature of the initial
transporter.
HW.460.2. A facility that
has arranged to receive
hazardous waste from a
foreign source must notify
U.S. EPA (40 CFR
264.12(a)(l) and
265.12(a)(l)).
Verify that the facility notifies the appropriate U.S. EPA Regional Administrator
in writing at least four weeks prior to the date the waste is expected to arrive at the
facility.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       115
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                        COMPLIANCE CATEGORY:
                                  HAZARDOUS WASTE MANAGEMENT
          REGULATORY
       REQUIREMENT OR
         MANAGEMENT
            PRACTICE
                        REVIEWER CHECKS
     WASTE MINIMIZATION/
     POLLUTION
     PREVENTION

     HW.500
     HW.500.1.  The  generator
     should have in place a waste
     minimization  program  to
     reduce   the  volume   and
     toxicity of hazardous wastes
     generated.   The generator is
     required    to   sign   the
     Generator's    Certification
     statement on each manifest,
     attesting   to    its   waste
     minimization program (MP).
Determine if the generator's waste minimization program includes practical
methods for  reducing the volume of hazardous wastes generated.  Determine
whether any or  all of the following methods  suggested  by  U.S.  EPA  are
incorporated into the program:

   — the generator retains  information  that documents waste  minimization
     activities.
   - the program includes:
        —provisions for top management assurance that waste minimization is a
         company-wide effort
        - characterization of waste generation and waste management costs
        —periodic waste minimization assessments
        — a cost allocation system
        - encourages technology transfer
        -program implementation and evaluation
        — waste minimization employee awareness plans
        — adequate funding
        -clearly delineated roles both within the company and among each
         facility generating waste.
   — conclude if facility  actions are resulting in the reduction of hazardous
     wastes.

(NOTE: Refer to Interim Final Guidance to Hazardous Waste Generators on the
Elements of a Waste Minimization Program, 58 FR 31114, May 28,  1993.)
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                                    117

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       118
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous
                  Waste Generators under RCRA

                          Appendix A:
  Hazardous Waste from Nonspecific Sources and from Specific Sources
                    (40 CFR 261.31 and 261.32)

-------
This Page Intentionally Left Blank

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                       Hazardous Waste from Nonspecific Sources and from Specific Sources
        Industry and
            EPA
         hazardous
         waste No.
                                 Table 1
               Hazardous Waste From Nonspecific Sources
                             (40 CFR 261.31)
Hazard
Code
                                                         Generic
       F001
The following spent halogenated solvents used in degreasing:
Tetrachloroethylene, trichloroethylene, methylene chloride, 1,1,1 -
trichloroethane, carbon tetrachloride, and chlorinated fluorocarbons; all spent
solvent mixtures/blends used in degreasing containing, before use, a total often
percent or more (by volume) of one or more of the above halogenated solvents
or those solvents listed in F002, F004, and F005; and still bottoms from the
recovery of these spent solvents and spent solvent mixtures.
  (T)
       F002
The following spent halogenated solvents: Tetrachloroethylene, methylene
chloride, trichloroethylene, 1,1,1-trichloroethane, chlorobenzene, 1,1,2-
trichloro-1,2,2-trifluoroethane, ortho-dichlorobenzene, trichlorofluoromethane,
and 1,1,2-trichloroethane; all spent solvent mixtures/blends containing, before
use, a total of ten percent or more (by volume) of one or more of the above
halogenated solvents or those listed in F001, F004, or F005; and still bottoms
from the recovery of these spent solvents and spent solvent mixtures.
  (T)
       F003
The following spent non- halogenated solvents: Xylene, acetone, ethyl acetate,
ethyl benzene, ethyl ether, methyl isobutyl ketone, n-butyl alcohol,
cyclohexanone, and methanol; all spent solvent mixtures/blends containing,
before use, only the above spent non- halogenated solvents; and all spent solvent
mixtures/blends containing, before use, one or more of the above non-
halogenated solvents, and, a total of ten percent or more (by volume) of one or
more of those solvents listed in F001, F002, F004, and F005; and still bottoms
from the recovery of these spent solvents and spent solvent mixtures.
  (I)*
       F004
The following spent non-halogenated solvents: Cresols and cresylic acid, and
nitrobenzene; all spent solvent mixtures/blends containing, before use, a total of
ten percent or more (by volume) of one or more of the above non-halogenated
solvents or those solvents listed in F001, F002, and F005; and still bottoms from
the recovery of these spent solvents and spent solvent mixtures.
  (T)
       F005
The following spent non-halogenated solvents: Toluene, methyl ethyl ketone,
carbon disulfide, isobutanol, pyridine, benzene, 2-ethoxyethanol, and 2-
nitropropane; all spent solvent mixtures^lends containing, before use, a total of
ten percent or more (by volume) of one or more of the above non-halogenated
solvents or those solvents listed in F001, F002, or F004; and still bottoms from
the recovery of these spent solvents and spent solvent mixtures.
       F006
Wastewater treatment sludges from electroplating operations except from the
following processes: (1) Sulfuric acid anodizing of aluminum; (2) tin plating on
carbon steel; (3) zinc plating (segregated basis) on carbon steel; (4) aluminum or
zinc-aluminum plating on carbon steel; (5) cleaning/stripping associated with
tin, zinc and aluminum plating on carbon steel; and (6) chemical etching and
milling of aluminum.
  (T)
       F007
Spent cyanide plating bath solutions from electroplating operations.
 (R,T)
                                                                                                               Al

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.
F008
F009
F010
F011
F012
F019
F020
F021
F022
F023
F024
Table 1
Hazardous Waste From Nonspecific Sources
(40 CFR 261.31)
Plating bath residues from the bottom of plating baths from electroplating
operations where cyanides are used in the process.
Spent stripping and cleaning bath solutions from electroplating operations where
cyanides are used in the process.
Quenching bath residues from oil baths from metal heat treating operations
where cyanides are used in the process.
Spent cyanide solutions from salt bath pot cleaning from metal heat treating
operations.
Quenching wastewater treatment sludges from metal heat treating operations
where cyanides are used in the process.
Wastewater treatment sludges from the chemical conversion coating of
aluminum except from zirconium phosphating in aluminum can washing when
such phosphating is an exclusive conversion coating process.
Wastes (except wastewater and spent carbon from hydrogen chloride
purification) from the production or manufacturing use (as a reactant, chemical
intermediate, or component in a formulating process) of tri- or
tetrachlorophenol, or of intermediates used to produce their pesticide
derivatives. (This listing does not include wastes from the production of
Hexachlorophene from highly purified 2,4,5-trichlorophenol.).
Wastes (except wastewater and spent carbon from hydrogen chloride
purification) from the production or manufacturing use (as a reactant, chemical
intermediate, or component in a formulating process) of pentachlorophenol, or
of intermediates used to produce its derivatives.
Wastes (except wastewater and spent carbon from hydrogen chloride
purification) from the manufacturing use (as a reactant, chemical intermediate,
or component in a formulating process) of terra-, penta-, or hexachlorobenzenes
under alkaline conditions.
Wastes (except wastewater and spent carbon from hydrogen chloride
purification) from the production of materials on equipment previously used for
the production or manufacturing use (as a reactant, chemical intermediate, or
component in a formulating process) of tri- and tetrachlorophenols. (This listing
does not include wastes from equipment used only for the production or use of
Hexachlorophene from highly purified 2,4,5- trichlorophenol.).
Process wastes, including but not limited to, distillation residues, heavy ends,
tars, and reactor clean-out wastes, from the production of certain chlorinated
aliphatic hydrocarbons by free radical catalyzed processes. These chlorinated
aliphatic hydrocarbons are those having carbon chain lengths ranging from one
to and including five, with varying amounts and positions of chlorine
substitution. (This listing does not include wastewaters, wastewater treatment
sludges, spent catalysts, and wastes listed in Sec. 261.31 or Sec. 261.32.).
Hazard
Code
(R,T)
(R,T)
(R,T)
(R,T)
(T)
(T)
(H)
(H)
(H)
(H)
(T)
A2

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
        Industry and
            EPA
         hazardous
         waste No.
       F025
       F026
       F027
       F028
       F032
       F034
       F035
                                 Table 1
               Hazardous Waste From Nonspecific Sources
                            (40 CFR 261.31)
Condensed light ends, spent filters and filter aids, and spent desiccant wastes
from the production of certain chlorinated aliphatic hydrocarbons, by free
radical catalyzed processes. These chlorinated aliphatic hydrocarbons are those
having carbon chain lengths ranging from one to and including five, with
varying amounts and positions of chlorine substitution.
Wastes (except wastewater and spent carbon from hydrogen chloride
purification) from the production of materials on equipment previously used for
the manufacturing use (as a reactant, chemical intermediate, or component in a
formulating process) of tetra-, penta-, or hexachlorobenzene under alkaline
conditions.
Discarded unused formulations containing tri-, tetra-, or pentachlorophenol or
discarded unused formulations containing compounds derived from these
chlorophenols. (This listing does not include formulations containing
Hexachlorophene sythesized from prepurified 2,4,5- trichlorophenol as the sole
component.).
Residues resulting from the incineration or thermal treatment of soil
contaminated with EPA Hazardous Waste Nos. F020, F021, F022, F023, F026,
andF027.
Wastewaters (except those that have not come into contact with process
contaminants), process residuals, preservative drippage, and spent formulations
from wood preserving processes generated at plants that currently use or have
previously used chlorophenolic formulations (except potentially cross-
contaminated wastes that have had the F032 waste code deleted in accordance
with 40 CFR 261.35 or potentially cross-contaminated wastes that are otherwise
currently regulated as hazardous wastes (i.e., F034 or F035), and where the
generator does not resume or initiate use of chlorophenolic formulations). This
listing does not include K001 bottom sediment sludge from the treatment of
wastewater from wood preserving processes that use creosote and/or
pentachlorophenol.
Wastewaters (except those that have not come into contact with process
contaminants), process residuals, preservative drippage, and spent formulations
from wood preserving processes generated at plants that use creosote
formulations. This listing does not include K001 bottom sediment sludge from
the treatment of wastewater from wood preserving processes that use creosote
and/or pentachlorophenol.
Wastewaters (except those that have not come into contact with process
contaminants), process residuals, preservative drippage, and spent formulations
from wood preserving processes generated at plants that use inorganic
preservatives containing arsenic or chromium. This listing does not include
K001 bottom sediment sludge from the treatment of wastewater from wood
preserving processes that use creosote and/or pentachlorophenol.
Hazard
Code
  (T)
  (H)
  (H)
  (T)
  (T)
  (T)
  (T)
                                                                                                              A3

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
        Industry and
            EPA
         hazardous
         waste No.
       F037
       F038
       F039
                                 Table 1
               Hazardous Waste From Nonspecific Sources
                            (40 CFR 261.31)
Petroleum refinery primary oil/water/solids separation sludge-Any sludge
generated from the gravitational separation of oil/water/ solids during the
storage or treatment of process wastewaters and oil cooling wastewaters from
petroleum refineries. Such sludges include, but are not limited to, those
generated in oil/water/ solids separators; tanks and impoundments; ditches and
other conveyances; sumps; and stormwater units receiving dry weather flow.
Sludge generated in stormwater units that do not receive dry weather flow,
sludges generated from non-contact once-through cooling waters segregated for
treatment from other process or oily cooling waters, sludges generated in
aggressive biological treatment units as defined in Sec. 261.3 l(b)(2) (including
sludges generated in one or more additional units after wastewaters have been
treated in aggressive biological treatment units) and K051 wastes are not
included in this listing. This listing does include residuals generated from
processing or recycling oil-bearing hazardous secondary materials excluded
under Sec. 261.4(a)(12)(i), if those residuals  are to be disposed of.
Petroleum refinery secondary (emulsified) oil/water/solids separation sludge--
Any sludge and/or float generated from the physical and/or chemical separation
of oil/water/ solids in process wastewaters and oily cooling wastewaters from
petroleum refineries. Such wastes include, but are not limited to, all sludges and
floats generated in: induced air flotation (IAF) units, tanks and impoundments,
and all sludges generated in DAF units. Sludges generated in stormwater units
that do not receive dry weather flow, sludges generated from non-contact once-
through cooling waters segregated for treatment from other process or oily
cooling waters, sludges and floats generated in aggressive biological treatment
units as defined in Sec. 261.3 l(b)(2) (including sludges and floats generated in
one or more additional units after wastewaters have been treated in aggressive
biological treatment units) and F037, K048, and K051 wastes are not included
in this listing.	
Leachate (liquids that have percolated through land disposed wastes) resulting
from the disposal of more than one restricted waste classified as hazardous
under subpart D of this part. (Leachate resulting from the disposal of one or
more of the following EPA Hazardous Wastes and no other Hazardous Wastes
retains its EPA Hazardous Waste Number(s):  F020, F021, F022, F026, F027,
and/or F028.).
Hazard
Code
  (T)
  (T)
  (T)
                                                                                                               A4

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.

K001

K002
K003
K004
K005
K006
K007
K008

K009
K010
K011
K013
K014
K015
K016
K017
K018
K019
K020
K021
Table 2
Hazardous Waste From Specific Sources
(40 CFR 261.32, Revised January 2001)
Wood Preservation
Bottom sediment sludge from the treatment of wastewaters from wood
preserving processes that use creosote and/or pentachlorophenol.
Inorganic Pigments
Wastewater treatment sludge from the production of chrome yellow and orange
pigments.
Wastewater treatment sludge from the production of molybdate orange
pigments.
Wastewater treatment sludge from the production of zinc yellow pigments.
Wastewater treatment sludge from the production of chrome green pigments.
Wastewater treatment sludge from the production of chrome oxide green
pigments(anhydrous and hydrated).
Wastewater treatment sludge from the production of iron blue pigments.
Oven residue from the production of chrome oxide green pigments.
Organic Chemicals
Distillation bottoms from the production of acetaldehyde from ethylene.
Distillation side cuts from the production of acetaldehyde from ethylene.
Bottom stream from the wastewater stripper in the production of acrylonitrile.
Bottom stream from the acetonitrile column in the production of acrylonitrile.
Bottoms from the acetonitrile purification column in the production of
acrylonitrile.
Still bottoms from the distillation of benzyl chloride.
Heavy ends or distillation residues from the production of carbon tetrachloride.
Heavy ends (still bottoms) from the purification column in the production of
epichlorohydrin.
Heavy ends from the fractionation column in ethyl chloride production.
Heavy ends from the distillation of ethylene dichloride in ethylene dichloride
production.
Heavy ends from the distillation of vinyl chloride in vinyl chloride monomer
production.
Aqueous spent antimony catalyst waste from fluoromethanes production.
Hazard
Code

(T)

(T)
(T)
(T)
(T)
(T)
(T)
(T)

(T)
(T)
(R,T)
(R,T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
                                                                                                 A5

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.
K022
K023
K024
K025
K026
K027
K028
K029
K030
K083
K085
K093
K094
K095
K096
K103
K104
K105
K107
Table 2
Hazardous Waste From Specific Sources
(40 CFR 261.32, Revised January 2001)
Distillation bottom tars from the production of phenol/acetone from cumene.
Distillation light ends from the production of phthalic anhydride from
naphthalene.
Distillation bottoms from the production of phthalic anhydride from
naphthalene.
Distillation bottoms from the production of nitrobenzene by the nitration of
benzene.
Stripping still tails from the production of methy ethyl pyridines.
Centrifuge and distillation residues from toluene diisocyanate production.
Spent catalyst from the hydrochlorinator reactor in the production of 1 , 1 , 1 -
trichloroethane.
Waste from the product steam stripper in the production of 1 , 1 , 1 -
trichloroethane.
Column bottoms or heavy ends from the combined production of
trichloroethylene and perchloroethylene.
Distillation bottoms from aniline production.
Distillation or fractionation column bottoms from the production of
chlorobenzenes.
Distillation light ends from the production of phthalic anhydride from ortho-
xylene.
Distillation bottoms from the production of phthalic anhydride from ortho-
xylene.
Distillation bottoms from the production of 1 , 1 , 1 -trichloroethane .
Heavy ends from the heavy ends column from the production of 1 , 1 , 1 -
trichloroethane.
Process residues from aniline extraction from the production of aniline.
Combined wastewater streams generated from nitrobenzene/aniline production.
Separated aqueous stream from the reactor product washing step in the
production of chlorobenzenes.
Column bottoms from product separation from the production of 1, 1- dimethyl-
hydrazine (UDMH) from carboxylic acid hydrazines.
Hazard
Code
(T)
(T)
(T)
(T)
(T)
(R,T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(C,T)
                                                                                                 A6

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.
K108
K109
K110
Kill
K112
K113
K114
K115
K116
K117
K118
K136
K149
K150
Table 2
Hazardous Waste From Specific Sources
(40 CFR 261.32, Revised January 2001)
Condensed column overheads from product separation and condensed reactor
vent gases from the production of 1,1-dimethylhydrazine (UDMH) from
carboxylic acid hydrazides.
Spent filter cartridges from product purification from the production of 1,1-
dimethylhydrazine (UDMH) from carboxylic acid hydrazides.
Condensed column overheads from intermediate separation from the production
of 1,1-dimethylhydrazine (UDMH) from carboxylic acid hydrazides.
Product washwaters from the production of dinitrotoluene via nitration of
toluene.
Reaction by-product water from the drying column in the production of
toluenediamine via hydrogenation of dinitrotoluene.
Condensed liquid light ends from the purification of toluenediamine in the
production of toluenediamine via hydrogenation of dinitrotoluene.
Vicinals from the purification of toluenediamine in the production of
toluenediamine via hydrogenation of dinitrotoluene.
Heavy ends from the purification of toluenediamine in the production of
toluenediamine via hydrogenation of dinitrotoluene.
Organic condensate from the solvent recovery column in the production of
toluene diisocyanate via phosgenation of toluenediamine.
Wastewater from the reactor vent gas scrubber in the production of ethylene
dibromide via bromination of ethene.
Spent adsorbent solids from purification of ethylene dibromide in the production
of ethylene dibromide via bromination of ethene.
Still bottoms from the purification of ethylene dibromide in the production of
ethylene dibromide via bromination of ethene.
Distillation bottoms from the production of alpha-(or methyl-) chlorinated
toluenes, ring-chlorinated toluenes, benzoyl chlorides, and compounds with
mixtures of these functional groups, (This waste does not include still bottoms
from the distillation of benzyl chloride.).
Organic residuals, excluding spent carbon adsorbent, from the spent chlorine gas
and hydrochloric acid recovery processes associated with the production of
alpha-(or methyl-) chlorinated toluenes, ring- chlorinated toluenes, benzoyl
chlorides, and compounds with mixtures of these functional groups.
Hazard
Code
(I,T)
(T)
(T)
(C,T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
                                                                                                 A7

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
        Industry and
            EPA
         hazardous
         waste No.
       K151
       K156
       K157
       K158
       K159
       K161
       K174
       K175
                                 Table 2
                 Hazardous Waste From Specific Sources
                 (40 CFR 261.32, Revised January 2001)
Wastewater treatment sludges, excluding neutralization and biological sludges,
generated during the treatment of wastewaters from the production of alpha- (or
methyl-) chlorinated toluenes, ring-chlorinated toluenes, benzoyl chlorides, and
compounds with mixtures of these functional groups.
Organic waste (including heavy ends, still bottoms, light ends, spent solvents,
filtrates, and decantates) from the production of carbamates and carbamoyl
oximes (This listing does not apply to wastes generated from the manufacture of
3-iodo-2-propynyln-butylcarbamate.).
Wastewaters (including scrubber waters, condenser waters, washwaters, and
separation waters) from the production of carbamates and carbamoyl oximes.
(This listing does not apply to wastes generated from the manufacture of 3-iodo-
2-propynyl n-butylcarbamate.).
Bag house dusts and filter/separation solids from the production of carbamates
and carbamoyl oximes. (This listing does not apply to wastes generated from the
manufacture of 3-iodo-2-propynyl n-butylcarbamate.).
Organics from the treatment of thiocarbamate wastes.
Purification solids (including filtration, evaporation, and centrifugation solids),
bag house dust and floor sweepings from the production of dithiocarbamate
acids and their salts. (This listing does not include K125 or K126.).
Wastewater treatment sludges from the production of ethylene dichloride or
vinyl chloride monomer (including sludges that result from commingled
ethylene dichloride or vinyl chloride monomer wastewater and other
wastewater), unless the  sludges meet the following conditions: (i) they are
disposed of in a subtitle C or non- hazardous landfill licensed or permitted by
the state or federal government; (ii) they are not otherwise placed on the land
prior to final disposal; and  (iii) the generator maintains documentation
demonstrating that the waste was either disposed of in an on-site landfill or
consigned to a transporter or disposal facility that provided a written
commitment to dispose  of the waste in an off-site landfill. Respondents in any
action brought to enforce the requirements of subtitle C must, upon a showing
by the government that the  respondent managed wastewater treatment sludges
from the production of vinyl chloride monomer or ethylene dichloride,
demonstrate that they meet the terms of the exclusion set forth above. In doing
so, they must provide appropriate documentation (e.g., contracts between the
generator and the landfill owner/operator, invoices documenting delivery of
waste to landfill, etc.) that the terms of the exclusion were met.
Wastewater treatment sludges from the production of vinyl chloride monomer
using mercuric chloride catalyst in an acetylene-based process.
Hazard
 Code
  (T)
  (T)
  (T)
  (T)
  (T)
 (R,T)
  (T)
  (T)
                                                                                                              A8

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.

K071
K073
K106

K031
K032
K033
K034
K035
K036
K037
K038
K039
K040
K041
K042
K043
K097
K098
K099
Table 2
Hazardous Waste From Specific Sources
(40 CFR 261.32, Revised January 2001)
Inorganic Chemicals
Brine purification muds from the mercury cell process in chlorine production,
where separately prepurified brine is not used.
Chlorinated hydrocarbon waste from the purification step of the diaphragm cell
process using graphite anodes in chlorine production.
Wastewater treatment sludge from the mercury cell process in chlorine
production.
Pesticides
By-product salts generated in the production of MSMA and cacodylic acid.
Wastewater treatment sludge from the production of chlordane.
Wastewater and scrub water from the chlorination of cyclopentadiene in the
production of chlordane.
Filter solids from the filtration of hexachlorocyclopentadiene in the production
of chlordane.
Wastewater treatment sludges generated in the production of creosote.
Still bottoms from toluene reclamation distillation in the production of
disulfoton.
Wastewater treatment sludges from the production of disulfoton.
Wastewater from the washing and stripping of phorate production.
Filter cake from the filtration of diethylphosphorodithioic acid in the production
of phorate.
Wastewater treatment sludge from the production of phorate.
Wastewater treatment sludge from the production of toxaphene.
Heavy ends or distillation residues from the distillation of tetrachlorobenzene in
the production of 2,4,5- T.
2,6-Dichlorophenol waste from the production of 2,4-D.
Vacuum stripper discharge from the chlordane chlorinator in the production of
chlordane.
Untreated process wastewater from the production of toxaphene.
Untreated wastewater from the production of 2,4-D.
Hazard
Code

(T)
(T)
(T)

(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
                                                                                                 A9

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.
K123
K124
K125
K126
K131
K132

K044
K045
K046
K047

K048
K049
K050
K051
K052
K169
K170
K171
Table 2
Hazardous Waste From Specific Sources
(40 CFR 261.32, Revised January 2001)
Process wastewater (including supernates, filtrates, and washwaters) from the
production of ethylenebisdithiocarbarnic acid and its salt.
Reactor vent scrubber water from the production of ethylenebisdithiocarbarnic
acid and its salts.
Filtration, evaporation, and centrifugation solids from the production of
ethylenebisdithiocarbarnic acid and its salts.
Baghouse dust and floor sweepings in milling and packaging operations from
the production or formulation of ethylenebisdithiocarbarnic acid and its salts.
Wastewater from the reactor and spent sulfuric acid from the acid dryer from the
production of methyl bromide.
Spent absorbent and wastewater separator solids from the production of methyl
bromide.
Explosives
Wastewater treatment sludges from the manufacturing and processing of
explosives.
Spent carbon from the treatment of wastewater containing explosives.
Wastewater treatment sludges from the manufacturing, formulation and loading
of lead-based initiating compounds.
Pink/red water from TNT operations.
Petroleum Refining
Dissolved air flotation (DAF) float from the petroleum refining industry.
Slop oil emulsion solids from the petroleum refining industry.
Heat exchanger bundle cleaning sludge from the petroleum refining industry.
API separator sludge from the petroleum refining industry.
Tank bottoms (leaded) from the petroleum refining industry.
Crude oil storage tank sediment from petroleum refining operations.
Clarified slurry oil tank sediment and/or in-line filter/separation solids from
petroleum refining operations.
Spent Hydrotreating catalyst from petroleum refining operations, including
guard beds used to desulfurize feeds to other catalytic reactors (this listing does
not include inert support media).
Hazard
Code
(T)
(C,T)
(T)
(T)
(C,T)
(T)

(R)
(R)
(T)
(R)

(T)
(T)
(T)
(T)
(T)
(T)
(T)
(I,T)
                                                                                                A10

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.
K172

K061
K062




K088


K069
K100

K084
K101
K102
Table 2
Hazardous Waste From Specific Sources
(40 CFR 261.32, Revised January 2001)
Spent Hydrorefining catalyst from petroleum refining operations, including
guard beds used to desulfurize feeds to other catalytic reactors (this listing does
not include inert support media).
Iron and Steel
Emission control dust/ sludge from the primary production of steel in electric
furnaces.
Spent pickle liquor generated by steel finishing operations of facilities within the
iron and steel industry (SIC Codes 331 and 332).
Primary Copper
(No Entries)
Primary Lead
(No Entries)
Primary Zinc
(No Entries)
Primary Aluminum
(No Entries)
Spent pot liners from primary aluminum reduction.
Ferroalloys
(No Entries)
Secondary lead
Emission control dust/ sludge from secondary lead smelting. (Note: This listing
is stayed administratively for sludge generated from secondary acid scrubber
systems. The stay will remain in effect until further administrative action is
taken. If EPA takes further action effecting this stay, EPA will publish a notice
of the action in the Federal Register.
Waste leaching solution from acid leaching of emission control dust/ sludge
from secondary lead smelting.
Veterinary _Pharmaceuticals
Wastewater treatment sludges generated during the production of veterinary
Pharmaceuticals from arsenic or organo -arsenic compounds.
Distillation tar residues from the distillation of aniline-based compounds in the
production of veterinary Pharmaceuticals from arsenic or organo -arsenic
compounds.
Residue from the use of activated carbon for decolorization in the production of
veterinary Pharmaceuticals from arsenic or organo-arsenic compounds.
Hazard
Code
(I,T)

(T)
(C,T)




(T)


(T)
(T)

(T)
(T)
(T)
                                                                                                All

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Industry and
EPA
hazardous
waste No.

K086

K060
K087
K141
K142
K143
K144
K145
K147
K148
Table 2
Hazardous Waste From Specific Sources
(40 CFR 261.32, Revised January 2001)
Ink Formulation
Solvent washes and sludges, caustic washes and sludges, or water washes and
sludges from cleaning tubs and equipment used in the formulation of ink from
pigments, driers, soaps, and stabilizers containing chromium and lead.
Coking
Ammonia still lime sludge from coking operations.
Decanter tank tar sludge from coking operations.
Process residues from the recovery of coal tar, including, but not limited to,
collecting sump residues from the production of coke from coal or the recovery
of coke by-products produced from coal. This listing does not include K087
(decanter tank tar sludges from coking operations).
Tar storage tank residues from the production of coke from coal or from the
recovery of coke by- products produced from coal.
Process residues from the recovery of light oil, including, but not limited to,
those generated in stills, decanters, and wash oil recovery units from the
recovery of coke by-products produced from coal.
Wastewater sump residues from light oil refining, including, but not limited to,
intercepting or contamination sump sludges from the recovery of coke by-
products produced from coal.
Residues from naphthalene collection and recovery operations from the recovery
of coke by-products produced from coal.
Tar storage tank residues from coal tar refining.
Residues from coal tar distillation, including but not limited to, still bottoms.
Hazard
Code

(T)

(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
(T)
A12

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous
                  Waste Generators under RCRA

                          Appendix B:
      Commercial Chemical Products or Manufacturing Chemical
              Intermediates Identified as Toxic Wastes
                        (40 CFR 261.33(f))

-------
This Page Intentionally Left Blank

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                           Commercial Chemical Products or Manufacturing Chemical
                                    Intermediates Identified as Toxic Wastes
                                               (40 CFR 261.33(f))

[Comment: For the convenience of the regulated community, the primary hazardous properties of these materials have been
indicated by the letters T (Toxicity), R (Reactivity), I (Ignitability) and C (Corrosivity). Absence of a letter indicates that the
compound is only listed for toxicity.]
Hazardous
Waste No.
U394
U001
U034
U187
U005
U240
U112
U144
U214
see F027
U002
U003
U004
U005
U006
U007
U008
U009
U011
U012
U136
U014
U015
U010
U280
U278
U364
U271
U157
U016
U017
U192
U018
U094
U012
U014
U049
U093
U328
U353
Chemical Abstracts
Number
30558-43-1
75-07-0
75-87-6
62-44-2
53-96-3
1 94-75-7
141-78-6
301-04-2
563-68-8
93-76-5
67-64-1
75-05-8
98-86-2
53-96-3
75-36-5
79-06-1
79-10-7
107-13-1
61-82-5
62-53-3
75-60-5
492-80-8
115-02-6
50-07-7
101-27-9
22781-23-3
22961-82-6
17804-35-2
56-49-5
225-51-4
98-87-3
23950-58-5
56-55-3
57-97-6
62-53-3
492-80-8
3165-93-3
60-11-7
95-53-4
106-49-0
Substance
A2213.
Acetaldehyde (I)
Acetaldehyde, trichloro-
Acetamide, N-(4-ethoxyphenyl)-
Acetamide, N-9H-fluoren-2-yl-
Acetic acid, (2,4-dichlorophenoxy)-, salts & esters
Acetic acid ethyl ester (I)
Acetic acid, lead(2+) salt
Acetic acid, thallium(l+) salt
Acetic acid, (2,4,5-trichlorophenoxy)-
Acetone (I)
Acetonitrile (I,T)
Acetophenone
2-Acetylaminofluorene
Acetyl chloride (C,R,T)
Acrylamide
Acrylic acid (I)
Acrylonitrile
Amitrole
Aniline (I,T)
Arsinic acid, dimethyl-
Auramine
Azaserine
Azirino[2,33,4]pyrrolo[l,2-a]indole-4,7-dione, 6-amino-8-
[[(aminocarbonyl)oxy] methyl]- l,la,2,8,8a,8b-hexahydro-8a-methoxy-5-methyl-
, [laS-(laalpha, 8beta,8aalpha,8balpha)]-
Barban
Bendiocarb
Bendiocarb phenol
Benomyl
Benz[j]aceanthrylene, l,2-dihydro-3-methyl-
Benz[c]acridine
Benzal chloride
Benzamide, 3,5-dichloro-N-(l,l- dimethyl-2-propynyl)-
Benz[a]anthracene
Benz[a]anthracene, 7,12-dimethyl-
Benzenamine (I,T)
Benzenamine, 4,4-carbonimidoylbis[N,N-dimethyl-
Benzenamine, 4-chloro-2 -methyl-, hydrochloride
Benzenamine, N,N-dimethyl-4-(phenylazo)-
Benzenamine, 2-methyl-
Benzenamine, 4-methyl-
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
Bl

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U158
U222
U181
U019
U038
U030
U035
U037
U221
U028
U069
U088
U102
U107
U070
U071
U072
U060
U017
U223
U239
U201
U127
U056
U220
U105
U106
U055
U169
U183
U185
U020
U020
U207
U061
U247
U023
U234
U021
U202
U278
U364
U203
U141
U367
U090
U064
U248
U022
Chemical Abstracts
Number
101-14-4
636-21-5
99-55-8
71-43-2
510-15-6
101-55-3
305-03-3
108-90-7
25376-45-8
117-81-7
84-74-2
84-66-2
131-11-3
117-84-0
95-50-1
541-73-1
106-46-7
72-54-8
98-87-3
26471-62-5
1330-20-7
108-46-3
118-74-1
110-82-7
108-88-3
121-14-2
606-20-2
98-82-8
98-95-3
608-93-5
82-68-8
98-09-9
98-09-9
95-94-3
50-29-3
72-43-5
98-07-7
99-35-4
92-87-5
1 81-07-2
22781-23-3
22961-82-6
94-59-7
120-58-1
1563-38-8
94-58-6
189-55-9
'81-81-2
50-32-8
Substance
Benzenamine, 4,4-methylenebis[2-chloro-
Benzenamine, 2-methyl-, hydrochloride
Benzenamine, 2-methyl-5-nitro-
Benzene (I,T)
Benzeneacetic acid, 4-chloro-alpha-(4-chlorophenyl)-alpha-hydroxy-, ethyl ester
Benzene, l-bromo-4-phenoxy-
Benzenebutanoic acid, 4-[bis(2-chloroethyl)amino]-
Benzene, chloro-
Benzenediamine, ar-methyl-
1,2-Benzenedicarboxylic acid, bis(2-ethylhexyl) ester
1,2-Benzenedicarboxylic acid, dibutyl ester
1,2-Benzenedicarboxylic acid, diethyl ester
1,2-Benzenedicarboxylic acid, dimethyl ester
1,2-Benzenedicarboxylic acid, dioctyl ester
Benzene, 1,2-dichloro-
Benzene, 1,3-dichloro-
Benzene, 1,4-dichloro-
Benzene, 1, l-(2,2-dichloroethylidene)bis[4-chloro-
Benzene, (dichloromethyl)-
Benzene, 1,3-diisocyanatomethyl- (R,T)
Benzene, dimethyl- (I,T)
1,3-Benzenediol
Benzene, hexachloro-
Benzene, hexahydro- (I)
Benzene, methyl-
Benzene, l-methyl-2,4-dinitro-
Benzene, 2-methyl-l,3-dinitro-
Benzene, (1-methylethyl)- (I)
Benzene, nitro-
Benzene, pentachloro-
Benzene, pentachloronitro-
Benzenesulfonic acid chloride (C,R)
Benzenesulfonyl chloride (C,R)
Benzene, 1,2,4,5-tetrachloro-
Benzene, l,l-(2,2,2-trichloroethylidene)bis[4-chloro-
Benzene, l,l-(2,2,2-trichloroethylidene)bis[4- methoxy-
Benzene, (trichloromethyl)-
Benzene, 1,3,5-trinitro-
Benzidine
l,2-Benzisothiazol-3(2H)-one, 1,1-dioxide, & salts
l,3-Benzodioxol-4-ol, 2,2-dimethyl-, methyl carbamate.
l,3-Benzodioxol-4-ol, 2,2-dimethyl-
1,3-Benzodioxole, 5-(2-propenyl)-
1,3-Benzodioxole, 5-(l-propenyl)-
7-Benzofuranol, 2,3 -dihydro-2,2-dimethyl-
1,3-Benzodioxole, 5-propyl-
Benzo [rst]pentaphene
2H-l-Benzopyran-2-one, 4-hydroxy-3-(3-oxo-l-phenyl-butyl)-, & salts, when
present at concentrations of 0.3% or less
Benzo[a]pyrene
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B2

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U197
U023
U085
U021
U073
U091
U095
U225
U030
U128
U172
U031
U159
U160
U053
U074
U143
U031
U136
U032
U372
U271
U280
U238
U178
U373
U409
U097
U389
U387
U114
U062
U279
U372
U367
U215
U033
U156
U033
U211
U034
U035
U036
U026
U037
U038
U039
Chemical Abstracts
Number
106-51-4
98-07-7
1464-53-5
92-87-5
91-94-1
119-90-4
119-93-7
75-25-2
101-55-3
87-68-3
924-16-3
71-36-3
78-93-3
1338-23-4
4170-30-3
764-41-0
303-34-4
71-36-3
75-60-5
13765-19-0
10605-21-7
17804-35-2
101-27-9
51-79-6
615-53-2
122-42-9
23564-05-8
79-44-7
2303-17-5
52888-80-9
1 111-54-6
2303-16-4
63-25-2
10605-21-7
1563-38-8
6533-73-9
353-50-4
79-22-1
353-50-4
56-23-5
75-87-6
305-03-3
57-74-9
494-03-1
108-90-7
510-15-6
59-50-7
Substance
p-Benzoquinone
Benzotrichloride (C,R,T)
2,2-Bioxirane
[1,1 -Biphenyl] -4,4-diamine
[1, r-Biphenyl]-4,4'-diamine, 3,3'-dichloro-
[1,1 '-Biphenyl] -4,4'-diamine, 3 ,3 '-dimethoxy-
[1,1 '-Biphenyl] -4,4'-diamine, 3 ,3 '-dimethyl-
Bromoform
4-Bromophenyl phenyl ether
1,3 -Butadiene, 1,1,2,3,4,4-hexachloro-
1 -Butanamine , N-buty 1-N-nitro so -
1-Butanol (I)
2-Butanone (I,T)
2-Butanone, peroxide (R,T)
2-Butenal
2-Butene, 1,4-dichloro- (I,T)
2-Butenoic acid, 2-methyl-,7-[[2,3-dihydroxy-2-(l-methoxyethyl)-3-methyl-l-
oxobutoxy]methyl]-2,3,5,7a- pyrrolizin-1-tetrahydro-lH-yl ester, [1S-
[lalpha(Z),7(2S*,3R*),7aarphall-
n-Butyl alcohol (I)
Cacodylic acid
Calcium chromate
Carbamic acid, lH-benzimidazol-2-yl, methyl ester.
Carbamic acid, [l-[(butylamino)carbonyl]-lH-benzimidazol-2-yl]-, methyl
ester
Carbamic acid, (3-chlorophenyl)-, 4-chloro-2-butynyl ester.
Carbamic acid, ethyl ester
Carbamic acid, methylnitroso-, ethyl ester
Carbamic acid, phenyl-, 1-methylethyl ester
Carbamic acid, [1,2-phenylenebis (iminocarbonothioyl)]bis-, dimethyl ester
Carbamic chloride, dimethyl-
Carbamothioic acid, bis( 1-methylethyl)- , S-(2,3,3-trichloro-2-propenyl)
ester
Carbamothioic acid, dipropyl-, S(phenylmethyl) ester
Carbamodithioic acid, 1,2-ethanediylbis-, salts & esters
Carbamothioic acid, bis( 1-methylethyl)-, S-(2,3-dichloro-2-propenyl) ester
Carbaryl
Carbendazim
Carbofuran phenol
Carbonic acid, dithallium(l+) salt
Carbonic difluoride
Carbonochloridic acid, methyl ester(I,T)
Carbon oxyfluoride (R,T)
Carbon tetrachloride
Chloral
Chlorambucil
Chlordane, alpha & gamma isomers
Chlornaphazin
Chlorobenzene
Chlorobenzilate
p-Chloro-m-cresol
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B3

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U042
U044
U046
U047
U048
U049
U032
U050
U051
U052
U053
U055
U246
U197
U056
U129
U057
U130
U058
U240
U059
U060
U061
U062
U063
U064
U066
U069
U070
U071
U072
U073
U074
U075
U078
U079
U025
U027
U024
U081
U082
U084
U085
U108
U028
U395
U086
U087
U088
Chemical Abstracts
Number
110-75-8
67-66-3
107-30-2
91-58-7
95-57-8
3165-93-3
13765-19-0
218-01-9

1319-77-3
4170-30-3
98-82-8
506-68-3
106-51-4
110-82-7
58-89-9
108-94-1
77-47-4
50-18-0
1 94-75-7
20830-81-3
72-54-8
50-29-3
2303-16-4
53-70-3
189-55-9
96-12-8
84-74-2
95-50-1
541-73-1
106-46-7
91-94-1
764-41-0
75-71-8
75-35-4
156-60-5
111-44-4
108-60-1
111-91-1
120-83-2
87-65-0
542-75-6
1464-53-5
123-91-1
117-81-7
5952-26-1
1615-80-1
3288-58-2
84-66-2
Substance
2-Chloroethyl vinyl ether
Chloroform
Chloromethyl methyl ether
beta-Chloronaphthalene
o-Chlorophenol
4-Chloro-o-toluidine, hydrochloride
Chromic acid H2CrO4, calcium salt
Chrysene
Creosote
Cresol (Cresylic acid)
Crotonaldehyde
Cumene (I)
Cyanogen bromide (CN)Br
2,5-Cyclohexadiene- 1 ,4-dione
Cyclohexane (I)
Cyclohexane, 1,2,3,4,5,6-hexachloro-
,lalpha,2alpha,3beta,4alpha,5alpha,6(beta)-
Cyclohexanone (I)
1,3-Cyclopentadiene, 1,2,3,4,5,5-hexachloro-
Cyclophosphamide
2,4-D, salts & esters
Daunomycin
ODD
DDT
Diallate
Dibenz [a,h] anthracene
Dibenzo [a,i]pyrene
1 ,2-Dibromo-3 -chloropropane
Dibutyl phthalate
o-Dichlorobenzene
m-Dichlorobenzene
p-Dichlorobenzene
3 ,3 '-Dichlorobenzidine
l,4-Dichloro-2-butene (I,T)
Dichlorodifluoromethane
1 , 1 -Dichloroethylene
1 ,2-Dichloroethylene
Dichloroethyl ether
Dichloroisopropyl ether
Dichloromethoxy ethane
2,4-Dichlorophenol
2,6-Dichlorophenol
1 ,3 -Dichloropropene
l,2:3,4-Diepoxybutane (I,T)
1 ,4-Diethyleneoxide
Diethylhexyl phthalate
Diethylene glycol, dicarbamate
N,N'-Diethylhydrazine
O,O-Diethyl S-methyl dithiophosphate
Diethyl phthalate
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B4

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U089
U090
U091
U092
U093
U094
U095
U096
U097
U098
U099
U101
U102
U103
U105
U106
U107
U108
U109
U110
uni
U041
U001
U404
U174
U155
U067
U076
U077
U131
U024
U117
U025
U184
U208
U209
U218
U226
U227
U410
U394
U359
U173
U395
U004
U043
U042
U078
U079
Chemical Abstracts
Number
56-53-1
94-58-6
119-90-4
124-40-3
60-11-7
57-97-6
119-93-7
80-15-9
79-44-7
57-14-7
540-73-8
105-67-9
131-11-3
77-78-1
121-14-2
606-20-2
117-84-0
123-91-1
122-66-7
142-84-7
621-64-7
106-89-8
75-07-0
121-44-8
55-18-5
91-80-5
106-93-4
75-34-3
107-06-2
67-72-1
111-91-1
60-29-7
111-44-4
76-01-7
630-20-6
79-34-5
62-55-5
71-55-6
79-00-5
59669-26-0
30558-43-1
110-80-5
1116-54-7
5952-26-1
98-86-2
75-01-4
110-75-8
75-35-4
156-60-5
Substance
Diethylstilbesterol
Dihydrosafrole
3 ,3 '-Dimethoxybenzidine
Dimethylamine (I)
p-Dimethylaminoazobenzene
7, 12-Dimethylbenz[a]anthracene
3 ,3 '-Dimethylbenzidine
alpha,alpha-Dimethylbenzylhydroperoxide (R)
Dimethylcarbamoyl chloride
1 , 1 -Dimethylhydrazine
1 ,2-Dimethylhydrazine
2,4-Dimethylphenol
Dimethyl phthalate
Dimethyl sulfate
2,4-Dinitrotoluene
2,6-Dinitrotoluene
Di-n-octyl phthalate
1,4-Dioxane
1 ,2-Diphenylhydrazine
Dipropylamine (I)
Di-n-propylnitrosamine
Epichlorohydrin
Ethanal (I)
Ethanamine, N,N-diethyl-
Ethanamine, N-ethyl-N-nitroso-
1 ,2-Ethanediamine, N,N-dimethyl-N'-2-pyridinyl-N'-(2-thienylmethyl)-
Ethane, 1,2-dibromo-
Ethane, 1,1-dichloro-
Ethane, 1,2-dichloro-
Ethane, hexachloro-
Ethane, l,l'-[methylenebis(oxy)]bis[2-chloro-
Ethane, l,l'-oxybis-(I)
Ethane, l,l'-oxybis[2-chloro-
Ethane, pentachloro-
Ethane, 1,1,1,2-tetrachloro-
Ethane, 1,1,2,2-tetrachloro-
Ethanethioamide
Ethane, 1,1,1-trichloro-
Ethane, 1,1,2-trichloro-
Ethanimidothioic acid, N,N'-[thiobis [(methylimino) carbonyloxy]]bis-,
dimethyl ester
Ethanimidothioic acid, 2-(dimethylamino)-N-hydroxy-2-oxo-,
methyl ester
Ethanol, 2-ethoxy-
Ethanol, 2,2'-(nitrosoimino)bis-
Ethanol, 2,2'-oxybis-, dicarbamate
Ethanone, 1-phenyl-
Ethene, chloro-
Ethene, (2-chloroethoxy)-
Ethene, 1,1-dichloro-
Ethene, 1,2-dichloro-, (E)-
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B5

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U210
U228
U112
U113
U238
U117
U114
U067
U077
U359
U115
U116
U076
U118
U119
U120
U122
U123
U124
U125
U147
U213
U125
U124
U206
U206
U126
U163
U127
U128
U130
U131
U132
U243
U133
U086
U098
U099
U109
U134
U134
U135
U135
U096
U116
U137
U190
U140
U141
U142
Chemical Abstracts
Number
127-18-4
79-01-6
141-78-6
140-88-5
51-79-6
60-29-7
1 111-54-6
106-93-4
107-06-2
110-80-5
75-21-8
96-45-7
75-34-3
97-63-2
62-50-0
206-44-0
50-00-0
64-18-6
110-00-9
98-01-1
108-31-6
109-99-9
98-01-1
110-00-9
18883-66-4
18883-66-4
765-34-4
70-25-7
118-74-1
87-68-3
77-47-4
67-72-1
70-30-4
1888-71-7
302-01-2
1615-80-1
57-14-7
540-73-8
122-66-7
7664-39-3
7664-39-3
7783-06-4
7783-06-4
80-15-9
96-45-7
193-39-5
85-44-9
78-83-1
120-58-1
143-50-0
Substance
Ethene, tetrachloro-
Ethene, trichloro-
Ethyl acetate (I)
Ethyl acrylate (I)
Ethyl carbamate (urethane)
Ethyl ether (I)
Ethylenebisdithiocarbamic acid, salts & esters
Ethylene dibromide
Ethylene dichloride
Ethylene glycol monoethyl ether
Ethylene oxide (I,T)
Ethylenethiourea
Ethylidene dichloride
Ethyl methacrylate
Ethyl methanesulfonate
Fluoranthene
Formaldehyde
Formic acid (C,T)
Furan (I)
2-Furancarboxaldehyde (I)
2,5-Furandione
Furan, tetrahydro-(I)
Furfural (I)
Furfuran (I)
Glucopyranose, 2-deoxy-2-(3-methyl-3-nitrosoureido)-, D-
D-Glucose, 2-deoxy-2-[[(methylnitrosoamino)-carbonyl]amino]-
Glycidylaldehyde
Guanidine, N-methyl-N'-nitro-N-nitroso-
Hexachlorobenzene
Hexachlorobutadiene
Hexachlorocyclopentadiene
Hexachloroethane
Hexachlorophene
Hexachloropropene
Hydrazine (R,T)
Hydrazine, 1,2-diethyl-
Hydrazine, 1,1-dimethyl-
Hydrazine, 1,2-dimethyl-
Hydrazine, 1,2-diphenyl-
Hydrofluoric acid (C,T)
Hydrogen fluoride (C,T)
Hydrogen sulfide
Hydrogen sulfide H2S
Hydroperoxide, 1 -methyl- 1 -phenylethyl-(R)
2-Imidazolidinethione
Indeno[l,2,3-cd]pyrene
1 ,3 -Isobenzofurandione
Isobutyl alcohol (I,T)
Isosafrole
Kepone
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B6

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U143
U144
U146
U145
U146
U129
U163
U147
U148
U149
U150
U151
U152
U092
U029
U045
U046
U068
U080
U075
U138
U119
U211
U153
U225
U044
U121
U036
U154
U155
U142
U247
U154
U029
U186
U045
U156
U226
U157
U158
U068
U080
U159
U160
U138
U161
U162
U161
U164
Chemical Abstracts
Number
303-34-4
301-04-2
1335-32-6
7446-27-7
1335-32-6
58-89-9
70-25-7
108-31-6
123-33-1
109-77-3
148-82-3
7439-97-6
126-98-7
124-40-3
74-83-9
74-87-3
107-30-2
74-95-3
75-09-2
75-71-8
74-88-4
62-50-0
56-23-5
74-93-1
75-25-2
67-66-3
75-69-4
57-74-9
67-56-1
91-80-5
143-50-0
72-43-5
67-56-1
74-83-9
504-60-9
74-87-3
79-22-1
71-55-6
56-49-5
101-14-4
74-95-3
75-09-2
78-93-3
1338-23-4
74-88-4
108-10-1
80-62-6
108-10-1
56-04-2
Substance
Lasiocarpine
Lead acetate
Lead, bis(acetato-O)tetrahydroxytri-
Lead phosphate
Lead subacetate
Lindane
MNNG
Maleic anhydride
Maleic hydrazide
Malononitrile
Melphalan
Mercury
Methacrylonitrile (I, T)
Methanamine, N-methyl- (I)
Methane, bromo-
Methane, chloro- (I, T)
Methane, chloromethoxy-
Methane, dibromo-
Methane, dichloro-
Methane, dichlorodifluoro-
Methane, iodo-
Methanesulfonic acid, ethyl ester
Methane, tetrachloro-
Methanethiol (I, T)
Methane, tribromo-
Methane, trichloro-
Methane, trichlorofluoro-
4,7-Methano-lH-indene, l,2,4,5,6,7,8,8-octachloro-2,3,3a,4,7,7a-hexahydro-
Methanol (I)
Methapyrilene
l,3,4-Metheno-2H-cyclobuta[cd]pentalen-2-one, l,la,3,3a,4,5,5,5a,5b,6-
decachlorooctahydro-
Methoxychlor
Methyl alcohol (I)
Methyl bromide
1-Methylbutadiene (I)
Methyl chloride (I,T)
Methyl chlorocarbonate (I,T)
Methyl chloroform
3 -Methylcholanthrene
4,4'-Methylenebis(2-chloroaniline)
Methylene bromide
Methylene chloride
Methyl ethyl ketone (MEK) (I,T)
Methyl ethyl ketone peroxide (R,T)
Methyl iodide
Methyl isobutyl ketone (I)
Methyl methacrylate (I,T)
4-Methyl-2-pentanone (I)
Methylthiouracil
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B7

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U010
U059
U167
U168
U026
U165
U047
U166
U236
U279
U166
U167
U168
U217
U169
U170
U171
U172
U173
U174
U176
U177
U178
U179
U180
U181
U193
U058
U115
U126
U041

U183
U184
U185
See F027
U161
U186
U187
U188
U048
U039
U081
U082
U089
U101
U052
Chemical Abstracts
Number
50-07-7
20830-81-3
134-32-7
91-59-8
494-03-1
91-20-3
91-58-7
130-15-4
72-57-1
63-25-2
130-15-4
134-32-7
91-59-8
10102-45-1
98-95-3
100-02-7
79-46-9
924-16-3
1116-54-7
55-18-5
759-73-9
684-93-5
615-53-2
100-75-4
930-55-2
99-55-8
1120-71-4
50-18-0
75-21-8
765-34-4
106-89-8
2
608-93-5
76-01-7
82-68-8
87-86-5
108-10-1
504-60-9
62-44-2
108-95-2
95-57-8
59-50-7
120-83-2
87-65-0
56-53-1
105-67-9
1319-77-3
Substance
Mitomycin C
5,12-Naphthacenedione, 8-acetyl-10-[(3-amino-2,3,6-trideoxy)-arpha-L-lyxo-
hexopyranosyl)oxy]-7,8,9,10-tetrahydro-6,8,ll-trihydroxy-l-methoxy-, (8S-
cis)-
1 -Naphthalenamine
2-Naphthalenamine
Naphthalenamine, N,N'-bis(2-chloroethyl)-
Naphthalene
Naphthalene, 2-chloro-
1 ,4-Naphthalenedione
2,7-Naphthalenedisulfonic acid, 3,3'-[(3,3'-dimethyl[l, l'-biphenyl]-4,4'-
diyl)bis(azo)bis[5-amino-4-hydroxy]-, tetrasodium salt
1-Naphthalenol, methylcarbamate
1 ,4-Naphthoquinone
alpha-Naphthylamine
beta-Naphthylamine
Nitric acid, thallium(l+) salt
Nitrobenzene (I,T)
p-Nitrophenol
2-Nitropropane (I,T)
N-Nitrosodi-n-butylamine
N-Nitrosodiethanolamine
N-Nitrosodiethylamine
N-Nitroso-N-ethylurea
N-Nitro so -N-methy lurea
N-Nitroso-N-methylurethane
N-Nitrosopiperidine
N-Nitrosopyrrolidine
5 -Nitro -o -toluidine
1,2-Oxathiolane, 2,2-dioxide
2H- 1 ,3 ,2-Oxazaphosphorin-2-amine, N,N-bis(2-chloroethyl)tetrahydro-,
2-oxide
Oxirane (I,T)
Oxiranecarboxy aldehyde
Oxirane, (chloromethyl)-
123-63-7 Paraldehyde
Pentachlorobenzene
Pentachloroethane
Pentachloronitrobenzene (PCNB)
Pentachlorophenol
Pentanol, 4-methyl-
1,3-Pentadiene (I)
Phenacetin
Phenol
Phenol, 2-chloro-
Phenol, 4-chloro-3 -methyl-
Phenol, 2,4-dichloro-
Phenol, 2,6-dichloro-
Phenol, 4,4'-(l,2-diethyl-l,2-ethenediyl)bis-, (E)-
Phenol, 2,4-dimethyl-
Phenol, methyl-
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B8

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U132
U411
U170
See F027
See F027
See F027
See F027
U150
U145
U087
U189
U190
U191
U179
U192
U194
Ulll
U110
U066
U083
U149
U171
U027
U193
See F027
U235
U140
U002
U007
U084
U243
U009
U152
U008
U113
U118
U162
U373
U411
U387
U194
U083
U148
U196
U191
U237
U164
U180
U200
U201
Chemical Abstracts
Number
70-30-4
114-26-1
100-02-7
87-86-5
58-90-2
95-95-4
88-06-2
148-82-3
7446-27-7
3288-58-2
1314-80-3
85-44-9
109-06-8
100-75-4
23950-58-5
107-10-8
621-64-7
142-84-7
96-12-8
78-87-5
109-77-3
79-46-9
108-60-1
1120-71-4
93-72-1
126-72-7
78-83-1
67-64-1
79-06-1
542-75-6
1888-71-7
107-13-1
126-98-7
79-10-7
140-88-5
97-63-2
80-62-6
122-42-9
114-26-1
52888-80-9
107-10-8
78-87-5
123-33-1
110-86-1
109-06-8
66-75-1
56-04-2
930-55-2
50-55-5
108-46-3
Substance
Phenol, 2,2'-methylenebis[3,4,6-trichloro-
Phenol, 2-(l-methylethoxy)-, methylcarbamate
Phenol, 4-nitro-
Phenol, pentachloro-
Phenol, 2,3,4,6-tetrachloro-
Phenol, 2,4,5-trichloro-
Phenol, 2,4,6-trichloro-
L-Phenylalanine, 4-[bis(2-chloroethyl)amino]-
Phosphoric acid, lead(2+) salt (2:3)
Phosphorodithioic acid, O,O-diethyl S-methyl ester
Phosphorus sulfide (R)
Phthalic anhydride
2-Picoline
Piperidine, 1-nitroso-
Pronamide
1-Propanamine (I,T)
1-Propanamine, N-nitroso-N-propyl-
1-Propanamine, N-propyl- (I)
Propane, l,2-dibromo-3-chloro-
Propane, 1,2-dichloro-
Propanedinitrile
Propane, 2-nitro- (I,T)
Propane, 2,2'-oxybis[2-chloro-
1,3 -Propane sultone
Propanoic acid, 2-(2,4,5-trichlorophenoxy)-
1-Propanol, 2,3-dibromo-, phosphate(3:l)
1-Propanol, 2-methyl- (I,T)
2-Propanone (I)
2-Propenamide
1-Propene, 1,3-dichloro-
1-Propene, 1, 1,2,3,3, 3-hexachloro-
2-Propenenitrile
2-Propenenitrile, 2-methyl- (I,T)
2-Propenoic acid (I)
2-Propenoic acid, ethyl ester (I)
2-Propenoic acid, 2-methyl-, ethyl ester
2-Propenoic acid, 2-methyl-, methyl ester (I,T)
Propham
Propoxur
Prosulfocarb
n-Propylamine (I,T)
Propylene dichloride
3,6-Pyridazinedione, 1,2-dihydro-
Pyridine
Pyridine, 2-methyl-
2,4-(lH,3H)-Pyrimidinedione, 5-[bis(2-chloroethyl) amino]-
4( lH)-Pyrimidinone, 2,3 -dihydro-6-methyl-2-thioxo-
Pyrrolidine, 1-nitroso-
Reserpine
Resorcinol
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
B9

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U202
U203
U204
U204
U205
U205
U015
See F027
U206
U103
U189
See F027
U207
U208
U209
U210
See F027
U213
U214
U215
U216
U216
U217
U218
U410
U153
U244
U409
U219
U244
U220
U221
U223
U328
U353
U222
U389
U011
U227
U228
U121
See F027
See F027
U404
U234
U182
U235
U236
U237
U176
Chemical Abstracts
Number
1 81-07-2
94-59-7
7783-00-8
7783-00-8
7488-56-4
7488-56-4
115-02-6
93-72-1
18883-66-4
77-78-1
1314-80-3
93-76-5
95-94-3
630-20-6
79-34-5
127-18-4
58-90-2
109-99-9
563-68-8
6533-73-9
7791-12-0
7791-12-0
10102-45-1
62-55-5
59669-26-0
74-93-1
137-26-8
23564-05-8
62-56-6
137-26-8
108-88-3
25376-45-8
26471-62-5
95-53-4
106-49-0
636-21-5
2303-17-5
61-82-5
79-00-5
79-01-6
75-69-4
95-95-4
88-06-2
121-44-8
99-35-4
123-63-7
126-72-7
72-57-1
66-75-1
759-73-9
Substance
Saccharin, & salts
Safrole
Selenious acid
Selenium dioxide
Selenium sulfide
Selenium sulfide SeS2 (R,T)
L-Serine, diazoacetate (ester)
Silvex (2,4,5-TP)
Streptozotocin
Sulfuric acid, dimethyl ester
Sulfur phosphide (R)
2,4,5-T
1,2,4,5-Tetrachlorobenzene
1,1,1 ,2-Tetrachloroethane
1 , 1 ,2,2-Tetrachloroethane
Tetrachloroethylene
2,3 ,4,6-Tetrachlorophenol
Tetrahydroruran (I)
Thallium(I) acetate
Thallium(I) carbonate
Thallium(I) chloride
Thallium chloride Tlcl
Thallium(I) nitrate
Thioacetamide
Thiodicarb
Thiomethanol (I,T)
Thioperoxydicarbonic diamide [(H2N)C(S)]2S2, tetramethyl-
Thiophanate-methyl
Thiourea
Thiram
Toluene
Toluenediamine
Toluene diisocyanate (R,T)
o-Toluidine
p-Toluidine
o-Toluidine hydrochloride
Triallate
1H-1 ,2,4-Triazol-3 -amine
1 , 1 ,2-Trichloroethane
Trichloroethylene
Trichloromonofluoromethane
2,4,5-Trichlorophenol
2,4,6-Trichlorophenol
Triethylamine
1,3,5-Trinitrobenzene (R,T)
1,3,5-Trioxane, 2,4,6-trimethyl-
Tris(2,3-dibromopropyl) phosphate
Trypan blue
Uracil mustard
Urea, N-ethyl-N-nitroso-
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
BIO

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
U177
U043
U248
U239
U200
U249
Chemical Abstracts
Number
684-93-5
75-01-4
1 81-81-2
1330-20-7
50-55-5
1314-84-7
Substance
Urea, N-methyl-N-nitroso-
Vinyl chloride
Warfarin, & salts, when present at concentrations of 0.3% or less
Xylene (I)
Yohimban-16-carboxylic acid, ll,17-dimethoxy-18-[(3,4,5-
trimethoxybenzoyl)oxy]-, methyl ester, (3beta,16beta,17alpha,18beta,20alpha)-
Zinc phosphide Zn3P2, when present at concentrations of 10% or less
  CAS Number given for parent compound only.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
Bll

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       B12
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous
                  Waste Generators under RCRA

                           Appendix C
      Toxicity Characteristics Constituents and Regulatory Levels
                         (40 CFR 261.24)

-------
This Page Intentionally Left Blank

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                            Toxicity Characteristics Constituents and Regulatory Levels
                                                 (40 CFR 261.24)
U.S. EPA
HWNo.
D004
D005
D018
D006
D019
D020
D021
D022
D007
D023
D024
D025
D026
D016
D027
D028
D029
D030
D012
D031
D032
D033
D034
D008
D013
D009
D014
D035
D036
D037
D038
D010
D011
D039
D015
D040
D041
D042
D017
D043
Constituent
Arsenic
Barium
Benzene
Cadmium
Carbon tetrachloride
Chlordane
Chlorobenzene
Chloroform
Chromium
o-Cresol
m-Cresol
p-Cresol
Cresol
2,4-D
1 ,4-Dichlorobenzene
1 ,2-Dichloroethane
1 , 1 -Dichloroethylene
2,4-Dinitrotoluene
Endrin
Heptachlor (and its epoxide)
Hexachlorobenzene
Hexachlorobutadiene
Hexachloroethane
Lead
Lindane
Mercury
Methoxychlor
Methyl ethyl ketone
Nitrobenzene
Pentachlorophenol
Pyridine
Selenium
Silver
Tetrachloroethylene
Toxaphene
Trichloroethylene
2,4,5-Trichlorophenol
2,4,6-Trichlorophenol
2,4,5-TP (Silvex)
Vinyl chloride
CAS No
7440-38-2
7440-39-3
71-43-2
7440-43-9
56-23-5
57-74-9
108-90-7
67-66-3
7440-47-3
95-48-7
108-39-4
106-44-5

94-75-7
106-46-7
107-06-2
75-35-4
121-14-2
72-20-8
76-44-8
118-74-1
87-68-3
67-72-1
7439-92-1
58-89-9
7439.97-6
72-43-5
78-93-3
98-95-3
87-86-5
110-86-1
7782-49-2
7440-22-4
127-18-4
8001-35-2
79-01-6
95-95-4
88-06-2
93-72-1
75-01-4
Regulatory
level (mg/L)
5.0
100.0
0.5
1.0
0.5
0.03
100.0
6.0
5.0
200.0 l
200.0 l
200.0 1
200.0 1
10.0
7.5
0.5
0.7
0.13 2
0.02
0.008
0.13 2
0.50
3.0
5.0
0.4
0.2
10.0
200.0
2.0
100.0
5.0 2
1.0
5.0
0.7
0.5
0.5
400.0
2.0
1.0
0.2
  If o-, m-, and p-cresol concentrations cannot be differentiated, the total cresol (D026) concentration is used.
2 Quantitation limit is greater than the calculated regulatory level. Therefore, the quantitation limit becomes the regulatory
level.
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
Cl

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                      This Page Intentionally Left Blank
This document is intended solely for guidance. No statutory or regulatory                                       C2
requirements are in any way altered by any statement(s) contained herein.

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous
                  Waste Generators under RCRA

                          Appendix D
      Commercial Chemical Products or Manufacturing Chemical
          Intermediates Identified as Acute Hazardous Waste
                (40 CFR 261.33(a) through 261.33(e))

-------
This Page Intentionally Left Blank

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                           Commercial Chemical Products or Manufacturing Chemical
                               Intermediates Identified as Acute Hazardous Waste
                                      (40 CFR261.33(a) through 261.33(e))

(Comment: For the convenience of the regulated community the primary hazardous properties of these materials have been
indicated by the letters T (Toxicity), and R (Reactivity). Absence of a letter indicates that the compound only is listed for
acute toxicity.]
Hazardous
Waste No.
P023
P002
P057
P058
P002
POOS
P070
P203
P004
POOS
P006
P007
POOS
P009
P119
P099
P010
P012
P011
P011
P012
P038
P036
P054
P067
P013
P024
P077
P028
P042
P046
P014
P127
P188
P001
P028
P015
P017
P018
Chemical Abstracts
Number
107-20-0
591-08-2
640-19-7
62-74-8
591-08-2
107-02-8
116-06-3
1646-88-4
309-00-2
107-18-6
20859-73-8
2763-96-4
504-24-5
131-74-8
7803-55-6
506-61-6
7778-39-4
1327-53-3
1303-28-2
1303-28-2
1327-53-3
692-42-2
696-28-6
151-56-4
75-55-8
542-62-1
106-47-8
100-01-6
100-44-7
51-43-4
122-09-8
108-98-5
1563-66-2
57-64-7
1 81-81-2
100-44-7
7440-41-7
598-31-2
357-57-3
Substance
Acetaldehyde, chloro-
Acetamide, N-(aminothioxomethyl)-
Acetamide, 2-fluoro-
Acetic acid, fluoro-, sodium salt
1 -Acetyl-2-thiourea
Acrolein
Aldicarb
Aldicarb sulfone
Aldrin
Allyl alcohol
Aluminum phosphide (R,T)
5-(Aminomethyl)-3-isoxazolol
4 - Aminopy ridine
Ammonium picrate (R)
Ammonium vanadate
Argentate(l-), bis(cyano-C)-, potassium
Arsenic acid H3AsO4
Arsenic oxide As2O3
Arsenic oxide As2O5
Arsenic pentoxide
Arsenic trioxide
Arsine, diethyl-
Arsonous dichloride, phenyl-
Aziridine
Aziridine, 2-methyl-
Barium cyanide
Benzenamine, 4-chloro-
Benzenamine, 4-nitro-
Benzene, (chloromethyl)-
1,2-Benzenediol, 4-[l-hydroxy-2-(methylamino)ethyl]-, (R)-
Benzeneethanamine, alpha, alpha-dimethyl-
Benzenethiol
7-Benzofuranol, 2,3-dihydro-2,2-dimethyl-, methylcarbamate
Benzoic acid, 2-hydroxy-, compd. With(3aS-cis)-l,2,3,3a,8,8a-hexahydro-
l,3a,8-trimethylpyrrolo[2,3-b]indol-5-yl methylcarbamate ester (1:1)
2H-l-Benzopyran-2-one, 4-hydroxy-3-(3-oxo-l-phenylbutyl)-, & salts, when
present at concentrations greater than 0.3%.
Benzyl chloride
Beryllium powder
Bromoacetone
Brucine
This document is intended solely for guidance.  No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
Dl

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
P045
P021
P021
P189
P191
P192
P190
P127
P022
P095
P189
P023
P024
P026
P027
P029
P029
P202
P030
P031
P033
P033
P034
P016
P036
P037
P038
P041
P040
P043
P004
P060
P037
P051
P044
P046
P191
P047
P048
P020
P085
Chemical Abstracts
Number
39196-18-4
592-01-8
592-01-8
55285-14-8
644-64-4
119-38-0
1129-41-5
1563-66-2
75-15-0
75-44-5
55285-14-8
107-20-0
106-47-8
5344-82-1
542-76-7
544-92-3
544-92-3
64-00-6

460-19-5
506-77-4
506-77-4
131-89-5
542-88-1
696-28-6
60-57-1
692-42-2
311-45-5
297-97-2
55-91-4
309-00-2
465-73-6
60-57-1
1 72-20-8
60-51-5
122-09-8
644-64-4
1 534-52-1
51-28-5
88-85-7
152-16-9
Substance
2-Butanone, 3,3-dimethyl-l-(methylthio)-, O-[methylamino)carbonyl] oxime
Calcium cyanide
Calcium cyanide Ca(CN)2
Carbamic acid, [(dibutylamino)-thio]methyl-, 2,3-dihydro-2,2- dimethyl- 7-
benzofuranyl ester
Carbamic acid, dimethyl-, l-[(dimethyl-amino)carbonyl]- 5-methyl-lH-pyrazol-
3-yl ester
Carbamic acid, dimethyl-, 3 -methyl- l-(l-methylethyl)-lH- pyrazol-5-yl ester
Carbamic acid, methyl-, 3-methylphenyl ester
Carbofuran
Carbon disulfide
Carbonic dichloride
Carbosulfan
Chloroacetaldehyde
p-Chloroaniline
1 -(o-Chlorophenyl)thiourea
3 -Chloropropionitrile
Copper cyanide
Copper cyanide Cu(CN)
m-Cumenyl methylcarbamate
Cyanides (soluble cyanide salts), not otherwise specified
Cyanogen
Cyanogen chloride
Cyanogen chloride (CN)C1
2-Cyclohexyl-4,6-dinitrophenol
Dichloromethyl ether
Dichlorophenylarsine
Dieldrin
Diethylarsine
Diethyl-p-nitrophenyl phosphate
O,O-Diethyl O-pyrazinyl phosphorothioate
Diisopropylfluorophosphate (DFP)
1,4,5,8-Dimethanonaphthalene, l,2,3,4,10,10-hexa-chloro-l,4,4a,5,8,8a,-
hexahydro-,(lalpha,4alpha,4abeta,5alpha,8alpha,8 abeta)-
1,4,5,8-Dimethanonaphthalene, l,2,3,4,10,10-hexa-chloro-l,4,4a,5,8,8a-
hexahydro-,(lalpha,4alpha,4abeta,5beta,8beta,8abeta)-
2,7:3,6-Dimethanonaphth[2,3-b] oxirene, 3,4,5,6,9,9-hexachloro-
la,2,2a,3,6,6a,7,7a-octahydro-,(laalpha,2beta,2aalpha,3beta,6beta,6a
alpha, 7beta, 7aalpha)-
2,7:3,6-Dimethanonaphth [2,3-b] oxirene, 3,4,5,6,9,9-hexachloro-
la,2,2a,3,6,6a,7,7a-octahydro-,(laalpha,2beta,2abeta,3alpha,6alpha,6
abeta,7beta, 7aalpha)-, & metabolites
Dimethoate
alpha,alpha-Dimethylphenethylamine
Dimetilan
4,6-Dinitro-o-cresol, & salts
2,4-Dinitrophenol
Dinoseb
Diphosphoramide, octamethyl-
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
D2

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
Pill
P039
P049
P185
P050
P088
P051
P051
P042
P031
P194
P066
P101
P054
P097
P056
P057
P058
P198
P197
P065
P059
P062
P116
P068
P063
P063
P096
P060
P192
P202
P007
P196
P196
P092
P065
P082
P064
P016
P112
P118
P198
P197
P050
P059
Chemical Abstracts
Number
107-49-3
298-04-4
541-53-7
26419-73-8
115-29-7
145-73-3
72-20-8
72-20-8
51-43-4
460-19-5
23135-22-0
16752-77-5
107-12-0
151-56-4
52-85-7
7782-41-4
640-19-7
62-74-8
23422-53-9
17702-57-7
628-86-4
76-44-8
757-58-4
79-19-6
60-34-4
74-90-8
74-90-8
7803-51-2
465-73-6
119-38-0
64-00-6
2763-96-4
15339-36-3
15339-36-3
62-38-4
628-86-4
62-75-9
624-83-9
542-88-1
509-14-8
75-70-7
23422-53-9
17702-57-7
115-29-7
76-44-8
Substance
Diphosphoric acid, tetraethyl ester
Disulfoton
Dithiobiuret
l,3-Dithiolane-2-carboxaldehyde, 2,4-dimethyl-, O- [(methylamino)-
carbonyljoxime
Endosulfan
Endothall
Endrin
Endrin, & metabolites
Epinephrine
Ethanedinitrile
Ethanimidothioc acid, 2-(dimethylamino)-N-[[(methylamino) carbonyl]oxy]-2-
oxo-, methyl ester
Ethanimidothioic acid, N-[[(metliylamino)carbonyl]oxy]-,methyl ester
Ethyl cyanide
Ethyleneimine
Famphur
Fluorine
Fluoroacetamide
Fluoroacetic acid, sodium salt
Formetanate hydrochloride
Formparanate
Fulminic acid, mercury(2+) salt (R,T)
Heptachlor
Hexaethyl tetraphosphate
Hydrazinecarbothioamide
Hydrazine, methyl-
Hydrocyanic acid
Hydrogen cyanide
Hydrogen phosphide
Isodrin
Isolan
3 -Isopropylphenyl N-methylcarbamate
3(2H)-Isoxazolone, 5-(aminomethyl)-
Manganese, bis(dimethylcarbamodithioato-S, S')-
Manganese dimethyldithiocarbamate
Mercury, (acetato-O)phenyl-
Mercury fulminate (R,T)
Methanamine, N-methyl-N-nitroso-
Methane, isocyanato-
Methane, oxybis[chloro-
Methane, tetranitro- (R)
Methanethiol, trichloro-
Methanimidamide, N,N-dimethyl-N'-[3-[[(methylamino)-carbonyl]oxy]phenyl]-,
monohydrochloride
Methanimidamide, N,N-dimethyl-N'-[2-methyl-4-
[[(methylamino)carbonyl]oxy]phenyl]-
6,9-Methano-2,4,3-benzodioxathiepin, 6,7,8,9,10, 10- hexachloro-l,5,5a,6
hexahydro-,3-oxide
9,9a-
4,7-Methano-lH-indene, 1,4,5,6,7,8,8- heptachloro-3a,4,7,7a-tetrahydro-
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
D3

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
P199
P066
P068
P064
P069
P071
P190
P128
P072
P073
P073
P074
P074
P075
P076
P077
P078
P076
P078
P081
P082
P084
P085
P087
P087
P088
P194
P089
P034
P048
P047
P020
P009
P128
P199
P202
P201
P092
P093
P094
P095
P096
P041
P039
P094
P044
P043
P089
P040
P097
Chemical Abstracts
Number
2032-65-7
16752-77-5
60-34-4
624-83-9
75-86-5
298-00-0
1129-41-5
315-8-4
86-88-4
13463-39-3
13463-39-3
557-19-7
557-19-7
1 54-1 1-5
10102-43-9
100-01-6
10102-44-0
10102-43-9
10102-44-0
55-63-0
62-75-9
4549-40-0
152-16-9
20816-12-0
20816-12-0
145-73-3
23135-22-0
56-38-2
131-89-5
51-28-5
1 534-52-1
88-85-7
131-74-8
315-18-4
2032-65-7
64-00-6
2631-37-0
62-38-4
103-85-5
298-02-2
75-44-5
7803-51-2
311-45-5
298-04-4
298-02-2
60-51-5
55-91-4
56-38-2
297-97-2
52-85-7
Substance
Methiocarb
Methomyl
Methyl hydrazine
Methyl isocyanate
2-Methyllactonitrile
Methyl parathion
Metolcarb
Mexacarbate
alpha-Naphthylthiourea
Nickel carbonyl
Nickel carbonyl Ni(CO)4, (T-4)-
Nickel cyanide
Nickel cynaide Ni(CN)2
Nicotine, & salts
Nitric oxide
p-Nitroaniline
Nitrogen dioxide
Nitrogen oxide NO
Nitrogen oxide NO2
Nitroglycerine (R)
N-Nitrosodimethylamine
N-Nitrosomethylvinylamine
Octamethylpyrophosphoramide
Osmium oxide OsO4, (T-4)-
Osmium tetroxide
7-Oxabicyclo[2.2. l]heptane-2,3-dicarboxylic acid
Oxamyl
Parathion
Phenol, 2-cyclohexyl-4,6-dinitro-
Phenol, 2,4-dinitro-
Phenol, 2-methyl-4,6-dinitro-, & salts
Phenol, 2-( 1 -methylpropyl)-4,6-dinitro-
Phenol, 2,4,6-trinitro-, ammonium salt(R)
Phenol, 4-(dimethylamino)-3,5-dimethyl-, methylcarbamate (ester)
Phenol, (3,5-dimethyl-4-(methylthio)-, methylcarbamate
Phenol, 3-(l-methylethyl)-, methyl carbamate
Phenol, 3-methyl-5-(l-methylethyl)-, methyl carbamate
Phenylmercury acetate
Phenylthiourea
Phorate
Phosgene
Phosphine
Phosphoric acid, diethyl 4-nitrophenyl ester
Phosphorodithioic acid, O,O-diethyl S-[2-(ethylthio)ethyl] ester
Phosphorodithioic acid, O,O-diethyl S-[(ethylthio)methyl] ester
Phosphorodithioic acid, O,O-dimethyl S-[2-(methylamino)-2-oxoethyl] ester
Phosphorofluoridic acid, bis(l-methylethyl) ester
Phosphorothioic acid, O,O-diethyl O-(4-nitrophenyl) ester
Phosphorothioic acid, O,O-diethyl O-pyrazinyl ester
Phosphorothioic acid, O-[4-[(dimethylamino)sulfonyl]phenyl] O,O- dimethyl
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
D4

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.

P071
P204
P188
P110
P098
P098
P099
P201
P070
P203
P101
P027
P069
P081
P017
P102
POOS
POOS
P067
P102
POOS
P075
P204

P114
P103
P104
P104
P105
P106
P106
P108
P018
P108
P115
P109
P110
Pill
P112
P062
P113
P113
P114
P115
P109
P045
P049
P014
P116
Chemical Abstracts
Number

298-00-0
57-47-6
57-64-7
78-00-2
151-50-8
151-50-8
506-61-6
2631-37-0
116-06-3
1646-88-4
107-12-0
542-76-7
75-86-5
55-63-0
598-31-2
107-19-7
107-02-8
107-18-6
75-55-8
107-19-7
504-24-5
1 54-11-5
57-47-6

12039-52-0
630-10-4
506-64-9
506-64-9
26628-22-8
143-33-9
143-33-9
1 57-24-9
357-57-3
1 57-24-9
7446-18-6
3689-24-5
78-00-2
107-49-3
509-14-8
757-58-4
1314-32-5
1314-32-5
12039-52-0
7446-18-6
3689-24-5
39196-18-4
541-53-7
108-98-5
79-19-6
Substance
ester
Phosphorothioic acid, O,O, -dimethyl O-(4-nitrophenyl) ester
Physostigmine
Physostigmine salicylate
Prumbane, tetraethyl-
Potassium cyanide
Potassium cyanide K(CN)
Potassium silver cyanide
Promecarb
Propanal, 2-methyl-2-(methylthio)-, O-[(methylamino)carbonyl]oxime
Propanal, 2-methyl-2-(methyl-surfonyl)-, O-[(methylamino)carbonyl] oxime
Propanenitrile
Propanenitrile, 3-chloro-
Propanenitrile, 2-hydroxy-2-methyl-
1,2,3-Propanetriol, trinitrate (R)
2-Propanone, 1-bromo-
Propargyl alcohol
2-Propenal
2-Propen-l-ol
1 ,2-Propylenimine
2-Propyn-l-ol
4-Pyridinamine
Pyridine, 3-(l-methyl-2-pyrrolidinyl)- , (S)-, & salts
Pyrrolo[2,3-b]indol-5-ol,l,2,3,3a,8,8a-hexahydro-l,3a,8-trimethyl-
,methylcarbamate (ester), (3aS-cis)-
Selenious acid, dithallium(l+) salt
Selenourea
Silver cyanide
Silver cyanide Ag(CN)
Sodium azide
Sodium cyanide
Sodium cyanide Na(CN)
Strychnidin-10-one, & salts
Strychnidin-10-one, 2,3-dimethoxy-
Strychnine, & salts
Sulfuric acid, dithallium(l+) salt
Tetraethyldithiopyrophosphate
Tetraethyl lead
Tetraethyl pyrophosphate
Tetranitromethane (R)
Tetraphosphoric acid, hexaethyl ester
Thallic oxide
Thallium oxide T12O3
Thallium(I) selenite
Thallium® sulfate
Thiodiphosphoric acid, tetraethyl ester
Thiofanox
Thioimidodicarbonic diamide [(H2N)C(S)]2NH
Thiophenol
Thiosemicarbazide
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
D5

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Hazardous
Waste No.
P026
P072
P093
P185
P123
P118
P119
P120
P120
P084
P001
P205
P121
P121
P122
P205
Chemical Abstracts
Number
5344-82-1
86-88-4
103-85-5
26419-73-8
8001-35-2
75-70-7
7803-55-6
1314-62-1
1314-62-1
4549-40-0
1 81-81-2
137-30-4
557-21-1
557-21-1
1314-84-7
137-30-4
Substance
Thiourea, (2-chlorophenyl)-
Thiourea, 1-naphthalenyl-
Thiourea, phenyl-
Tirpate.
Toxaphene
Trichloromethanethiol
Vanadic acid, ammonium salt
Vanadium oxide V2O5
Vanadium pentoxide
Vinylamine, N-methyl-N-nitroso-
Warfarin, & salts, when present at concentrations greater than 0.3%
Zinc, bis(dimethylcarbamodithioato- S,S')-
Zinc cyanide
Zinc cyanide Zn(CN)2
Zinc phosphide Zn3 P2, when present at concentrations greater than 10% (R,T)
Ziram.
1 CAS Number given for parent compound only.
This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
D6

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous
                  Waste Generators under RCRA

                          Appendix E
           Hazardous Waste Storage Incompatibility Chart

-------
This Page Intentionally Left Blank

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
                                Hazardous Waste Storage Incompatibility Chart

                         Substances in bold have detailed example lists on the next page.
 If the material contains:
It may not be stored with any of the following:
Acid (pH below 2.0)
Caustics (pH above 12.5)
Reactive Metals
Alcohol
Water
Aldehydes
Halogenated, Nitrated, or Unsaturated Hydrocarbons
Reactive Organic Compounds and Solvents
Spent Cyanide and Sulfide Solutions
Oxidize rs
 Caustic (pH above 12.5)
Acid (pH below 2.0)
Reactive Metals
Alcohol
Water
Aldehydes
Halogenated, Nitrated, or Unsaturated Hydrocarbons
Reactive Organic Compounds and Solvents	
 Reactive Metals
Caustics
Acids
Alcohol
Aldehydes
Halogenated, Nitrated, or Unsaturated Hydrocarbons
Reactive Organic Compounds and Solvents
Oxidize rs
 Reactive Organic Compounds and Solvents
Caustics
Acids
Reactive Metals
 Spent Cyanide and Sulfide Solutions
Acids
 Oxidize rs
Acetic or Other Organic Acids
Concentrated Mineral Acids
Reactive Metals
Reactive Organic Compounds and Solvents
Ignitable [Flammable/Combustible] Wastes*
* "Ignitable" in this context refers to substances with a flashpoint below 140 x °F, and includes:
Combustible substances, with a flashpoint below 140 x °F
Flammable substances, with a flashpoint below 100 x °F.

Some Deadly Combinations

Acids + Oil or Grease = Fire       Flammable Liquids + Hydrogen Peroxide = Fire/Explosion
Acids + Caustics = Heat/Spattering Aluminum Powder + Ammonium Nitrate = Explosion
Caustics + Epoxies = Extreme Heats        Sodium Cyanide + Sulfuric Acid = Lethal Hydrogen Cyanide
Chlorine Gas + Acetylene = Explosion      Ammonia + Bleach = Noxious Fumes

In general:   Reactives must be segregated from Ignitables
Acids must be segregated from Caustics
Corrosives should be segregated from Flammables
Oxidizers should be segregated from EVERYTHING
Many Corrosives are "Water Reactive"
Most Organic Reactives must be segregated from Inorganic Reactives (metals)

This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
                                                      El

-------
Protocol for Conducting Environmental Compliance Audits of Hazardous Waste Generators under RCRA
Ignitables
(Flammables/Combustibles)
Corrosives
Acids Caustics
1
Carburetor Cleaners
Engine Cleaners
Epoxy, Resins, Adhesives, and Rubber Cements
Finishes
Fuels
Lacquers
Paints
Paint Thinners
Paint Wastes
Pesticides that contain Solvents (such as Methyl Alcohol, Ethyl
Alcohol, Isopropyl Alcohol, Toluene, Xylene).
Petroleum Solvents (Drycleaning Fluid)
Solvents:
Acetone
Benzene
Carbon Tetrachloride (Carbon Tet)
Ethanol (Ethyl Alcohol)
Ethyl Benzene
Isopropanol (Isopropyl Alcohol)
Kerosene (Fuel Oil #1)
Methanol (Wood Alcohol)
Methyl Ethyl Ketone (MEK)
Petroleum Distillates
Tetrahydroruran (THF)
Toluene (Methacide, Methylbenzene, Methylbenzol,
Phenylmethane, Toluol, Antisal 1A)
White Spirits (White Spirits, Mineral Spirits, Naptha)
Xylene (Xylol)
Stains
Stripping Agents
Varsol
Waste Fuels
Waste Ink
Wax Removers
Wood Cleaners










Battery Acids
Degreasers and Engine
Cleaners
Etching Fluids
Hydrobromic Acid
Hydrochloric Acid (Muriatic
Acid)
Nitric Acid (<40%)
(Aquafortis)
Phosphoric Acid
Rust Removers
Sulfuric Acid (Oil of Vitriol)




Reactive Metals

Lithium (Batteries)
Aluminum
Beryllium
Calcium
Magnesium
Sodium
Zinc Powder










Oxidize rs
Chlorine Gas
Nitric Acid (>40%), aka Red
Fuming Nitric
Nitrates (Sodium Nitrate,
Ammonium Nitrate)
Perchlorates
Perchloric Acid
Perioxides
Calcium Hypochlorite (>60%)
Acetylene Sludge
Alkaline Battery Acids
Alkaline Cleaners
Alkaline Degreasers
Alkaline Etching Fluids
Lime and Water
Lime Wastewater
Potassium Hydroxide (Caustic
Potash)
Rust Removers
Sodium Hydroxide (Caustic
Soda, Soda Lye)


Reactive Organic
Compounds and Solutions


Alcohols
Aldehydes
Chromic Acids (from chrome
plating, copper stripping
and aluminum anodizing)
Cyanides (from electroplating
operations)
Hypochlorides (from water
treatment plants, swimming
pools, sanitizing
operations)
Organic Peroxides (including
Hydrogen Peroxide)
Perchlorates
Permanganates
Sulfides











This document is intended solely for guidance. No statutory or regulatory
requirements are in any way altered by any statement(s) contained herein.
E2

-------
Protocol for Conducting Environmental Compliance Audits of
        Hazardous Waste Generators under RCRA

                     Appendix F
    User Satisfaction Questionnaire and Comment Form

-------
This Page Intentionally Left Blank

-------
                                             User Satisfaction Survey
                                           (OMB Approval No.  1860.01)
                                                Expires 9/30/2001

We would like to know if this Audit Protocol provides you with useful information. This information will be used by EPA to
measure the success of this tool in providing compliance assistance and to determine future applications and needs for
regulatory checklists and auditing materials.

1.   Please indicate which Protocol(s) this survey applies to:

    Title:
    EPA Document Number:
2.   Overall, did you find the Protocol helpful for conducting audits:

    Yes	   No	

    If not, what areas of the document are difficult to understand?

3.   How would you rate the usefulness of the Protocol(s) for conducting compliance audits on a scale of 1-5?

    1 = not useful or effective, 3 = somewhat useful/effective,  5 = very useful/effective

    Low                 Medium        High
    12345       Introduction Section
    12345       Key Compliance Requirements
    12345       Key Terms and Definitions
    12345       Checklist
4.   What actions do you intend to take as a result of using the protocol and/or conducting the audit? Please check all that
    apply.

    	 Contact a regulatory agency
    	 Contact a compliance assisstance provider (e.g., trade association, state agency, EPA)
    	 Contact a vendor
    	 Disclose violations discovered during the audit under EPA's audit Policy
    	 Disclose violations discovered under EPA's Small Business Policy
    	 Obtain a permit or certification
    	 Change the handling of a waste, emission or pollutant
    	 Change a process or practice
    	 Purchase new process equipment
    	 Install emission control equipment (e.g.,  scrubbers, wastewater treatment)
    	 Install waste treatment system (control technique)
    	 Implement or improve pollution prevention practices (e.g., source reduction, recycling)
    	 Improve organizational auditing program
    	 Institute an Environmental Management  System
    	 Improve the existing Environmental Management System (e.g., improve training, clarify standard operating
          procedures, etc.)
          Other

-------
5.    What, if any, environmental improvements will result from the actions to be taken (check all that apply)?

    	  reduced emissions
    	  waste reduction
    	  reduced risk to human health and the environment due to better management practices
    	  reduced quantity and toxicity of raw materials
    	  water conservation
    	  energy conservation
    	  conserved raw materials
    	  conservation of habitat or other environmental stewardship practice:	
          other:
          no environmental improvements are likely to result from the use of this document
6.   How did you hear about this document?
    	  trade association
    	  state technical assistance provider
    	  EPA internet homepage or website
    	  document catalog
    	  co-worker or business associate
    	  EPA, state, or local regulator
    	  other (please specify)	
7.   In order to understand your response, we would like to know what function you perform with respect to environmental
    compliance and the size of your organization.

	Company Personnel            	 Trade Association              	 Compliance Assistance
     	  Environmental Auditor          	  National                       Provider
     	  Corporate Level                	  Regional                       	 EPA
           Plant-level                           Local                               State
           Legal                         	 Manager                       	 State Small Business
           Environmental Manager         	 Information Specialist                 Assistance
           Operator - (e.g.,                                                    	Local
           Pollution Control                                                   	Other	
           Equipment                                                              	
           Other:
      Regulatory Personnel          	 Vendor/Consultant
      	  State                         	 Environmental Auditor
            Local                             Environmental
            EPA                               Engineer/Scientist
                                              Attorney
    How many employees are located at your facility (including full-time contractors?)

        0-9       10-49       50-100       101-500       More than 500

-------
Optional (Please Print)

Name:                                  Address:
Title:	City:	State:_

Zip code:	

Organization Name:	
Phone: (  1	E-mail:
Please return all pages (1 thru 3) of this survey by folding pages 1 and 2 into page 3 and using the preprinted, pre-stamped
address on the reverse side of page 3. If you have accessed this document electronically from one of EPA's web sites, simply
e-mail this questionnaire to: satterfield.richard(g)epa.gov.

-------
This Page Intentionally Left Blank

-------
                                       EPA/625/C-05/XXX
                                              May 2005
             HEALTH CARE GUIDE TO
    POLLUTION PREVENTION IMPLEMENTATION
THROUGH ENVIRONMENTAL MANAGEMENT SYSTEMS
                       m  _
            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.

-------
                                      -FOREWORD-
     The U.S. Environmental Protection Agency (EPA) is charged by Congress with protecting the Nation's



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, EPA's 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'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's 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's 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's 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, Acting Director



                                                      National Risk Management Research Laboratory
                                                in

-------
                                  - ACKNOWLEDGMENTS -
      This second edition of the Health Care Guide to Pollution Prevention Implementation through Environmental Management
Systems was developed by the Kentucky Pollution Prevention Center (KPPC) and the United States Environmental Protection Agency
(U.S. EPA) Health Care EMS Workgroup under the leadership of Tim Piero and Linda Longo respectively. The Health Care EMS
Workgroup consists of participants from U.S. EPA; the Veterans Health Administration; the Kentucky Pollution Prevention Center; the
Detroit Medical Center; and the University of Texas M.D. Anderson Cancer Center.

      Health Care EMS Workgroup members from EPA Headquarters offices:
      Office of Enforcement & Compliance Assurance/Federal Facilities Enforcement Office/Planning Prevention & Compliance
        Program (Federal Facilities) - Diane Lynne, Greg Snyder, Will Garvey
      Office of Enforcement & Compliance Assurance/Office of Compliance/Sector Analysis & Implementation Branch (Sector
        Notebook/Compliance Assistance Center) - Seth Heminway
      Office of Prevention Pesticides & Toxic Substances/Office of Pollution Prevention & Toxics/Pollution Prevention Division
        (H2E) - Chen Wen, Paul Matthai, Tom Murray, Christopher Kent, Kathy Davey
      Office of Policy Economics & Innovation/Office of Business & Community Innovation/Sector Strategy Division (Sector
        Strategies) - Shana Harbour, Leigh Cash, Janice Bryant
      Office of Policy Economics & Innovation/Office of Business & Community Innovation/Performance Incentive Division
        (Performance Track Program) - Tim Stuart (retired), Michael Kane
      Office of Solid Waste & Emergency Response/Office of Solid Waste (EMS) - George Faison, Bob Springer, Mimi Guernica
      Office of Air & Radiation/Office of Atmosphereic Programs/Climate Protection Partnerships Division (Energy Star Program) -
        Clark Reed

      Health Care EMS Workgroup members from EPA Regional offices:
      Rl - Martha Curran, Anne Fenn, Janet Bowen
      R2 - John Gorman, Kathleen Malone, Diane Buxbaum, Linda Longo
      R3 - Jeff Burke (retired), William Arguto
      R4 - Dan Ahem, Anthony Shelton, Mark Robertson, Becky Allenbach, Delane Anderson, Stacey Bouma
      R5 - Donna Twickler, Lee Regner, Dolly Tong
      R6 - James Sales, Joyce Stubblefield, Gabriel Gruta
      R7 - Gary Bertram, Ruben McCullers, Diana Jackson
      R8 - Whitney Trulove-Cranor, Dianne Thiel
      R9 - Eileen Sheehan, Piper Stege, Larry Woods, Kelly Doordan
      RIO - Domenic Calabro, Viccy Salazar, Robert Drake, Michael Fagan, Michele Wright

      Health Care EMS Workgroup additional members:
      Kentucky Pollution Prevention Center - Tim Piero, Chris Wooton, Terry Durham
      Hospitals for a Healthy Environment - Laura Brannen
      Detroit Medical Center - Sheila Finch
      University of Texas MD Anderson Cancer Center - John Gamble
      Veterans Health Administration - Arnie Bierenbaum, Jack Staudt, Linda Martin

US EPA Region 2 - Special thanks to the following for compliance section contributions: Adrian Enache, Dan Kraft, Ellen Banner,
Kathleen Malone, Diane Buxbaum, Harish Patel, John Gorman, Phil Greco, Chris Jimenez, Bruce Kiselica, Mike Lowy, Linda Longo.

      Special  thanks to Sheila  Finch (mailto:sfinch@dmc.org) and  the  Detroit Medical Center  and  John Gamble
(mailto:jgamble@mdanderson.org) and University of Texas M.D. Anderson Cancer Center for their input and review for this guide.
      Mention of trade names, products or services does not constitute and should not be interpreted as constituting an actual or implied
endorsement or recommendation for use by the U. S. EPA, the Kentucky Pollution Prevention Center, Detroit Medical Center, the University
of Texas M.D. Anderson Cancer Center, St. Mary's General Hospital, Cambridge Memorial Hospital or any other organization(s) affiliated
with or mentioned in this manual. The tools and examples used to illustrate points made in the text of this manual are provided by the
Kentucky Pollution Prevention Center, Detroit Medical Center, University of Texas M.D. Anderson Cancer Center, St. Mary's General
Hospital and Cambridge Memorial Hospital.
      The term "ISO 14001" may be mentioned throughout EMS implementation in this guide. It is simply the international benchmark
by which EMSs may be audited and registered by an outside third party. ISO 14001 registration is voluntary. A benefit of ISO 14001
registration is that a third party helps maintain a health care facility's focus on maintaining and improving its environmental performance.
However, registration requires extra financial resources and time involved. Health care facilities can still achieve the benefits of an EMS
with or without ISO 14001 registration.
      Considerable effort has been taken to ensure the accuracy of information in this manual. Regulatory requirements can vary based
on locale. Please verify your requirements with applicable federal, state, and local authorities.
                                          May 2005 (September 2002,1st Edition)


                                                        iv

-------
                                       -ABSTRACT-
     Medical waste incineration, persistent bioaccumulative toxins (PBTs) and hazardous material use and
disposal have heightened scrutiny of the health care industry's impacts on the environment. Given the mission
of health care to promote health and wellness, hospitals must proactively manage activities, products and services
to minimize these significant environmental impacts.

     While many hospitals voluntarily undertake environmental initiatives, their efforts often fail due to the
lack of an established and sustainable environmental management system (EMS), which uses proven business
management practices to integrate environmental concerns into an organization's activities, products and services.

     In response, the Kentucky Pollution Prevention Center (KPPC) worked with the United States
Environmental Protection Agency (EPA) and hospital administrators from across the country to revise the
Health Care Guide to Pollution Prevention Implementation through Environmental Management Systems.

     The manual is written for EMS implementers and covers the following key areas:
     •  Strategies for getting started;
     •  Components of an EMS;
     •  Example health care environmental aspects;
     •  Strategies for developing staff buy-in and participation in the EMS;
     •  Focusing on a performance-based, results-oriented EMS;
            •  Setting goals and objectives with specific examples of health care programs;
     •  Implementing and maintaining an EMS.

     The Health Care Guide to  Pollution Prevention Implementation through Environmental Management
Systems provides example EMS procedures and  forms used in four ISO 14001 EMS certified hospitals. The
latest revisions include more EMS hospital case studies, more compliance resources, the KPPC EMS Auditing
Tool,  the EPA Region 1 Compliance Audit Tool, and a supplement to legal and other requirements for EMS
implementation.

-------
                           - TABLE  OF  CONTENTS -
                                                                                   PAGE
Section 1:     Introduction                                                          1
What are Environmental Management Systems? What are the Benefits?                       1
U.S. and Canadian Case Studies                                                        3
       University of Texas M.D. Anderson Medical Center (U.S.)                           4
       Detroit Medical Center (U.S.)                                                   7
       Cambridge Memorial Hospital (Canada)                                          10
       St. Mary's General Hospital (Canada)                                             12

Section 2:     Getting Started                                                        17
Introduction                                                                         17
Structure, Responsibility and Accountability                                             18
       Getting Support and Buy-In for an EMS                                          18
              Senior Management and Board                                           18
       Overview of Hospital Corporate Structure and EMS Roles and Responsibilities          18
              Board of Trustees                                                      18
              Senior Management                                                    18
              Middle Management                                                    19
              Hospital Employees                                                    19
       EMS: Choosing the EMS Representative(s)                                       20
              EMS Management Representative                                        20
              Environmental Coordinator/EMS Specialist                                21
              Choosing the EMS Team                                                21
              Green Team Members                                                   22
              Green Team Expectations                                                22
              Meeting Structure                                                      23
              Reporting Structure                                                     23
       Standard EMS Implementation Cycle                                             24

Section 3:     Components of an EMS                                                25
EMS Component Description                                                          25
Environmental Policy                                                                 26
       Developing the Policy                                                          26
       Things to Consider When Writing the Policy                                       26
       Communicating the Environmental Policy                                         27
              Hospital Staff                                                          27
              Patients, Visitors and the Community                                      28
              Contractors and Suppliers                                                28
       EMS Example                                                                28
Environmental Aspects and Impacts and Determining Significance                           29
       Introduction                                                                  29
              Standard Pick List of Aspects and Impacts                                  31
       Roles and Responsibilities in Identifying Aspects and Impacts                        32
       Determining Significance                                                      32
       Change Management and Continual Improvement                                  33
              EMS Examples                                                        33
                                              VI

-------
       Helpful Hints for Getting Started                                                 33
       EMS Examples                                                                34
Legal and Other Requirements                                                          35
       Additional Information                                                          36
Objectives and Targets                                                                 37
       Setting Performance-Based Objectives and Targets                                  37
       Implementation Tips                                                            37
       Additional Information                                                          38
Environmental Management Programs (EMP)                                             39
       Saint Mary's General Hospital EMP Example                                       39
              Biomedical Waste Reduction EMPs                                        39
              Recycling and Reuse EMP                                                40
              Spill Response and Emergency Preparedness EMP                           42
              Landscaping Practice EMP                                                42
              Mercury Reduction EMP                                                 43
              Additional Information                                                   43
Training                                                                              44
       Contractors and Suppliers                                                       45
       Getting Started                                                                 45
       Lessons Learned                                                                45
Communication                                                                       46
       External Communication                                                        46
       Internal Communication                                                         46
       Contractors and Suppliers                                                       48
       Additional Information                                                          48
Documentation/Document Control                                                       49
       Kinds of Documents a Hospital will have in its EMS                                49
       List of EMS Documents                                                         49
       Additional Information                                                          50
Operational Controls                                                                   51
       Hospital Considerations                                                         51
       Additional Information                                                          51
Emergency Preparedness and Response                                                   52
       Implementation Tips                                                            52
Monitoring and Measurement                                                           53
       Additional Information                                                          53
Nonconformances and Corrective and Preventive Action                                    54
       Additional Information                                                          54
EMS Records                                                                         55
       Additional Information                                                          55
EMS Auditing                                                                        56
       Types of Audits                                                                56
       Internal Auditing Program Components                                            56
       Audit Program Tips                                                             57
       Additional Information                                                          58
Management Review                                                                  59

Section 4:     Continual Improvement                                                61
Pollution Prevention Opportunities for the Health Care Industry                              61
       Introduction                                                                   61
                                               vn

-------
       Materials Management                                                         62
       Environmentally Preferable Purchasing (EPP)                                     63
              EPP Best Practices                                                     64
              Additional EPP Resources                                               64
              Cleaning Products and Chemicals                                         64
              Energy Efficiency                                                      67
              ENERGY STAR: Strategies for Superior Energy Management                 68
                     How Health Care Facilities Can Leverage ENERGY STAR            68
                     ENERGY STAR Tools and Resources Available Online               70
                     Case Study: Shriners Hospital for Children - Houston                 72
                     Join ENERGY STAR                                            73
Additional Pollution Prevention for Hospital Waste Streams                                74
       Chemotherapy and Antineoplastic Chemicals                                      74
       Formaldehyde                                                                74
       Inventory Control                                                             74
       Laundry and Laundry Detergent                                                 75
       Aerosols                                                                    75
       Batteries                                                                    75
       Mercury                                                                     76
              Sphygmomanometers                                                   77
              Gastroenterology                                                       77
              Thermometers                                                         77
              Nonclinical Mercury                                                   77
              Additional Information                                                 78
              Pollution Prevention Opportunities for Mercury                             78
       Pesticides and Landscaping                                                     79
       Polyvinyl Chloride (PVC) and Dioxin                                            79
              Additional Information                                                 80
       Pharmacy                                                                    80
       Radiology                                                                    80
       Recycling/Safe Disposal                                                       81
       Solvents                                                                     82
Conclusion                                                                         84

Appendix A:   EMS Examples                                                       85

Appendix B:   Additional Resources                                                  157

Appendix C:   Kentucky Pollution Prevention Center
              Environmental Management Systems (EMS) Auditing Tool                183

Appendix D:   U.S. EPA Region 1 Compliance Audit Tool                               241

Appendix E:   Compliance - A Supplement to Legal and Other Requirements             251
Federal Regulation of Medical Waste                                                   251
       Code of Federal Regulations and the Federal Register                               252
Clean Air Act (CAA)                                                                 252
       Air-Conditioning and Refrigerator Service                                         253
       Asbestos                                                                    253
       Boilers                                                                      253
                                              Vlll

-------
       CAA Title V Operating Permit                                                  254
       Medical Waste Incinerators                                                     254
Clean Water Act (CWA)                                                               255
       Wastewater Dischargers                                                        256
              Indirect Dischargers                                                    256
              Direct Dischargers                                                     257
       Stormwater Discharges                                                        257
       Aboveground or Underground Oil Storage Containers                              258
Emergency Planning and Community Right to Know Act (EPCRA)                          259
Federal Insecticide, Fungicide and Rodenticide Act (FIFRA)                                261
Resource Conservation Recovery Act (RCRA)                                            263
Safe Drinking Water Act (SDWA)                                                      266
Toxic Substances  Control Act (TSCA)                                                  268
U.S. EPA Voluntary Audit Policy                                                       269
U.S. EPA National Environmental Performance Track Program                              273
       Standard Criteria for Program Eligibility                                          273
              Environmental Management Systems (EMS)                               273
              Continuous Improvement Criteria                                        274
              Community Outreach                                                  274
              Sustained Compliance                                                  275
              Small Business Criteria                                                 276
Other Organizations                                                                  277
       American Hospital Association (AHA)                                           277
       Hospitals  for a Healthy Environment (H2E)                                       277
       Joint Commission on Accreditation of Healthcare Organizations (JCAHO)             278
                                              IX

-------

-------
- SECTION 1 -
INTRODUCTION

What are Environmental Management Systems?
What are the Benefits?

Environmental management systems (EMS) represent a new and systematic approach to environmental
performance. Successful EMSs apply the building blocks of effective organizational management to
environmental performance through accountability, assigned responsibilities, employee involvement, written
policies, training, corrective action, senior management review and senior staff involvement. All components
work together to continually improve a hospital's environmental performance.
An EMS challenges an organization to identify its most significant environmental issues and to
address these through objectives and targets. By using pollution prevention in this process, a hospital can
achieve improved operating efficiencies and cost savings through implemented waste reduction and energy
efficiency opportunities. This provides economic benefit increasingly important to successful hospitals.
The most effective EMSs are built with the hospital mission in mind: patient and community health
and well-being. This mission should be used to help determine which of a hospital's environmental issues are
most significant. This gains support for the EMS both inside and outside of the hospital. Inside the hospital,
management and staff see how good environmental performance supports the mission, helping the EMS
become part of how things are done. Outside the hospital, it demonstrates good corporate citizenship which
is respected in the community. U.S. EPA offers programs such as the National Performance Track Program
and the Voluntary Audit Program, which provide additional recognition opportunities that capitalize on EMS
success.
Atypical hospital can build an EMS on many of the organization's practices already in place through
other requirements such as the Joint Commission on Accreditation of Healthcare Organization (JCAHO),
other state and federal regulatory requirements and other facility-wide mission statement/goals. For example,
the JCAHO Environment of Care standard contains numerous opportunities for managing environmental
operations, procedures and staff training. An EMS encompasses these requirements together and give staff an
important opportunity to play in minimizing hospital waste and preventing compliance violations. As
- 1 -

-------
compliance is a core component of environmental performance, this manual features an updated section on

common federal environmental compliance requirements in the health care industry.

Building an EMS to fit a hospital's needs can be done within a small area of the hospital or for the

entire hospital all at once. Applying the EMS concepts to one department initially can help identify gaps and

determine where to improve for the next department or for the entire hospital. By starting with a smaller area,

required staff resources can be less intense and lessons learned can be applied to streamline subsequent

efforts later on.

This manual is organized following successful implementation of EMSs in numerous organizations

health care and private industry organizations. The manual describes each part of an EMS and provides EMS

examples (including EMS documentation) that can be downloaded and adapted for the reader's own use. It

also provides useful references to other programs and web links, information on U.S. EPA voluntary programs

and federal compliance resources to help in understanding applicable legislation. Immediately following are

case studies featuring both U.S. and Canadian hospital experience in implementing and benefiting from an

EMS. All of the hospital examples that follow have an ISO 14001 registration for their EMS program. An ISO

14001 registration is not required and a hospital can achieve the same benefits from an EMS whether or not it

pursues registration.
-2-

-------
         - U.S. AND CANADIAN CASE STUDIES -
                      Table of Contents
                                                      PAGE No.
I.   University of Texas M.D. Anderson Cancer Center
II.  Detroit Medical Center
III.  Cambridge Memorial Hospital                           10
IV.  St. Mary's General Hospital                             12

-------
Click here to return to U.S. and Canadian Case Studies Table of Contents.
I. The University of Texas M.D. Anderson Cancer Center
The University of Texas M.D. Anderson Cancer Center knows how to take care of its patients and its

community. Under the guidance of Linda Lee, Executive Director of Environmental Health, the health care

facility achieved International Organization for Standardization (ISO) 14001 and Occupational Health and

Safety Assessment Series (OHSAS) 18001 registration-an unprecedented effort in the U.S. health care

industry. M.D. Anderson Cancer Center management chose an Environmental Health & Safety

Management System (EHSMS) approach to elevate Environmental, Health and Safety (EHS) programs from

compliance to a leadership level. Lee also credits the EHSMS with assisting the center's ongoing efforts to

operate safely for its patients and the community, to meet compliance efforts and implement best practices.

Such innovation is encouraged at M.D. Anderson Cancer Center, a research-driven cancer center with

the mission to eliminate cancer in Texas, the nation and the world through outstanding integrated patient

care, research, education and prevention programs. For Lee, it made sense to implement a comprehensive

EHSMS within the center's Facilities Management Division, which consists of 1,400 employees who work

at the center's main campus in Houston and the Science Park campus in Bastrop, Texas.

"M.D. Anderson Cancer Center's EHS programs continue to grow together," says Lee. "We focused on

the center's Facilities Management Division because many of the environmental impacts reside here. We

needed to consider these programs more holistically."

Initially, Lee began EHSMS efforts by taking on many of the responsibilities of implementation within

the Environmental Health and Safety Department. "It was our product to begin with, but I soon learned that

the nature of the work was going to require spreading responsibility around the division. And really that's

what a systems-based approach is meant to do."
-4-

-------
Lee initially relied on representatives, or "champions" from each of the eight departments within the

Facilities Management Division to promote and complete the EHSMS efforts in their respective areas. Lee

expanded this effort into what she calls the "systems and programs champions" concept in which the

EHSMS is now broken down into program and media areas-air, safety, construction, water, etc.-with a

representative from each program area along with champions on the EHSMS systems side.

The EHSMS Work Group led by John Gamble, Director of Environmental Quality, Matt Berkheiser,

Occupational Health and Safety Programs Manager, and Devina Patel, JCAHO programs manager, provide

overall EHSMS direction. Environmental health and safety staff provided EHSMS training to hospital staff

during initial implementation efforts and continue to provide EHSMS training as part of orientation training

for new employees.

The EHSMS Work Group drives the significant environmental aspects identification process through

the EHSMS Core Team. The team is made up of representatives from each facilities management

department. They help promote EHSMS throughout the center and provide input on the significant

environmental aspects. The final aspects list is presented to the vice president of operations for review and

approval.

Gamble credits the risk discovery process for identifying opportunities for improvement in pollution

prevention, reduction of accidents and energy conservation. Key targets are set for each of these objectives.

This discovery, hazard prioritization and risk management have been the greatest benefits of the EHSMS

says Gamble since, "it allows us to focus our efforts and resources."

M.D. Anderson Cancer Center's environmental management program (EMP) targets in energy

conservation, pollution prevention and chemical procurement facilitated the hospital's participation in U.S.

EPA's Performance Track Program, which looks for measurable and continually improving environmental

performance, something that M.D. Anderson Cancer Center already tracks and reports semiannually

through its EHSMS. Gamble says, "The EHSMS helped make our existing monitoring and measuring

efforts more robust." The center also launched a comprehensive environmental health and safety

compliance initiative in parallel to its EHSMS system auditing program. Both programs are now

integrated. Task and process mapping will add additional sustainability to the EHSMS program.

Gamble also notes that EHSMS brings environmental visibility and management of environmental

change to the center's construction projects. Project managers are more aware of environmental issues and
-5-

-------
can now navigate through the maze of environmental impacts with the Project Managers Handbook for

Construction Safety and specific environmental health and safety design criteria.

     Hospitals may or may not choose to pursue ISO 14001 and OHSAS 18001 registration, but Gamble

stands by M.D. Anderson Cancer Center's decision to do so.

     "We see the value in a third party auditor coming in every six months to examine what we do," says

Gamble.  "It helps drive continual improvement and maintain focus on the system and environmental health

and safety performance results."
   John H. Gamble, P.E.
   Director of Environmental Quality
   University of Texas M.D. Anderson Cancer Center
   Houston, Texas 77030
   Tel:       (713) 745-1422
   Fax:       (713) 745-2025
   Email:     mailto:jgamble@mdanderson.org
                                              -6-

-------
Click here to return to U.S. and Canadian Case Studies Table of Contents.
II. Detroit Medical Center
— '
—
'r-'S^^ '^-"-.'
Detroit Medical Center (DMC) is the city's leading health care system and largest private employer

with more than 13,000 employees. Comprised of 10 hospitals and institutes, two nursing centers and more

than 50 primary care practices throughout southeast Michigan, the DMC medical system features 2,000

licensed beds, 3,000 affiliated physicians and is the teaching and clinical research site for Wayne State

University.

Following this spirit of community leadership, DMC's board of directors expressed interest in having

a system-wide plan to assure compliance with applicable laws and regulations and to track ever-changing

environmental standards.

"Senior management saw the EMS approach as the most effective and efficient way to achieve

management of the environmental processes," says Sheila Finch, DMC's Interim Director of Environment

of Care and ISO Administrator. The DMC achieved the ISO 14001 registration in December 2001 making

it the first hospital in the United States to achieve registration in the environmental system.

Finch credits this top management support and teamwork throughout DMC for success in EMS

implementation and operation. DMC organized EMS teams at each facility. The safety officer led the

teams. Members of the team were comprised of representatives from key stakeholders with environmental

process functions. The safety officers served as the site management representatives and helped to

facilitate the EMS process in the facility. Pharmacy, environmental services, laboratory, epidemiology

(infection control), plant operations, patient care services, radiology/nuclear medicine, respiratory and

food and nutrition services were key members of the site team. A DMC management representative

functioned as the corporate oversight representative for the EMS/ISO 14001 implementation.
-7-

-------
Facility teams were also essential in taking the EMS message to their facilities including the medical

staff. Teams provided EMS awareness training and updates through department meetings, email and

newsletters. Posters, flyers, reminder cards on identification badges and computer-based training modules

were developed for employees. Training was one of the most important resources committed to EMS

implementation.

"At first, the EMS was viewed as additional work and a separate program. Now the EMS process is

viewed as an expansion of the JCAHO Environment of Care Standards. Utilizing the JCAHO

Environment of Care Standards as a baseline, EMS was implemented to improve environmental processes,

identify pollution prevention initiatives, address environmental regulations and identify cost savings by

improving efficiency of the processes. Integration of EMS standards with established processes helped to

make a smooth transition, gain support and help the staff relate to the EMS program," says Finch.

According to Finch, the staff's challenge was to learn and understand the EMS/ISO terminology.

There were many similarities. The "Plan, Do, Check, Act" in EMS was similar to the JCAHO model of

"Design, Implement, Monitor and Measure." EMS management programs were similar to the JCAHO

performance improvement initiatives, and EMS determination of significant environment aspects was

similar to the JCAHO emergency management requirement for performing a hazard vulnerability study.

Finch constructed a crosswalk comparison that linked each EMS requirement to the DMC-related policy.

Finch states that the most challenging EMS element was the development of the environmental

aspects. "This element was tedious, time-consuming and a little frustrating at times," she says. "Aspects

is not a term used in health care and thus required many sessions to complete the "Master Environmental

Aspects List." Departments worked together to identify the aspects. Identification of activities and

services was the starting point. Once that was developed, staff was asked the consequence of ignoring or

not addressing the aspect to the environment; that determined the impacts."

One lesson learned was to implement discovery methods to capture more quantitative, baseline data

early in EMS implementation on environmental performance.

"It is difficult to go back and capture EMS-related cost data, number of training hours and the like,"

says Finch. "But we are beginning to see tangible, quantifiable achievement from three years of EMS

operation, mostly in cost savings from medical and solid waste reduction." There are additional intangible

benefits to having an EMS states Finch. "We see achievements in process improvements and level of

ownership,

-------
increased regulatory compliance, more pollution prevention initiatives and an overall increase in

environmental awareness as part of how we do business."

     With any new process there are lessons learned, adds Finch. Implementation lessons learned that

Finch would not change were: involving key stakeholders in the implementation phase; maintaining shared

electronic files with EMS resources for each site management representative; use of templates, flow

sheets, quick reference tools and preprinted forms to help communicate the EMS process; and involving

staff in the setting of objectives and targets.

     Things that Finch would change if implementing the system today include: providing more resources

to key stakeholders; spending more time on training the staff on the terminology differences; the use of

existing management tools, including financial accounting methods in the EMS design phase;  and

identifying personnel that would be responsible for legal and other requirements.

     There have been benefits outside of the traditional environmental arena.  Communication, initially a

challenge because of the breadth and scope of EMS implementation efforts, became one of the chief

benefits.

     "We established 'read-only' access to a shared electronic folder for key stakeholders and provided

templates, flow sheets, quick-reference tools, preprinted forms and templates that helped communicate the

EMS process quickly and efficiently," states Finch. "As we implemented, we really saw strong

communication take root across the facilities that resulted in expertise sharing, a spirit of cooperation and

team building that comes from working for a common goal."
     Sheila A. Finch, CHSP, CHMM, M.S. MT(ASCP)
     Interim Director, Environment of Care/ISO Administrator
     Detroit Medical Center
     6071 West Outer Drive
     Detroit, Michigan 48235
     Attn: Sinai-Grace Hospital L439
     Tel:      (313)966-1297
     Email:   mailto:sfinch@dmc.org
                                               -9-

-------
Click here to return to U.S. and Canadian Case Studies Table of Contents.
III. Cambridge Memorial Hospital
Cambridge Memorial Hospital (CMH) is a 277-bed facility that provides the 120,000 residents

of Cambridge and North Dumfries, Ontario, Canada, with acute, ambulatory and long-term care

services. This health care facility was the first hospital in North America to implement an EMS and

obtain ISO 14001 registration.

During recent years, the board of directors established a new vision, moving from a model of

"curing the sick" to one focused on improving the health of the community and the local

environment. Implementing an EMS was seen as a milestone in achieving this vision.

In June 1998, CMH's board of directors approved an environmental policy for the hospital,

which marked the beginning of EMS implementation. Work on the EMS implementation continued

through year 2000.

Cambridge Memorial achieved a 20 percent reduction in biomedical waste in each of the first

two years of EMS operation. The hospital implemented an integrated pest management program,

eliminating the use of chemical pesticides and herbicides and added criteria for energy conservation

into the process of selecting new products and equipment. As part of its chemical substitution

program, CMH initiated a mercury-free medicine campaign to phase out products containing mercury

and eliminate the release of mercury into the environment. Prior to EMS inception in May 1998, the

hospital shut down its 25-year-old incinerator, eliminating its contribution to local air pollution and

reducing greenhouse gas and energy consumption. Staff training and community awareness is key to

meeting the hospital's environmental goals. CMH actively pursues Green Team initiatives to promote

environmentally friendlier and healthier alternatives to transportation, such as carpooling, public
-10-

-------
transportation, biking, walking, etc.

Sustainable building design is a key element used in planning a new 115,000-square-foot

addition to the hospital, which has participated in the Commercial Building Incentive Program

(CBIP) and C-2000 Advanced Commercial Building Program through the Office of Energy Efficiency

in Natural Resources Canada. CBIP buildings must use less than half the energy of conventionally

designed buildings.

The CMH Green Team made a formal pledge to develop a comprehensive program to eliminate

the release of mercury to the environment. A mercury audit was completed to identify all mercury

sources. Twenty-one staff members representing three hospital areas received educational in-service

sessions to alert the staff about mercury spills response procedures as well as the environmental and

health consequences of the use of mercury. Measures continue to be implemented to phase out

products containing mercury, such as blood pressure measuring devices. A final sweep through CMH

was completed to verify that all mercury blood pressure cuffs and thermometers have been properly

removed and replaced.

CMH pledged a 30 percent reduction in biomedical waste as part of the Ministry of the

Environment P2 Pledge Program (P4). The P4 program is a voluntary initiative that encourages

companies and organizations to commit to reducing pollutant releases, hazardous or liquid industrial

waste or toxic chemicals. Cambridge's reduction in biomedical waste in 1999 earned the P3 (People,

Prosperity and the Planet) Reduction Achievement Award. CMH continued its track record with a 20

percent reduction in 2000.

CMH credits the Green Team's approach with speeding EMS implementation efforts and

providing not only an effective training outreach mechanism throughout the hospital, but also a

support network for EMS implementation efforts as well.
Mary Jane Hanley, Environmental Specialist
Cambridge Memorial Hospital
700 Coronation Boulevard
Cambridge, ON N1R3G2
Tel: 519-621-2333ext.l720
Fax: 519-740-4928
Email: mailto:mhanley@cmh.org
-11 -

-------
Click here to return to U.S. and Canadian Case Studies Table of Contents.
IV. St. Mary's General Hospital
St. Mary's General Hospital is a 168-bed facility that serves nearly 500,000 people in southern

Ontario. St. Mary's was recently designated the region's Cardiac Care Center.

The hospital began to develop its EMS under a university-planned venture between St. Mary's,

Cambridge Memorial Hospital, Cambridge, Ontario, and the University of Waterloo, Waterloo,

Ontario. In October 2001, St. Mary's became ISO 14001-registered, the second North American

hospital to achieve this distinction. As a result of the hospital's EMS, St. Mary's has been the

honored recipient of a number of provincial and regional awards.

Board of Trustee environmental concerns about chemical usage spearheaded an initial

investigation of how the hospital managed its environmental affairs. Investigation results led to

additional board and senior management-level discussions concerning other environmental issues and

identified the need for the hospital to proactively address its internal and external environment.

After reviewing recommendations outlined in reports from a local university environmental

class, the hospital's Director of Facilities Services brought the idea of an EMS to senior management

and the Board of Trustees. The Board hired a recent graduate to implement the EMS. Through this

joint effort with Cambridge Memorial, St. Mary's planned, developed and implemented its EMS

using the ISO 14001 standard as a guide.

St. Mary's is committed to promoting "Health care for a healthy environment," and through

continual environmental education, promotion and awareness, all levels of hospital staff and

volunteers are aware of and participate in the hospital's environmental pledge.

Principle EMS accomplishments to date include the following:
- 12-

-------
Waste Management

Improved biomedical waste segregation and establishment of comprehensive recycling

programs are two key achievements. Since 1998, St. Mary's has reduced biomedical waste by 38

percent by weight and implemented programs to recycle the following:
• Glass, cans (aluminum and steel), plastic, newspaper, cardboard, boxboard, paper (all
grades), alkaline and nickel-cadmium batteries, all types of metal, photocopier cartridges,
cold packs, Styrofoam boxes.
• Fluorescent tubes. St. Mary's recycled the mercury, glass, aluminum and phosphor powder
in more than 2,000 florescent tubes.
• Cardboard through a take-back program with its suppliers.
• Unused patient and cafeteria food through a local organics composting company.
• Biomedical waste containers through newly selected medical waste hauler.

Energy Conservation

St. Mary's "energy plan" addresses new construction and renovation projects; equipment

(lighting, powerhouse equipment, etc.); and internal energy education/communication of hospital

staff. The hospital formed a multidisciplinary team of energy conservation consultants, architects,

mechanical and electrical engineers to design an energy-friendly addition to house its new Cardiac

Care Center. Design plans will allow St. Mary's to reduce energy usage 30 percent compared to

conventionally designed buildings.

In addition, St. Mary's:
• Purchased a hydro usage software program to identify and target energy usage patterns;
• Performed a steam trap survey and implemented resulting recommendations;
• Replaced all T12 fixtures with more energy-efficient T8s;
• Developed an energy education program with a mascot that provides energy tips and
reminders;
• Formed an "Energy Team" to standardize purchases of energy-conserving office equipment
and small appliances;
• Plans to upgrade to more energy-efficient windows.

Landscape Management

In 2000, St. Mary's was among the first hospitals in Ontario to eliminate chemical pesticide and

herbicide usage on hospital grounds. By working with the hospital's current landscaping company

and landscaping professionals, St. Mary's maintains a healthy, chemical-free landscape. St. Mary's

no longer mows on smog-alert days. Newly designed landscape plans will incorporate, where

possible, drought-resistant/salt-tolerant/native plants, ground covers and other environmentally

conscious options.
- 13-

-------
Alternative Transportation

To promote green transportation, St. Mary's:
• Circulated an Employee Alternative Transportation Survey for staff to evaluate
transportation habits and identify future initiatives that the hospital staff would like to see;
• Purchased additional bicycle racks;
• Implemented a "Share-a-Ride" program on the hospital's internal email system that allows
staff wishing to carpool to find another individual in their area.
This goal is ongoing, and future plans provide staff with discounted bus passes, safe biking

lessons and improved showering facilities.

Chemical Recycling & Wastewater Discharges

St. Mary's is a member of the Health Care Without Harm's Mercury Medicine Campaign. To

date, the hospital eliminated all mercury-containing devices in patient care areas. The hospital works

to identify alternatives for pressure and floating switches in powerhouse equipment and to find a

replacement for the mercury thermometer standard for calibrating medical equipment.

Through a regional business water quality program, St. Mary's has identified and remediated

many water-polluting processes. In particular, St. Mary's installed xylene and formalin recycling

equipment and eliminated related discharges.

Senior Management Approval and Support

Senior management support and buy-in is critical and needs to be communicated to all staff

prior to starting the process. A letter of support circulated throughout the hospital is one way to

communicate this support.

Staff Involvement

Everyone has responsibilities under the EMS - not just the EMS management representative.

Be sure to ask staff (front line, nursing, physicians and management) to participate in the EMS

wherever and whenever possible (e.g., Green Team, hospital auditing team, implementing objectives

and targets, fun initiatives, etc.).

Integration of Documentation

Designing an EMS involves the development of policies, procedures and work instructions by

the EMS representative and department managers/supervisors. Integrate document formats with the

hospital's existing systems.
-14-

-------
Recognize the Efforts of Individuals and Departments

     To maintain momentum, formally recognize individuals and departments that demonstrate

enthusiasm, participation and involvement in the EMS.

Be Creative

     Come up with fun ideas and initiatives to get staff involved. Use existing national holidays,

such as Earth Day, to organize fun events.
Shannon-Melissa Dunlop, Environment, Health and Safety Specialist
St. Mary's General Hospital
911 Queens Boulevard
Kitchener, ON, Canada
N2M 1B2
Tel:        (519)749-6406
Fax:       (519)749-6426
Email:     mailto:sdunlop@stmaryshosp.on.ca
                                           -15-

-------

-------
- SECTION 2 -
GETTING STARTED
Introduction

Getting started on an EMS can be a daunting experience, making top management support and a team

approach vital to success. Getting started requires senior management approval and buy-in. Management

needs to understand the benefits of the EMS, why it will be good for the hospital and how it will save the

hospital money. Keep in mind that cost savings from pollution-prevention projects (including energy

efficiency) is just one benefit to communicate to management. EMSs also provide improved operational

efficiencies, increased staff ownership of environmental performance and opportunity for enhanced hospital

image in the community.

An EMS does not have to be established for the entire hospital. It can simply focus on a smaller area

within the hospital (one or more departments). Possibilities include facilities maintenance, purchasing, food

services or environmental services. Starting on a pilot scale allows transfer of "lessons learned" to other

departments later in their implementation. A team effort includes laboratory staff, food service personnel,

facilities management, the surrounding community as well as top management. This bottom-up philosophy

to getting started and understanding all roles will make the EMS experience more productive and meaningful

in the end.

Also consider the benefits of International Organization for Standardization (ISO) 14001 registration.

While there are other EMS certification organizations [e.g., Code of Environmental Management Principles

(CEMP)], ISO 14001 is the most commonly used standard to benchmark EMSs. The decision to pursue ISO

14001 is completely voluntary and involves third party auditing of the EMS. This "outside set of eyes" often

helps a hospital maintain and improve its environmental performance, foster a continual improvement ethic

and contributes to a more efficient and maintained EMS.

However, registration requires extra financial resources and time involvement. Health care facilities

can still achieve all of the benefits an EMS provides with or without ISO 14001 registration. This manual is

designed to assist with implementation of a successful EMS in either case.
-17-

-------
Structure, Responsibility and Accountability

Getting Support and Buy-In for an EMS

Senior Management and Board

It is essential to gain senior management and board support before implementation. Schedule a meeting

with senior management to discuss and provide the following:
• A description of what an EMS is and why it will benefit the hospital.
• The environmental issues, particularly compliance-related, that the hospital currently faces (highlight
environmental legal concerns and due diligence issues, such as incineration, biomedical waste,
hazardous waste, PVC/mercury, spill response, etc.).
• The expected resources and time requirements for initial development and implementation of an EMS.
• Senior management's roles and responsibilities in implementing and maintaining the EMS.

Overview of Hospital Corporate Structure and EMS Roles and Responsibilities

While internal management structures may vary from hospital to hospital, all operate with distinct levels

of senior management, middle management and associates. All levels have active roles to play in

environmental management.

Board of Trustees

This governing body is often comprised of hospital staff as well as community and health care

professionals. Board members are responsible for the overall direction and planning of the hospital. Trustees

approve corporate programs, make significant hospital decisions and discuss current and future hospital

initiatives. Their EMS responsibilities should include the following:
• Establish the environment as a priority by approving and abiding by the environmental policy.
Support cost-effective environmental initiatives that protect the hospital from legal and financial
liability and promote environmental health in the community.
Look to board members as potential environmental allies. Board members may live in the local

community and share the same environmental concerns as staff and local residents. Tap into these influential

and professional resources for EMS implementation support.

Senior Management

Senior management consists of the president, chief executive officer and vice presidents/directors/

program managers from various functional centers throughout the hospital. These managers plan present and

future hospital programs/operations and ensures that they remain efficient, effective and fiscally responsible.

The decision to implement an EMS should first be presented to and approved at the senior management
- 18-

-------
level prior to going to the board for comments and final approval. Senior management is the first line of

communication to the board of trustees and is often aware of agenda items and topics to be reviewed at

monthly board meetings. The hospital's senior management team also approves and allocates funds for the

hospital's upcoming operating budget. Senior management's EMS responsibilities include the following:
• Approve the overall EMS and ensure that EMS remains suitable, adequate and effective.
• Appoint EMS representative(s). Define EMS management representative and EMS administrative
representative positions as job functions (either one person with a dual role or two separate
positions). For more information, see the "Choosing the EMS Representative" in this section.
• Establish the environment as a priority by approving and abiding by the environmental policy.
• Support cost-effective environmental initiatives that protect the hospital from legal and financial
liability.
• Ensure that the resources (e.g., human, physical and financial) essential to the implementation and
continuation of the EMS are available.
• Conduct management review of the EMS.

Without senior management support, the EMS will likely fail.

Middle Management

Hospital middle management includes program/department managers, supervisors and coordinators that

oversee the day-to-day management of such hospital programs as patient services, support services and

facility management. Middle management plays a significant role in the EMS, particularly in the follow-

through stages associated with staff environmental training, awareness activities and standard operating

procedures. Middle management EMS responsibilities include the following:
• Implement, comply with and maintain the EMS within the scope of their functional roles.
• Comply with all applicable environmental requirements, policies and procedures.
• Attend EMS general awareness training.
• Ensure employees are given the time and opportunity to attend EMS and other relevant environmental
training, participate as auditees and auditors (as interested or chosen) and assist in writing effective
work instructions for their respective work areas.
Hospital Employees

Excluding management, hospital employees include physicians/doctors, nurses, specialists,

technologists, support staff and all other union and nonunion staff. Hospital employees' responsibilities

include the following:
• Implement, comply with and maintain the environmental management system within the scope of
their functional roles.
• Comply with all applicable environmental requirements, policies and procedures.
• Attend EMS training, participate as auditees and auditors (as interested or chosen) and assist in
writing effective work instructions for their respective work areas as it relates to EMS objectives.
• Give ideas to middle management on how the system can be improved, provide feedback on EMS
-19-

-------
and waste minimization ideas.

Recruit keen frontline staff to assist with identification and communication. Ask each department to

designate one employee as an EMS contact or delegate. Use this person to transfer environmental

information to and from the department.

Choosing the EMS Representative(s)

Depending on the management structure, there are a number of ways to delegate responsibility for

developing an EMS. Some organizations have two individuals who coordinate all aspects of the EMS -

usually an existing hospital management representative at the senior administration level that functions as the

EMS management representative and an environmental coordinator/EMS specialist at middle management or

specialist level.

The environmental coordinator/EMS specialist performs the majority of EMS procedure development

and hospital-wide communication. In turn, the EMS management representative, with the ability to allocate

funds, approves all resulting EMS-related procedures and programs. This structure ensures that a hospital

management representative oversees the performance of the environmental coordinator/EMS specialist and

the overall system performance.

EMS Management Representative

In two of the case study examples, the senior management position responsible for materials

management and support services (e.g., housekeeping, maintenance, nutrition, purchasing, sterilization,

waste, health and safety, etc.) was appointed as the EMS management representative. This is because many

of the perceived high-risk or environmentally significant issues fell within these departments. The

responsibilities of the EMS management representative include the following:
• Provide leadership in environmental management and environmental performance.
• Ensure that the resources (e.g., human, physical and financial) essential to the implementation and
continuation of the EMS are available.
• Review and define employee roles and responsibilities as they relate to the EMS.
• Provide feedback and sign off on EMS team requests as appropriate.
• Report on the performance of the EMS to senior administration for review.

The EMS management representative's position should receive acknowledgment and support from the

hospital's senior administration. (See the "Interoffice Memo" on page 86.)
-20-

-------
Environmental Coordinator/EMS Specialist

When selecting the environmental coordinator/EMS specialist, consider these main things:
• Knowledge of environmental programs and issues
• Knowledge of basic EMS elements
Knowledge of the ISO 14001 standards
• Experience in developing and leading training sessions
If internal resources are available, assign the role of environmental coordinator/EMS specialist to a staff

member (possibly someone in the health and safety department with environmental interest). If not, hire

someone to fulfill the role (which is often the case). EMSs are still new in the health care sector and it may

be unlikely to find an individual on staff who has both hospital knowledge and EMS experience. More often,

someone with environmental knowledge is hired and learns the industry.

Consider hiring a student to assist with EMS development, or recruit local college students with an

interest in the environment and knowledge of ISO 14001 to help with EMS development. Students are

enthusiastic and are willing to learn the necessary skills of EMS implementation at a fraction of the cost of a

full-time professional.

Choosing the EMS Team

In health care, it is a common practice for management to assemble multidisciplinary teams of hospital

staff for development and implementation of new patient care programs. Likewise, a multidisciplinary

"Green Team" can help develop EMS objectives and targets, awareness programs, research and staff

communications.

When considering who should be a member of the hospital's Green Team, identify departments that

traditionally have many environmental issues. EMS team members should have substantial knowledge and

experience in these areas. For example, many facilities adopt waste management issues as an initial EMS

objective or environmental program. Typically custodial services handle waste management and would be

good to include as would those who generate waste.

Secondly, it is essential to have representation from management and other departments that influence

the decision-making process of environmental programs. For example, the purchasing department is

responsible for products, services and equipment brought into the hospital, communicates with contractors

and suppliers on a regular basis and is closely linked to the finance and other departments. Purchasing can be

a key player in "green procurement," which is critical when working on reducing polyvinyl chloride (PVC)

medical supplies, mercury thermometers and disposable versus reusable products. The largest group will
-21 -

-------
probably be medical and/or nursing staff; therefore a medical/nursing representative should be on the team.

A member from the financial department can prove beneficial to the Green Team. When determining

significant aspects and impacts, the Green Team member from the financial department can provide specific

cost information for different processes and procedures. This type of accounting for information related to

specific environmental activities is called Environmental Management Accounting. Environmental

Management Accounting (EMA) makes capital investment decisions, process/product design decisions and

performance evaluations. EMA differs from traditional accounting in that it includes societal and private

costs across the entire life cycle of an activity or use of a product. This accounting provides a more accurate

cost assessment during the significance determination step in an EMS. Visit http://www.epa.gov/oppt/acctg/

indexold.html for more information.

Green Team Members

The Green Team should represent key departments in the hospital - especially those that deal firsthand

with environmental issues. An ideal Green Team will consist of members from the following areas:
• Purchasing • Nursing
• Housekeeping • Finance
• Management • Worker representation
• Surgery • Laboratory
• Cafeteria • Facilities Management
• Infections Control • Safety and Health Coordinator

Green Team Expectations

The Green Team's role in EMS planning and implementation may differ from site to site. The following

is a list of possible responsibilities for the Green Team:
• Aid in the identification of environmental aspects, associated impacts and determination of
significant aspects.
• Provide input into the development of environmental objectives and targets, environmental
management program(s) and other related EMS programs (e.g., members as "champions" of certain
objectives).
• Assist in the development and maintenance of EMS documents, particularly work instructions that
may apply to specific areas.
• Help identify the hospital's training needs. Train individuals on the EMS, the environmental policy,
objectives and targets applicable in their work areas and work instructions to follow in order to
meet the objectives and targets or otherwise minimize environmental impacts.
• Facilitate communication with frontline staff concerning environmental issues and relevant sections
of the EMS. Direct questions, issues and any external communications to the EMS representative(s).
• Provide input on environmental issues that may affect the hospital.
• Build enthusiasm in the hospital for environmental performance, programs and changes.
• Make recommendations for continual improvement in the hospital's environmental performance.

-22-

-------
These responsibilities should be clearly explained and communicated to all members during the first few

Green Team meetings to ensure that everyone clearly understands their roles and the team's focus.

Meeting Structure

The Green Team may need to meet monthly as various components of an EMS require input on a regular

basis. If it is possible to meet at this frequency, utilize interhospital communication modes such as email and

interdepartmental mail between formal meeting as needed. Set meeting agendas and keep them. People

become less attentive if meetings continue past the allotted time. Designate someone to take notes/minutes of

each meeting. Minutes document proof of meetings and discussions EMS internal audits and external audits

(if ISO 14001 registered).

Promote open dialogue and communication among members. Begin meetings with "icebreakers" to

introduce members to one another. Incorporate short activities into the team's agenda to facilitate members'

discussion of environmental issues in health care, their communities and their neighborhoods. Provide

education, information and an inclusive environment during meetings. Open discussion of issues is essential

to the progression of the EMS and the success of the team's goals.

Reporting Structure

The Green Team should report back to the EMS coordinator as necessary (e.g., quarterly updates,

monthly reports and annual reports). When the team focuses on specific EMS-related decisions, such as

recommending/setting environmental objectives and targets, they must report back to senior management for

budgeting approval.
-23-

-------
 O
 >
O

 c
 o

 CB
  M

  5


  3)
 E

CO
LJJ
                            ID

                            ,£3
I
o
o
a

a

o
c.

b
ID
                               ti
                                  ca
 ID

."s
 O
                                  ID
                                     U  60
                                     ••S  S
                                     .£ 'H,
 « ID
-g ft  .S


'-S c  o
 M O  -TJ
'S 'J3  ID
 •3 nS  -tJ

 g,-  d

 o
                       ID
                    4_i  trt
                    f3  
-------
     - SECTION 3 -
COMPONENTS OF AN EMS
EMS Component Descriptions
ENVIRONMENTAL
POLICY
PLANNING
IMPLEMENTATION & OPERATION
CHECKING &
CORRECTIVE ACTION
Environmental
Aspects and
Impacts
Legal and Other
Requirements
Environmental
Objectives and
Targets
Environmental
Management
Programs
Structure and
Responsibility
Training,
Awareness and
Competence
Communication
EMS
Documentation
Document
Control
Operational
Control
Emergency
Preparedness and
Response
Monitoring and
Measurement
Nonconformance
and Corrective
and Preventative
Action
Records
EMS Audits
MANAGEMENT REVIEW
A statement of a hospital's
commitment to compliance, pollution
prevention and continual improvement.
An analysis of the hospital's activities,
products, services to identify those that
may have a "significant" impact on the
environment.
A method of identifying, applying and
updating all environmental compliance
requirements.
Set achievable goals based on the
hospital's significant aspects or issues,
legal requirements, financial
capabilities, etc.
Develop specific actions; designate
resources and timelines for the
completion of environmental
objectives and targets.
Determine responsibilities under the
EMS (to ensure that adequate
resources are allocated).
Ensure that hospital staff receives
training that relates to their
environmental responsibilities.
Establish methods for relaying and
documenting environmental
communications with staff, patients,
visitors, contractors, etc.
Maintain all EMS-related
documentation to ensure that they are
available and up-to-date. Promptly
remove obsolete documents.
Ensure that all documentation
(policies, procedures, etc.) are
controlled, dated, approved and
reviewed.
Review operating procedures that
relate to positions/processes to address
significant environmental impacts.
Train staff on the importance of
conforming to the procedures.
Establish procedures to address
environmental disasters and accidental
releases to air, land and water.
Track key components of
environmental performance.
Provide a means for documenting
environmental issues/hazards. Identify
corrective and/or preventive actions to
prevent reoccurrence.
Maintain records that relate to
environmental performance,
compliance, inspections, etc.
Perform periodic audits to ensure that
all components of the EMS work
properly.
Provide EMS-related information to
senior management for periodic review
and/or approval to ensure continual
improvement of the system.
Similar to a hospital's mission statement, health and safety
policy, etc.
Examples: use, handling and proper disposal of radioactive
materials, use of significant amounts of energy and water
in facilities management, etc.
Also include voluntary- or industry-specific codes,
(Accreditation Standards), memorandums of
understanding, codes of practice, etc.
Can be hospital-wide (e.g., reducing energy use) or
department-specific (e.g., implementing an organics
recycling program in Food Services.)
Use as a way to determine budgetary requirements for
implementation of an objective.
Include the roles of senior management, management,
front-line staff, patients, contractors, etc.
Some training may require general awareness (e.g., overall
knowledge of environmental policy), and others may
require competence (e.g., spill training).
Use existing modes of internal communications when
possible (e.g., hospital newsletters, emails, displays,
posters, staff meetings, etc.)
Consider creating an electronic version of the EMS manual
(for a hospital-wide system available to all staff).
Updating and editing an electronic system requires much
less time than revising paper manuals.
Utilize existing hospital formats/templates of
procedure/policy documentation.
Example: Ensure all staff handling chemicals (especially
laboratory, diagnostic, housekeeping and maintenance
staff) are aware of and utilize proper chemical handling,
transport and disposal procedures.
Hospitals commonly use universal "Emergency Codes"
(e.g., Code Red/Fire, Code Brown/Chemical Spills, etc.)
Track the progress of objectives, occurrence of regulatory
inspections, calibration records, etc.)
Tap into existing means for reporting hazards and incidents
(e.g., employee incident reporting forms, departmental
inspections, etc.)
Keep in a centralized location (if possible, the EMS
administrator's office/work area)
Example: Form an EMS audit team of a few keen staff
members.
Tap into existing reporting structures (e.g., monthly
reports, annual reviews, management meetings, etc.)
          -25-
-------
     It takes parts working together for an EMS to work. The table on the preceding page  presents these

parts with a short description; more detailed descriptions will follow throughout the manual with in-depth

suggestions for implementation and examples of EMS documentation. Modify and use these examples as

appropriate.

     Realize that a typical hospital has some of these components already in place.  A complete gap audit

using an assessment tool (see p. 182 of this manual) will help identify which EMS components are in place to

build on and which components are missing. A hospital may implement the components of an EMS in an

order different from that presented in this manual or may find itself working on several components at a time.

Flexibility is the key.

                                Environmental  Policy


Developing the Policy

     The environmental policy can be created any time during  EMS implementation.  Some organizations

draft the policy first and use it as a primary communication from top management to all employees. Others

identify their significant environmental aspects, legal requirements and objectives and targets prior to

developing the policy in order to accurately depict the organization's future environmental goals and guiding

principles.

     In either case, the environmental policy is the cornerstone of an EMS. Like other hospital mission

statements or policies, the environmental policy should ultimately reflect the environmental values and senior

management's commitment.  Some environmental policies are  short and concise; others are more elaborate

and detailed. Review hospital policies and procedures to help identify the context in which this document is

developed.

Things to Consider When Writing the Policy
     1.  The policy should be appropriate to the activities and services. For example, what are the
         significant aspects and impacts associated with the operations, activities and services?
         Consider these when developing the wording in the policy. Also, is the scope of the EMS
         intended for one or several departments in the organization, or will it apply to all departments?
         This details the scope of the policy or, in other words, areas of the hospital where the EMS
         applies.
     2.  The policy should include a statement of commitment to comply with relevant environmental
         legislation and regulations as well as with other requirements to which the organization
         subscribes.
     3.  The policy should include a statement of commitment to continual improvement in
         environmental performance and pollution prevention. It should also provide a framework for


                                               -26-
-------
         establishing and reviewing progress toward objectives and targets.  An organization achieves
         continual improvement by setting and meeting objectives and targets. The EMS provides an
         administrative framework for systematically establishing, reviewing progress toward and
         achieving objectives and targets.
     4.   The policy should also include a statement of management commitment to keep the EMS
         suitable, adequate and effective. The policy is the driving instrument for crystallizing senior
         management support of and resources for the EMS.  Senior management's signature on the
         policy represents this commitment.
     5.   Ensure that the policy reflects the values set forth in the hospital's mission statement.  Hospital
         mission statements often include a commitment to provide quality patient care services,
         promote healthy living and to provide a healthy and safe workplace for staff and volunteers.
         Consider including supporting statements from the mission when writing the policy. This helps
         integrate the policy into the overall management of the hospital and may help cement senior
         management's approval.
     6.   Is the policy clear, concise and understandable? The policy will be a tool  for EMS
         communication both internally and externally and should be developed with the end user in
         mind. One facility implementing an EMS wrote a three-page environmental policy. It was
         difficult for the employees to relate to the length and wording of the policy. Generally, an
         environmental policy should be no longer than one page. Some EMS organizations wish to
         have an environmental policy statement in addition to the environmental policy itself. The
         policy statement is a condensed version of the policy and consists of a statement of the
         hospital's commitment to continual improvement, compliance with legal and other
         requirements and pollution prevention.

Communicating the Environmental Policy

Hospital Staff

     Communicate the environmental policy to all hospital staff.  The following are examples of ways to

communicate the policy to hospital staff:
     1.   Post copies of the policy in highly visible, frequently visited locations within the hospital (e.g.,
         cafeteria, near the time clock, front or main lobby area,  outside main elevator landings, within a
         permanent environmental display board, outside the CEO's office, on a hospital
         accomplishment board and at any other location that staff frequently visit). One environmental
         health and safety management representative posted the policy, significant aspects, objectives
         and targets  and contractor environmental  information sheet on a bulletin board in the hallway
         between the work and break area. Area supervisors would take their teams to the bulletin board
         and review this information at the end of the weekly health and safety meeting.
     2.   One facility put a copy of its environmental policy on the back of the vacation/holiday leave
         schedule handed out to employees.  By hanging onto the vacation/holiday leave schedule,
         employees would always have a copy of the environmental policy.
     3.   Many organizations place the environmental policy on a business card-sized insert that can be
         slipped  into the back of staff/visitor identification badges. Other ways of communicating the
         policy include showing it on the hospital television network, at hospital entrances/exits and in
         environmental training.
     4.   Post a copy of the policy within the  hospital's main policy and procedure manual (either paper
         or electronic version).
                                               -27-
-------
     5.  Include the policy in the hospital newsletter.
     6.  Post the policy on the hospital's Web site.
     7.  Ask to include the policy as an agenda item at each departmental staff meeting.
     8.  Ask to be included on the agenda at the hospital's management meetings. Ask for enough time
         to cover the definition of an EMS, the contents of the environmental policy and the EMS roles
         and responsibilities of management staff.  This can be an EMS training opportunity.
     9.  Educate new staff on the environmental policy during their hospital orientation.  Attach a copy
         of the environmental policy to the orientation package for reference.
Patients, Visitors and the Community

     The environmental policy is the only document in the EMS that must be publicly available (for

organizations pursuing ISO 14001 registration). Posting the policy in a highly visible location within the

hospital or on the hospital's Web site are just a few ways to provide the policy publicly. Share more

information about the EMS than the policy, such as environmental aspects and progress toward objectives and

targets. Most of an organization's environmental  information is already publicly available due to

environmental reporting under applicable regulations.

Contractors and Suppliers

     Contractors and suppliers should be aware of the hospital's commitment to the environment and the

environmental policy.  They can impact a hospital's environmental performance and should follow EMS

procedures.  Their commitment is essential, particularly on such issues as reducing product packaging, green

procurement and products and services they provide.

     St. Mary's General Hospital sent recent contractors and suppliers (those with whom the hospital had

done business in the prior two years) an environmental awareness brochure, which outlined the hospital's

environmental commitment. The hospital also sent a questionnaire asking for input on how the contractors

could help the hospital attain certain environmental goals. Supplier and contractor response was positive and

assisted hospital purchasing in  developing a "green" products and services database. In turn, participating

suppliers were able to promote additional product lines to the hospital for future possible business.
EMS Example
Example of Detroit Mercy Hospital's EMS/Environmental Policy                      Pages 87-93
                                                -28-
-------
                      Environmental Aspects & Impacts

                          and Determining  Significance

Introduction

     One of the first steps to implementing an EMS is for the hospital to identify environmental issues (also

called environmental aspects) to determine the associated impacts, or environmental changes, and identify

which are not significant to the hospital. A hospital must consider these significant environmental impacts

when setting its EMS objectives and targets. Establishing and implementing operational controls, such as

work instructions, will minimize the significant environmental impacts and help an organization meet its

objectives and targets. Monitoring and measurement requires the hospital to track its progress against the

significant environmental impacts and objectives and targets.

     The end of this discussion covers topics, such as training, communication, documentation/document

control and other EMS support components, that support a fully functional EMS.

    Environmental Aspect: An element of an organization's activities, products or services, that can
    interact with the environment. (Definition from ISO 14001 Standard.) Environmental aspects are
    often referred to as the cause of change to the environment.

    Example: Environmental aspects for landscaping  practices may include air emissions, natural
    resource consumption (e.g., water or fuel), chemical usage and possible spillage.

    Environmental Impact: Any change to the environment, whether adverse or beneficial, wholly or
    partially resulting from an organization's activities, products or services. (Definition from ISO 14001
    Standard.) Environmental impacts are the resulting change in the environment.

    Example: The environmental impact(s) associated with landscaping chemical usage may include air
    pollution, human health effects, groundwater and/or storm sewer contamination as well as flora and
    fauna (plant and animal) health effects.

     While identifying the aspects and impacts can be daunting, it is critical to identify all of the possible

aspects because subsequent EMS requirements are based on them. It is quite possible to have numerous

aspects of which only a few were significant according to a facility's criteria. One manufacturing facility had

550 aspects of which 50 were significant according to its criteria. Eventually the facility set objectives and

targets for 10 of the most significant aspects. There will be many aspects, but not all of them will be

significant, and not all significant aspects need objectives and targets.

     The first step in identifying aspects is setting the scope of the EMS. Is the entire hospital included,  or

selected hospital buildings on site or just specific departments? An EMS can be implemented in one part of

the hospital on a pilot project basis and then use lessons learned from that experience to implement the EMS
                                               -29-
-------
throughout the entire hospital.  A positive experience with implementing an EMS in one department can build

momentum as the EMS is started in other departments.

     Next, identify activities and services within areas of the hospital where the EMS will apply. As a

starting point, identify aspects and impacts associated with each activity or service. Techniques used to

identify aspects include process mapping (charting how materials flow from entry into the hospital, how/

when/where the materials are used, and disposal/recycling of the materials); interviewing; benchmarking

against other hospitals and health care organizations; and inspections and audits.

     Environmental aspects drive the EMS. An EMS encourages health care organizations to systematically

address the environmental aspects and impacts associated with its activities, products and services. This is a

perfect opportunity for pollution prevention, which can often eliminate or greatly reduce many environmental

aspects. For those aspects that cannot be eliminated at the source, other pollution prevention alternatives can

be used to manage them in a more environmentally friendly manner.

     Identify the impacts associated with each aspect.  Impacts are the changes in the environment that occur

as a result of the aspect.   Examples of impacts include increases in ground level ozone (air pollution);

degradation of water quality or drinking water supplies; conservation of natural resources (through recycling,

for example); and soil pollution (from accidental spills). Ask whether or not the organization can control or

influence each aspect. The degree of control or influence over different aspects will vary. For example, energy

usage is an aspect. While a hospital may not control what kind of fuel the utility burns to provide power, the

hospital does have considerable control over how much energy it uses and requires from its utility and in turn

how much air pollution the utility produces in generating electric for the hospital.

     Table 1 and Table 2 on pages  102-109 show example aspects and impacts for a health care organization.

Essential information to include in  an aspects/impacts inventory include the following:
     1.   The name of the activity, product or service with a short description;
     2.   The environmental aspect(s) associated with each  activity, product or service;
     3.   Legal Requirements: Is the environmental aspect(s) of the activity, product or service
          regulated?
     4.   Actual/potential impacts  associated with each aspect;
     5.   Significance rating. (In the example, frequency, consequence and degree of control are each
          independently rated and then combined for a "total significance" score.) Determining
          significance is  explained in detail later in this section.

     Aspects identification is a perfect opportunity for pollution prevention, which can be used to eliminate

or greatly reduce an aspect. For aspects that cannot be eliminated, pollution prevention can often be used to

minimize them.

                                                -30-
-------
Standard Pick List of Aspects and Impacts
Aspects:
Air Emissions
Energy Usage
Raw Material Usage
Water Usage
Hazardous Waste Generation
Solid or Hazardous Waste Generation
(Incineration)
Solid Waste Generation
Solid and Hazardous Waste Generation
Recycling/Reuse
Wastewater Recycling/Reuse
Wastewater Discharge
Potential for spills
Impacts:
Increased air pollution
Decreased air pollution
Elimination of air pollution
Depletion of natural resources
Conservation of natural resources
Depletion of natural resources
Conservation of natural resources
Increased landfill loading
Decreased landfill loading
Conservation of natural resources
Increased air pollution
Depletion of natural resources
Increased landfill loading
Decreased landfill loading
Conservation of natural resources
Increased landfill loading
Decreased landfill loading
Conservation of natural resources
Decreased landfill loading
Conservation of natural resources
Conservation of natural resources
Increased water pollution
Decreased water pollution
Potential for air, soil, and water
contamination
Other Impacts:

Increased noise pollution
Decreased noise pollution
Elimination of noise pollution

Increased light pollution
Decreased light pollution
Elimination of light pollution

Increased land use
Decreased land  use
Elimination of land use
                                           -31 -
-------
Roles and Responsibilities in Identifying Aspects and Impacts



     It is possible to identify environmental aspects and impacts individually or to enlist help from staff



throughout the hospital. Involving staff on a Green Team divides the workload and gives the members more



of a "hands-on" involvement early in EMS implementation.  Provide aspects/impacts training to the Green



Team and review and monitor the department's work outcomes to ensure continuity among the department's



lists. This approach is an effective way to build rapport with department managers and personnel and to begin



building buy-in to the EMS.



     Alternatively, it is possible to develop the aspects inventory as an individual. This approach may take



longer to complete and will require frequent updates for the Green Team, but allows greater control over and



continuity of the aspects list.



     Either way, it is beneficial to involve frontline staff and departmental managers in completion and



maintenance of the aspects inventory. Employees may be aware of environmental issues and opportunities



unknown to management and have ideas on how to address them.  Employee involvement also builds interest



and understanding in ways that are real to work areas and their experience.  This builds employee ownership



in and understanding of the EMS, which is essential when asking employees to develop work instructions that



address significant aspects in their work areas, to measure environmental performance, track progress against



hospital EMS objectives and targets and significant impacts and otherwise do their jobs with the environment



in mind.






Determining Significance



     Once aspects and impacts are known, determine which are most significant. While there are no hard and



fast rules or requirements, commonly used significance criteria include cost, volume/toxicity of waste,



frequency of the environmental aspect and whether the aspect is regulated or has compliance concerns.  Some



examples of hospital-specific criteria include JCAHO requirements or other regulatory requirements, patient



care, employee risks and community concerns. These criteria become the filter used to tell which aspects are



most important.



     Table 3 on page 110  shows one approach to determining significance. The significance ranking method



is based on a scale of one through five. Each impact is given a score from one to five for its relative



consequence importance, frequency of occurrence and the degree of control the hospital can exert over the



impact; these three scores  are multiplied to give the impact an overall score which is used  compare that
                                               -32-
-------
impact to others. The hospital in this example shows that any impact that ranked 27 or higher or had legal

requirements associated with it was considered significant.

Change Management and Continual Improvement

     With this initial list of aspects in hand, begin addressing the most significant aspects first; remaining

aspects can be addressed later as part of continual improvement process.

     How the hospital identifies aspects and determines significance is information to include in a written

procedure.  As shown in the example, aspects procedure, scope, responsibilities and references to related

documentation are all necessary components to address.

     A current aspects list is important, and should be included as part of the aspects procedure with

reference to how the organization reviews its activities, products and services for new aspects and impacts.

This keeps perspectives current and will provide potential new objectives and targets. In one case, an

automotive manufacturer changed from a lead-based electro-coat material to a lead-free alternative.  During

the six-month surveillance audit to maintain its ISO 14001 registration, the facility proudly showed this to its

auditors as an example of continual improvement. The auditor congratulated the facility and promptly asked

the facility if it had updated its list of aspects to reflect the new waste stream resulting from the modified

process.

     Train departmental  managers to evaluate any new or future processes, activities or services for new

aspects and impacts and to communicate this information to the EMS representative.  Involving and providing

training to purchasing staff is especially important. Purchasing often has firsthand knowledge of new

equipment and processes and can notify the EMS representative of new significant environmental issues.

New pieces of equipment may be acquired during the capital budgeting process. Work with the finance

department to identify opportunities to evaluate the environmental impacts of equipment prior to its approval.

Such notifications also allow the EMS representative to identify any potential new regulatory requirements as

well.

EMS Examples
Environmental Review of New Projects                                             Pages  94-95
Project Environmental Checklist                                                   Pages  96-97

Helpful Hints for Getting Started
     1.   Keep categories of aspects  and impacts general.  While technical proficiency as an
         environmental specialist allows greater detail, consider that most people in a hospital do not
         have an environmental/technical background and experience.  Keep categories general to


                                                -33-
-------
         facilitate staff participation.
     2.   As the aspects/impacts list is developed, certain activities, aspects and impacts may repeat (e.g.,
         energy usage) and apply across departments. In these cases, a hospital may choose to manage
         the aspects through many departments, rather than through an individual department.
     3.   Not all aspects and impacts are negative or detrimental to the environment. Recycling
         programs, household hazardous waste collection days that the hospital sponsors and other
         environmental improvement efforts will have positive aspects and should be included when
         identifying aspects and impacts.  Recycling, for example, reduces raw material and energy
         usage. Include positive activities in the aspects/impacts inventory, and designate the outcome
         as a positive impact (+).
     4.   Impacts can relate to the immediate changes to the environment (e.g., vapors from chemical use
         affecting human health) or eventual changes to the environment (e.g., the generation of garbage
         will eventually impact natural  resources as a landfill utilizes land space).

EMS Examples
     Aspects and Impacts Inventory for a Health Care Facility                        Pages  98-104
     Master Environment Aspects List                                             Pages  105-107
     Environmental Aspects and Impacts Inventory Template                          Page   108
     Significant Evaluation Criteria                                                Page   109
     Tool to Determine Significance                                               Page   110
     Environmental Aspects - Laboratories                                         Page   111
     Environmental Aspects and Impacts: Energy Use Example                       Page   112
     Environmental Aspects - Janitorial  Operations                                  Page   113
     Identification of Aspects, Determination of Significant Aspects
       and Setting of Obj ectives and Targets                                       Pages  114-116
                                               -34-
-------
                         Legal and Other Requirements



     Unlike many other EMS components, management of legal and other requirements (e.g., compliance



paperwork and obtaining environmental permits) generally remains under the direction of the environmental



specialist due largely to its specialized nature. However, everyone in the health care organization can affect



whether the hospital stays in compliance by following necessary instructions and working in an



environmentally friendly manner.  Compliance resources, such as the U.S. EPA Healthcare Environmental



Resource Center (www.hercenter.org), help hospitals identify and track legal and other requirements.



     The desire to improve/assure compliance and keep current with changing environmental regulations



may be initial reasons the board of trustees or senior management want to implement an EMS.  Therefore, it



is important to provide an initial baseline of the organization's environmental legal requirements. One of the



best ways to do this as part of an EMS is to develop a table or matrix of all the environmental legal



requirements (including applicable citations and where pertinent files are kept electronically or on paper) and



to conduct a thorough compliance audit against these requirements.  (See "Compliance Resources" in



Appendix B for common hospital compliance requirements and commonly found violations). This status can



be reported as one of the first steps of progress toward an EMS. It is important that trustees and senior



management understand that while an EMS does not assure compliance with U.S. EPA or JCAHO



requirements, it puts mechanisms in place that make compliance more likely.  Many organizations conduct a



comprehensive compliance audit annually.



     Compliance findings should be corrected as soon as possible.  Once the EMS is fully implemented,



these findings can be addressed through the checking and corrective action system.



     There are also additional reasons for addressing compliance early in the EMS implementation process.



First, compliance issues that come up later in the EMS implementation process have the tendency to divert



necessary resources, time and attention from EMS implementation efforts. It is sometimes difficult to refocus



and get EMS efforts back on track. For this reason, a hospital should conduct a compliance audit prior to



EMS implementation. Successfully addressing compliance problems through the EMS builds credibility and



encourages others to use the EMS to address environmental concerns in work areas. Second, failure to find



and address compliance findings can result in fines, penalties and poor publicity.



     Once the initial list of compliance requirements is identified, keep this list up-to-date. Environmental



managers use a variety of resources to stay current on compliance requirements including the following:
                                               -35-
-------
•      Legal counsel (e.g., attorneys)
•      Regulatory inspectors
•      Health care associations and associated resources such as workshops, newsletters and updates
•      Professional journals
•      Commercial updates and databases
•      Environmental consultants
•      Web sites
•      Contractors and suppliers

     EMS also includes "other" requirements as part of what an organization must track and use in assessing

its performance.  Others include requirements an organization undertakes voluntarily, such as the U.S. EPA's

Hospitals for a Health Environment (H2E), which sets voluntary goals of eliminating mercury-containing

products and waste by 2005 and a 33 and 50 percent reduction goal for waste by 2005/2010 respectively. Visit

the H2E Web site at http://www.H2e-online.org.

     Once these  initial steps are completed, it may be good to write an EMS procedure for administering

environmental legal and other requirements.  In addition to assigned responsibilities, the procedure should

include the list/matrix of environmental legal and other requirements, how the organization stays current with

its legal and other requirements and how the organization assesses its performance against these

requirements.

     Write the procedure to reflect how steps are actually performed in the organization. Writing a procedure

that does not match the sequence can result in a discrepancy between what is documented and actual practice,

or in other words, a nonconformance in the EMS.

     Remember that it is important to keep abreast of all state and federal regulations as they may change

over time. For example, the U.S. EPA recently promulgated a revised final Spill Prevention Control

Countermeasure  (SPCC) under the Clean Water Act. There are new compliance dates under this new rule that

someone, such as the facility manager, may need to know.  Refer to the compliance section in the back of this

manual for current federal regulations and references to Web sites and the Federal Register. It may be helpful

to assign one person to keep track of changes to state and federal regulations and notify any departments that

might be affected by such changes.
Additional Information
Legal and Other Requirements Procedure                                           Pages  117-118
Appendix E: Compliance Resources: A Supplement to Legal and Other Requirements    Pages  251-279
                                               -36-
-------
                                Objectives and  Targets


Setting Performance-Based Objectives and Targets

     An EMS requires setting performance-based objectives and targets. Objectives are overall

environmental goals. Targets are detailed performance guidelines, quantifiable where possible, set to achieve

the objectives. The more measurable the objectives and targets, the easier it will be to track performance.

     Use the EMS Green Team(s) to help identify possible objectives and targets.  There is no required

number of objectives and targets; however, consider the following factors in setting objectives and targets:
•       Significant environmental aspects. These are the environmental aspects rated most significant. For
        example, for mercury reduction, consider an objective of "reduce mercury waste" in the hospital with
        a target reduction of 10 percent per year.
•       Compliance. Consider compliance-based guidelines as an EMS objective and target. For example,
        an EMS objective of "maintain compliance with applicable environmental regulations" and a
        related target as "submit all necessary paperwork on time" or "no written notices of violation."
•       Views of external parties. This is essential for hospitals.  Input from patients, visitors and community
        neighbors is important particularly considering the hospital's mission to protect the health of the
        community for which it serves.
•       Technological options. Current technology may limit pursuing certain objectives and targets.  Atone
        EMS facility, ink cartridges from office copy machines could not be recycled because cost-effective
        technology was not available.  At some point, cost-effective technology could become available, but
        until then the toner requires landfilling.
•       Financial guidelines.  Pursue objectives and targets that make financial sense.
•       Operational and business guidelines.  Many EMS organizations include environmental objectives
        and targets in the annual business plan, ensuring that they are in line with overall hospital
        requirements and receive the necessary resources. Are there objectives and targets that can operate in
        line  with or otherwise  complement other hospital objectives and targets?

Implementation Tips

     Consider the following tips:
•       Focus on setting pollution prevention-based objectives and targets. Pollution prevention eliminates
        waste before it is created.
        Make sure the objectives and targets are challenging, yet attainable.
•       Choose a manageable  number of objectives for the available resources, time and personnel. Narrow
        the possibilities by considering the necessary financial and physical resources to reach each objective.
        Initially, objectives and targets with high payback and low cost may be needed to maintain senior
        management support.  Be aware of senior management's expectations; high payback/low cost may not
        be possible all of the time.
        Objectives and targets should be S.M.A.R.T (Specific, Measurable, Achievable, Results-oriented and
        Time-dependent.)
•       Don't try to  address all environmental issues the first time around.
•       Objectives can focus on individual activities or processes, be department-specific or hospital-wide.
•       Develop performance  indicators for each objective and target that can be used to track and evaluate
                                               -37-
-------
       progress.
•      Regular updates of progress toward objectives and targets should be communicated throughout the
       hospital, especially to those who work to achieve them..
•      Document objectives and targets, and train staff on what they must do to help meet objectives and
       targets that apply to their work.  Do this by posting a display, writing an article for the hospital
       newsletter, etc.

Additional Information
Objectives and Targets Procedure                                                  Pages  119-120
                                              -38-
-------
           Environmental Management Programs  (EMPs)


     EMSs require identifying the organization's environmental aspects; determining which are most

significant; and considering objectives and targets for the selected significant aspects. Environmental

Management Programs (EMPs) are the plans that define how to achieve the objectives and targets. EMPs

outline roles/responsibilities, action plans, deadlines and resources needed to accomplish objectives and

targets much as is done with JCAHO Environment of Care requirements (e.g., hazardous material and

emergency preparedness).  These plans are examples for how to establish and maintain EMPs; or the EMP

and JCAHO planning under environment of care can be integrated into one process.  For example, JCAHO

requires an annual review of the overall performance and effectiveness of the plan and evaluation of

progress toward performance improvements. This is an effective management framework for reviewing

progress toward EMS objectives and targets under the EMPs as well.

     Key things to consider when working on EMPs:
•       Delegate responsibility for tasks among associate managers, members of the EMS teams, staff, etc.
•       Do not reinvent the wheel. Find out how other hospitals  address similar environmental aspects
        impacts.
•       Utilize the resources and pollution prevention programs highlighted  in this manual.
•      Not all objectives may be completed in a one-year time period (e.g., energy consumption can be a
       multiyear objective that requires substantial financial budgeting).
•       EMPs should be periodically reviewed and revised to incorporate any changes. As the
        organization achieves objectives and targets and sets new ones, EMPs should correspondingly
        come into  and go out of existence.
•       Regular updates of the EMPs should be given to the EMS teams as well as senior management
        (e.g., management review).
•       Look at the full range of options before making a decision.
                   Example: Saint Mary's General Hospital EMP

Biomedical Waste Reduction EMP

     Biomedical waste management and disposal was one of St. Mary's General Hospital's most

significant aspects (e.g., highly regulated, costly, potential health and safety issues).

     The first step in St. Mary's biomedical waste reduction program was to address the risk, cost and

compliance associated with the operation and maintenance of the hospital's incinerator. A formal review

of the incineration equipment and usage indicated that the incinerator would be shut down permanently.

St. Mary's contracted the waste disposal services of a responsible,  licensed medical waste hauler who also
                                             -39-
-------
contractually assisted in the hospital waste reduction efforts.  The hospital performed a biomedical waste

audit of all departments, focusing primarily on the departments that produced the largest amount of

biomedical waste (e.g., emergency room, operating rooms, laboratory). The waste audit's goal was to

review current proper container usage, review staff's knowledge of proper disposal methods and to

determine possible waste reduction actions for each area.

     The audit revealed these findings:
•       70-80 percent of all of the biomedical waste bags were filled with garbage (gloves, plastic, cups,
        paper towels, etc.).
•       Proper signage was not adequate on containers.
•       Some rooms only had biomedical (red) bags, and all garbage was being disposed in that container.
•       Staff were putting objects that could be recycled into red bags and garbage bags.
•       Rooms that produced no biomedical waste had red bags ("Just in case!").
•       Staff were not aware of what went into the red bags and did not know what constituted
        "biomedical waste."
•       Departments often used large containers for red bags and small containers for garbage.  Staff often
        migrated to the largest, closest container for waste disposal.
     Following are  actions resulting from the audit:
•       Red bag containers were removed from rooms that produced only garbage.
•       Proper signage was placed above the majority of containers to dispel myths about what was to be
        placed in a red bag.
•       Biomedical and garbage containers were switched so that the larger containers contained a black
        bag (garbage).
•       Environmental services (housekeeping) staff received training on how to properly segregate
        biomedical waste to help identify departmental problem areas in the future.
•       Hospitalwide waste education was delivered to all floors. (Light snacks and beverages  were
        brought to each floor, which boosted attendance.)
     In one year the hospital decreased its biomedical waste stream by 22 percent, even with an eight

percent increase  in surgeries in the hospital's operating rooms (main generators  of biomedical waste) and

ongoing hospital growth.  Overall, the initiative resulted in a 38 percent reduction in biomedical waste

weights since 1998.

     It is important to understand that the waste separated out of the biomedical waste stream will

primarily be garbage and hence garbage to be landfilled will increase. Evaluate existing hospitals' reuse

and recycling programs and modify/expand these to divert additional possible trash from the landfill.

Recycling and Reuse EMP

     When St. Mary's General Hospital began developing its EMS, the hospital had already implemented

a few recycling and reuse programs. Most departments used a "blue box" for glass, cans, plastic,
                                               -40-
-------
cardboard and newspaper. Many administration offices and clerk areas had deskside cardboard boxes for

paper waste (colored paper, magazines, envelopes, etc.). The Nutrition and Food Services Department

already collected food waste from the cafeteria trays and sent it to a local pig farmer for reuse.

     When the EMS team cited improved recycling as one of its objectives and targets, the hospital

evaluated current recycling service providers and investigated many nonconventional recycling and reuse

opportunities.  St. Mary's joined forces with two other regional hospitals to develop the Regional Hospital

Recycling Initiative.  By combining negotiations for contracts,  the hospitals increased their buying power

and received discounted prices for pick-up services. The chosen recycling company would be able to

perform "milk runs" to pick up the hospital's glass, cans, plastic and paper/newsprint recycling containers.

     With pick-up service of the "general" recyclables underway, newly purchased recycling containers

were dispersed throughout the hospital to incorporate a "segregated" recycling system. The "recycling

stations," which were primarily located in kitchenette  areas, lunchrooms, lobby areas and the cafeteria,

consisted of three slim plastic containers that contained glass, cans and plastic.  The blue boxes that were

previously in place were redesignated for cardboard and newspaper. Widely distributed plastic deskside

recycling containers replaced the cardboard deskside paper recycling containers.

     Other recycling efforts included the following:
•      Pagers, personal electronic organizers and other information technology devices generate a large
       number of alkaline and nickel-cadmium batteries.  Due to the hazardous nature of this material  if
       disposed (metal and battery acid), the hospital ships these materials out for recycling  and reuse.
       Plastic buckets (reused from the  Nutrition  and Food Services Department) are placed on floors  for
       battery collection. When the containers are full, Environmental  Services personnel transport the
       buckets to battery disposal drums and return empty buckets to the floor.  The hospital pays for
       disposal of alkaline batteries while nickel-cadmium batteries are collected free of charge.
•      Fluorescent tubes contain mercury vapor, and as a "Mercury-Free Medicine Campaign" hospital,
       St. Mary's needed to dispose of the mercury content properly.  The hospital enlisted the service of
       a local company that recycles all fluorescent tube components. When a tube is changed by
       Engineering Services, the spent tube is placed back in its original box and attached to a skid for
       transport. In 2001, St. Mary's  collected 1,414 florescent tubes resulting in the recycling of 393  kg
       of glass, 5 kg of aluminum, 6 kg  of phosphor powder and 0.04 kg of mercury.
•      The hospital was recycling cardboard, but  not boxboard (tissue boxes, glove boxes, various supply
       boxes, etc.). The hospital implemented this recycling alternative and now collects and bails
       boxboard along with cardboard.
•      The pharmacy department also identified reuse opportunities.  Drugs and medications that need
       refrigeration  are always delivered in Styrofoam containers with cold packs. The pharmacy
       department now offers the Styrofoam containers and cold packs to staff for reuse.
                                               -41 -
-------
Spill Response and Emergency Preparedness EMP
     Health care facilities with on-site laboratories utilize a large number of chemicals on a daily basis. In

addition, health care facilities receive numerous shipments by trucks that carry chemicals or hospital

supplies. At any given time, these situations could result in a chemical spill, internally or externally. For

this reason, one of St. Mary's objectives focused on spill prevention and response.

     First, the hospital performed an emergency preparedness audit of high-risk areas. Inventory was

taken of all equipment. Findings showed that all aspects of emergency preparedness and response that deal

with fires, evacuation, disasters and bomb threats were adequately addressed through the hospital's

emergency code system.  However, little information was available on emergency response for internal

and/or external chemical spills and handling chemically contaminated casualties. Personal protective

equipment and spill clean-up equipment was lacking.

     In response, the hospital's environment health and safety specialist developed a "Code Brown-

Chemical Spill Response Procedure" and assembled a Hospital Spill Response Team.  The Code Brown

procedure dictates what the Hospital Spill Response Team and the hospital staff should do in a case of a

chemical emergency. The hospital also purchased three hospital spill kits, four full-face  respirators (in

addition to what the hospital already had) and personal protective equipment (chemical-resistant gloves,

suits and goggles). Each member of the Hospital Spill Response Team receives annual comprehensive

spill response training, respirator training and Code Brown responder training. All new hospital staff

receive  Code Brown training during their hospital orientation session, and existing staff receive annual

Code Brown training as part of the hospital's code review sessions. Since program inception, there have

been no reportable chemical spills.

Landscaping Practice EMP

     Landscaping provides a variety of environmental challenges, such as pesticide usage and lawn mower

emissions. Hospitals often have immune-deficient individuals entering and leaving the hospital's property.

For this reason, St. Mary's recognized the importance of being proactive and eliminating pesticide and

herbicide use in current landscaping practices. The hospital worked with its current landscaping company

to investigate the opportunities available to the hospital. Identified options included the following:
•       The hospital developed a "green landscaping policy."
•       All spot spraying was stopped.
•       Increased aerating, reseeding and fertilizing are used to reduce herbicide use.
•       Shrubbery and other vegetation prone to attacks by pests were promptly removed and replaced
                                               -42-
-------
        with  native and drought- and insect-resistant alternatives.
•       St. Mary's uses microbial pest intervention to kill lawn grubs.
•       Future landscaping plans will reduce the amount of grass around the facility to promote the usage
        of groundcover, gardens and other vegetation that does not require labor-intensive upkeep.
•       Scheduled mowing to avoid smog alert days.
•       Use of a natural fertilizer (corn gluten meal) with inherent herbicidal qualities.
•       Use of environmentally friendly alternatives to salt for ice removal on walkways.

Mercury Reduction EMP

     Consider mercury reduction as one hospital  EMP. Links to the Sustainable Hospital Project and the

Hospitals for a Healthy Environment are in the reference section of this manual. Consider the following

ideas in EMP development:
•       Eliminate, reduce or recycle products or waste that contain mercury wherever possible.
•       Assess inventory of mercury in equipment, materials (also chemicals and pharmaceuticals), in
        storage and in waste streams.  Check cleaning supplies for mercury content.
•       Gather life cycle cost information of purchasing/using products that are mercury-free compared
        to those that are not.
•       Switch to mercury-free products (e.g., thermometers, lab reagents).
•       Separate products that contain mercury before they get into the incinerator waste stream.
•       Use fluorescent lighting. Fluorescent lighting requires four times less energy than incandescent
        lighting. This means less mercury emissions at the point of power generation.
•       Eliminate purchase of products that contain mercury through environmentally preferable
        purchasing. Create and enforce agreements with vendors to supply only mercury-free products.
•       Develop a broad-based communications program to increase awareness of human health and
        environmental dangers of mercury.
•       Include articles devoted to mercury reduction, handling and proper disposal in staff newsletters.
•       Include specific information about the proper handling of mercury in employee orientation and
        "right-to-know" training.
•       Ensure that all personnel—including temporary workers—are familiar with the facility's mercury
        handling procedures and protocols to prevent mercury from being disposed in sharps
        containers, red bags or solid waste containers.
•       Include information about waste reduction and pollution prevention at  in-service training
        sessions.
•       Encourage personnel to read labels.
•       Place placard or labels on or above red bags, sharps containers and solid waste containers that
        state "No Mercury."
•       Make sure mercury spill kits are available in all labs, nursing stations, ICU/ER/Surgery rooms,
        patient rooms and storage/maintenance facilities.

Additional Information
Procedure for Environmental Management Programs                          Pages  121-122
                                               -43-
-------
                                           Training

     Training is essential to the success of any EMS because employees have potential significant

environmental impacts and ideas on how to improve environmental performances. Existing environmental,

health and safety training are opportunities to conduct EMS training.

     An EMS requires the following kinds of training:

     1.   EMS awareness training for all employees should be conducted. It highlights the policy,

         objectives and targets that apply hospital-wide as well as general roles and responsibilities

         (e.g., who the EMS representative is). Employees need to know and understand why the EMS

         and related information is important. There are many ways to provide this training. One

         company created a bulletin board displaying the company's policy, significant aspects and

         impacts and objectives and targets. During morning meetings, the line supervisors went with

         the line team to the bulletin board and reviewed this  information until the time of the ISO

         14001 registration audit. This approach was excellent for several reasons: 1) It built on a

         system already in place; 2) The regular meeting established and reinforced the importance of

         knowing the information; and 3) The employees knew where to go when the auditors asked

         them questions about these areas of the EMS.

     2.   Work area training provides task-specific training to  employees to understand the

         environmental impacts of the work, how to minimize the environmental impacts and what must

         be done to meet their work area's EMS objectives  and targets. Training should cover written

         work instructions, particularly those that minimize significant impacts or help meet objectives

         and targets. Employees should also be acquainted with any monitoring and measurement

         responsibilities that apply.

     3.   Compliance training ties into training specific to the  work area.  Employees should know what

         they must do to help ensure compliance in this work area.

     4.   EMS internal auditor training for employees who are expected to perform this function.

     5.   Senior management may need additional training to address their roles and responsibilities in

         the system. In short, senior management ensures the continued suitability, adequacy and

         effectiveness of the EMS. In addition, they do the following:
         •   Provide essential resources that implement and control the EMS, such as human resources
            (employees' time and skills), technological resources and money.
         •   Appoint a management representative who 1) ensures EMS requirements are established,
                                                -44-
-------
            implemented and maintained; and 2) reports on EMS performance and possible need for
            improvement.
         •   Participate in EMS Management Review.
     6.  Lead auditor training - should the hospital choose to pursue ISO 14001 registration, have at

         least one person attend ISO 14001 lead auditor training.


Contractors  and Suppliers

     It may be necessary to have on-site EMS training for contractors and suppliers, perhaps in conjunction

with safety training provided to suppliers and contractors during orientation.

Getting Started

     Providing EMS training is time-intensive.  EMS training starts with identifying significant

environmental impacts and determining where these are in the hospital. Next, determine which job positions

are tied most closely to the impacts. These are the people who will need EMS work area training.  In some

cases, it may be possible to combine EMS and compliance training. Establishing a training matrix that

outlines which work positions are tied most closely to the significant environmental impacts and objectives

and targets, as well as training each job function should receive, will facilitate development and delivery of

training at the right time.

Lessons  Learned
•        Incorporate EMS training into existing training or meetings. For example, use management review
         as a time to provide EMS training to senior management. Employees will prefer this approach to
         attending additional meetings.
•        The method of training is optional. One environmental health and safety manager posted the
         policy, significant aspects, objectives and targets on an EMS bulletin board near the time clock
         where employees punch in/out.
•        Look for opportunities to begin training early. Training is one way of communicating EMS efforts
         and building familiarity. Communicate the results of staff's work back to them, particularly on
         successes.
•        Remember training qualifications for the individual who provides the EMS training. How are
         instructors prepared and qualified to give EMS training?
                                                -45-
-------
                                     Communication



External Communication



     An EMS calls for effective internal and external communication. The environmental policy is the only



information an EMS representative must communicate to others outside the hospital; in practice, however, a



typical hospital provides information about the environmental efforts through publicly available pollution



prevention plans, annual reports, regulatory records and emergency response training.  Develop a procedure



to handle external requests for information on the EMS. The basic elements to document external requests



include who made the contact, the date, the nature of the request and response and what, if any, materials



were sent.



     There are various interested parties who may request information on the EMS. Potential interested



parties include the public, environmental groups, other hospitals, state and federal regulatory authorities,



contractors/suppliers, local emergency officials and neighbors. External communication procedures could



consider requests on a case-by-case basis.  This allows the flexibility to assess the credibility of the contact



and what information to provide.



     Communicate environmental expectations to contractors and suppliers.  They should be aware of the



environmental policy and hospital's significant environmental impacts; objectives and targets particularly



those they can affect. Contractors and suppliers are EMS partners. For example, hospitals may set an



objective to purchase only mercury-free products.  The extent to which suppliers are invited to participate



could directly impact whether the hospital achieves mercury-free status.





Internal Communication



     Develop a formal procedure for communicating EMS information at various levels and functions



throughout the hospital.  It is important to consider both top-down communication, as well as bottom-up



communication throughout all levels and functions of hospital personnel. While communicating with senior



management is important and necessary, there are many benefits to tapping into the knowledge of custodial



staff nurses, purchasing and the cooking staff, to name a few. The formal procedure does not preclude



informal communication, but rather attempts to ensure consistent and systematic communication is occurring.



EMS policy, responsibilities, results and environmental aspects (and subsequent changes to aspects) are



examples of items to communicate internally. Changes, such as revised objectives and targets, progress



toward achieving objectives and targets, updates to existing procedures, environmental incidents and new
                                               -46-
-------
regulatory requirements should be communicated. In addition to establishing a framework for relaying

information to employees, internal communication should also include how employees provide EMS-related

information.

     Training is the most common way to communicate with employees, but there are many other ways, such

as email, in-house television and newsletters. The type of EMS information shared depends on the audience.

Tailor the nature and frequency of communications to employees' expectations and needs. This varies from

organization to organization.

     Once  senior management grants approval for the EMS, communicate with hospital staff. Examples of

communication tools follow:

•      Work with the communications and public relations personnel to create a letter of support from the
       CEO/president to all hospital staff.  This letter reinforces the senior management's commitment to the
       project when staff ask the question, "Why are we doing this?" Use the environmental policy as part
       of the first communication of the EMS if the policy has been developed.
•      Develop department-specific training sessions on what the EMS is and why the hospital is proceeding
       with development.
•      Develop displays, table cards, emails and articles in the hospital's newsletter to get the word out.
       Focus on the environmental issues faced by the health care industry and how the EMS will encourage
       and support the statements set forth in the  hospital's mission statement.
•      Ask for involvement and input from staff.  They are an excellent source for good ideas, and sharing
       ideas builds ownership in the EMS.
•      Plan an environmental fair.  Include information on local recycling programs; composting programs;
       hazardous waste depots; healthy landscaping ideas for home; mercury take-back programs;
       local environmental not-for-profit groups; environmentally safe hospital products; energy
       conservation and efficiency; alternative transportation methods (busing, biking, carpooling to and
       from work); and water conservation initiatives.
•      Always be enthusiastic. Enthusiasm is contagious and makes sessions fun.

     Ideally,  hospital staff will embrace the idea of "green health care" as it goes hand-in-hand with the

overall mission of the health care industry. To promote interest in the EMS among hospital staff, illustrate

how the EMS makes work easier, makes the workplace safer and/or addresses problem(s) in each area.  Here

are  some keys to success:
•      Find ways within the hospital's culture to show how the EMS advances the hospital's mission.  If
       cost-cutting is a key factor that motivates people, show how the EMS will save money.  If patient care
       and staff safety is key, show how the EMS accomplishes this.
•      Ask skeptics for possible environmental problems in their area(s) and use the EMS as a way to fix
       these problems.  This creates opportunities for changing attitudes and garnering enthusiasm.
•      Listen to outspoken resistors, but be more  aware of those who say nothing or agree very easily.
       Generally, vocal resistors will vent, get on board and  exceed what is asked of them.  Silent resistors
       or those who agree very easily tend to fall short of expectations.
       Whenever possible, recognize individuals  who make  success possible.  Acknowledge individuals in


                                                -47-
-------
       newsletters and any other hospital staff appreciation programs.
       Keep the staff aware of the program's continuing success. This promotes enthusiasm and encourages
       the staff to put forth their best effort to make the program work.

Contractors and Suppliers

     Communicating environmental requirements to contractors/suppliers is often one of an environmental

manager's least favorite things to do. However, it can be one area of tremendous "bang for the buck" when it

comes to environmental performance, particularly considering the contractors' environmental impacts.

Contractor performance can directly impact whether an organization meets objectives and targets. For

example, solid waste left by a contractor can affect whether an organization meets a solid waste reduction

objective and target.

     Hospital EMS information sent to corporate office addresses may not always be communicated on their

end to the people that actually come out and do the work. Consequentially, it may be important to find

alternate ways to make sure such EMS information is provided to workers. One way is to include it in the

safety/health training or in contractor handbooks. Another way is to distribute it at check-in points (e.g.,

security checkpoints or information desks) at the hospital.

Additional Information
External Communication Procedure                                                Pages  123-124
Internal Communication Procedure                                                Pages  125-126
                                               -48-
-------
                      Documentation/Document Control

     Document control ensures that everyone works from the latest operational guidelines. Along with

training, documentation development and control are among the more time-consuming tasks in implementing

an EMS. Unfortunately, some environmental managers dismiss out-of-hand implementation of an EMS

because they perceive the documentation component as overly burdensome with no added value. As with

other system components, an EMS spells out the minimum requirements and leaves discretion on how to meet

the requirement to the hospital. Consequentially, the hospital determines whether the requirements are met in

an easily managed or difficult manner and what benefits the hospital achieves through the effort. Generally

speaking, effectively written and administered documentation prevents the loss of "institutional memory" and

ensures the consistency of results in operations. Documentation, such as written work instructions, is also a

valuable training aid during the EMS process.


Kinds of Documentation a Hospital  will  have in its EMS
Environmental Policy. This is the capstone document of the EMS that provides the overall direction, context
and organizational commitment to the EMS and environmental performance. Once established and approved
by senior management, the policy will likely have few changes.

EMS Manual and Systemwide Procedures. These procedures describe how basic EMS functions (e.g., aspects
identification and significance determination) are accomplished. There should be a procedure for each EMS
component. Make note of how these procedures reflect how the requirements are completed. Because many
parts of an EMS will be new to the hospital (e.g., aspects), these will be new procedures; however, other EMS
areas, such as training and communication, may build  on existing hospital procedures. Once written, these
procedures may change more frequently than the policy but less so than work instructions. Systemwide
procedures should be included in the EMS manual.

Work Instructions. These are work area or activity-specific documents that spell out how to perform activities
in the hospital. Cross-reference work instructions to the significant environmental aspects and objectives and
targets to which they relate. Work instructions can also be referenced under the "Resources" section of the
environmental management program (EMP), where  a hospital describes how it will complete the EMP. A
hospital may also likely need to create new work instructions to conform to newly discovered activities found
in the EMS process. Work instructions should be reviewed/updated 1) during system implementation; and 2)
during the annual review/update  of hospital aspects/impacts.

Forms, records, labels, tags, etc. These types of documentation are used to show that the system is
functioning as indicated in the other levels of documentation.

List of EMS Documents
(there may be additional documents the hospital wishes to include)
•      Environmental Policy
•      Objectives and targets
•      EMPs and action plans to achieve objectives and targets
•      Master Document Control List (lists all EMS documents across all levels)

                                              -49-
-------
•      Systemwide procedures (note: each major component of the EMS as shown following should have a
       procedure)
              -Environmental aspects and impacts (include significance criteria)
              -Legal and other requirements
              -EMPs
              -Structure and responsibility
              -Training, awareness and competence
              -Communication (internal and external)
              -Documentation/document control
              -Operational control, including work instructions
              -Emergency preparedness and response
              -Monitoring and measurement
              -Nonconformance and corrective and preventive action
              -Records
              -EMS Audit
              -Management Review
•      Records

     There may be additional documentation a hospital wishes to document. Practical considerations in

deciding whether to document include the following:
•   If a task is important enough for two people to do the same way, document.
•   Determine if there is any existing documentation within the hospital that meets the need. Try to
    incorporate existing documentation by reference, ensuring that it is current, or modify existing
    documentation to fit the EMS need. The more consistent EMS documentation is with existing hospital
    documentation, the more likely people will follow and feel comfortable with what is asked of them in
    following what the documentation asks.
•   Use the "new employee" test to determine if there is sufficient detail in the procedure or work instruction.
    Could someone new in the position pick up a work instruction, for instance, and successfully complete
    the specified task? This is critical because a good work instruction contains institutional "know-how"
    gained from experience not just rote steps.
     Document control requirements are pretty straightforward and common sense. EMS documents must be

legible; identifiable (someone should be able to pick up a document and know what it relates to); and

maintained in an orderly fashion. For these reasons, EMS documentation has document control headers/

footers like those shown in examples in this manual.
Additional Information
EMS Document Control Procedure                                                Pages 127-128
                                               -50-
-------
                                 Operational Controls

Hospital Considerations

     An EMS requires an organization or hospital to put operational controls in place for the activities and

services associated with the significant aspects and objectives and targets. This is to help minimize any

determined significant impacts and to help ensure that objectives and targets are met.  Generally, operational

controls are written work instructions but can also include training, test results and "control points" such as

those found in air and water discharge permits. When determining which of these additional work

instructions should be documented, consider such factors as task frequency and complexity, personnel

turnover and level of supervision. Written work instructions are also excellent training aids.

     For example, one facility's EMS set an objective and target to reduce its hazardous waste by 10 percent

over the upcoming year. It generated one hazardous waste stream associated with lacquer coating copper

winding used around electric motors. It implemented three work instructions to help get to the 10 percent
reduction. One work instruction specified that employees chip lacquer off the mix beaters instead of using

new solvent. Another instruction directed the use of used solvent to purge lines, and the third specified

cleaning the lacquer measuring cylinder at the end of the day instead at the end of every shift. All of these

together helped the facility reduce the lacquer use and corresponding hazardous waste generation.

     If any operational controls involve contractors and suppliers, make sure they are aware of their

responsibilities.


Additional Information
Operational Control  Procedures                                                    Pages   129-133
                                                -51 -
-------
                  Emergency Preparedness and Response

EMS emergency preparedness and response has four requirements:
•      Assess potential for accidents and emergencies.
•      Prevent incidents and associated environmental impacts.
•      Respond to incidents.
•      Mitigate impacts associated with incidents.
     Often, an EMS serves as an opportunity to view existing plans and regulations (e.g., Resource

Conservation Recovery Act, Emergency Planning Community Right to know Act) and to apply a more

preventive approach in these areas by focusing on the potential for accidents and emergencies. Ask

hypothetical questions that relate to hazardous materials, activities and processes. Consider normal scenarios

as well as start-up, shutdown and other abnormal scenarios for possible emergencies.

     Periodically test emergency response procedures (at least annually).  Review and revise emergency

preparedness and response procedures, particularly after accidents or emergency situations and make any

necessary improvements. This ensures that emergency response remains suitable, adequate and effective.

Write down how these are accomplished in an EMS procedure.

Implementation Tips

•      Make sure emergency evacuation routes are clearly posted. At one facility, intricate facility layout
       diagrams were photocopied on an 8.5" by 11" sheet of paper.  This made it difficult to read. Some
       diagrams were actually posted in nearly hidden areas - in one case, at floor level near an ice machine
       in the break area. Emergency evacuation routes should be legible and posted prominently in each
       work area.
       Correct deficiencies in the emergency system. At one facility, managers realized they had a low head
       count during a recent emergency. The missing worker was wearing required hearing protection in a
       loud area and did not hear the emergency alarm. No one was assigned to notify him in this
       circumstance. Address emergency preparedness and response findings promptly.
       Visitors and contractors should also be aware of emergency systems. Address who will be responsible
       for patient and visitor safety and evacuation in an emergency and what procedures will follow. This
       is critical in a hospital environment with a continual flux of visitors.
                                              -52-
-------
                         Monitoring and Measurement

     It is critical to monitor and measure performance against the EMS objectives, targets and significant

environmental impacts. One of the best ways to accomplish this is to write monitoring and measurement

requirements, including EMS control point measurements, into EMS work instructions to help ensure

completion.  The JCAHO requires monitoring conditions of the environment and recommends at least one or

more performance improvement initiatives that could include hazardous material and waste spills, exposures

and other related incidents and reporting of these results to the organization's leaders and multidisciplinary

improvement teams. Measures used in JCAHO efforts may be cross-referenced and leveraged for the EMS.

     Choose measures carefully. Too many create information overload and an ineffective system; too few

do not provide enough information to make good decisions.  Information gathered through monitoring and

measurement should be used strategically to detect overall performance trends and possible need for

corrective and preventive action. This allows for identification and correction of gradually declining

performance before it becomes a nonconformance in the system. Some possible measures include the

following:
•      Number of computers and monitors recycled/diverted from landfill (mercury) compared to previous,
       baseline years. There is mercury in the computer relays and switches in laptop screens and batteries.
       Computer monitors contain lead. Recycling or otherwise reusing computer electronics keep mercury
       and lead PBTs out of the environment.
•      Number of mercury spills compared to prior years.
       Annual or monthly energy usage (electricity and other).
•      Water use  (normalized).
       Pounds of red bag waste is reduced (normalized).
•      Number of mercury products replaced with mercury-free alternatives.
•      Results of periodic compliance audits.
     Calibrate and maintain equipment used to measure environmental performance.  This ensures that

readings are correct. For example, one facility set a goal of recycling a set percentage of scrap rubber.  The

facility collected scrap rubber in gaylord-style crates and fork-lifted the crates onto a scale for measurement.

It then calibrated the scale annually and kept records of calibration. In many cases, it is possible to refer to

guidelines in equipment manufacturer manuals, to rely on calibration already being performed or otherwise

subcontracted . When calibration is performed by outside parties, keep an in-house record of calibration.

Additional Information
Monitoring and Measurement Procedure                                            Pages   134-135
Calibration Procedure                                                            Page   136-137
Regulatory Compliance Audit Procedure                                            Page   138-140
                                               -53-
-------
                              Nonconformances and

                      Corrective and  Preventive Action

     Identifying and addressing nonconformances ensures an effective checking and corrective action system,

which, in turn, drives continual improvement. Nonconformances are opportunities to continually improve

work performance. They come from any number of sources including: 1) internal EMS audits; 2) external

EMS audits as conducted by third parties, such as ISO 14001 auditors; and 3) the hospital's own employees.

     Corrective actions refer to actions taken to address nonconformances that have already occurred.

     Preventive actions are actions taken to prevent a nonconformance from occurring. Preventive actions are

often made as a result of effective monitoring and measurement. For example, watch trends in hospital

wastewater discharge data, and take action when concentrations of pollutants become excessive.

     Identifying the root cause of the corrective/preventive action is key. This often demands more intense

time and focus to determine why the problem occurred or could have occurred, but is worth the investment.

With respect to compliance, an effective corrective/preventive action procedure is the component that

provides an EMS the most credibility in the eyes of environmental regulators. If a nonconformance repeatedly

occurs, it may be that the true root cause has not been correctly identified.

     The hospital should have a procedure for how it addresses nonconformances. Begin by having auditors

and employees  fill out a corrective/preventive action form. Department managers are often responsible for

suggesting the remedy on the corrective/preventive action form with approval coming from the environmental

management department or senior management, particularly if and when a capital investment must be made.

Environmental management may present suggested corrective/preventive actions at management review

meetings. Senior management plays a key role in ensuring that  corrective and preventive actions are suitable,

adequate and effective.




Additional  Information
Procedure for Nonconformance, Corrective and Preventive Action                     Pages  141-143
Nonconformance Recommendation Form                                          Pages  144-146
Audit Report and Corrective Action Summary                                      Page   147
                                             -54-
-------
                                       EMS  Records

     Records demonstrate that the EMS is working. As with all other EMS components, designating

responsibility is an important first step. The hospital  should determine who will be responsible for

maintaining the various EMS records. In some cases, this may be more than one person (responsibilities

should be documented). For example, the environmental specialist may continue to be responsible for

completing and maintaining paperwork that is submitted to environmental regulators, while records that

demonstrate the completion of EMS training specific to the work area may be kept with the work area

supervisor.

     A hospital should consider keeping the following EMS records on hand:
•      Aspects/impacts inventory and significance determination
•      Communication records (internal and external)
•      Documented roles and responsibilities (usually done at front of EMS manual, in systemwide
       procedures and/or work instructions)
•      Monitoring & measurement records (to track progress against significant impacts and objectives and
       targets) including compliance audits and calibration records
•      Monitoring equipment calibration
•      Sampling monitoring data
•      Compliance-related materials, such as permits, reporting, notifications, etc.
•      Testing of procedures (e.g., under emergency preparedness and response)
•      EMS audit records
•      Corrective/preventive actions including  changes such as those to documentation
•      Training records
•      Management review records (agenda, sign-in sheet, meeting minutes including action items)

     Hospitals may be able build on existing recordkeeping procedures, including  retention/destruction

guidelines.  Factors to consider in  how long to keep records include: 1) any legally mandated retention

requirements (e.g.,  U.S. Clear Air Act sets five-year retention requirements); 2) hospital requirements; and 3)

the ongoing usefulness of the records versus potential liability concerns. While there are only  several places

that an EMS requires records be kept, there are additional records a hospital should keep.
Additional Information
EMS Recordkeeping Procedure                                                    Page   148
                                                -55-
-------
                                      EMS Auditing

Types of Audits

     There are three different types of EMS audits: compliance audits, internal audits and EMS gap audits.

     Compliance audits compare performance against a set of environmental requirements (e.g., table of

legal/other requirements) that rely largely on following a paper trail of permits, sampling data and reports.

     Gap audits are audits conducted EARLY in the EMS implementation process and identify the EMS

components already in place as well as areas that need work in order to have a complete EMS. Many times,

senior management prefers to conduct the gap audit prior to deciding to implement an EMS in order to

estimate the level of resources necessary for implementation.  An example gap audit tool can be found on the

beginning of page 181.

     Internal audits drive continual improvement by checking system performance against the EMS

documentation. Initially, EMS internal audits will focus on ensuring the EMS components in place. As a

system evolves, focus will shift to environmental performance results.


Internal Auditing Program Components

     Internal  EMS audits  check to see if the system is performing as indicated in the EMS manual and work

instructions. There are several components of an internal EMS audit program.
•      An EMS audit procedure.  The procedure covers audit team selection and training, preparing a
       written audit plan, prior notification of audits, audit scope (areas  and activities covered), audit
       frequency, key roles and responsibilities of audit methods and how to report and follow up on audit
       results. Audit results are addressed through the corrective and preventive action processes.
•      An internal audit team. The size of the internal audit team depends on the size of the hospital and the
       number of significant environmental impacts in the hospital.  There should be enough auditors to
       prevent one from  auditing his/her own work area and enough backup auditors on hand in the  event of
       illness or turnover.
•      In manufacturing  facilities with 200-300 employees, it is common to see four to nine internal EMS
       auditors. Typical internal auditor training includes in-class instruction as well as on-the-job auditing.
       EMS  internal auditor training courses, such as those American National Standards Institute-Registrar
       Accreditation Board offers (http://www.rabnet.com), are available. These should cover EMS
       components and effective auditing techniques. On-the-job training helps new auditors better
       understand environmental standards, facility operations and
       environmental science.
•      Another effective  training technique is pairing an experienced auditor with the trainee. At one
       automobile manufacturer, an internal audit team conducted an EMS audit in the paint booth facility
       on its own and with the EMS management representative to provide ISO 14001 interpretative
       guidance. The employee auditors on the team led the audit, conducted the questioning, identified
       findings and presented these findings to the paint booth facility managers.
•      Audit frequency and audited areas. Audit frequency correlates to the importance of the activity being
       audited and the results of previous audits of that area. Generally, organizations conduct internal


                                               -56-
-------
       audits of all areas at least once or twice a year.
•      Maintaining audit records. Audit agendas, audit notes and checklists, and most importantly,
       nonconformances written as a result of the internal audits are the most common records that show an
       EMS audit program is in place.
     EMS audits maintain management and employee focus on the EMS and environmental performance,

find opportunities to improve the EMS and environmental performance and ensure that environmental efforts

remain cost-effective and tied to the overall hospital mission. At the paint booth facility mentioned above, the

audit team began its audit in the control room, where readings on the thermal incinerator were at the correct

800 degrees Fahrenheit.  Subsequent audit team investigations at the incinerator showed readings of more

than 1,200 degrees Fahrenheit.  The manager took great interest in these readings, realizing energy and cost

savings that could result by lowering the operating temperature.

Audit Program Tips

     Successful audits help the EMS and improve environmental performance. While there are many classes

that cover the technical aspects of effective auditing techniques, effective people  skills are just as important

and should be considered in establishing internal auditor teams or selecting an outside contractor to conduct

audits. The perceptions auditors create with hospital staff and management should reflect positively on the

EMS efforts. Some things to consider are:
•      Understand that  auditing may impose on those who are audited.
•      Find hospital personnel who have auditing experience. Their familiarity with auditing will be an
       asset, even if they need environmental training. They should be familiar  with how to put those being
       audited at ease.
•      Depending on the size of the hospital and the nature of the auditing, utilize teams of auditors
       throughout the hospital. Put at least one experienced auditor on each team. Two to three auditors per
       team allows one person to ask questions and the other to write responses  and observe the work area.
       Several pairs of eyes are better than one.
•      Good listening and effective questioning are key in the auditing process.  "Yes/No" questions leave
       too much room for misinterpretation and generally fail to provide the auditor with enough
       information.  People generally like to talk about what they do in their job. Detail-driven questions
       provide the auditor with an honest assessment of operations within the work area.
•      Audits are like an "open-book" test. Auditees can use resources around them to answer auditor
       questions.  Information doesn't have to be memorized.
•      Provide advance notice to areas that will be  audited.  People generally do not like "surprise"
       inspections" audits.  One EMS representative set the  audit schedule for areas six months in advance
       and would send reminders two weeks and one week before the  audit.
•      Set an audit schedule and stick to it. It is impossible to review every record or talk to every employee
       during each audit. Sampling helps stay on schedule.
•      Conduct questioning within the scope of the audit.
•      Report in terms of departments or areas audited. Do not reference specific individuals. Audits are not
       meant to get people in trouble.
•      Audit findings can be positive. Be positive on accomplishments. Pay compliments when in order.

                                                -57-
-------
•      Disagreements within the audit team should be handled outside of the auditee's presence.
•      Consider the auditors'experience. Do the auditors have any health care experience?  Auditor
       familiarity with health care means a more focused audit.
•      Don't let company politics interfere with the audit.
•      Collect objective evidence (e.g., documentation, forms, memos, procedures, policies and records) of
       EMS conformance. Auditing should check management commitment to EMS conformance and
       environmental performance (not focus on why something did or didn't work).  Identifying root causes
       comes later in the corrective action request.
•      Auditors should focus on what is seen during the audit and how it meets a given standard.
•      Use audit results to identify trends and patterns  in EMS deficiencies. These become opportunities for
       continual improvement.
     Address audit findings in the corrective and preventive action system.  This enhances system growth and

development.

     To learn more about EMS auditors, auditing and training courses log on to http://www.rabnet.com.

Additional Information
Sample Environmental Management System Audit  Checklist                         Pages  149-152
Kentucky Pollution Prevention Center Gap Audit Checklist                           Pages  183-240
                                               -58-
-------
                                Management Review

     Management review serves several functions in the EMS to ensure that: 1) the system remains suitable,

adequate and effective as senior management promised in the environmental policy; 2) the EMS remains cost-

effective; and 3) suitable progress is made toward the EMS objectives and targets and approving new

objectives and targets as needed. The management review examines long-term environmental management

and EMS performance trends. For this reason, organizations will conduct the management review once a year.

     Questions to consider during the management review include the following:
•      Are EMS roles, responsibilities and procedures current? Do any need to be updated?
•      Do objectives and targets need to be updated?
•      Are there any repeat nonconformances or other patterns in nonconformances that show up from EMS
       audits or compliance audits that need to be addressed? Are there any trends in monitoring and
       measurement data that require management attention?
•      Are there anticipated environmental regulatory changes that need planning and resources?
•      Are there any new stakeholder concerns to address?

     Managing expectations regarding the EMS is key. Depending on the aggressiveness of hospital pollution
prevention and energy efficiency efforts prior to EMS implementation, cost savings in the early years of the

EMS may be considerable. Later, as the "low-hanging fruit" is achieved, subsequent pollution prevention and

energy efficiency efforts may yield smaller cost savings. This is important to convey to senior management,

particularly if significant cost savings are expected early in the EMS' operation.
                                               -59-
-------
-------
                                  - SECTION 4 -
                      CONTINUAL IMPROVEMENT

                    Pollution Prevention Opportunities
                         for the Health Care Industry

Introduction
     Much of this guide focuses on EMS implementation. Implementation should be a means to an end, not
the end itself. Once the EMS is implemented, it will serve as a tool to help achieve environmental
improvements. Pollution prevention is an excellent way to get these results. With the numerous, products and
services that hospitals employ, there are many pollution prevention opportunities to save materials, energy,
time and reduce expenses. This is one of the most important areas of financial return for an EMS.
        Pollution prevention is any practice that reduces the amount of any hazardous substance,
   pollutant or contaminant entering any waste stream or released into the environment prior to
   recycling, treatment or disposal. Examples include environmentally preferable purchasing, raw
   material substitution, process or procedure modification, improvement in inventory control, training,
   maintenance and housekeeping.
     Consider pollution prevention while identifying significant aspects and setting objectives and targets.
The U.S. EPA ranks options for managing waste in descending order of preference. This ranking encourages
reliance on those approaches that minimize the generation of waste and environmental releases.
     SOURCE REDUCTION is assigned the highest priority because it emphasizes elimination or
reduction of wastes at the point of generation.  Specifying purchase of a digital thermometer, rather than one
containing mercury, for example, reduces the heavy metal content in the waste and reduces the need for
recycling, treatment or disposal.  Source reduction is typically less expensive than collecting, treating and
disposing of waste. It also reduces risks for workers, the community and the broader environment.
     REUSE is the next preferred option. Implementing measures to reuse products and packages for the
original purpose reduces purchasing costs and packaging wastes as well as wastes from patient care activities.
                                            -61 -
-------
Health care facilities find that reusable linens, reusable patient supplies, such as bedpans and emesis basins,

as well as reusable dishes and cutlery for food service are generally economically and environmentally

preferable to disposable counterparts, although there are costs incurred in cleaning and sterilizing items for

reuse.

     RECYCLING encourages regeneration of materials into usable items.  Paper and paper products, such

as corrugated cardboard, glass food and beverage containers, metals and certain plastics may be recyclable.

However, important factors in evaluating recycling options include the local environmental and economic

consequences associated with the collection and processing of materials for recycling as well as the

associated energy and resource costs.

     TREATMENT to reduce the volume or the potentially harmful environmental impacts of the waste is

ranked at the lowest end of the spectrum. Medical waste treatment technologies include autoclaving,

hydropulping, pyrolysis, microwave, incineration, chemical treatment and irradiation. Treatment precedes

disposal, the least favored option. Ultimately, however, some wastes and medical waste treatment residues

require land disposal. The  costs of treatment and disposal are significant, and both have inherent

environmental impacts, including emissions to air and water.


Materials  Management

     This section identifies key pollution prevention concepts in the areas of materials management including

strategies such as environmentally preferable purchasing.  There are generally three ways to manage materials

effectively to reduce waste, cost and environmental impact. From most to least desirable: 1) during

acquisition (use environmentally preferable purchasing techniques to screen materials); 2) during product use

through best practices to maximize material life; and 3) reuse/recycle/safely disposing of materials as last

resorts.  Pollution prevention focuses on the first two. Measures of success for effective materials

management include reduced purchase expenses, reduced waste generation and reduced waste management

costs.
     Some examples include:
        Legacy Good Samaritan Hospital purchases permanent waterproof mattresses instead of
        disposable egg crate foam mattresses in 95 percent of its bedding. The initial purchase was
        significant, but the decision paid for itself in just one year. The savings in purchasing costs per year
        were $80,710. The disposal savings per year were $817 and prevented 16,350 pounds of waste
        annually.
•       The Legacy Health System switched from paper/plastic blend disposable coffee cups to an all-plastic
        recyclable cup. Employees were encouraged to bring their own mugs to the cafeteria for a discount.
        Savings in purchasing costs per year were $24,000. Savings in disposal cost per year were $1,417.
                                                -62-
-------
       Waste reduced was 28,333 pounds.
•      Mercy Healthcare of Sacramento purchases reusable liquid-proof surgical gowns and towels at six
       facilities, which saves $60,000 per year and prevents 50,000 pounds of waste per year.

Environmentally  Preferable Purchasing (EPP)

     Environmentally Preferable Purchasing (EPP) is the purchase of products or services that have a lesser

or reduced effect on human health and the environment when compared with competing products or services.

EPP includes the total effect of the product including packaging, disposal, quality and cost.

     While biomedical and radiological wastes have received considerable attention, many health care

organizations have overlooked everyday solid waste. U.S. hospitals generate close to two million tons of

solid waste per year, of which  nearly half is paper and cardboard, and the remainder is plastics (15 percent)

and food (10 percent). EPP directly impacts solid waste generation as the following success story shows.

EPP can also screen out mercury-containing and PVC-containing items.
         The University of Texas-Houston Health Science Center arranged with its office supplier to

    deliver supplies in reusable organic cotton bags instead of cardboard boxes. This step saved the

    university recycling and waste disposal costs.  The Health Science Center also replaced all mercury

    thermometers with alcohol thermometers and has worked to purchase radioactive chemicals with

    shorter half-lives.  From Health Care EPP Network Information Exchange Vol. 2, No. 1, January

    2000.
     Group Purchasing Organizations (GPOs) can facilitate EPP implementation because they leverage

volume to achieve discounts on pricing.  The same principle applies to packaging issues as packaging costs

the supplier also. In one instance, a medical supply distributor saved $22,500 annually in purchase of new

cardboard boxes by saving and reusing boxes from suppliers to ship customer orders. Other benefits included

reducing staff time to flatten boxes for recycling and assembling boxes for new orders.

     Another way to improve purchasing is to create a Preferred Vendor Program. Any list of preferred

products or vendors  should have clear environmentally friendly criteria and avoid unfair trade or liability

issues. There are many ways to create a Preferred Vendor Program.

     Some businesses require suppliers to do one or more of the following:
•      Achieve and maintain ISO 14001 registration.
•      Maintain and provide a current list of environmentally preferable products.
                                                -63-
-------
       Complete environmental impact questionnaire(s) for total operations.
EPP Best Practices
       Purchase products in bulk, totes or in recyclable containers.
•      Purchase products with less packaging or reuse packaging.
       Take care in ordering "custom packs." While there is less waste on individual item packaging,
       waste from unused supplies can generate more waste. Negotiate to exclude certain items in
       patient care kits that are repeatedly not used in patient procedures and become unused waste.
•      Monitor requests for chemicals and implement policies to reduce over-purchasing that result in
       waste generation.
•      Procure chemicals through a central department or person.
       Purchase smaller quantities of chemicals and supplies not frequently used.
•      Control acquisition and use of reagents that have limited shelf life.  These supplies should be
       ordered in smallest practical container (e.g. ethyl ether and its formation of explosive peroxides).
•      Avoid over-purchase of supplies.  Order reagents and chemicals in exact amount to be used. Be
       careful when ordering extra quantities to take advantage of unit cost savings.  Net savings can be lost
       through increased disposal costs of unused chemicals.
       Encourage  suppliers to become responsible partners by providing quick delivery of small orders
       and accepting the return of unopened stock such as sealed bottles of stable chemicals.

Additional EPP Resources:
•      Hospitals for a Healthy Environment Web site for a How To Guide on Hospital EPP
       (http://www.geocities.com/EPP_how_to_guide/EPP 1 .htm)
•      The Massachusetts Office of Technical Assistance EPP newsletter
       (http ://www. state .ma.us/ota/otapubs .htm#eppnet)
•      The Nightingale Institute for Health and the Environment's EPP tool
       (http://www.nihe.org)
•      HealthCare Purchasing News Online
       (http: //www. hpnonline.com)

Cleaning Products and Chemicals

     Environmentally Preferable Purchasing (EPP) of cleaning supplies and other common cleaning

chemicals positively impacts the health of staff, patients and  visitors.  Many cleaning  chemicals are

flammable and contain chlorinated solvents. The choice of chemicals may also provide an opportunity for

reducing and eliminating hazardous wastes.

     Some advantages of establishing an EPP program for chemicals including the following:
       Creation of a safer environment
•      Continued cleaning effectiveness. Many of the new-generation environmentally friendly cleaning
       products are high-level disinfectants and include the  same infection control/sterilization capabilities
       that the old chemicals possessed.
       Reduced concerns about potential chemical incompatibility.
•      Environmentally friendly cleaning attributes including biodegradability and reduced toxicity.
       Potentially fewer cleaning products.
•      Potential to streamline purchasing with fewer products.
       Reduce the chance for exposure to dangerous chemicals.
•      Environmental stewardship -  "Lead the Charge."


                                               -64-
-------
     Some people may oppose EPP for many of the same reasons they might oppose an EMS.
•      It is new - people may not want to cooperate.
       It is different - people are unsure of different ideas.
•      Change is often challenging and can be time-consuming.
•      Training will likely be necessary.

     EPP helps evaluate the use of less hazardous materials and cleaning agents in noncritical requirements.

Examples and tips for chemical change-out in a hospital environment include the following:
•      Using simple alcohols and ketones instead of petroleum hydrocarbons. Toluene and xylene are
       examples of compounds to replace.  Terpene-based solvents and naphtha isoparaffinic hydrocarbons
       may be substituted for xylenes used in slide-cleaning in some applications. Citrus-based alternatives
       may reduce worker exposure but may produce hazardous waste due to possible flashpoints less than
       140 degrees Fahrenheit.
       Evaluate physical cleaning methods that may replace and reduce chemical cleaning requirements.
•      Evaluate the use of sonic or stream cleaning instead of alcohol-based disinfectants or other forms of
       chemical sterilization.
•      Evaluate specialty detergents, potassium hydroxide or sonic baths to replace chromic and sulfuric
       acid for cleaning glassware.  Sodium or potassium dichromate  dissolves in sulfuric acid and chromic
       acid cleaning solutions are common methods of cleaning glassware.  However, there are alternative
       cleaning agents that are effective and less hazardous.
•      Use biodegradable or aqueous detergents  where possible. In some cases, powerful cleansers are still
       essential.

     The following are EPP criteria used to evaluate cleaning and other chemicals. Failure of a product to

meet any of the criteria listed below should trigger search for a more environmentally friendly product.

Carcinogen: Try to eliminate the use of products containing known and probable carcinogens. The

following organizations classify known or probable carcinogens.
•      American Conference of Governmental Industrial Hygienists (ACGIH)
       International Agency for Research on Cancer (IARC)
•      National Institute of Occupational Safety and Health (NIOSH)
•      National Toxicology Program (NTP)
•      Occupational Safety and Health Administration (OSHA)

Flammability/Flash Point: Use products that do not ignite easily.

Corrosiveness (pH): Use products that have a pH closer to neutral (pH7).

Chronic Health Risks:  Use products that pose no potential for chronic health risks.

Skin/Eye Irritant: Use products that are less irritating to the skin and eyes.

Volatile Organic Compound (YOG) Content: Use products with the lowest VOC levels possible. Products

that contain less than 10 percent VOC by weight are best.

Ozone-Depleting Compounds:  Use products that do not contain ozone-depleting compounds.
                                                -65-
-------
Biodegradability: Use products that are partially or completely biodegradable.



Product Packaging: Use products that are packaged in recyclable or reusable containers (such as use of



refillable product distribution devices and/or concentrates) and containers made with a percentage of post-



consumer recycled materials. Additionally, products that use little or no polypropylene and/or polystyrene



("Styrofoam") packaging are favored.



Energy Needs: Use products that work effectively in cold water, which decreases the amount of energy



consumption necessary.



No Sealed Aerosol Spray Cans: Chemical cleaning products should be available in either a liquid form or



manual pump action sprays and/or concentrates that can be dispensed into pump bottles for use.



Dyes and Fragrances: Use products that do not contain dyes or fragrances.








     Many floor cleaners used in hospitals contain harsh chemicals, such as quaternary ammonium chlorides



and butoxyethanol, which can be harmful to human health and the environment. To reduce risk of cross-



contamination for patients, conventional mopping techniques require janitors to change the cleaning solution



after mopping every two or three rooms. This means that cleaning solutions are constantly being disposed



and replenished. There are three drivers for changing the way custodial staff maintain floors in patient care



areas: 1) to reduce chemical and water use and disposal; 2) to reduce cleaning times for patient rooms; and 3)



to reduce custodial staff injuries and workman's compensation claims from the repeated motions of mopping



and wringing.



     Microfiber mop heads, a relatively recent innovation, may help. These mop  heads weigh  approximately



five pounds less than conventional loop mops and are changed after each room. This benefits the custodial



staff by reducing the effort of wringing a conventional mop and not changing the water between rooms



(provided the mop head is not put back into the water once used in a room).



     Pilot test results indicate a 60 percent lifetime cost savings for mops, a 95 percent reduction in chemical



costs associated with mopping tasks and a daily 20 percent labor savings associated with mopping. There



were only a few limitations to this option.  The medical center found that it was best to use conventional



mops in areas contaminated with an extraordinary amount of blood or other bodily fluid and in  greasy, high-



traffic kitchen areas.  Microfiber mop heads are best laundered in a standard commercial washer and dryer



with controlled  heat settings and standard laundry detergent is used.



     Test products for effectiveness. A chemical-cleaning or recycled-content product that meets the
                                                -66-
-------
desirable attributes still may be deemed ineffective for its intended purpose(s) after testing.





Energy Efficiency
    Energy Efficiency Success Story



         A well-designed and researched energy conservation strategy can provide significant immediate,



    short- and long-term cost-saving benefits.  Saint Joseph's Medical Center in Yonkers, New York,



    achieved savings of more than $250,000 a year through energy conservation efforts. (Source:  Dunn,



    Philip, Hospitals and Health Network).
     The health care industry is one of the most energy-intensive in the United States annually spending $6



billion on energy costs and using an average 228 kBtu energy usage per square foot per year - more than twice



the energy as atypical office space.  Hospitals run continuously, and certain uses, such as diagnostic



equipment, large air-handling systems and technical equipment are particularly energy-intensive.



     Consequently, energy efficiency presents a great cost savings opportunity. Every dollar a nonprofit



health care organization saves on energy equates to generating new revenues of $20 for hospitals or $10 for



medical offices. For medical offices, for-profit hospitals, and nursing homes, a five percent reduction in



energy expenses can boost earnings per share by a penny.



     In the long-term, gaining control over energy use begins by examining the facility's historical electric,



gas, oil and steam use as well as peak demand periods. Convert energy usage to a standard measure, such as



Btu/square foot. Where possible, use such measures to compare energy performance against other hospitals



and institutions. This can highlight higher-than-expected usage and allow for corrective action.



     A further reason for facility managers to understand energy use is to guard against major cost swings



due to variations in electric and gas rates.  Emerging utility deregulation creates opportunities to purchase



electricity and gas from the lowest cost supplier. Energy managers who know the most about their energy use



will be able to leverage that knowledge to obtain the best energy contracts. Health care organizations have



the opportunity to conserve energy as part of an EMS.
    Energy Efficiency Success Story



         Mercy Hospital in Pittsburgh, participated in Energy Star and instituted a comprehensive energy



    plan that resulted in operational and cost savings of more than $1 million.  Mercy accomplished this



    by retrofitting lighting to high efficiency T8 lamps and electronic ballasts, expanding its energy
                                                -67-
-------
    management system to allow for better monitoring and control, installing variable speed drives on

    chilled water pumps and replacing chillers and cooling towers with new high efficiency equipment.
 CHANGE FORTHE
 BETTER WITH
 ENERGY STAR
ENERGY STAR: Strategies for Superior Energy Management
     Energy Star is a U.S. EPA program that works to make energy efficiency easy by recognizing the best

performing products, homes, buildings and organizations. Energy Star's approach, tools and resources give

health care facility managers an easy way to gauge the facility's progress. For health care organizations,

superior energy management is an important aspect of environmental management that can provide healthy

dividends. Energy Star offers superior energy efficiency strategies and resources to help health care

organizations achieve and be recognized for leadership in energy management.

     The U.S. EPA's Energy Star uses a systems approach comparable to the EMS Plan-Do-Check-Review

cycle of continual improvement to achieve energy conservation. More than 875 hospitals and health systems

across the country have partnered with the U.S. EPA Energy Star. Energy Star Buildings and Green Lights

Health Care Partners have experienced an average annual savings of $0.63 per square foot1.

'Source: 1995 Energy Information Agency, Commercial Building Energy Consumption Survey data for health care, converted to 2002

dollars.

How Health Care Facilities Can Leverage Energy Star

The Value of the Energy Star Approach

     Organizations that adopt a systematic approach to energy management can achieve cost savings as high

as 35 percent. Energy Star identifies an effective approach for a high-performance energy management

strategy.

Commit to Continuous Improvement: Organizations seeing the financial returns from superior energy

management continuously strive to improve energy performance. Success is based on regularly assessing

energy performance and implementing steps to increase energy efficiency.  No matter the size or type of

organization, the common element of successful energy management is commitment. Organizations make a
                                              -68-
-------
commitment to allocate staff and funding to achieve continuous improvement. To establish an energy



program, leading organizations form a dedicated energy team and institute an energy policy.








Assess Energy Performance: Understanding current and past energy use is how many organizations identify



opportunities to improve energy performance and gain financial benefits. Assessing performance is the



periodic process of evaluating energy use for all major facilities and functions in the organization and



establishing a baseline for measuring future results of efficiency efforts.








Set Performance Goals: Performance goals drive energy management activities and promote continuous



improvement.  Setting clear and measurable goals  is critical for understanding intended results, developing



effective strategies and reaping the financial gains. Well-stated goals guide daily decision-making and are the



basis for tracking and measuring progress. Communicating and posting goals  can motivate staff to support



energy management efforts throughout the organization.








Create an Action Plan: Successful organizations use a detailed action plan to ensure a systematic process to



implement energy performance measures. Unlike the energy policy, the action plan is regularly updated,



usually on an annual basis, to reflect recent achievements, changes in performance and shifting priorities.








Implement Action Plan: Gaining the support and cooperation of key people  at different levels within the



organization is an important factor for successful implementation of the action plan. Reaching goals



frequently depends on the awareness, commitment and capability of the people who will implement the



projects defined in the action plan.








Evaluate Progress: Evaluating progress includes formal review of both energy use data and the activities



carried out as part of the action plan compared to the performance goals. Evaluation results and information



gathered during the formal review process is used by many organizations to create new action plans, identify



best practices and set new performance goals.








Recognize Achievements: Providing and seeking recognition for energy management achievements is a



proven step for sustaining momentum and  support for the program. Recognizing those who help the
                                                -69-
-------
organization achieve these results motivates staff and employees and brings positive exposure to the energy

management program. Receiving recognition from outside sources validates the importance of the energy

management program to internal and external stakeholders and provides positive exposure for the entire

organization.


ENERGY STAR Tools & Resources Available Online

     Energy Star provides the tools and resources needed to implement a successful energy management

strategy.  Technical guidance, procurement policies, demonstrated best practices, communications resources

and awards can distinguish the organization as an  environmental leader.
                                                                            Make Commitment
                                                                           Assess Performance
                                                                              & Sat Goals
EPA's National Energy Performance Rating System

http://www.energystar.gov/benchmark

     The U.S. EPA's National Energy Performance Rating

System in Portfolio Manager is a free Internet-based system

specifically designed to help businesses track and

objectively compare energy use on a continual basis for both

individual and large groups of buildings.

     The rating system uses a 1 - 100 scale to give relative

meaning to energy use: Hospitals that rate high on the scale

are considered better energy performers (lower energy use)

than those with low ratings (higher energy use). A rating of

50 is defined as the industry average.


     The rating system assists in the following:
       Establish a baseline energy performance for the hospital or hospital campus.
•      Compare the hospital's energy performance to other similar hospitals across the United States.
       Track and manage progress over time by regularly re-benchmarking.


ENERGY STAR Target Finder fhttp://www.energystar.gov/index.cfm?c=target_fmder.bus_target_fmder)

     Target Finder is an Internet-based tool that helps manage energy during the design of a new building. It

allows selection of an  aggressive energy performance target for a building design and compares estimated
                                                -70-
-------
energy consumption to the established target. Target Finder provides an energy performance rating for whole-

building energy use.


ENERGY STAR Delta Score Estimator (http://www.energystar.gov/index.cfm?c=delta.index)

     The Delta Score Estimator provides a quick way to identify the relationship between the percent energy

saved in a building and the energy performance rating score of a building using Energy Star. Once a facility

is benchmarked and a current energy performance rating established, Delta Score can:
•      Estimate a new energy performance  rating by entering a percent reduction in energy use.
       Given a target energy performance rating, estimate the percent energy reduction needed to move from
       the existing to the target energy performance rating.

ENERGY STAR Financial Value Calculator (http://www.energystar.gov/

index.cfm?c=assess_value.bus_fmancial_value_calculator&layout=print)

     The Financial Value Calculator analyzes portfolio-wide or single building opportunities using a variety

of metrics that range from simple payback to increased earnings per share based on various levels of energy

reductions.


ENERGY STAR Products (http://www.energystar.gov/index.cfm?fuseaction=fmd_a_product)

     Choose Energy Star qualified products  such as TVs, VCRs, computers and other office equipment when

purchasing products. Visit http://www.energystar.gov and select the "Products" link to learn more about

potential savings when procuring products that use 25 to 50  percent less energy without compromising quality

or performance.


ENERGY STAR Training (http://es.netspoke.com/attendee/default.asp)

     Free online training sessions help establish the partnership  with Energy Star, educate staff on the use of

Energy Star tools and provide further education to staff about the depth of Energy Star's tools and resources.

Participation is easy and convenient.
                                                -71 -
-------
                           Case Study: Houston Shriners Hospital

     Houston Shriners Hospital was built in 1996 and is dedicated entirely to children's acute care

specialty services.  As with the other 21 Shriners hospitals, Houston Shriners Hospital stands out

because it does not have a billing department - all operations and services are funded by donations

from individuals and corporations.

     Houston Shriners Hospital's energy management team consists of an energy manager, four

engineers, a laborer, a biotech professional and a secretary.  Since beginning its Energy Management

Initiative in 1997, the hospital's utility costs have decreased 40 percent.

     When the hospital first benchmarked its energy performance in 2002 using Energy Star's

Portfolio Manager, it received a rating of 42 (for 1996 data) and began investigating energy efficient

strategies.  It  instituted several low-cost operations and maintenance opportunities as well technology

upgrades that improved the hospital's energy rating to 75. Details follow.


Lighting: Houston Shriners Hospital installed  LED exit signs that use one-tenth the amperage of
standard signs; occupancy sensors in public areas and mechanical timers in nonpublic areas to keep
the lights off when areas are not in use.
Fan Systems: Houston Shriners Hospital balanced the air and water systems throughout the hospital,
decreasing usage by 68,900 kWh in nine months. The hospital also installed  energy-efficient motors
and variable frequency drives.
HVAC: Houston Shriners Hospital installed new energy-efficient motors and two new chilled water
pumps.  For one area, the hospital installed a split-HVAC system so that rooms are air conditioned by
the larger part (87.6 ton) of the system when they are fully occupied and by the smaller (1.5 ton)
when they are not. With the enhanced split-HVAC system in place, Houston Shriners Hospital
interlocked a  new air-conditioning unit through the energy management system and allows only one
of the units to operate at a time. HVAC certification and refrigeration maintenance were considered
essential to optimize performance.
     Houston Shriners Hospital energy manager maintains and regularly reviews records of all of the

energy bills, savings, anticipated savings, future technologies for investment and opportunities for

savings.  The  hospital keeps detailed spreadsheets regarding energy use and uses the Portfolio

Manager tool track progress. To date, Houston Shriners Hospital has achieved a gross savings of 24

percent in energy consumption (and additional savings through energy contract negotiations),

prompting the associate executive administrator to request that energy managers at the other Shriners

hospitals consider energy saving opportunities.

     Increased energy savings translate directly to increased funding for the  hospital's mission - to
                                            -72-
-------
    provide the quality of pediatric orthopedic care necessary to provide children the opportunity to be

    productive and involved members of their communities.

    Communications:  Houston Shriners Hospital has communicated with its employees, board of
    directors, headquarters and community through emails and phone calls.  Communication to
    headquarters led to the implementation of energy efficiency efforts at that hospital.
    Testimonial: While some facility managers do not believe they have the funding or time to
    implement energy saving measures, Houston Shriners Hospital believes they can ill afford not to look
    at opportunities to increase energy efficiency.  Technologies and operational changes save a
    significant amount of money every month that can be used to further the hospital's mission.
    - Delbert Reed, Director of Engineering & Maintenance, Houston Shriners Hospital
Join ENERGY STAR

     To partner with Energy Star, the hospital's CEO, CFO or senior administrator must sign the partnership

letter, committing the organization to continuous improvement of energy efficiency. As part of this

commitment, the hospital agrees to:
       Measure, track, and benchmark energy performance.
•      Develop and implement a plan to improve energy performance, adopting the Energy Star strategy.
       Educate staff and the public about the hospital's partnership and achievements with Energy Star.


For more information, visit the ENERGY STAR Web site, http://www.energystar.gov.
                                                -73-
-------
   Additional Pollution Prevention  for Hospital Wastestreams


Chemotherapy and Antineoplastic Chemicals

     Chemotherapy and antineoplastic chemicals are generally handled through a central clinical laboratory

or pharmacy. Administrative controls represent the best alternative to reducing these wastes.
       Minimize the cleaning frequency and volume of gauze materials used for the compounding hood.
       Cleaning frequency depends on drug handling volume and the amount of spillage that occurs in the
       hood. Emphasize proper handling practices and techniques to minimize hood cleaning frequency and
       waste generation. These instructions can be added to existing OSHA training conducted for the
       hoods.
•      Purchase drug volumes according to need. Overpurchasing results in the generation of outdated
       materials that must be disposed.  Reducing waste is accomplished by computing daily
       compounding requirements of each  drug and ordering appropriately sized containers. Work with
       the supplier to return outdated drugs.
•      Centralize the location of chemotherapy compounding areas.

Formaldehyde
       Formalin (formaldehyde and water) is used to disinfect dialysis machines. Check with the machine
       vendors to determine if bleach, paracetic acid or other disinfectants can be used instead of formalin.
       Carefully evaluate all substitutes for cleaning effectiveness and comply with all machine manufacture
       requirements. If formaldehyde must be used, use the smallest sized container (quantity) of
       formaldehyde possible.  Provide training to staff on the importance of this in reducing waste and
       costs.
•      Determine the minimum required formalin concentration. Effective formalin concentration for
       disinfecting and cleaning machines  and disinfecting dialyzers is in the  Centers for Disease Control
       guidelines. Formalin concentrations used to disinfect dialysis machines vary among machines and
       hospitals. Formalin is typically purchased in concentrations that range from 10 to 37 percent.  Many
       machines will dilute the 37 percent formalin to a 10:1 ratio to achieve a 4 percent disinfecting
       concentration. Formalin concentrations of 2 percent are not recognized as effective disinfectants.
       In autopsy and pathology laboratories, it may be possible to reuse formaldehyde in specimen
       preservation. These solutions retain their desired properties for periods far longer than the usual
       holding times for specimens.  In addition, the desired preservation properties may be effective  at
       concentrations less than the standard 10 percent.
       Formalin usage may be reduced in dialyzers. The use of special incubators to heat dialyzers in 1
       percent formalin solution at 40° C for 24 hours is an effective alternative to using 4 percent
       formalin at room temperature  for 24 hours.

Inventory Control

     After environmentally preferable purchasing (EPP), effective inventory management is the next strategy

for waste reduction. A good inventory control program includes the following:
•      A first-in, first-out chemical policy.  For example, chemicals purchased first should be used first.
       Reduce high-volume chemical inventories to a supply of four weeks or less.
                                              -74-
-------
•      Central distribution.  Chemicals should be delivered to a central location at the hospital (one common
       dock area) and distributed throughout the facility by a designated individual. Ideally, this individual
       would be a central supply/stores staff member.
       Chemical standardization promotes sharing of chemicals between users. A computerized, running
       inventory of unused reagent chemicals for reuse in other departments is helpful.
               Develop data (chemical inventories) by user groups identifying high volume users and
               generators.
               Locate caches of unused reagents/chemicals and determine why they are accumulating.
       •       Monitor reagent/chemicals half-life and expiration dates.
               Ensure that the identity of all chemicals is clearly marked on all containers. It is illegal to
               ship unused reagent chemicals, containers, and solution mixtures and unidentified wastes for
               disposal without proper labeling.

Laundry and Laundry Detergent

     Optimizing the use of laundry chemicals and minimizing accidental spills is achieved through work

training, prepackaged laundry chemicals or the use of automated laundry feed. Laundry chemicals are often

supplied in five-gallon containers; instead consider receiving chemicals in totes.

     Poor handling of laundry chemicals leads to accidental spills,  underuse or overuse of chemicals.

Underuse of laundry chemicals results in poorly cleaned articles that must be cleaned again. Overuse of

laundry chemicals increases the volume of chemicals and increases raw material costs. Optimizing the use of

laundry chemicals and minimizing accidental spills is achieved through worker training, prepackaged laundry

chemicals or the use of an automated laundry chemical feed system. While laundries might incur capital

costs to install an automated system, the savings from optimal chemical usage and reduction in labor costs

may have long-term benefits.


Aerosols

     Aerosols are present in many areas throughout the hospital but primarily in the facility maintenance

areas in health care organizations. Aerosols include adhesive cleaners, electronic solvent cleaners, touch-up

paints and ceiling tile renewers.
       Discourage the use of aerosols.
•      Request products in recyclable nonaerosol pump sprays.
       Dispense a full aerosol can upon return of an "empty."
•      Recycle aerosol containers.


Batteries

     Batteries are used in numerous applications including cameras, pagers, flashlights, exit signs, alarm

systems, backup power sources in medical monitors, hearing aids, smoke detectors, glycometers and many
                                                -75-
-------
others. Common varieties of batteries include alkaline magnesium, nickel-cadmium, silver-cadmium



mercuric oxide, lithium and zinc-air. Check state regulations regarding how to handle these spent batteries, as



they often must be considered hazardous waste due to the metal content.  In some cases, recycling spent



batteries may be possible.



     Carefully consider the use of rechargeable batteries. They may not be appropriate in all situations,



especially those involving lifesaving equipment where a partially recharged battery could result in equipment



failure and death. While some batteries such as the nickel-cadmium are rechargeable,  they will eventually



need disposal.



     Contact the hospital's commercial hazardous waste provider to find out if they will recycle batteries.



For information on rechargeable battery recycling visit Rechargeable Battery Recycling Corporation at



http://www.rbrc.org/consumer/uslocate.html to find the rechargeable battery recycling location closest to you



or call (800) BATTERY. To recycle lithium batteries, call Battery Solutions, Inc., at (313) 467-9110.  For



additional resources on other types  of batteries, visit Recycler's World at



http://www.recycle.net/battery/index.html.






Mercury



     Mercury is probably the most common persistent bioaccumulative toxin (PBT) in hospitals. Ten to 20



percent of mercury released into the environment in the United States comes from the  health care industry,



with medical waste incinerators as the fourth largest point source of mercury. Local wastewater treatment



plants identify hospitals as industrial pollution sources and impose strict wastewater limits for mercury



(hospitals are known to contribute 4-5 percent of the total wastewater mercury load). Mercury releases



impact human health as well as the  environment. In a survey conducted by the National Institute for



Occupational Safety and Health, researchers estimated that 70,000 American workers are potentially exposed



to mercury vapors on the job, including nurses, lab technicians and others working in health care facilities.



Identifying starting points for mercury reduction is easy.
    Mercury Success Story



         Newton Wellesly Hospital in Massachusetts significantly reduced its use of mercury compounds



    by identifying mercury-containing compounds in use and requiring department managers using these



    products to develop a time frame for elimination. Where elimination is not possible, the manager
                                                 -76-
-------
    must present an acceptable rationale to the hospital safety committee. The safety committee, in turn,



    is required to maintain a readily retrievable log of mercury-containing products and processes in use,



    the rationale for continued use and a time frame for the reconsideration of available alternatives.
Sphygmomanometers



       A California Department of Health Services found that Sphygmomanometers and gastroenterology



accounted for approximately 90 percent of the mercury in seven surveyed hospitals. Each mercury



sphygmomanometer (sphygs) contains between 70 to 90 grams of mercury.  Of additional concern is that most



sphygs are located in patient rooms, waiting areas, triage centers, offices where the risk of patient or health



care worker exposure to mercury is higher, through potential breakage of these devices.  Cost associated with



a mercury sphyg spill cleanup ranges from $600 to more than $10,000. The accuracy of readings from



mercury-based sphygs can be affected by lack of proper equipment maintenance and training.






Gastroenterology



       Various tubes used to clear the gastrointestinal passages, such as Cantor, Blackmore, bougie and



Miller-Abbot tubes account  for the second largest volume of mercury in the hospitals inventoried in



California. A single set of bougie tubes contain up to 454 grams of mercury. Internal breakage can occur.



The Food and Drug Administration reports more than 58 incidents from 1991 to 2000 in which such mercury-



containing tubes broke inside patients, releasing mercury internally. Nonmercury substitutes are available for



all of these tubes. Some substitutes can be weighted with air, water or mercury while others are preweighted



with tungsten.  Because the mercury in G.I. tubes functions as a weight rather than a measurement device, the



performance of alternatives  is less questionable. Tungsten-weighted alternatives have the advantage of being



opaque in X-rays allowing detection of the dilator as it moves through the body.



Thermometers



     Although fever and lab thermometers accounted for less than  1 percent of the mercury sources identified



at the seven California facilities audited, they are important sources of mercury contamination in



nonhazardous waste streams. They are often disposed improperly in red bag waste, which is incinerated and



releases mercury into the air.






Nonclinical Mercury



     Nonclinical mercury is generally found in sphyg repair kits as elemental mercury (at about 800 grams of



mercury). The elimination of mercury sphygs from a hospital can potentially reduce a facility's nonclinical





                                               -77-
-------
mercury load by up to 40 percent. Additionally, because aneroid units often do not require calibration using a

mercury barometer, the barometer can usually be eliminated. If other devices require calibration, consider

replacing the mercury barometer with a one-millibar precision aneroid (these can cost less than $250).

Another option is to simply call the local airport or weather station for a mercury column reading.

     There are many viable mercury-free products for hospitals pursuing a mercury-free environment. The

Sustainable Hospitals Web site (http://www.sustainablehospitals.org) is  perhaps the most comprehensive

resource available for finding alternatives.


Additional Information
Possible Sources of Mercury                                                        Pages  153-155

Pollution Prevention Opportunities for Mercury
•      Conduct an inventory/preliminary assessment of mercury in equipment, materials (also chemicals and
       Pharmaceuticals), in storage and  in waste streams. Examine cleaning supplies for mercury
       content.
       Gather life cycle cost of purchasing/using mercury-containing products versus mercury-free products.
       Consider potential risk of mercury spills and regulatory fines/penalties associated with unintentional
       releases.
•      Eliminate purchase of mercury-containing products through environmentally preferable purchasing
       and purchase contracts with vendors/suppliers.
•      Segregate mercury-containing products before they get into incinerator waste stream (conduct
       training for proper disposal).
•      Use T8 fluorescent lighting. T8 lighting is more energy efficient than  incandescent T12 bulbs. This
       allows hospitals to place less demand on the utility company. Coal combustion is one of the
       largest sources of mercury in the United States.

     Communicating and involving employees in mercury elimination is critical to success. At one hospital,

a worker reported that broken thermometers are sharp and disposed of them in "sharps" containers used for

waste hypodermic needles.  In other instances, workers reported throwing away materials used to clean up

mercury spills in infectious "red bag" waste.  The contents of these containers  were later incinerated,

resulting in an otherwise preventable release of mercury into the environment.

     Some mercury reduction opportunities follow:
•      Include articles devoted to mercury reduction, handling and proper disposal in staff newsletters.
       Include specific information about the proper handling of mercury in new-employee orientation and
       "Right-to-Know" training.
       Ensure that all personnel, including temporary workers, are familiar with mercury
       handling procedures and protocols to prevent mercury from being disposed in sharps containers,
       red bags or solid waste containers.
•      Include information about waste  reduction and pollution prevention in in-service training sessions.
       Encourage personnel to read labels.


                                                -78-
-------
•      Place placard or labels on or above red bags, sharps containers and solid waste containers that state
       "No Mercury."
•      Have mercury spill kits available in all labs, nursing stations, ICU/ER/Surgery rooms, patient rooms
       and storage/maintenance facilities. Provide training on proper usage of the kits.

Pesticides and Landscaping

     Reduce generation of pesticide waste by grounds maintenance activities with the following tips and

techniques:
•      Work with a contracted grounds maintenance service to eliminate pesticides and herbicides and to use
       plants that are native to the area that do not have to be watered or treated with pesticides as often.
•      Use mulching mowers to eliminate bagging grass wastes.
       Use nonchemical pest control methods such as cornmeal gluten as a natural herbicide.
•      Use dry pesticides that are spread on the ground and watered into the ground. This may
       eliminate the need for pesticide spraying containers and the resulting contaminated wastewater from
       clean-up.

Polyvinyl Chloride (PVC) and Dioxin

     Polyvinyl chloride (PVC) is a commonly used polymer in the production of plastic hospital products

because of its low cost, flexibility and optical properties. Twenty-five percent of all health care products such

as IV bags, blood bags and tubing are made with PVC.  Other PVC hospital products include: basins,

hemodialysis equipment, patient identification bracelets, bedpans, inflatable splints, respiratory therapy

products, stationary supplies, catheters, lab equipment, drip chambers, medical gloves, thermal blankets,

internal feeding devices and packaging.  Hospitals also have basic construction materials and furnishings such

as water pipes and wall coverings that may contain PVC.

     When burned, PVC releases dioxin, a PBT (persistent bioaccumulative toxin) and probable U.S. EPA

carcinogen.  Hospital PVC incineration accounts for nearly half of all dioxin released into  the environment in

the United States. This is almost completely avoidable considering that only 1-2 percent of a hospital's  waste

stream needs incineration. The first step for the hospital is to ask its vendors which products contain PVC.

Then, identify alternatives and develop and implement a PVC reduction plan as part of the EMS.

     Potential for patient exposure to diethylhexylpthalate (a softener added to PVC plastics); potential for

the PVC product to be incinerated  upon disposal; volume of PVC use; and availability of substitute products

are all drivers for PVC reduction. When establishing an organizationwide PVC reduction plan, include the

following priorities:
•      Target disposable PVC health care products, especially within neonatal intensive care units, maternity
       departments and pediatrics.
•      Phase out the purchase of PVC-containing office supplies,  furnishings, furniture products
       and construction products.  Specify PVC-free purchases.
                                                -79-
-------
Additional Information
Polyvinyl Chloride (PVC) Products in Hospitals                                     Page   156

Pharmacy
     Open formularies make monitoring patient drug use more difficult and can significantly contribute to
the volume of drugs that must be disposed.  Open formularies allow providers to dispense samples to patients.
This dispensing practice encourages the development of secondary storage areas.  Once established,
secondary storage areas and their environments cannot be controlled. When drugs are improperly stored
(e.g., improper cooling requirements), they may become obsolete and require disposal, increasing disposal
costs. The U.S. EPA states that pharmaceutical products do not become waste until the decision is made to
discard them. If the damaged or outdated products are returned to the manufacturer, distributor or third-party
processors with the intent to receive, reclaim or destroy, they are regarded as products (not waste) at the time
they are shipped.  The only requirement for shipping becomes proper Department of Transportation labeling.
     Monitor outside drug sources. Medical providers (who may have off-site offices) with hospital
privileges accumulate  samples that may become a disposal problem for pharmacies. Typically, pharmacies
dispose of these drugs gratuitously for the provider.

Radiology
     Full-service hospitals usually have a radiology department. The main waste stream is water containing
used photographic developing solutions (fixer and developer) and silver. Silver-containing effluent from the
fixer is passed through a steel wool filter and otherwise treated to recover this metal.
     Store materials properly. Many chemicals  are sensitive to temperature and light. Chemical containers
list the recommended storage conditions.  Meeting the recommended conditions will increase shelf life.
     Extend processing bath life. Techniques for extending bath life include: 1) adding ammonium
thiosulfate, which doubles the allowable concentration of silver buildup in the bath; 2) using an acid stop bath
prior to the fixing bath; and 3) adding acetic acid to the fixing bath as needed to keep the pH low. Accurately
adding and monitoring chemical replenishment of process baths will cut down chemical waste.
     Use countercurrent washing to replace the commonly used parallel tank system.  This reduces the
amount of generated wastewater. In countercurrent washing, water from previous rinsing is used in the initial
film-washing stage.  Fresh water enters only at the final stage, at which point much of the contamination is
                                               -80-
-------
already rinsed off the film.

     Implement dry laser film processing. This process reduces the chemicals that are manually poured into

the machine and does not need to be connected to the sanitary sewer for chemical discharge.

Recycling/Safe Disposal
    General Recycling Success Story

         Thomas Jefferson University Hospital in Philadelphia has cut in half the amount of trash it

    sends to the landfill since implementing its program to recycle paper, glass, metal and plastic. This

    resulted in a savings of $150,000 a year in waste disposal costs. To educate and motivate staff,

    Support Services Manager Ed Barr takes representatives of various departments on monthly visits to

    the landfill, where they sort through and audit the hospital's trash.
     Generally, recycling is the most common of all the available solid waste reduction options for hospitals.

In order to have a successful recycling program, education is essential. Educate staff about proper waste

segregation practices as soon as they enter the organization to ensure that they are aware of the hospital's

recycling programs and the costs and liabilities associated with improper disposal of hospital wastes.


Administrative and office areas - office paper, corrugated cardboard, other paper, cans, bottles.
Foodservice areas - glass,  metal, cans, plastic containers, corrugated cardboard.
Public areas - newspaper, magazines, bottles, cans.  Make sure bins in public areas as well as bins with
specialized openings (e.g., holes big enough only for aluminum cans, slots for newspapers instead of large
openings where it might look like a trash can) are clearly marked.

     Due to such large quantities  of paper and cardboard, many hospitals choose reusable totes.  Reusable

totes are most cost-effective when used to replace a constant cardboard need, such as distribution from central

supplies to satellite locations. Color-coded, stackable containers are the most feasible option.

     The Nightingale Institute estimated that approximately 19 percent of waste stream generated by surgical

services is blue sterile wrap. Other hospital areas that typically generate considerable quantities of this waste

include central distribution, purchasing, pharmacy and labor/delivery rooms.  This makes collection within

the hospital relatively easy  because it is already well known where the waste is coming from and staff can be

easily trained to collect the  wrap from these key areas. Due to the relatively low value of this material for

recycling, attention must be given to keeping costs as low as possible because the  facility is not going to get
                                                 -81 -
-------
much money back in return for the recycled product, especially if the material is collected internally. The

best thing to do in this situation is to identify a local market for polypropylene or No. 5 plastics to minimize

transportation distances and in turn save money on the facility budget.  Establish a low-cost collection and

transport system and generate a significant quantity to encourage vendor interest.

     Kitchen and food service operations are also often overlooked. Although food waste itself represents

only 10 percent of the hospital's waste stream, nearly 15 pounds of associated waste glass, cans and

cardboard are typically generated per patient from food trays. One option for food waste is to divert organic

food waste to composting. When considering this option, consider space limitations and fitting the size of the

compost container/system to the amount of food waste generated.  Obtaining management buy-in for

employee support and properly running the composting bin both help overcome misconceptions associated

with this recycling program. Case study examples suggest that properly administered food composting

systems can handle  100-300 pounds  of food waste daily.


Solvents

     Solvents are predominantly a laboratory-related waste stream and are used for fixation and preservation

of specimens in histology and pathology and for extractions in laboratories. Halogenated solvents are

generally more toxic and persistent than nonhalogenated solvents. Halogenated compounds used in hospitals

include methylene chloride, chloroform, tetrachloroethylene, chlorobenzene, trichloroethylene, 1,1,1-

trichloroethane and  refrigerants. Pollution prevention is the best option for solvents, but if use of a solvent

cannot be eliminated, work practice modification may be the next best bet.
•      If using solvent, conduct initial cleaning with used solvent and then fresh solvent for the final
       cleaning. This countercurrent cleaning decreases the amount of solvent used.  When solvent
       used for the initial cleaning step becomes too dirty, replace it with solvent from the second cleaning
       step and so on.
•      Using a wide variety of solvents will produce a wide variety of waste streams to manage.
       Investigate the possibility of using one type of solvent for equipment and  other cleaning. By
       switching to one type of solvent, it may be cost-effective to have onsite distillation.
•      Before placing labware in autoclaves or other cleaning equipment, drain chemicals out of containers
       and collect in proper disposal receptacles.  This significantly reduces the amount of contaminated
       wastewater  entering the publicly owned treatment works  (POTW) system.
•      Carefully evaluate citrus-based substitutes.  Citrus-based alternatives may reduce worker exposure
       but may also produce a hazardous waste due to flashpoint less than 140°F. These citrus-based
       solvents may process  samples  slower than xylene and will require temperature and time
       modifications. Generally, these products are effective on samples in the micrometer range. However,
       thicker samples may be difficult or impossible to process. Evaluate hazardous waste and quality
       issues before using xylene alternatives.
•      Do not mix wastes unnecessarily. Sometimes wastes are mixed without respect to characteristic and
                                                -82-
-------
compatibility at the point of generation.
Mounting chemicals are used to stabilize the sample on the slide and contain polymers and solvents
such as toluene and xylene. Control the inventories of these chemicals because they have limited
shelf lives.
Evaluate routine laboratory processes or tests such as fixation and extraction to determine if
quantities of reagents are reducible.  The evaluation can include using calibrated solvent dispensers
and unitized test kits; reducing volumes of reagents; and increasing the use of instrumentation in tests
and experiments.
                                         -83-
-------
                                        Conclusion



     Those who use this manual as a guide to environmental management system implementation may find a



new perspective on environmental management and realize the potential opportunities and benefits that EMSs



can provide.



     An EMS challenges all hospital employees to identify and prioritize its environmental aspects, take



steps to minimize adverse environmental impacts and set new objectives and targets to continually improve



environmental performance.



     A successful EMS builds on effective environmental performance—including environmental



compliance and pollution prevention—in conjunction with the hospital mission of patient care and



community health and well-being.



     We hope this manual continues to serve as a useful resource to your hospital with the same rewards as



many other organizations have seen from their efforts.
                                              -84-
-------
                                - APPENDIX A -
                              EMS EXAMPLES
 NOTE: This appendix includes actual environmental management system tools used by hospitals that



  provided assistance with the development of this manual. These documents are not indicative of all



 such documents used by the health care industry for implementation of environmental management



systems. For the purposes of this manual, these documents are simply models by which representatives



    of the health care industry may use and/or reference to develop and implement environmental



                management systems within their own health care organizations.
                                         - 85
Click here to return to Table of Contents.
-------
                          INTEROFFICE MEMO

      TO:         Hospital Staff                    CC:


      FROM:      President

      DATE:       8/13/98
      SUBJECT:   ISO MANAGEMENT REPRESENTATIVE
                   APPOINTMENT/APPROVAL
      As President at [insert hospital name and location] I appoint [insert name] to assume the
      responsibilities as EMS Management Representative and [insert name] to assume the
      responsibilities as EMS Coordinator/Specialist. Responsibilities and reporting functions
      will be consistent with those outlined in [insert hospital name] EMS  Policies and
      Procedures.
      [signature]
      President
Click here to return to page 20.                   - 86 -
-------
Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 OBJECTIVE
 UBJJU^llVJL
 To establish a framework for effectively managing environmental aspects associated with operational
 activities and controlling their impact on the environment.


 SCOPE
 All employees, physicians, students and volunteers within the EMS scope.
 DEFINITIONS
 The following definitions apply:
 • Continuous Improvement - Process of enhancing the environmental management system to achieve
 improvements in overall environmental performance in line with the organization's mission and
 environmental policy.
 • Environment - Surroundings in which an organization operates, including air, water, land, natural
 resources, flora, fauna, humans and their interrelation.
        NOTE - Surroundings in this context extend from within an organization to the global system.
 • Environmental Aspect - Element of an organization's activities, products or services that can interact
 with the environment.
        NOTE - A significant environmental aspect is an environmental aspect that has or can have a
 significant environmental impact.
 • Environmental Impact - Any change to the environment, whether adverse or beneficial, wholly or
 partially resulting from an organization's activities, products or services.
 • Environmental Management System - The 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.
 • Environmental Objective - Overall environmental goal, arising from the environmental policy, that an
 organization sets itself to achieve and which is quantified where practicable.
 • 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 - Detailed performance requirement, quantified where practicable, applicable to
 the organization or parts  thereof, that arises from the environmental objectives and that needs to be set and
                                                 87
Click here to return to page 28.
-------
Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 met in order to achieve those objectives.
 • Interested Party - Individual or group concerned with or affected by the environmental performance of
 an organization.
 • Prevention of Pollution - Use of processes, practices, materials or products that avoid, reduce or control
 pollution, which may include recycling, treatment, process changes, control mechanisms, efficient use of
 resources and material substitution.
 • EMS Committee: Site EMS representatives are core members of the EMS Committee. Additional key
 stakeholders will be added to the committee as determined by the agenda. Other interested parties will
 attend meeting on a periodic basis.
 POLICY
 The (insert hospital name) will establish and maintain an Environmental Management System (EMS), as
 outlined in the ISO 14001:1996 Standards.
 PROVISIONS

 General
 The (insert hospital name) shall establish and maintain an environmental management system, the
 requirements of which are described in the ISO 14001:1996 Standards.  Senior leadership will convey the
 importance of the EMS to employees in the following manner:
        a. Establish policies and methods of mechanisms for communication;
        b. Allocate resources;
        c. Establish support systems;
        d. Mandate necessary training; and
        e. Monitor conformance and implement improvement strategies when necessary.

 Environmental Policy
 The environmental policy serves as a framework for setting and reviewing environmental objectives and
 targets. It has been implemented, maintained and communicated to all employees and made available to
 the public. The hospital environmental policy is as follows:
 "In accordance with its mission, the (insert hospital name) is dedicated to the health and safety of its
 patients,  employees, customers, community and environment. Further the (insert hospital name) is
 committed to continuous improvement, prevention of pollution and compliance with relevant
 environmental regulations and other requirements. "
Click here to return to page 28.                     - 88 -
-------
Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 PLANNING

 Environmental Aspects
 Processes, services, products, activity or changes to an existing process, service, product or activity will be
 evaluated for environmental impacts. The evaluation will consider normal operating conditions, shutdown
 and start-up conditions and the impact when normal operating conditions are not followed and an
 emergency situation occurs. Consideration will also include the regulatory status of the new process and
 the potential to:
        a. Produce emissions to the air;
        b. Release to sanitary sewer or water source;
        c. Generate waste (hazardous, solid or recyclable);
        d. Contaminate the land;
        e. Use raw materials or natural resources;
        f Cause negative impact to human health.

 The evaluation results will be documented and forwarded to the site EMS representative. The EMS
 Environmental Aspect Checklist can be used to document the evaluation. The EMS Committee will
 review all documentation for significance of environmental aspects and the placement on the Master
 Environmental Aspect list in an existing category or new category of activity. The environmental aspects
 will be grouped according to category of activities. Environmental aspects that are regulated, impact air,
 land, water, human health, generate waste or use raw materials or natural resources will be considered
 significant.

 Legal and Other Requirements
 Management staff must ensure that department operations are in compliance with applicable
 environmental requirements.  Corporate Audit and Compliance will assist managers in obtaining
 information related to new regulations. A number of resources are utilized in managing regulatory
 oversight, including, but not limited to:
        a. The Federal Register
        b. Web-based software
        c. Professional journals and publications

 Environmental objectives and targets aimed at the prevention of pollution are established and documented
 at the system and department levels. Objectives are based on legal requirements, technological, business,
 financial and operational requirements, as well as views of interested parties.  System level objectives and
 targets are documented as continuous improvement initiatives, and the EMS Committee tracks progress.
 At the site level, each EMS site representative is responsible for reporting on the system objectives and
 targets at the environment of care and/or leadership performance improvement committee meetings.

 Environmental Management Programs
 Programs or methods for attaining system environmental objectives and targets have been established and
 are monitored by EMS representatives. Documentation, on a Program Tracking Form identifies the
Click here to return to page 28.                      - 89 -
-------
Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 following:
        a. Designation of responsibility for achieving objectives and targets;
        b. The necessary time frames and resources; and
        c. Scheduled review and updates as necessary.

 The EMS Committee maintains documentation on the environmental management programs. Progress on
 the EMS objectives and targets is reported to the System Quality Medical Safety Council at a minimum of
 annually.
 IMPLEMENTATION AND OPERATION

 Structure and Responsibility
 Senior leadership has ensured the success and maintenance of the EMS through the following actions:
        a. Roles, responsibility and authority have been defined within (insert hospital name here) policies
        and procedures.
        b. Resources have been provided; this includes human resources, specialized skills, technology
        and financial resources.
        c. A management representative has been appointed who ensures that:
         The environmental management system is established, implemented and maintained in
        accordance with ISO 14001 standard; and
         The performance of the environmental management system is reported to senior leadership for
        review and as a basis for improvement of the EMS.

 Training, awareness and competence
 Department managers identify training and competency needs. All staff will receive general awareness of
 the EMS. Personnel whose work may create a significant impact upon the environment will be competent
 on the basis of education, training and/or experience. Training programs ensure that employees are aware
 of the following:
        a. EMS requirements, as appropriate to their scope of responsibility;
        b. Work activities that pose either an actual or potential significant environmental impact;
        c. Roles and responsibilities related to EMS conformance, including emergency management,
        response requirements and regulatory compliance; and
        d. Potential consequence(s) of departing from operating procedures.

 Communication
 Communications regarding the  EMS have been established and maintained in the following manner:
        a. Methods for internal communication include electronic mail correspondences, employee
        newsletters, management forums and department meetings.
        b. Methods for external communication include receiving, documenting and responding to
        communication regarding environmental issues from  external interested parties.
        c. The (insert hospital name), as policy,  does not make available to the public information about
        its significant environmental aspects.
Click here to return to page 28.                      - 90 -
-------
Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 Environmental Management System Documentation
 Documentation that describes the core elements of the EMS and provides guidance to related documents
 is found within this policy. In addition to this, the following documentation has been established and
 maintained:
        a. Master Environmental Aspect List
        b. ISO 14001 Standard and Related (insert hospital name) Policies

 Document Control
 EMS documents are controlled as stated in (policy number) (policy name) and (policy number) (policy
 name).

 Operational Control
 Operational controls, in the form of policies, procedures or management operating directives ensure that
 work is performed under controlled conditions.  Operational controls include the following:
        a. Documented procedures to cover situations where, without them, deviations from the
        environmental policy and the objectives and targets could occur.
        b. Procedures that include operating criteria.
        c. Communication with suppliers and contractors regarding policy and procedures related to the
        identifiable significant environmental aspects and other relevant requirements.

 Emergency Management and Response
 The (insert hospital name) has established procedures and plans that identify the potential for and
 response to accidents and emergency situations. The policies and procedures aim to prevent and mitigate
 the environmental impacts that may be associated with accidents  and emergency situations. Emergency
 management and response is addressed in, though  not limited to,  the following policies:
        • Safety Management Plan (policy number)
        • Hazardous Material Management Plan (policy number)
        • Emergency Management Plan  (policy number)
        • Related Emergency Code Plans
        • Interim Life Safety (policy  number)
        • Fire  Drills (policy number)

 Emergency procedures/plans will be  reviewed and revised where necessary, particularly after the
 occurrence of accidents or emergency situations. These procedures/plans will be tested where practicable.

 CHECKING AND CORRECTIVE ACTION

 Monitoring and Measurement
 The (insert hospital name) evaluates  and improves its environmental performance through monitoring and
 measurement activities (performance improvement). Key characteristics of (insert hospital name)
 operations and activities that may have a significant impact on the environment are monitored and
 measured as part of the environment  of rounds.  Results from environmental rounds are reported at the site
 environment of care meetings.
Click here to return to page 28.                     - 91 -
-------
Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 Equipment used for monitoring purposes is calibrated and maintained. Records of theses results are
 maintained as stated in (policy number).

 Through internal monitoring (audits) (policy number) and environment of care rounds (policy number),
 compliance with relevant environmental legislation and regulations will be evaluated at least every 12
 months. Findings, corrective/preventive actions and other recommendations from these audits will be
 reported to the site Environment of Care Committee and/or the site Leadership Performance Improvement
 Committee. External audit results may also be used to document compliance.

 Nonconformance and Corrective and Preventive Action
 Responsibilities and authority for documenting corrective and preventive action are defined in (policy
 number) (policy name), Incident Reporting (policy number) and quality and environmental management
 system audits (policy number). Potential nonconformances are also identified through the Compliance
 Hotline, where environmental issues are referred to safety officers.
        a. Handling and investigating nonconformance;
        b. Taking action to mitigate any impacts caused;
        c. Initiating and completing corrective and preventive actions.

 Corrective and preventive actions eliminate the causes of actual and potential nonconformances and are
 appropriate to the magnitude of the problem and its associated impact. Any implemented changes shall be
 recorded in documented procedures.

 Records
 Control of records is defined within (policy number) and (policy number). Retention periods for
 environmental records are defined in the (policy name/number). Where regulatory requirements dictate a
 retention period differing than the  stated (insert hospital name) standard, the regulatory requirement
 supersedes (insert hospital name) retention policy.

 Environmental Management System Audit
 Internal audits are conducted at planned intervals to determine whether or not the EMS:
        a. Conforms to established requirements;
        b. Has been properly implemented and maintained.

 The process and methodology for conducting internal audits is outlined in (policy number). Internal audit
 results are reported at site Environment of Care and/or Leadership Performance Improvement Committee
 and are part of the management review process.

 Management Review
 Management review occurs at least, annually, at the System Quality Medical Safety Council (Attachment
 8).   As part of management review, the following elements of the EMS are reviewed:
        a. Results from audits;
        b. The extent to which objectives and targets have been met;
Click here to return to page 28.                     - 92 -
-------
Title: ENVIRONMENTAL MANAGEMENT SYSTEM POLICY
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
        c. The continuing effectiveness and suitability of the environmental management system;
        d. Concerns from relevant interested parties; and
        e. The need for changes to policy, objectives and other elements of the EMS.
 ADMINISTRATIVE RESPONSIBILITY

 President
 The president of the operating units/designee has overall administrative responsibility for this policy.

 Management Representative (MR)
 The site safety officer is responsible for overall implementation of the EMS.
 Chief Executive Officer/President    Date
 (Insert Hospital Name)
 Executive Vice President and Chief Operating Officer   Date
 (Insert hospital name)
 Chief Nursing Officer, Senior Vice President, Patient Care Service  Date
 (Insert hospital name)
 Supersedes:

 Review Date:
Click here to return to page 28.                      - 93 -
-------
Title: ENVIRONMENTAL REVIEW OF NEW PROJECTS
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 PURPOSE/SCOPE

     This procedure defines the method for identifying and evaluating the environmental issues of new
     projects at the (hospital name) to:

          a)  Ensure that appropriate consideration be given to environmental issues prior to project
             approval and funding.
          b)  Ensure that new environmental aspects generated by projects are identified and their
             significance evaluated.
          c)  Provide a mechanism for the amendment of environmental management system elements
             and programs, where relevant, to ensure that the environmental management system applies
             to such projects.

 ACTIVITIES AFFECTED

     All areas and departments

 FORMS USED

     Project Environmental Checklist

 REFERENCES

     (Policy number) Environmental Aspect, Objectives and Targets and Management Programs

 DEFINITIONS

     None

 EXCLUSIONS

     None

 PROCEDURE

        7.1    Areas/departments initiate Project Appropriation Requests when needed for project
               funding to become apparent.

        7.2    The initiating activity or designee shall identify and evaluate environmental issues
               associated with the project.  A summary of this evaluation shall be documented on a
               Project Environmental Checklist form and the form added to the Appropriation Request.
               This process may be undertaken in liaison with the Environmental Coordinator (or other
               competent individual) at the discretion of the initiating activity and shall include an
                                               94
Click here to return to page 33.
-------
Title: ENVIRONMENTAL REVIEW OF NEW PROJECTS
Policy Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
                identification of environmental aspects and requirements for obtaining approvals from
                environmental regulatory agencies.

         7.3     The initiating activity shall submit the Appropriation Request and complete Project
                Environmental Checklist for review to the environmental management representative.

         7.4     The environmental management representative or designee shall review the proposed
                project to ensure that all relevant environmental issues have been identified, and if
                incomplete shall return the Appropriation Request and Project Environmental Checklist
                to the initiating activity for alteration.

         7.5     The environmental management representative or designee shall review the
                environmental aspects of the project, considering their significance in line with (policy
                number).

         7.6     Following appropriate review, the environmental management representative or designee
                may approve the project by returning the Appropriation Request to the initiating activity
                for further processing. If a project is not acceptable, the initiating activity will coordinate
                any necessary actions to satisfy concerns identified.  The initiating activity in conjunction
                with the environmental management representative or designee  will coordinate any
                necessary prevention, mitigation or control activities associated with the project.
 GENERAL RULES
         U
         8.2
 RECORDS
Environmental aspects associated with projects shall be evaluated for significance by the
Cross Functional Team per (policy number).

Changes to the Environmental Management System resulting from an environmental
review of a project will be approved by the facility/plant management.
 Records shall be retained consistent with (policy number).
 RECORD OF REVISIONS
Revision Date

Description

Sections Affected

Click here to return to page :
                                -95-
-------
Title: PROJECT ENVIRONMENTAL CHECKLIST
Project Number: Hospital Name: Project Description:
Date Approved:
Next Revision Date:
AIR EMISSIONS
Will this project/process change/produce air emissions?
Will this project/process change an air permit or permit modification?
Does the change require air pollution controls?
Does the project/process change/require the use or purchase of ozone
depleting substances?
WATER DISCHARGES
Does the project/process change results in a wastewater, sanitary or
stormwater discharges?
Will the project/process change/result in changes to water discharge flow
rates?
Will the discharge require a permit modification?
Will new or additional pretreatment be necessary?
Are facility discharges to a common sewer altered?
STORAGE TANKS
Will underground storage tanks be installed?
Will tanks be installed to store hazardous waste or materials, petroleum
products or propane?
WASTE GENERATION
Will the project/process change/produce a waste or recyclable material?
Will the waste be classified as special or hazardous?
Will off-site disposal be necessary?
Are special handling, abatement or disposal measures necessary?
ENERGY USE
Will the project/process change/affect facility energy usage?


YES




NO





YES





NO






YES


NO



YES




NO





YES

NO


Click here to return to page 33.
                                                     -96-
-------
Title: PROJECT ENVIRONMENTAL CHECKLIST
Project Number:
Date Approved:
Next Revision Date:
Hospital Name:
Project Description:
 OTHER CONSIDERATIONS
 Do recycling options and costs need to be considered?
 Does the project/process change/require use of toxic, hazardous
 or carcinogenic materials?
 Do project/process materials require special handling or storage?
 Does the project cause land disturbances?
 Do pollution prevention issues need to be addressed?
 Does the project/process change/impact the surrounding community
 (e.g., odor, noise, etc.)?
 Are there any wildlife or land use issues?
 Does the project/process change/alter or add to current facility aspects?
 Does the project/process change/require a change to emergency
 response methods?
      YES
NO
 Initiating Activity Manager
Date
 Environmental Management Representative
Date
Click here to return to page 33.
                                            -97-
-------
Example Aspects and Impacts for a Health Care Facility
Activity/Service Aspect Possible Impact(s)

1. Nursing/Medical Floors/Operating Rooms/Day Surgery/Emergency/Intensive and Critical Care Units/Isolation Areas, etc.
Basic Patient Care (including
surgical procedures, daily care,
isolation cases, etc.)
Operation of Medical and
Other Equipment
Compressed Gas Usage
(oxygen, nitrous oxide, etc.)
Laser Usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Biomedical waste generation (sharps,
items contaminated with blood and/or
body fluids, isolation supplies, etc.)
Raw material usage (cleaning chemicals,
sterilants, high-level disinfectants,
formaldehyde, medications, etc.)
Potential chemical spills (emergency)
Energy usage
Hazardous waste generation (batteries)
Raw material usage (chemicals)
Possible fire hazard (emergency)
Chemical leakage (emergency)
Energy usage
Possible fire hazard (emergency)
Possible occupational exposure to
radiation
Potential water pollution from leaking landfill,
Natural Resource Depletion (Land), Resource
Depletion (e.g., raw material depletion)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air/Water Pollution, Resource
Depletion (e.g., raw material depletion)
Air, Water, and Soil Pollution (e.g. air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. smoke)
Human Health, Air Pollution (e.g. chemical vapors),
Resource Depletion (e.g., raw material depletion)
Air, Water, or Soil Pollution (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air emissions (smoke)
Human Health
2. Diagnostic Imaging (Nuclear Medicine, X-Ray, Radiology, Ultrasound, Cat Scan, Cardiac Catheterization Procedures, etc.)
Basic Patient Care (Operating
Medical Equipment,
Performing Invasive
Procedures and Contrast
Injections)
Film Processing (Wet and Dry
Laser)
Biomedical waste generation
Radioactive biomedical waste generation
(Half-life of radioactive isotope must be
spent before leaving department)
Solid waste generation (packaging, use
of disposable materials, etc.)
Raw material usage (cleaning, high-
level disinfectant, etc.)
Possible ehemical spill (emergency)
Possible occupational exposure to
radiation during x-ray process
Minor radioactive excreta sanitary
disposal
Possible radioactive spill (emergency)
Solid waste generation (packaging, film,
etc.)
Raw material usage (film processing
chemicals, plastic film, etc.)
Water consumption
Wastewater discharges (depends on state
or socal water regulations)
Silver recovery from film
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. incineration),
Natural Resource Depletion (Land), Resource
Depletion (e.g., raw material depletion)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous)
Human Health
Natural Resource Depletion (water)
Human Health, Waste (Hazardous)
Air, Water, or Soil Pollution (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Natural Resource Depletion (water)
Water Pollution (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Positive Impact (reduced impacts on air, water, soil
(pollution); reduced energy resources impacts
(combustion & depletion of natural resources);
reduced impacts on mineral resources (depletion)
Click here to return to page 34.
                                                      -98-
-------
Nuclear Laboratory Work
Possible Occupational Exposure to
Radiation
Possible Air Emissions (often fume
hoods are used as precautionary
measures when preparing injectables)
Human Health
Human Health, Air Pollution (e.g. vapors discharged
through fume hoods)
3. Laboratory (Histology, Pathology, Morgue, Autopsy, Blood Bank,
Daily Operation of Analysis
Machines (Aspects may differ
depending on the type of
equipment and how the
chemical waste is disposed)
Manual Analysis (urine, blood,
staining, etc.)
Chemical Use, Transportation,
& Disposal
Flammable Storage Rooms
Chemical Recycling (Process is
used to reclaim used chemicals
such as alcohol, Formalin,
Xylene, etc.)
Processes Utilizing Fume
Hoods and Ventilation
Equipment
Performing an Autopsy
Biomedical waste generation
Hazardous waste generation
Raw material usage (chemicals)
Possible Chemical Spill (Emergency)
Energy usage
Water Consumption
Wastewater Discharges (depends on
State or Local Water regulations)
Biomedical waste generation
Raw material usage (chemicals)
Possible Chemical Spill
Water Consumption
Wastewater Discharges (depends on
State or Local Water regulations)
Raw material usage (chemicals)
Possible Chemical Spill
Air Emissions
Hazardous waste generation
Possible Fire/Explosion Hazard
Possible Wastewater Discharges
(depends on State or Local Water
regulations)
Chemical Storage & Raw material usage
(chemicals)
Possible Chemical Spill (Emergency)
Possible Fire/Explosion Hazard
Air Emissions
Raw material usage (chemicals)
Chemical Recycling
Air Emissions
Hazardous waste generation
Possible Chemical Spill (Emergency)
Possible Fire/Explosion Hazard
Air Emissions
Energy usage
Raw material usage (a primary use
is formaldehyde)
Possible Chemical Spill (Emergency)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Resource Depletion (e.g. raw material
depletion)
Positive Impact (+) (e.g. reduced purchase of
chemical, reduced impacts associated with disposal)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Click here to return to page 34.
                                                      -99-
-------

Btomedical waste generation
(Anatomical)
Atr Emissions- (aerosol'cutting Dories)
Energy usage
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. dust)
Impacts to Air, Water or Sod (e.g., air pollution and
other pollution products from combustion). Natural
Resource Depletion (e.g. oil, natural gas, etc.)
4, 1 .11 vii niiiiii'iilLiI Services/ Hou&ekeeiiii)i>
i hgh-level Disinfecting and
Cleaning Procedures
Transporting Biomedicat Waste
Laundry (may be a separate
department or contracted
off-site)
5. ( entral Slerili/uliou
Operation of Ethytene (Hide
Steriti/er
Operation of Hydrogen
Peroxide Sterilizers
Operation of High
Temperature,' Pressure/ Steam
Sterilizers
Biological Testing
Raw material usage (chemicals)
Possible Chemical Spill (Emergency)
Water Consumption
Wastewater Discharges
Air Emissions (ex. chemicals used lor
stripping floors)
Possible Biomedical Waste Spill
(Emergency)
Energy usage
Raw material usage (detergents, fabric
softeners)
Possible Chemical Spill (Emergency)
Water Consumption
Wastewater Discharges

Compressed Ci as Storage and Raw
material usage
Air Emissions
Energy usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Raw material awge (Hydrogen peroxide,
packaging, etc.)
Energy usage
Water Consumption
Wastewater Discharges
Water Consumption
Wastewater Discharges
Energy usage
Biomedical waste generation
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Atr Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water). Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land).
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion). Natural
Resource Depletion (e.g. oil, natural gas. etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion ( Water)
Impacts to Water (e.g. chemical contamination to
water). Natural Resource Depletion (water)

Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill). Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Resource Depletion (e.g. raw material
depletion)
Impacts to Air, Water or Soil (e.g., air pollution and
oilier poi lull-on products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water). Natural Resource Depletion (water)
Impacts to Air, Water or Soil (e.g., air pollution and
oilier pollution products from combustion). Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
6. Nutriliun Fond Service*/ ( iili'lei'ia>!Rf
-------

Solid waste generation (packaging, use
of disposable materials, etc.)
Solid waste generation - Recycled (food
waste, plastic, cans, glass, etc.)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Positive Impact (+) (reduced natural resources needed
for landfill)
7. Pharmacy
Preparing Antineoplastic/
Cytotoxic Drugs
Disposing of Narcotics
(Possible on-site disposal by
Pharmacists)
Needle, Vial, IV Bag, Drug
Return Disposal
Biomedical waste generation
(Cytotoxic/Antineoplastic drugs)
Air Emissions (Requires Fume Hood)
Possible Occupation Exposure to
Cytotoxic Material
Biomedical waste generation (May be
regulated in your area-to dispose of
narcotics already rendered
unrecoverable)
Generation of Biomedical Waste (May
be regulated in your area)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
Human Health, Air Pollution (e.g. incineration),
Waste (Hazardous), Natural Resource Depletion
(Land)
8. Physiotherapy/ Occupational Therapy, Wellness Clinics, Recreational Therapy, etc.
Daily Operation of Equipment
(ex. Wax Machine,
Hydrocollator, Whirlpool,
Ultrasound, Laser, etc.)
Energy usage
Solid waste generation (packaging, use
of disposable materials, etc.)
Water Consumption
Wastewater Discharges (depends on
State or Local Water regulations)
Raw material usage (These departments
mainly use cleaning chemicals and
possibly chlorine for the whirlpool)
Possible Chemical Spill
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
9. Engineering/Maintenance
Operation of Powerhouse
Equipment (Boilers, Water
Softeners, Dealkalizers, Fire
Pumps, Vacuum Pumps,
Medical Air Pumps,
Cleaning Salt (Brine) Tank
Welding/Cutting Metal
PCB Storage (Outside or
Inside)
Asbestos Handling and
Removal
Energy usage (Powerhouse equipment
are high consumers of energy- often to
produce energy)
Air Emissions (often regulated
discharges through a stack)
Water Consumption
Wastewater Discharges (ex. blow down
from boiler, flushing pumping systems,
etc.)
Raw material usage (There are a number
of chemicals, mainly in drums, used for
Powerhouse equipment)
Possible Chemical Spill (Emergency)
Fuel Consumption- Natural Gas (back-up
Diesel Fuel)
Hazardous waste generation
Air Emissions
Scrap Metal Recycled
Chemical (Compressed Gas) Use as
Fuel- acetylene, oxygen, argon, etc.
Compressed Gas Storage
Noise/Heat/Radiation Exposure
Possible Fire/Explosion (Emergency)
Possible PCB Leak (Emergency)
Hazardous waste generation (Asbestos)
Air Emissions
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. emissions as a
result of combustion, chemical emissions, etc.)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (e.g. natural gas, oil,
hydro-electricity, etc.)
Human Health, Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health
Positive Impact (+)
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health
Human Health, Air
Human Health, Groundwater, Storm Sewer
Human Health, Air Pollution (e.g. airborne asbestos
fibers), Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Air Pollution (e.g. airborne asbestos
fibers)
Click here to return to page 34.
                                                   - 101 -
-------

Above-Ground and/or Under-
Ground Storage Tanks
Operation of Diesel Generator
(Back-Up Power)
Electrical Operations (repairing
electrical equipment, changing
light fixtures and ballasts, etc.)
Cooling and Heating Processes
Painting Processes
Possible Improper Handling of Asbestos
Waste (Emergency)
Possible Fuel Spillage (Emergency)
Air Emissions
Energy usage
Fuel Consumption (Diesel)
Air Emissions
Possible Fire Hazard (Emergency)
Hazardous waste generation- Possibly
Recycled (Fluorescent Tubes, Ballasts)
Hazardous waste generation- PCB
Ballasts (if you have these in your
facility), Mercury (small mercury pods in
light switches)
Solid waste generation (packaging, use
of disposable materials, etc.)
Possible Electrical Fire/Electrical Shock
Scrap Electrical Wire - Recycled
Water Consumption
Wastewater Discharges
Air Emissions
Energy usage
Raw material usage (biocides)
Possible Chemical Spill (Emergency)
Raw material usage (Latex, alkyd and
oil-based paints, varsol, urethane, etc.)
Possible Chemical Spill (Emergency)
Air Emissions (chemical, dust from
sanding drywall, etc.)
Water Consumption
Wastewater Discharges (process of
cleaning brushes)
Hazardous waste generation
Solid waste generation (packaging, use
of disposable materials, etc.)
Human Health, Air Pollution (e.g. airborne asbestos
fibers)
Human Health, Air Pollution (e.g. vapors)
Human Health, Air Pollution (e.g. vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Natural Resource Depletion (e.g. diesel oil)
Human Health, Air Pollution (e.g. vapors)
Human Health, Air Pollution (e.g. smoke, vapors)
Positive Impact (+) if Recycled, if not, Human Health,
Air Pollution (e.g. mercury vapor), Waste
(Hazardous), Natural Resource Depletion (Land)
Human Health, Air Pollution (e.g. chemical/mercury
vapor), Waste (Hazardous), Natural Resource
Depletion (Land)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Human Health, Air Pollution (e.g. smoke)
Positive Impact (+) - (decreased natural resources
required for landfill)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. dust, chemical
vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors),
Waste (Hazardous), Natural Resource Depletion
(Land)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
10. Shipping/Receiving/Stores
Receiving, Storing and
Transporting High Risk
Supplies (Chemical, Pharmacy,
Radioactive, etc.)
Unpacking Supplies
Chemical Storage (Priority, high risk
items should be transported to their
designated destination immediately after
arrival, however, due to timing there may
be a period of time where these items are
stored)
Possible Radioactive Isotope Spillage
(Emergency)
Possible Chemical Spill Internal/External
(Emergency)
Possible Fire/Explosion Hazard
Solid waste generation (packaging, use
of disposable materials, etc.)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health
Human Health, Air Pollution (e.g. chemical vapors),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. smoke, chemical
vapors)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Click here to return to page 34.
                                                  - 102-
-------

Solid waste generation - Recycled
(cardboard, boxboard, plastics, etc.)
Positive Impact (+) (decreased natural resources
needed for landfill)
11. Landscape Management/ External Environment
Grounds-keeping Practices
Snow Removal/Salting During
Winter Months
Use of Equipment (Gas-
Powered Lawn Mowers)
Water Consumption
Raw material usage (Pesticides/
Herbicides/ Fertilizers)
Possible Chemical Spill (Emergency)
Raw material usage (salt, sand,
environmental alternatives available)
Air Emissions (Particularly problematic
to passing staff, visitors, etc., on high
SMOG Days)
Fuel Consumption
Natural Resource Depletion (Water)
Human Health, Resource Depletion (e.g. raw material
depletion), Air Emissions, Groundwater
contamination , Impact to local Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora Fauna
Human Health, Resource Depletion (e.g. raw material
depletion), Other- Flora and Fauna
Human Health, Air Pollution (e.g. combustion
emissions), Other- Flora and Fauna
Natural Resource Depletion (e.g. gasoline, oil)
12. General Hospital Operations & External Concerns
General Hospital-wide
operations and Administration
Processes
Use of Mercury Containing
Devices
On-Site Waste Disposal
(Incineration)
Compressed Gas Storage
Parking Lots
Railway or Highway
Environmental Incident (in
close proximity to your
hospital's location)
Local Industry Environmental
Incident (in close proximity to
your hospital's location)
Solid waste generation (packaging, use
of disposable materials, etc.)
Solid waste generation - Recycled
(paper, cardboard, boxboard, plastic,
cans, glass, etc.)
Energy usage (office equipment-
computers, photocopiers, personal
radios, heaters, fax machines, lighting,
etc.)
Air Emissions (possible photocopier
emissions)
Water Consumption (toilets, sinks, water
fountains, etc.)
Wastewater Discharges (toilets, sinks,
water fountains, etc.)
Possible Chemical Spillage (Emergency)
Air Emissions
Heat/Noi se/Vibration
Generation of Hazardous and Non-
Hazardous Waste (Ash may be
considered hazardous or non-hazardous
depending on your state regulations)
Possible Fire/Explosion Hazard
(Depending on what is put into the
incinerator- look to state regulations to
determine what waste can be disposed of
by incineration)
Possible Air Emissions/Gas Leak
(Emergency)
Possible Fire/Explosion Hazard
(Emergency)
Possible Chemical Spill (Emergency)
Possible Chemical Spill (Emergency)
Possible Fire/Explosion Hazard
(Emergency)
Possible Chemical Spill (Emergency)
Possible Fugitive Air Emissions
(resulting in external air exclusion
procedures)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Positive Impact (+) (decreased natural resources
needed for landfill)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. chemical vapors)
Natural Resource Depletion (Water)
Impacts to Water (e.g. chemical contamination to
water), Natural Resource Depletion (water)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. combustion
emissions)
Human Health
Human Health, Air Pollution (e.g. combustion
emissions), Waste (Hazardous), Natural Resource
Depletion (Land)
Human Health, Air Pollution (e.g. smoke, combustion
emissions)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors)
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Impacts to Water (e.g. storm sewer, groundwater),
Other- Flora and Fauna
Click here to return to page 34.
- 103-
-------
Construction- Demolishing and
Re-building Structures
Solid waste generation (materials not
reusable or recyclable)
Fuel Consumption- (mainly mobile
equipment)
Energy usage
Air Emissions- exhaust from forklifts,
trucks, dust, fugitive emissions, etc.
Compressed Gas Use and Storage
Possible Fire/Explosion Hazard
Noise and Vibration
Raw material usage (chemicals,
construction materials, etc.)
Possible Chemical Spill (Emergency)
Impacts on Air, Water, or Soil (e.g. potential water
pollution from leaking landfill), Natural Resource
Depletion (Land), Resource Depletion (e.g., raw
material depletion)
Natural Resource Depletion (e.g. natural gas, oil,
hydro-electricity, etc.)
Impacts to Air, Water or Soil (e.g., air pollution and
other pollution products from combustion), Natural
Resource Depletion (e.g. oil, natural gas, etc.)
Human Health, Air Pollution (e.g. combustion
emissions), Other- Flora and Fauna
Human Health, Air Pollution (e.g. chemical vapors),
Other- Flora and Fauna
Human Health, Air Pollution (e.g. smoke, chemical
vapors), Other- Flora and Fauna
Human Health
Human Health, Resource Depletion (e.g. raw material
depletion)
Human Health, Air Pollution (e.g. chemical vapors),
Other- Flora and Fauna
Other Areas to Consider Including:
Day Clinics
Special Testing
Off-Site or Satellite Facilities
Mobile Units owned and operated by the hospital such as Ambulance and Patient Transport services
Click here to return to page 34.
- 104-
-------
  a
  •a;

  s
  a
  o
  a
 w
  a

Product, Activity, Service
+.
.
I|



0
,Tj
All Emergencj- Codes, Accidental Spills, Releases to th>
Environment
a
o

a! *"'
(«>H a
Contamination/Negative af
People, Property, Equipme
Community, Air

,

a |
6fl —
~ PS
a S
w *«*
5 *
Of f
I/* a nmu4
g -2 5
o c d
111


5
t/1
Sinks, Hoppers, Floor Drains, Eye Wash Fountains,
Emergency Showers, Decontamiuatiou Showers,
Portable AC Units, Humidifiers, Walk-in-Refrigerator
Automated Equipment, Morgue Grinder, Wastewater
Discharge, leaky pipes, scrub agents, RO water system
Snow Plowing
P
S
t3 4 •**
•0 U «
™ d •«
Release to and Potential to
contaminates to Public Ow
Treatment Work Facility o
Water




£*"*
F"
"3
fiS
t/5
o
"fc-
* >f
J S
§|

O
3

Compressed Gas Cylinders, Hyperbaric Chambers
a
w
a

|*BM|
lJ.j
Contamination of Air and ]
Health Exposure

o

D»
«
0 „,

' jj»j
ra *
faf W w"-
S ^U rt
S3 S! "O
111
t pjj O i^"*
E O O

<-<
O

Everything not hazardous or recyclable, Lawn Debris
SM
4- "S
,« a

t^ M
Contamination of Soil, Air,
Groundwater, Storm Wate
exposure to Human Health

"«

o
O.
JJ2
T3

C5 !~j
s «
ao g
tj3 i^*-
ffl ^
^1


„.
,..4
0
wf
Cultures and Stocks of Infectious Ageats, Pathological
Waste, Liquid Human and Animal Waste, Blood and
Blood Products, Body Fluids, Sharps, Needles, Syringe
Scalpels, TV Tubing with needles attached, Laboratory
Instruments or Glassware that could cause puncture,
Pneumatic Tubes

^—

a
£ .
Contamination of Soil,
Groundwater/S torin Watei
Human Health exposure
1£ 4^
d wi

a £
3 r;

« 1
f^ fe"H
d' Cj
g 0
•r M
e «
d a,
rtj i/^
(3=3

IT,
O

Hoods, Mop Head Dryer, Chemo hoods. Chemical'
Biological Hood, ETO, Mold Room, Paint Hood



t-
•&
Potential effect OE Air Qua





o
*5
d
.2
-(/^
"^
9 \f
^ "o
^ffl

VO
0

Rooms designed to exhaust to the outside (Negative
Pressure Room, Soiled Utilirv- Rooms, Housekeeping
Closets, Staff Restrooms)


, •••
~
^4
Potential contamination of
Human Health exposure,
degradation of Air Quality
,
-?

J S
1 O
- o
o *-
•i s
a P
HH ,53
0 ^
^ a
* S
«s "
^_, ^

r-
O
3
Security Vehicles, Plant Operations, Delivery Trucks, ^
Department Owned Vehicles, Utility Systems





Degradation of Air Qualirv



-
S "P?
p 5
t^
d •«
© d
'" <5
• ^ »/^ fjr,
a - 3
1 1 ^
*n t** 
-------
  d
  o

  a
  a





i4i
Product, Activity, Servic*
z
o.
S
i—i
"re
a
Potential Envirouine]
d
o
Aspect Desciipti
*
o.
JJ2
*












*
Human Health exposiu
<
Radioactive Materia
Waste





S
d >.
djS J2
g "°
-turn -^
-S P.
AD Patient Specimens, aD Personnel com
with Patient Specimens, Specimens trans
Pneumatic Tub Svstem.

a
es
a
s

Potential for SpiDs and
Health exposure
d
rtj
Exposure to Specim*
and Blood Products

o
fi
O
a * *" d
o 3 a *
•S R O M
i a ^ s
S rt p^ i
« | ^ o'
nn Mri ^ *uj
•S *• ^ *P •«
J2 * es hn IS
Listed as hazardous in 40 CFR 261, Exhi
Characteristics, Toxic, Reactive, Ignitabl
aud Combustible, Corrosive. Listed as H
MSDS, Hazardous by definition or by i e<
Gasoline, Weed Control Products, Pestici

O aj
a "»
.2 S
** ^
#3 d
Sa ^
t^. • .
Release to Air, contami
Soil, Grouadwater/Stoj
Human Health exposui
Mi 
Air" Quality and Hiima:
Exposure

Charging Batteries

<^i
f^i
O





«•>
Cytotoxic Drugs, Antineoplastic Drugs,
Chemotherapeutic. (Preparation, Handlt
Administration and Disposal)



sJ'
•Sz
,ffl 4i
Contamination of SoU,
Groundwater/Storni \A
Human Health exposui

Generation, handlin
storage, disposal of
Cheino Materials an
Waste

*r
f-i
O


S
'f
O p^
H 5
on f5
Heating, Electricity, Natural Gas, Coolin
Water Treatment. Oil, Emergency Genei

^
u
EH
O
f
Oj
Depletion of Natural R

Consumption of
Natural Resources


05
UH



a
s
n.
Above Ground and Underground Storag
5

[jj1
•i,
£ -3
if! U-l
Contamination of Soil,
Groundwater Sanitary
Emission, Potential for

Above Gl'ound and
Underground Diesel
Storage Tanks


p^
UH






Operation of eniei'geucy generator






0-
d
S
Emergency Generat


P^
UH






Operation of Cogenerator






*
to
P
bl
a
W

Cogenerator


P^







Liquid Oxygen Cylinder






Potential for Fire
o
Potential for release
Liquid Oxygen


f^l
UH
•g
"S
"|
I,
^^

a/
Acthit\r that produces noise that exceeds
noise levels
o
**
s

,.?*,
4^
Damage to Human He?
Noise Exposure
rtj
Excessive Noise Lev«
(Intel nal/Exterual)


f*v|
UH



fell
a
*E™*
1
Acrivitj" that could result in a fire or rnoE
required by insurance agents






Potential for Fire
a
.°
«
£
a.
O
.®


<•"-!
^
«
A
C5
SI
d
on
* —
Excessive heat conditions or clothing thai
during prolonged use





*
Human Health exposui

5?
i


*?;
UH




















Click here to return to page 34.
                                                   -  106-
-------
  V

  Q,
  t/>

  -<
  •w
  S
  '!•

  S

  o
  W

  C/5







r3LV.[»
in
'£•
"C

•*£
a
•o
o





'o
(5
Potential Environmental Imp
d

a.

£
*h^
a

a
tr?


a
o
"-C
1
a
©
y
ie*
O

a
Mi
.9
B=l
•S
o
i
o
'C
o
a

k.
53
^

f "8 5' _
(Tj piri *** H
Air, Sanitaiy Sewers, Ground
Water, Human Health exposur
Waste Generator, Consuinptioi
Natural Resources (Depletion),
Renovation, RemodeMng, and/o
New Construction

S
* (S-
"o5 g
fc "
!l
a *•
o a
y G
l-H

£



t'
a
u

GM
*v
|l
a! a!
uo a
•«
«
N
Human Health Exposure to Ha

C'
13
M-I
*
u
onfined Spa
y

*O
Mi





^
La
*V?
Of
V
p
a<
H^
o
bd
•tr

o
w
O
requiring 1
f**"*
2
^
-i
•e
S
N
Human Health Exposure to Ha

^
*
is
o
a.
peratioE of
quipmeiit
O M-I

'yQi
M-i

*&
•^r
a
o
T3
a
o
a
d
o
C
*
<^v
0-
4"
•w
s
^jy
(/>
1 1
li
^* jp«
•t* V
11
0 g
*
cquisition o!
iipplies/Serv
< -------












^
K
O
t-
o
s

z
^^

^
H
^
0.

HH
Q
z
"^^
^^
H
U
t^
0.
^
-J
"^C
H
Z

£d
^
Z
o
PS
HH
Z
SAMPLE E
































































































ing/Medical Floors
m
•_
Z
[DEPARTMENT


















































Q
f^
IDATE APPROV

































































































Q
UJ
^
tu
HH
H
C/5
 .3
o 2i
^ pd
"^r ^
g 'S
R 3
OJ r-
" 1
S o
.i- O
y. tr
fc1 -1
•"§ e
c3 0
c« .-a
C/!J ' ^

^ x&
C« -g
S JH
4^ ^
•£
m ~3
c« K
f|
o3 K
"S —
^ EC

-3 ^-^
5 ^
*c ~^
-^ g^
i) -^
v; ^.
fii
JR: Air/Atmosphere, SOIL: Soil ,
Non-Hazardous Waste (i.e. recycl
finitions: A
TE-NON:
issues
Impact Abbreviation D€J
Hazardous Waste, WAS
negative environmental :
TOTAL
SIGNIF.
DEGREE
OF
CONTROL
FREQ.
RATING


CONSEQ.
RATING




£
!_
o &

® §,

W •—
CH S>
^ '-C
< 2
HH — i«
2
1






at
tu
S
O

o£
i
z
W O
£ *

5 N
^ "*£
X
35 ^
H Z
C/5 C/5
O
-J
0
C/5
C£
HH
^
C/5
H
»J g

O c£
tU HH
3 i=
0-
tu
PH
H
U
tu
Q-
ENVIRONMENTAL AS

tu
y
ACTIVITY/SEF












if
Ci Q
^-v
x|











X

X


X











%
3
00
Solid waste generation (packag
of disposable materials, etc.)














^-^
*!
x





^









^











t/r fe

•« "1 -§
Biomedical waste generation (
items contaminated with blood
body fluids, isolation supplies,












S g
11
&< Q


X






























Raw material usage (cleaning
chemicals, sterilants, high-leve^
disinfectants, formaldehyde,
medications, etc.)
















X





X









X











f 	 ,
o
S)
1
'3-
o
1
o
"S

00 8
.S S
"^ >->
o rt
-------
                    TOOL TO               SIGNIFICANCE
       List top 5 aspechtfi nip acts Mow, Rank (Item using the stale uf 1-5, five bring
                tilt most significant Add the stores la get a first cut priori ty<

                *  How la P riorillw? (ONE SUGGESTION far Scaring Ciildt)
Scale
1
2
3
4
5
Scop*
unnoticeable
only oii department
o rfsnization-widi
cratsldi the
or^aoiaation; local
impact
outsidi the
ofSanijation;
r^ional impact
Sevirity
no potL'rrtial impact on
health/environ meat
10 actual impact on
health/environ meat
luw impact oo
health/envinin nient
sifniicant damage to
health/environ meat
senre damage to
health/environ neat
Cost
$«- 200
S2(H>-5.IHH>
$5,000-
5HJHH»
$50,000-
250,000
greater
than
S2NI.IHW
Compliance
minimal
recorikteplng
oily, waratag
only
chil penalty E
mi nor fine
cwil p«iialQ' :
major fine
cri m i na 1 peialtj' :
strip«d silt
Do- able
resources in-
hOUJH
time
available and
budget
planned
time
available
planning wfll
be done
no planning
done
Occurrence of
Impact
improbable /
never
infrequent (l/yr
butI/cnffl)
continuous nsn-
going baas)
Asipeft / ImpUtt





Scope





Sewrhv





Cost





Compliance





Do-al>fc





Ottu rreiw;*





Total





Click here to return to page 34.
                                      - 110-
-------
I *

o °
H M •
O H






















































O





















.



o





















.



a:





















.



a





















.



D





















.



a:





















.






























c
o
u
«
3
c
o
%









a*
?
,>;
a>
3
Click here to return to page 34.
                                                   - Ill -
-------
  O
  H
  U
  ^
  a.
  S

  ^
  £ <
  -
  <
  H

•t2
Reduction Effoi

5 "a
G a
o o

S ~5
0> ^ ^O"
Sk

^, 	 ^

^•rt
^2 2
u£ G
^^ H
^ **
&§

U
s
o
e
Commoi

Activity or
Operation
-j— >
a
O *J
S § a>
^H (50
PH H Cd
Q-> $ ti
"? "V S
2 3 ^>
<^ C/3 hJ
ana

^
O o
a a
1$ o
r^ *— '
(^5

10 ^
(X) vN
^o" ^^
l/~)

oj
*§
>
o
a
o
Personal Computers
Servers
Computer Lab Operati
nan
Computers/
Information
Systems
x
X O
£ *
System upgrades
Insulation/windo1
Temperature Con
O&M BMP's
n n 13 13

"S £
o •£
a B
& a
rX O
f~*>

O~4 k
^O O~4
o" ^°
O*s
CO



O5
-2
Air Conditioners
Furnaces
Fans
Boilers and Water Hes
anna
Heating and
Cooling
05
3
Sensor Controls
Delamping
High efficiency b
Relamping
Tandem wiring
13 n 13 n n

"S £
o •£
a B
& a
/^ o
_ o
O X
o ^-v,
*O O
fsp *°
^H
CO




(50
Offices/ Admin Lightir
Outdoor Lights
Laboratories
Operating rooms
anna
3f

rt
&b
05 .
O , K^
B (50
PQ "o
11
0 H
H n

"a
o
a o
li °
J^ ^s
c^~-

C^~- y^
CO
ON"
O






Spectrometers
Ovens
Hoods
Cleaning Equipment
Microscopes
nnnnn
Lab
Equipment


Coil maintenance
System upgrade
O&M BMPs
nan

"S £
o -g
a 2
& a
rX O
f~^

C~~- k
CO !>•
^t-" ro
CO


(50
a
• ^H
?H .^j
QD "^
flj TO
Food Service/Campus
Vending
Laboratory Cooling NI
On-campus Commerci
anna
Refrigeration
                                                                                                      I
                                                                                                      o
                                                                                                      t/5
                                                                                                      =
                                                                                                      o
Click here to return to page 34.
                                                    - 112-
-------



S
o
ii
I
N
U
P
O

2







&.
u
Z
o
u
Z
o
COMM


ACTIVITY OR
OPERATION

(N
^ O
O O
a «
£ .2
K ta
1 i
s ^
PH ^-j
"^ §

-^ ri
§ -B
S °
o ^
.^ O ^ j_;

S , i O r^
? s a s
nnnn




^.j.
en
§
"§ TS 111,
s o S R &
o s -g ^ ,y .a
'£ u 'Q _ o =« o
1 1 1 ! ! I '!
_b en ,rt S d i! O
"R ^ ^ ^ o? & ^
in S w o  tg S
1 & -g 8
,g ft 3 -9
(N J 6 &




en
"rH
.2
.a°
Other toxi
nnnnn
td r-< ^
5 '^ M
Z ,, 1 (2
tf 8 F! ™ £
| o 1 ~ S 1
a | t£ S O O
ed\ V N


o
tj »
1 1

"lO N
1 1
P ^
PH ^

^H ^
B fl
| .0
1 0
PH .R
-h O ,V LH
& "3 0,

? Q J 0
nnnn

























+2
o
o o o
S -o &
rl O H
"^3 ' — i '
O & O
|||
ffl & -3
(N ^2 O
nan









GLASS CLEANING
^ Glass Cleaners
                                                                                                 o

                                                                                                 ft
10
o

'>

S
o>


§
                                                                                                 a   -i
s
ft
qn
o
o
M
3
^a
60
S
|
2
1
o
ft
X
10
_• o
S.H
Is of conce
Iso, minim
ca <"
o ^
1
M
-s
o
ffi
^H
O
o
S
a
o
Q

t/i
D
jx.html or
?









^
t

cd
•fi
^
'3
cd
!
s
o
AH
ta
If
£
1
'S
s
3
1
'S
o
rable Produ
'£
1
"3
Environment
^_;
o
fl
1
•g
^
o
ft
60
'S
X
o
x
42
tj
Td
g
ft
o

Minimize us
(N
^
.1
£
1
g
^^
en
&
13
•2
ernative prc
^
o
"9
•^
en
•s

M
"a
o
^
en
'S
^
_£H
13
"S
cS
ca
VI
-s
o
1
•g
"2
I
^
PH
^
OJ
en
J3
O
Program's
60
_o
"o
.2
equipment ai
See Occupat
National Tox

m

•f3
a
o
ft
60
.a
en
t§
O
en
1
en
0
'a1
PH
|
PH
'cS
g
See the Janit
^



-2
Q

1
n/Effect
o
1
o-
;sponsible
s^
Click here to return to page 34.
                                                     -113-
-------
 Title: PROCEDURE FOR IDENTIFICATION OF ASPECTS, SIGNIFICANCE AND OBJECTIVES AND
 TARGETS
 Policy Number:
 Date Approved:
 Next Revision Date:
Prepared By:
Approved By:
 PURPOSE

 The purpose of this procedure is to determine the method by which aspects are identified and by
 which significant aspects are determined.
 ACTIVITIES AFFECTED

    Cross Functional Team
 •   Plant Operating Committee (OCM)
 •   Internal Auditors
 FORMS USED

 None


 REFERENCES

 •   Aspects, Significant Aspects and Establishing Environmental Objectives and Targets
 •   Environmental Regulations and Other Requirements - Obtaining and Maintaining Information
 •   External Communications
 •   Internal Environmental Communications
 •   Internal Environmental System Audits
    Compliance Assurance
 •   Responding to Community Complaints/Inquiries
    Contractor Management
 •   Aspects Database
 •   Environmental Aspects Identification Worksheets
Click here to return to page 34.
                                        - 114-
-------
 DEFINITIONS

 SARA - Superfund Amendment Reauthorization Act
    -   Tier II Reporting Levels (10,000 Ib)
        Toxic Chemical Release Inventory Levels (25,000 Ib manufactured, processed,
        10,000 Ib - otherwise used)
 EXCLUSIONS

 None


 PROCEDURE

 •   Aspects will be identified, significance determined and objectives and targets set following
    Aspects Procedure.
 •   A Cross Functional Team (CFT), whose membership shall represent each functional activity
    of the facility, is responsible for the identification of aspects, the determination of significant
    aspects and the setting of objectives and targets.
 •   Aspects are identified by using Aspects Spreadsheets, expert knowledge and interviews of
    functional areas.
 •   Aspects encompass all functional areas whose activities, products or services the plant can
    control or over which the facility can have influence.
 •   Consideration of interested parties shall be utilized in the determination of significant aspects.
    Interested parties are defined as employees, customers, stockholders, agencies, business and
    residents adjacent to the facility.  Views of interested parties are received through the external
    communications procedure, Responding to Community  Complaints/Inquiries.
 •   Legal and other requirements are considered to be significant.
 •   Volumes of materials stored/consumed are considered significant when meeting SARA
    reporting.
 •   Other criteria used for significance determination shall include but, not be limited to, emission
    inventories, pollution prevention and waste minimization programs, property assessments,
    contractor activities, and environmental compliance audits.
 •   Objectives and targets shall be established at each relevant function and level within the plant
    organization.
 •   Legal and other requirements, significant environmental impact, technology options, financial,
    operational and business requirements shall be considered in setting of objectives and targets.
 •   Objectives and targets shall be established for all significant aspects.
 •   The aspects, significant aspects and objectives and targets shall be summarized and presented
    at the Operating Committee Meeting (OCM) for review and concurrence.
Click here to return to page 34.                    - 115 -
-------
 GENERAL RULES

 Exceptions to the criteria listed in Section 7, shall be justified and noted in the Aspects Database.

 ENVIRONMENTAL RECORDS

 •   Completed Aspects Spreadsheets
 •   Completed Aspects Database


 RECORD OF REVISIONS
Date:


Description:
Converted into a procedural format
Reformat header and footer
Pages affected:
All
All
Authorized by:


Click here to return to page 34.
- 116-
-------
Title: PROCEDURE FOR LEG ALAND OTHER REQUIREMENTS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
 PURPOSE

 To ensure that appropriate persons have access to and understand all legal and other requirements that are
 applicable to the environmental aspects of (hospital name)'s activities.
 SCOPE

 This procedure governs the operations and programs conducted by (hospital name), located at (hospital
 address).
 RESPONSIBILITY

 It is the responsibility of the EMS representative and/or designee to ensure that all legal and other
 requirements are maintained and to inform staff of the legislative, regulatory and other requirements with
 which the hospital must comply.

 It is the responsibility of the department managers/supervisors to implement new or to revise existing
 programs or operations to meet applicable regulation requirements and to ensure that employees are aware
 of the legislation, guidelines, regulations, etc. that affect their area(s) of operation.

 It is the responsibility of all employees of (insert hospital name) to inform the EMS representative and/
 or designee should they learn of new and changed legislation and other requirements.
 PROCEDURE

 The EMS representative and/or designee is responsible for identifying and documenting the legislative and
 other requirements associated with the hospital's aspects.

 The EMS representative and/or designee is responsible for identifying new or changed legislation,
 regulations and bylaws by reviewing the federal, state and municipal legislative Web sites and any other
 tools that may be available for updating compliance on a regular basis.

 The EMS representative and/or designee retains copies of applicable environmental legislation for referral.
 Copies of legal and other requirements are retained in the Environmental Legislation and Regulations
 binder. Discard obsolete documents when new changes are made.

 Department managers must communicate and implement changes that occur as a result of amendments to
 legal or other requirements within their departments.
                                                117
Click here to return to page 36.                     - 11 / -
-------
 The EMS representative, in collaboration with associated management, will address legislative or other
 changes that affect the hospital corporation and/or nonspecific departments.

 In the incidence of noncompliance with changes in regulatory requirements, the EMS representative and/
 or designee, in consultation with department managers/supervisors, will create a corrective action plan to
 address the issue(s).
 DEFINITIONS

 Definitions relating to the content of the EMS are contained in the glossary.


 REFERENCES

 ISO 14001 - 96 - Environmental Management System Standard


 EXHIBITS

 N/A
Click here to return to page 36.                     - 118 -
-------
Title: PROCEDURE FOR OBJECTIVES AND TARGETS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
 PURPOSE

 To describe the methods utilized by the hospital to identify environmental objectives and targets.
 SCOPE

 This procedure governs the operations and programs conducted by [hospital name], located at [insert
 hospital address}.
 RESPONSIBILITY

 It is the responsibility of the EMS representative and/or designee, in consultation with the Green Team, to
 ensure that environmental objectives and measurable targets are set on a regular basis.

 It is the responsibility of the EMS representative and/or designee to track environmental performance of
 the environmental objectives and targets and to communicate progress to the Green Team, senior
 management and hospital staff.

 It is the responsibility of senior management to designate resources and staff to ensure that environmental
 objectives are met.
 PROCEDURE

 Annually, the EMS representative and/or designee, the Green Team and/or senior management (if
 objectives require actions that have a financial cost of >$1000.00) will set and approve environmental
 objectives and targets based on:

 •         The environmental policy
 •         Significant hospital environmental impacts
 •         Input from hospital staff, senior management and interested parties
 •         Changes in legal or other requirements
 •         Compliance and other internal audit findings
 •         Environmental emergencies or incidents
 •         Technological options available
 •         Tinancial and operational requirements

 The environmental targets must be S.M.A.R.T (Specific, Measurable, Achievable, Results-oriented and
 Time-dependent.)
Click here to return to page 38.
                                              -119-
-------
 The approved environmental objectives and targets will be documented on the "Objectives and Targets
 Chart" (Exhibit 1- EMS-4.3.3-1).

 Refer to the Procedure for Environmental Management Program(s) (EMS-4.3.4) for the identification of
 actions to achieve designated environmental objectives and targets.

 The EMS representative and/or designee will communicate objectives and targets to the hospital staff via
 email, displays, environmental information sessions and hospital orientation on a regular basis.

 The EMS representative and/or designee monitors the progress of environmental objectives and targets by
 identifying performance indicators. Regular progress reports are presented to the Green Team during
 monthly meetings. Maintenance of data pertaining to progress of environmental objectives and
 environmental performance is outlined in the Procedure for Monitoring and Measurement (EMS- 4.5.1).

 If at any time, the EMS representative and/or designee, Green Team and/or senior management wishes to
 change, revise or alter the approved environmental objectives and targets to represent progress or lack
 thereof, the EMS representative and/or designee will make the necessary changes and send the revised
 document back to the Green Team for approval.

 Significant aspects and environmental issues not formally addressed through this procedure will be
 addressed/managed on a priority/as-needed basis by the EMS representative and/or designee and the
 Green Team.
 DEFINITIONS

 Definitions relating to the content of the EMS are contained in the glossary.


 REFERENCES

 ISO 14001 - 96 - Environmental Management System Standard
 EMS- 4.2   Environmental Policy
 EMS- 4.3.1  Procedure for Environmental Aspects
 EMS- 4.3.2 Procedure for Legal and Other Requirements
 EMS- 4.3.4 Procedure for Environmental Management Program(s)
 EMS- 4.4.7 Procedure for Emergency Preparedness and Response
 EMS- 4.5.1  Procedure for Monitoring and Measurement
 EMS- 4.5.3  Procedure for Records


 EXHIBITS

 Exhibit 1- EPPM-4.3.3-1, Objective and Targets Chart
Click here to return to page 38.                    - 120 -
-------
Title: PROCEDURE FOR ENVIRONMENTAL MANAGEMENT PROGRAMS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
  PURPOSE

  To ensure that a procedure is in place to establish and maintain Environmental Management Program(s)
  to achieve the identified objectives and targets.
  SCOPE

  This procedure governs the operations and programs conducted by [hospital name], located at [insert
  hospital address}.
  RESPONSIBILITY

  It is the responsibility of the EMS representative and/or designee, in consultation with the Green Team to
  develop, on a regular basis, Environmental Management Program(s) for each environmental objective and
  target.

  It is the responsibility of the EMS representative on behalf of the Green Team, to approve the
  Environmental Management Program(s) under $1000.00 and to designate appropriate resources and staff
  to ensure that these programs are implemented and maintained.

  It is the responsibility of a representative from senior management to comment and approve those
  Environmental Management Program action(s) that require $1,000.00 or more (capital) for
  implementation.

  It is the responsibility of designated staff to follow through with the Environmental Management
  Program(s) and to track and report progress of activities to the EMS representative and/or designee.
  PROCEDURE

  Annually, the EMS representative and/or designee, in consultation with the Green Team, will develop and
  set environmental objectives and targets as described in the Procedure for Objectives and Targets.

  The EMS representative and/or designee, in consultation with the Green Team then develops and
  documents the "Environmental Management Program(s)" (Exhibit l-EMS-4.3.4-1) for achieving the
  appointed environmental objectives and targets.

  Environmental Management Program(s) must include (but is not limited to): actions for achieving the
  objectives and targets, responsible parties, the time frame(s) for completion and other stakeholder
  involvement.
                                               121
Click here to return to page 43.
-------
 A member of senior management will review the Environmental Management Program(s) to ensure
 economic feasibility, appropriateness and to allocate adequate resources for implementation.

 After inputting comments from the representative of senior management, the EMS representative
 approves the Environmental Management Program(s) for under $1000.00.  Senior management approves
 all actions with a cost of $1000.00 or more (capital).

 The EMS representative and/or designee, Green Team members and other designated personnel, will
 accomplish the duties set forth in the Environmental Management Program(s) in the time frame
 determined.

 The EMS representative and/or designee monitors the progress of Environmental Management
 Program(s) and reports the progress of the program(s) to the Green Team, senior management and
 hospital staff on a regular basis. Maintenance of data pertaining to the progress of the Environmental
 Management Program(s) is outlined in the Procedure for Monitoring and Measurement (EMS- 4.5.1) and
 the Procedure for Records (EMS- 4.5.3).

 If at any time, the EMS representative and/or designee, members of senior management and Green Team
 wish to change, revise or alter the approved environmental management program(s) to represent progress
 or lack thereof, the  EMS representative and/or designee will make the necessary changes and send the
 revised document back to the Green Team for approval.

 Upon completion of the Environmental Management Program(s), the EMS representative and/or designee
 will review the overall effectiveness of the program(s) against the intended objective and target. If any
 issues or concerns arise, action plans may be developed to correct any deficiencies.
 DEFINITIONS

 Definitions relating to the content of the EMS are contained in the glossary.


 REFERENCES

 ISO 14001 - 96 - Environmental Management System Standard
 EMS -4.3.3 Procedure for Obj ective s and Targets
 EMS- 4.5.1 Procedure for Monitoring and Measurement
 EMS- 4.5.3 Procedure for Records


 EXHIBITS

 Exhibit 1- EMS-4.3.4-1, Environmental Management Program Chart
Click here to return to page 43.                     - 122 -
-------
Title: EXTERNAL COMMUNICATION PROCEDURE
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
 PURPOSE

 To define the method(s) that will be utilized to receive, document and respond to relevant communication
 from external interested parties.
 SCOPE
 All of the external communication that relates to environmental aspects.
 DEFINITIONS

 External Communication - That communication that occurs with interested parties in which there is a
 concern or a complaint from the external interested.
 REFERENCES

 Emergency Preparedness & Response Procedure
 Significant Aspects
 Environmental Policy
 Environmental Communications Request Form
 Emergency Response List
 PROCEDURE

 The communication from an external interested party is received by the company receptionist, Corporate
 Communications or by a member of the Environmental Affairs Section.

 Information received by the company receptionist or Corporate Communications is forwarded to
 Environmental Affairs.

 The members of Environmental Affairs will verify the nature of the communication and either  address it
 immediately (not requiring written documentation) or record the individuals/groups name and phone
 number and nature of the communication on the environmental communication, and Environmental
 Affairs will either address the communication in a timely manner or consult with upper management if
 necessary.

 The decision to communicate significant environmental aspects is done on a case-by-case basis by the
 manager of Environmental Affairs and upper management if necessary. An environmental communication
 will be used to document the communication.
Click here to return to page 48.
                                            - 123-
-------
 Once in the tracking system, the communication will be kept for consideration during updating significant
 aspects and objectives and targets.

 The communication will be  completed by Environmental Affairs or Corporate Communications
 depending upon the nature, size and scope of the situation.

 A summary of the response  or a copy of the response (if written) will be logged into the environmental
 communications environmental communication tracking system.

 In the event the emergency response system is activated, communication methodologies will be
 implemented consistent with those outlined in the Emergency Response Plan.
 RETENTION REQUIREMENT

 This document will be retained until revised.


 SPECIAL CIRCUMSTANCES

 N/A


 MEASUREMENT OF PERFORMANCE

 The performance of this portion of the EMS shall be measured through audits conducted by internal
 auditors, audit team and third-party auditor of which certification is acquired.


 EXHIBITS

 N/A
Click here to return to page 48.                    - 124 -
-------
Title: INTERNAL COMMUNICATION PROCEDURE
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
 PURPOSE

 To establish the methods that will be utilized to communicate internally on environmental aspects and the
 Environmental Management System.
 SCOPE

 The scope includes all of the internal communication that relates to environmental aspects.
 DEFINITIONS

 •      Internal Communication - That communication that occurs between employees, or contractors
        suppliers who work on behalf of [insert hospital name] within the confines of the site.
 •      Reference Material
 •      All EMS Procedures
        All EMS Records
 •      Environmental Policy
 PROCEDURE

 Environmental Affairs communicates to facility personnel relevant information regarding the
 environmental management system in the following manner:

 •      Policy - Distribute Policy Cards and send fliers to all employees
 •      Significant Aspects - The list is discussed with section managers.
 •      Legal and Other requirements - Distribute a list of general regulations through General Awareness
        Training. Distribute specific legal requirements to relevant engineering sections.
 •      Objectives and Targets - The objectives are discussed with section managers.
 •      EMP - The EMP's are given approval or disapproved with reason why disapproved.
 •      Structure and Responsibility - Roles and responsibility are distributed.
 •      Training Awareness Competency - All training is considered communication.
 •      Communication - The methods to communicate to Environmental Affairs through general
        awareness training.
 •      EMS Documentation - Copies of the manual will be communicated via the web site.
 •      Document Control - General document control requirement are communicated to section managers
        via review meeting and section ISO Representatives via Internal Auditor Training Class.
 •      Operational Control - General document control procedures are reviewed and recommendations
        are communicated to relevant sections via the Environmental Key Point proposal.
 •      Emergency Preparedness and Response - The Emergency response are communicated during the
Click here to return to page 48.
                                             - 125-
-------
        annual RCRA training.
 •      Monitoring and Measuring - The requirements for generating documented monitoring measuring
        Procedures and to perform calibration on monitoring/measuring equipment is communication to
        section ISO representatives via "objectives and targets".  Performance tracking for objectives and
        targets are communicated back to the responsible sections.
 •      Nonconformance Corrective and Preventive Action - Nonconformance reports will be reviewed
        and response will be communicated back to the report initiator.
 •      Records - General record keeping requirement will be communicated to section managers.
 •      EMS audits - Results of EMS audits are communicated to upper management and relevant section
        managers. Training requirements for internal auditors and training schedules are communicated to
        relevant ISO section representatives.
 •      Management Review - The necessary information to carry out the review will be communicated to
        senior management.

 Facility personnel communicate to Environmental Affairs and other relevant sections regarding the
 environmental management systems in the following manner:

 •      Significant Aspects - New developments that might impact the environmental Impact Assessment
        Form.
 •      Objectives and Targets - Relevant sections will communicate status.
 •      EMP - Relevant sections will communicate status.
 •      Structure and Responsibility -  Changes in the organizational structure will be communicated from
        HR.
 •      Training Awareness and Competency - Training personnel and reporting results back to E/A.
 •      Document Control - More specific (section) document control requirements are communicated to
        those employees who have responsibility to generate or modify documents.
 •      Operational Control - Status of controlling the relevant operations (activities).
 •      Emergency Preparedness and Response - Report emergencies.
 •      Monitoring and Measuring - Inform E/A of the current monitoring/measuring and calibrations
        being done or needing to be done. Report appropriate monitoring and measuring results to E/A.
 •      Nonconformance Corrective and Preventive Action - Report nonconformances and communicate
        new procedures or requirements that are a result of corrective and preventive action.
 •      Records - Submit Environmental related records to E/A.
 •      EMS audits - Communicate results within own section and to Environmental Affairs to promote
        awareness and to prevent future occurrences.
 •      Management Review - Communicate results to relevant personnel within own sections.
        a.     Retention Requirement
                       This document will be retained until revised.
        b.     Special Circumstances
                       None.
        c.     Measurement of Performance
                       The performance of this portion of the EMS shall be measured through audits
                       conducted by internal auditors, audit team and 3rd party auditor of which
                       certification is acquired.

 EXHIBITS

 N/A
Click here to return to page 48.                    - 126 -
-------
Title: PROCEDURES FOR DOCUMENT CONTROL
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
 PURPOSE

 To ensure that all EMS documentation required by the ISO 14001 Standard is established and maintained
 so that they can be located, periodically reviewed and kept up-to-date.

 To ensure documentation is available at all locations where operations essential to the effective
 functioning of the environmental management system are performed.
 SCOPE

 This policy governs the EMS documentation related to the operations and programs conducted by
 [hospital name], located at [insert hospital address].
 RESPONSIBILITY

 It is the responsibility of the EMS representative and/or designee to maintain the EMS documentation in a
 manner consistent with the ISO 14001 requirements.
 PROCEDURE

 An electronic version of the EMS Policy and Procedure Manual is available to all hospital staff on the
 hospital's computer system.

 The EMS representative and/or designee is the only individual with open access to the electronic EMS
 Policy and Procedure Manual. The EMS representative and/or designee is responsible for maintaining the
 electronic version of the manual.

 A paper copy of the EMS Policy and Procedure Manual is retained and available for use in the EMS
 repre sentative 's office.

        Both the paper copy and electronic copy of the EMS Policy and Procedure Manual are "Master"
        copies and are maintained by the EMS representative and/or designee.

        If a new document supersedes an existing document, the existing document is removed and
        recycled by the  EMS representative and/or designee.

        The EMS representative and/or designee must ensure that "Obsolete" documents are replaced
        with dated "Master" copies.

        Documents retained for legal and/or knowledge preservation are identified in the Master
        Document Control List.
Click here to return to page 50.
                                             - 127-
-------
 Versions or specific components of the manual are available to community members and/or staff as
 Educational/Informational Tools only.

 If at any time, an employee wishes to comment on an EMS procedure, he/she must contact the EMS
 representative to request needed changes.

 If at any time an employee would like to report a nonconformance, he/she must fill out an Employee
 Incidence Report, and/or inform the EMS representative of the occurrence.

 The following is documented on the Master Document Control List:

 •       Identification, location, current revision number, revision schedule and the retention time of key
         EMS documents required to ensure compliance with the ISO 14001 Standard.
 •       Applicable environmental legislation, and/or potential liabilities.
 DEFINITIONS

 Definitions relating to the content of the EMS are contained in the Glossary.


 REFERENCES

 ISO 14001-96- Environmental Management System Standard
 EPPM-4.4.3- Procedure for Communication
 EPPM-4.4.4- Procedure for Environmental Management System Documentation
 EPPM-4.5.2- Procedure for Nonconformance and Corrective and Preventative Action.


 EXHIBITS

 Exhibit 1- EMS-4.4.5-1- Master Document Control List
Click here to return to page 50.                     - 128 -
-------
  Title: DIESEL GENERATOR INSPECTION & TESTING PROCEDURE
  Document Number:
  Date Approved:
  Next Revision Date:
Prepared By:
Maintenance, Engineering
Services
Approved By:
Director, Engineering Services
 PURPOSE

 To ensure the diesel generator is in proper working order, tested and inspected regularly in order to
 provide backup power for the hospital.
 PROCEDURE

 The diesel generator must be tested every week for a maximum of 0.5 hours to ensure the machinery is in
 proper working order.

 Inform switchboard operators of testing prior to performing any tests.

 Perform following testing perimeters on a weekly basis:

        Pre-checks of diesel generator:

                a)     Perform pre-checks & record levels:
                       - oil level
                       - coolant level
                       - battery electrolite level
                       - battery electrolite level
                       - block heater
                       - dip day tank

        Starting diesel generator:

                a) In lower powerhouse (transfer switch area) perform:
                       - lamp tests
                       - turn control switch to "Test" position to start diesel generator
                       - reset any resulting alarms.

        Running tests of diesel generator:

                a)     Once diesel generator is running perform running checks of the louvres and
                       battery charger and record the following:
                       - starts
                       - lube oil pressure
                       - lube oil temperature
                       - coolant temperature
                       -RPM
                       - percentage load
                                               129
Click here to return to page 51.
-------
                      - battery voltage (during test)
                      - generator voltage phases 1, 2 & 3
                      - generator amperage phases 1, 2 & 3
                      - frequency

               b)      After performing running checks, proceed back to lower powerhouse (transfer
                      switch) and record:
                      - normal power voltage phases 1, 2,& 3
                      - normal power frequency
                      - emergency power voltage phases 1, 2 & 3
                      - emergency power frequency

       Shutting down diesel generator tests:

               a)      Prior to the 30-minute mark, turn the control switch to the "Auto" position. (Machine
                      will run for 5 minutes before it transfers back to normal operating power.) Wait for
                      power to transfer.

               b)      Reset any power alarms that may have gone off.

       Aboveground storage tanks:

               a)      Dip aboveground storage tank(s) and record level(s).
               b)      Visually observe and record condition of tank(s) (e.g., rusting, leakage, other
                      abnormalities).
               c)      Ensure all  other safety features are working properly.
Click here to return to page 51.                     - 13 0 -
-------
Title: SAFE STORAGE OF COMPRESSED GAS CYLINDERS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Health and Safety Specialist
Approved By:
Director, Human Resources
 PROCEDURE

 Proper Storage:

 Store cylinders in a well-ventilated area.

 Store cylinders away from fire risk and away from sources of heat or ignition.  Mark the area "No
 Smoking."

 Store cylinders upright, on a firm,  level, well-drained surface, and secure cylinder (with chains) to
 prevent from falling.

 Store nothing else in the cylinder storage area. In particular avoid oil, paint and corrosive or flammable
 liquids.

 Segregate full and empty cylinders.

 Segregate cylinders  in the storage area according to gas type (e.g., flammable, inert, oxidizing, toxic,
 etc.).

 Cylinders containing oxygen or oxidizing gases must be separated from cylinders containing flammable
 gases by minimum 3 meters or by a fire resistant partition.

 Cylinders containing inert gases may be stored with cylinders containing oxygen or oxidizing gases.

 Toxic or corrosive gas cylinders must be  stored separately from ALL other gas cylinders.  Follow the
 instructions on the gas Material Safety Data Sheet.

 Propane or butane cylinders must be stored a minimum of 3 meters away from ANY other gas cylinder
 type.
 Transportation To and From Departments

 Move one tank at a time for transporting to and from department(s).

 Ensure tanks are tied to wall when they reach their destination points.
Click here to return to page 51.                    - 131 -
-------
Title: MERCURY SPILL CLEAN-UP AND DISPOSAL
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Supervisor, Housekeeping and
CSR
Approved By:
Environment, Health and Safety
Specialist
 PURPOSE

 To ensure that mercury spills are cleaned up properly and promptly and disposed of in accordance with
 applicable legislation.

 POLICY STATEMENT

 The hospital is committed to the to the immediate reduction and eventual elimination of mercury.

 PROCEDURE

 1.      Clean-Up

         1.      In case of a large uncontained mercury spill, call a "Code Brown" (procedure found in
                Hospital Policy and Procedure Manual.

         2.      For a small contained mercury spill, secure spilled area and immediately obtain the
                mercury spill kit and a full-faced respirator (with mercury cartridges) from the hospital
                spill kit in the Housekeeping Department.

                NOTE: Only those individuals who have received fit-testing and fit-checking training are
                to use the respirators. If you have not received training call an Environmental Services
                personnel.

         3.      In all cases, wear gloves and a full-face respirator when treating mercury spills.

         4.      Block the area from foot traffic for a large radius (minimum 6-foot radius) around the
                center of the spill site.

         5.      Check clothing, footwear, bedding, etc. for mercury and mercury debris. Remove
                contaminated clothing, footwear, etc. and place at the edge of the spill site.

         6.      Collect and treat any visible and collectible mercury using VYTAC MIS from mercury
                spill kit.

         7.      Wet the MIS with a water spray and agitate the mixture with a stirring stick or similar tool
                to assure that all the mercury is in contact with MIS. In less then a minute, all the mercury
                should be amalgamated and solidified. If drops of liquid mercury remain, add more MIS
                and repeat the procedure until all the mercury is solidified.

                NOTE: It will require approx.  120-150 grams of MIS to treat 100 grams (only 8 ml) of
                mercury.
Click here to return to page 51.                     - 132 -
-------
     8.  The solidified amalgam is safe to collect using the brush and dust pan that is provided in the
        mercury spill kit. The collected residue should be placed in a closed plastic container and clearly
        marked as "containing mercury."

     9.  Store the bucket the hospital's Flammable Storage Room for disposal by a licensed hazardous
        waste company.

     10. Apply VYTAC MVS to all areas that might be contaminated with mercury particles. Make sure
        that crevices, cracks and inaccessible areas are covered. For maximum vapor suppression, it is
        recommended that a 3-5 mm coverage be applied.

        NOTE: MSV should only be regarded as a temporary solution.

     11. MSV will immediately suppress any further generation of vapors. Remove at the earliest
        convenience. Contaminated residues should be collected by either sweeping up or the use of a
        high filtration (HEPA) vacuum which is available through Engineering Services. The residue
        contains mercury and should be disposed of in the same sealed plastic container. MSV darkens as
        it becomes contaminated  with mercury, indicating its presence.

     12. If visible mercury is coated with MSV it can be treated using MIS, following standard procedures.
        Caution: A slight hydrogen sulphide odor may develop during the neutralization process.
Click here to return to page 51.                     - 13 3 -
-------
Title: PROCEDURE FOR MONITORING AND MEASUREMENT
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
 PURPOSE

 To ensure that the key characteristics of the hospital's operations and activities that can have a significant
 impact on the environment are tracked and measured on a regular basis to ensure environmental
 compliance and to provide a basis for environmental performance.
 SCOPE

 This policy governs the operations and programs conducted by (hospital name), located at (insert hospital
 address).
 DEFINITIONS

 Definitions relating to the content of the EMS are contained in the glossary.


 RESPONSIBILITY

 The EMS representative and/or designee is responsible for establishing and maintaining the monitoring
 database on a regular basis.

 Department managers/supervisors are responsible for ensuring that regular monitoring of key
 characteristics of their departments operations are monitored and documentation is maintained


 PROCEDURE

 Compliance

         An Environmental Compliance Audit will be conducted by the hospital at a minimum of every
         three years using the hospital's subscription compliance software program or by an outside
         consulting firm to assess regulatory compliance issues relating to all "significant environmental
         aspects" and issues identified in previous audits, inspections and assessments.

         Monthly workplace safety inspections performed by the members of the Health and Safety
         Committee will identify hazards that may have the potential to have negative environmental
         impacts. The members of the HSC performing the monthly inspections will relay this
         information to the EMS representative through monthly reports/meetings.
                                              1 34
Click here to return to page 53.
-------
 Control of Monitoring and Measurement Equipment

         Any equipment used to measure and monitor key characteristics of the environmental
         management system is maintained in order to provide confidence in the accuracy of the
         measurements. The following outlines the components of the system designed to provide that
         confidence.

         Department managers/supervisors inform the EMS representative and/or designee when new
         measuring and monitoring equipment has been purchased in their departments. The EMS
         representative and/or designee enters the information into the Monitoring and Measurement
         Documentation Chart.

         Operating procedures relating to the calibration and monitoring processes of departmental
         equipment are developed and maintained by the department managers/supervisors and/or
         designees.

         Trained individuals within each department, Engineering Services personnel and/or external
         companies perform the calibration of hospital monitoring  equipment. Hospital equipment
         calibrated by Engineering Services is included in the preventative maintenance computer
         program in Engineering Services. Work orders are printed and performed based on the frequency
         of calibration for each piece of equipment entered into the system (frequency based on
         manufacturers guidelines and/or vendor's recommendations). Records of calibration are placed
         on, or in a close proximity to, the piece of equipment undergoing calibration testing and/or are
         kept by the external company performing the regular calibration of equipment.

         The EMS representative and/or designee periodically reviews the calibration records, to ensure
         that the operations are being performed as scheduled. If not, the EMS representative will notify
         the department, individual and/or Engineering Services to request that it be done.

 Monitoring of Environmental Performance Indicators

        The EMS representative and/or designee will compile, on a regular basis, data required for
        ensuring objectives and targets are met in the Environmental Performance Indicator Binder.

        Data relating to, and/or location of data relating to the key  characteristics of the facilities
        operations are documented in the Environmental Performance Indicators Binder.
 REFERENCES

 ISO 14001 - 96 - Environmental Management System Standard


 EXHIBITS

 Exhibit 1- EMS- 4.5.1-1 Monitoring and Measurement Documentation Chart
Click here to return to page 53.                     - 13 5 -
-------
Title: CALIBRATION AND MAINTENANCE OF MONITORING EQUIPMENT
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
 PURPOSE

 This procedure defines the mechanism and requirements for verification of measurement and testing
 equipment used to monitor and control significant environmental aspects.
 SCOPE

 This policy applies to associated operations and activities conducted by (hospital name), located at (insert
 hospital address).
 RESPONSIBILITY

 N/A


 PROCEDURE

 The hospital shall identify and list measuring and testing equipment deemed necessary to monitor and
 control significant environmental aspects for permitted sources and other appropriate equipment.

 The list should include definition of the characteristics, frequencies and location of the equipment
 requiring calibration. Verification will be maintained in the using department. All equipment not owned
 by (hospital name), such as utility meters, will be calibrated and maintained by the owner.

 Approved outside testing organizations may be used to verify measuring and testing equipment at a
 prescribed interval.

 All other applicable measuring and testing equipment shall be maintained and verified by facilities
 personnel according to manufacturer's recommendations/guidelines.

 The department manager/supervisor or designee is responsible for maintaining lists, verification and
 maintenance records (if any) for equipment in this area.

 Any deviations from the proper operation or verification of measuring and testing equipment shall be
 reported to the department manager/supervisor and/or the EMS representative for the appropriate actions
 to be taken.

 Deviations from procedures which affect environmental compliance shall be reported immediately to the
 EMS representative.
Click here to return to page 53.                    - 1J o -
-------
 DEFINITIONS

 N/A


 REFERENCES

 ISO 14001 - 96 - Environmental Management System Standard
 Environmental and Energy Reports
    Air Emissions Management
    Significant Environmental Aspects
 Calibration Matrix of Key Activities
 Agency Reporting
 Internal Environmental System Audits


 EXHIBITS

 N/A
Click here to return to page 53.                   -137-
-------
Title: REGULATORY COMPLIANCE AUDITS
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
    Regulatory Compliance Audits



    1.    Purpose/Scope



         This procedure defines the mechanism for the planning and implementation of regulatory



         compliance audits at [hospital name].



    2.    Activities Affected



         All areas and departments



    3.    Forms Used



         3.1   Audit Checklist



         3.2   Corrective and Preventive Action Request (CAR)



         3.3   Internal Environmental Audit Summary Report



         3.4   Audit Schedule



    4.    References



         4.1   Nonconformance and Corrective and Preventive Action



         4.2   Environmental Management System Management Review



         4.3   ISO 14001:1996, Elements 4.5.1 and 4.5.4



    5.    Definitions



         5.1   Auditee: individual audited.



         5.2   Auditor: audit team member performing the audit.



         5.3   Audit Criteria:  policies, practices, procedures or other requirements against which the



               auditor compares objective evidence about the subject matter.



         5.4   Audit Program Leader: individual responsible for maintaining the Environmental Audit



               Program.



         5.5   CAR:  corrective and preventive action request that identifies observed nonconformance.
                                              138
Click here to return to page 53.
-------
         5.6   Finding: an existing condition supported by objective evidence.



         5.7   Nonconformance: the nonfulfillment of specified system requirement.



         5.8   Objective Evidence: qualitative or quantitative information, records or statements of fact



              pertaining to the existence and implementation of an EMS element, which is based on



              measurement or test and which can be verified.



   6.    Exclusions



         None



   7.    Conducting the Compliance Assessment Audit



         7.1   The environmental management representative (EMR) or designee is responsible for



              planning, scheduling and implementing internal environmental regulatory compliance



              assessment audits, including the identification of necessary resources. These audits



              should be objective. Those running the department should not do their own audit (e.g.,



              housekeeping should not do the audit for the housekeeping department).



         7.2   The EMR or designee  develops and maintains the environmental compliance assurance



              program and issues program support documents, based on company environmental



              compliance assurance  guidelines, where available.



         7.3   During a compliance assessment audit, assessment team members will record



              information, such as: items checked, individuals interviewed, any possible regulatory



              noncompliance issues. The assessment team shall promptly notify the EMR or designee



              of any possible regulatory noncompliance. Upon verification of noncompliance, the



              EMR shall notify facility management.



         7.4   The assessment team reviews possible regulatory noncompliance issues with the



              responsible and accountable area department representative. The team also prepares a



              CAR identifying the issues, necessary corrective and preventive actions and the



              individuals responsible for completing the actions. The  EMR or designee and area or



              department manager will concur with the CAR before its issuance.



         7.5   Upon completion of the corrective and preventive action, the area or department manager



              will acknowledge completion of these actions by signing the original CAR and returning



              it to the EMR or designee.



         7.6   A member of the assessment team will verify corrective  and preventive actions in a
Click here to return to page 53.                     - 139 -
-------
               timely manner. When full compliance is determined or corrective and preventive



               actions are accepted, the assessment team member will sign the original CAR and



               return it to the EMR or designee for the closure and filing.



         7.7   Each calendar quarter, the EMR or designee will present a summary of open CARs that



               are based on regulatory noncompliance to facility management for review.



    8.    General Rules



         8.1   Records, including CARs, that relate to potential or actual noncompliance issues will be



               treated as confidential and will be kept separate from those that relate to internal EMS



               audits.



         8.2   Potential nonconformance issues (Note: a noncompliance is a nonconformance) must



               receive prompt attention and timely corrective and preventive action.



         8.3   All audit records shall be marked "Environmental Audit Report: Privileged Document"



               (U.S. only) and distributed to individuals who need to know their contents in order to



               assess, respond to or remedy a potential or actual nonconformance.



    9.    Records



         Records shall be retained consistent with record keeping procedure.








    Record of Revisions
Revision Date

Description

Sections Affected

Click here to return to page 53.                     - 140 -
-------
Title: PROCEDURE FOR NONCONFORMANCE, CORRECTIVE AND PREVENTIVE ACTION
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
EMS Representative
Approved By:
EMS Management Representative
    1.    Purpose

         1.1  To ensure that a process is in place to define responsibility and authority for handling and

               investigating nonconformances, take action to mitigate resulting impacts and initiate and

               complete corrective and preventive action.

    2.    Scope

         2.1   This procedure applies to the operations and programs conducted by (insert hospital

               name), located at (insert hospital address).

    3.    Definitions

         3.1  Definitions relating to the content of the EMS are contained in the glossary.

    4.    Responsibility

         4.1  It is the responsibility of the EMS representative and/or designee to:

         •     Lead the Environmental Auditing Team to find hospital nonconformances.
         •     Investigate the occurrence of nonconformances.
         •     Aid in the development, follow through and evaluation of corrective/preventive actions in
               consultation with the department managers/supervisors.
         •     Revise EMS procedures as a result of nonconformances.
         •     Organize staff retraining when necessary.
         4.2   It is the responsibility  of the department managers/supervisors to:

         •     Verify the occurrence of nonconformances within their departments.
         •     Identify and follow through with corrective/preventive actions.
         •     Evaluate the effectiveness of the corrective/preventive actions taken.
         •     Prevent reoccurrence of nonconformances.
    5.    Procedure

         5.1   Nonconformances can be identified by:
         •     Internal/external audits
         •     Compliance audits
         •     Regulatory inspections
         •     Observation by staff members
         •     Internal/External communications
         •     Review of emergency  preparedness and response procedures after the occurrence of a
               spill or environmentally related accident
         •     Management review process
Click here to return to page 54.                      - 141 -
-------
         5.2   Nonconformances not identified through an EMS Audit are to be recorded on the



               hospital's current Employee Incident Reporting Form, and/or an employee can contact



               the EMS representative to report the nonconformance. (This will be documented on an



               Employee Incident Reporting Form.



         5.3   When the EMS Internal Auditing Team finds a nonconformance during an audit, the



               nonconformance is formalized and documented in the EMS Audit Report. Identified



               nonconformances are also documented on the Nonconformance Corrective Action Report



               and sent to the associated department managers/supervisors for remediation.



         5.4.  The EMS representative and/or EMS Internal Auditing Team conducts an initial severity



               evaluation of the nonconformances  identified to determine if it is a MAJOR or MINOR



               nonconformance:



               •   MAJOR- a serious, possibly reoccurring deficiency within the EMS that adversely



                   affects the  hospital (e.g., a missing requirement of the ISO 14001  standard, and/or a



                   system is not functioning as it is documented).



                   - Requires documented corrective and preventive actions.



               •   MINOR- an  isolated deficiency in the functioning of a system that does not affect the



                   performance of the hospital's overall EMS (e.g., a documented procedure is not



                   followed consistently, and/or a part of a procedure is missing).



                   - May not require documented corrective and preventive actions."



                              (Taken from St. Mary's General Hospital's EMS, Kitchener, Ontario, Canada, 2001)



         5.5   The EMS representative and/or associated department managers/supervisors address



               major and minor nonconformances as they occur.



         5.6   For major nonconformances, the associated department manager/supervisor, EMS



               representative, and/or other responsible position identifies and documents corrective and/



               or preventive actions in the "Correction" section  of the Employee Incident Reporting



               Form.  Proposed actions, responsibilities and target dates are to be included in this



               corrective and/or preventive action plan.



         5.7   The EMS representative and/or a management representative approves corrective and/or



               preventive actions.



         5.8   Department managers/supervisor and/or delegated departmental staff follow through
Click here to return to page 54.                     - 142 -
-------
               with identified corrective/preventive actions.

         5.9   If the nonconformance relates to EMS documentation or legislative and other

               requirements, the EMS representative will proceed with the identified corrective and/or

               preventive actions.

         5.10  The EMS representative conducts a follow-up inspection/audit/review to determine if

               corrective/preventive action(s) has been completed and is effective.

         5.11  If hospital staff identified the nonconformance, the EMS representative will report

               progress back to the initiating staff member within two weeks.

    6.    References
         ISO 14001 - 96 - Environmental Management System Standard
         EMS-4.3.2- Procedure for Legal and Other Requirements
         EMS-4.4.3- Procedure for Communication
         EMS- 4.3.7-Procedure for Emergency Preparedness and Response
         EMS- 4.5.1- Procedure for Monitoring and Measurement
         EMS-4.5.4 Procedure for Environmental Management System Audits
         EMS-4.6 Procedure for Management Review
    7.    Exhibits

         N/A
Click here to return to page 54.                     - 143 -
-------
                NONCONFORMANCE/RECOMMENDATIONFORM

   As per the Nonconformance, Corrective and Preventative Action of the hospital's
   Environmental Management System (ISO 14001), all *major nonconformances identified
   through the process of internal inspections (performed by the EMS Internal Auditing
   Teams) must be documented, have corrective/preventative actions identified,
   responsibilities designated and timelines set for remediation.

   Department: ENGINEERING SERVICES/LABORATORY
   Program Manager/Supervisor: BILL JONES

   Return Form To: EMS REPRESENTATIVE
   By Date: (2 weeks from Audit Date) APRIL 15, 2002
   Audit Team: SALLY WILSON, JOE PALMER, MELISSA SMITH, PAUL TAIT
   Audit Date: APRIL 1, 2002
      Nonconformance
   (Site section of Standard/
   EMS in contravention)
  Recommendation(s)
    Corrective/
Preventative Actions
Dates of Completion
   4.3.1-Aspects and
   Impacts Manager audited
   were unaware of their
   responsibilities to update

   the aspects list annually.
Increase awareness
through education
(managers meetings and
emails).
Attended Manager's
Meeting on May 23,
2002 to discuss
Aspects updating
process. Managers
were given a copy of
their department and
are to respond with
any changes by June
30, 2002.
May 23, 2002 -
Managers Meeting
June 30, 2002-
Receive all updated

aspects list

July 19, 2002 (have
aspects list updated).
   4.3.1-Aspects and
   Impacts
   Managers were unaware
   of their responsibilities to
   inform the EMS
   Representative of any new
   products/equipment that
   may have a significant
   impact on the
   environment.
Increase awareness
through education
(managers meetings and
emails).
Same as above
Same as Above
   * Major Nonconformance. a serious, possibly reoccurring deficiency that adversely
   affects the Hospital, a missing requirement of the CAN/CSA ISO 14001: 1996 Standard,
   a system is not functioning as it is documented. Requires documented corrective or
   preventative actions.
Click here to return to page 54.
                                        - 144-
-------
  Problem Identified: June 2001
Resolution Due Date:  July 2001
  Problem Identified By: Laboratory Supervisor
 Problem (described existing or anticipated problem):  EMS Management Team failed to
 conduct a cost-benefit analysis on implementation of new chemical tracking and
 inventor)1 system, which was identified as an action item during the first quarter EMS
 steering committee meeting. Original due date for analysis was May 1,2001.
 Most Likely Cnuse(s):
 • EMS Management Team focused on preparing for regulatory compliance audit during
 June 2000.
 * Laboratory did not follow-up with EMS Management Team.
 • Lack of information to estimate costs of implementing system above.

 Possible Solution(s):
 * Schedule working meeting between laboratory staff and EMS Cost-Benefit
 Analysis team.
 * Research chemical tracking and inventory systems (assign to laboratory staff)
 * Report to EMS Management Team.
 Implemented Solution (s):
 Due Date: July 2001 Completed: July 2001
 * Laboratory staff researched existing chemical tracking and inventory systems and
 reported to EMS Management Team on June 30, 2001.
 * Laboratory and EMS cost-benefit team met on July 7, 2001 to discuss findings.
 • EMS Management Team completed cost-benefit analysis on July 15, 2001 and plans to
 implement new systems are being determined cooperatively between laboratory staff and
 EMS team.
 Resolution (confirm effectiveness of I m pi em en ted solutions):
 Responsible Person                                         Effective Date
Click here to return to page 54.                   - 145 -
-------
  Problem Identified: May 25, 2001
Resolution Due Date: May 30, 2001
  Problem Identified By: Hazardous Waste Management Staff
 Problem (described existing or anticipated problem) Requires Corrective Action:
 Four of 17 drums of hazardous waste stored in storage area B behind the Maintenance
 Building were improperly labeled; one had no waste accumulation start date, two had no
 waste description, and one had no label.
 Most Likely Cause(s):
 • New employee in Maintenance Building started at the beginning of May and didn't
 receive training during first week of work.
 • Laboratory where new employee works didn't receive phone number for waste
 management department to receive support in handling and storing waste.
 • Supply of labels was low and existing labels were old and ineffective.

 Possible Solution(s):
 • Schedule and complete training for new employee(s).
 • Meet with all laboratory managers in Maintenance Building to review hazardous waste
 management procedures.
 • Provide new supply of labels and phone number magnets.
 Implemented Solution(s):
 Due Date: May 30                              Completed:  May 30
 • Trained new employee May 28
 • Conducted meeting with laboratory manager May 28
 • Resupplied labels and magnets May 30
 Resolution (confirm effectiveness of implemented solutions): Maintenance Building
 staff has been trained/briefed on hazardous waste handling procedures and no further
 deficiencies have been noted for 3 months. (Dates September 1, 2001)
 Responsible Person                                          Effective Date
Click here to return to page 54.                  - 146 -
-------
O  J£
O  i



















istrative
c
sm Admi
%
O)






































£
-t— •
C/D
C/D
(~>

£=
CD - — -
C/D -i-2
CD d

>• £
"-G £
CD -g
tf> !=r
¥1 CD
"ci ' —
=> • • 0
g.1 -^ g
S--Q -2 :o
O CD > — O
!£ •<= If " -g"
•5 S- H «? &









ro
E
< —
^
^
CO
0
!
gj
0
T3
CO
-t±
0
C2-
[2
^
^
















"S.
d>
C3
"35 J2
co Q








C/D

-s
CD
CO
_^
-i-Z

^
CD
cn
CD
£=
CD
"o.
-8
"d
"CD
CL
1
CD
CD
\—
>,
CO


c
CO
o
1
1
o
o















. 	 .
^§
CD
"CD
^
~cz
"CD
CL
CD
CD


h—
-c
R
o
^
f^f
o
•s ~
Q 1"
8



^
5 •*


0






0 0
«* §
1 —
o
0
Q-
0
-Q
i
0
Dlt







CQ
Q-
O
t»
^









cn
=*
"O

it
m
1




•_ __
n -£2
1^"



3












































































































































































































































































































































_iH
"Sb
(U . .
£3 (U

r , f^^
00 ^
OJ -g
~^ C3
^oo OC
I -S
s ^
0 3
o •<















1
•^3
s
C3
"o
CL>
CL>
P^
I—!


CL>
1
OH
OH
O
s
S
c^>
»5
TO
=tt
-<

c
ca
ra


'"So
•3
o

"•~_^

ca
•O
"jjji)
•3
O
£
:S
0
=
-Sf
•3
o
B
c
o>
£~
w
Pd

&
uu
pa-
3
1
"c-

•O
C
-------
Title: EMS RECORDKEEPING PROCEDURE
Document Number:
Date Approved:
Next Revision Date:
Prepared By:
Approved By:
 PURPOSE
 This procedure is used to maintain EMS records.
 Stepl


 Step 2



 Step 3
The EMS manager and other personnel selected by the EMS manager are responsible for
identifying records that are maintained by the hospital as part of the EMS.
 Step 4
 StepS
The EMS manager and other
personnel will maintain all
records in a single location.

The EMS manager and other
personnel will maintain a
document index of all records
that are maintained as part of the
EMS, the data and person
responsible for the length of
retention for each type of
record.

The EMS manager and other
facility personnel will identify
and note on the document
index any restrictions on
records necessary for security.

The EMS manager and other
facility personnel will review
the records and purge obsolete
records at least every (insert
time frequency appropriate for
your hospital and circumstances).
Types of Records To Maintain (Examples):

   Legal, regulatory and other code requirements
   Results of environmental aspects identification
   Reports of progress toward meeting objectives
   and targets
   Permits, licenses and other approvals
   Job descriptions and performance evaluations
   Training records
   EMS audit and regulatory compliance audit
   reports
   Reports of identified nonconformities,
   corrective action plans and corrective action
   tracking data
   Hazardous material spill/other incident reports
   Communications with customers, suppliers,
   contractors and other external parties
   Results of management reviews
   Sampling and monitoring data
   Maintenance records
   Equipment calibration records
     Responsible Person:

     Signature and Date:
Click here to return to page 55.
                                                -148-
-------
          ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
Complete all applicable audit items. S = Satisfactory, D = Deficient.
Document evidence and comments.   Standards being audited:
Auditors:
                                  Date:
(S)


















(D)


















Item
4.2 Environmental Policy
a) Staff can correctly verbalize Environmental
Policy (prevention of pollution, compliance
with legal requirements, and continuous
improvement)
b) Environmental Commitment/Policy is posted
4.3 Planning
4.3.1 Environmental Aspects
a) Staff can identify environmental aspects for
their department. (Reference: Master
Environmental Aspect List)
b) Staff has knowledge of how to handle
significant environmental aspects in their area.
4.3.2 Legal and Other Requirements
a) Dept. manager can correctly verbalize
regulatory requirements that are applicable to
their department.
b) Dept. operations are compliant with
regulatory requirements (e.g., JCAHO, CMS,
NFPA, EPA, OSHA/MIOSHA).
c) Compliance with relevant environmental
legislation and regulations has been periodically
evaluated. (4.5.1)
4.3.3 Objectives and Targets
a) Dept. manager and staff can speak to hospital
system EMS objectives [prevention of pollution
(recycling), generation and handling of medical
waste, handling and disposal of chemotherapy
waste].
b) Progress on system objectives and targets
have been reported at EOC and/or LPICC
meetings.
4.3.4 EMS Programs
a) Managers have knowledge/awareness of
system EMS objectives and targets.
b) Copies of tracking forms have been
maintained at each site (Safety Officer, LPICC,
and or EOC Committee).
c) Managers and staff can speak to
environmental measures or indicators tracked
within the department.
Evidence/Comments


















Click here to return to page 58.
- 149-
-------
          ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
 Complete all applicable audit items. S = Satisfactory, D = Deficient.
 Document evidence and comments.   Standards being audited:
 Auditors:
                                  Date:
(S)















(D)















Item
4.4.1 Structure and Responsibility
a) Staff correctly verbalize that environmental
concerns are referred to the site safety officer
(EMS management representative).
b) Resources to implement and maintain the
EMS have been provided (human,
technological, financial).
4.4.2 Training, Awareness & Competence
a) Training needs/competencies have been
identified and effective training has been
provided (competency records/employee files).
b) Employees demonstrate awareness of:
• Department procedures.
• Significant environmental impacts,
actual or potential, associated with their
work activities.
• The environmental policy, emergency
preparedness procedures and responses
required.
• Risks associated with deviating from
environmental and safety
policy/procedures.
4.4.3 Communications
a) Internal communication is effective: staff has
knowledge of how to report environmental
concerns, understand how to report concerns via
the Compliance Hotline.
b) External communication phone logs have
been kept up to date, and issues are addressed.
4.4.4 EMS Documentation
4.4.5 Document Control
a) Master document control list references
departmental documents and procedures
necessary for an effective EMS.
b) Documents and posted instructions are dated
and have been approved (manager's
initials/signature).
c) Master document control list has been
updated.
d) Documents not in use are removed from use
and labeled "obsolete," or "for reference only"
or "retired."
Evidence/Comments















Click here to return to page 58.
- 150-
-------
          ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
 Complete all applicable audit items. S = Satisfactory, D =  Deficient.
 Document evidence and comments.    Standards being audited:
 Auditors:
                                  Date:
(S)



















(D)



















Item
4.4.6 Operational Controls
a) Employees can access on-line policies.
b) Department procedures for managing
significant environmental aspects have been
established and implemented.
c) Policies and procedures have been
communicated to suppliers and contractors.
4.4.7 Emergency Preparedness and Respons
a) Staff has knowledge of Emergency policies
and procedures, know what action to take in an
emergency.
b) Emergency codes and drills have been tested.
4.5.1 Monitoring & Measurement
a) Environmental Rounds have been conducted
as scheduled; results have been documented.
b) Monitoring equipment has been calibrated as
scheduled; records are retrievable.
4.5.2 Nonconformances/Corrective &
Preventive Action
a) Staff has knowledge of how to report an
incident or nonconformance (safety
officer or Compliance Hotline).
b) Corrective and preventive actions are
appropriate to the nature and magnitude
of the problem identified (e.g., critical
problems are addressed promptly with
action to prevent recurrence).
4.5.3 Records
a) Environmental records are stored and
retained as stated in 1 CG 017. (Where
applicable, regulatory requirements may dictate
retention period.)
b) Records are retrievable.
c) Records are stored to protect from loss and/or
damage.
4.5.4 EMS Audit
a) Internal monitoring (audit) results are
maintained and retrievable.
b) Action plans are documented and have been
implemented. Action plans are effective.
Evidence/Comments




e














Click here to return to page 58.
- 151 -
-------
          ENVIRONMENTAL MANAGEMENT SYSTEMS AUDIT CHECKLIST
Complete all applicable audit items. S = Satisfactory, D = Deficient.
Document evidence and comments.   Standards being audited:
Auditors:                                                                   Date:
(S)




(D)




Item
4.6 Management Review
a) Management review has been conducted at
least annually.
b) Management review includes:
• Internal audit results
• Changes in EMS policy, objectives or
other elements of the EMS
• A review of the EMS for continued
suitability, adequacy and effectiveness.
c) Management Review is documented; records
are retrievable.
Evidence/Comments




Click here to return to page 58.
- 152-
-------
                             Possible Sources of Mercury
  Thermometers
  Body temperature thermometers
  Clerget Sugar test thermometers
  Heating and cooling system
         thermometers
  Incubator/water bath thermometers
  Minimum/maximum thermometers
  National Institute of Standards and
         Technology calibration
         thermometers
  Tapered bulb (armored) thermometers
  Sphygomanometers
  Gastrointestinal tubes
  Cantor tubes
  Esophageal dialators (bougie tubes)
  Feeding tubes
  Miller Abbott tubes
  Dental amalgam
  Pharmaceutical supplies
  Contact lens solutions and other
         ophthalmic products containing
         thimerosal, phenylmercuric nitrate
  Diuretics with mersalyl and mercury
         salts
  Early pregnancy tests kits with mercury
          containing preservatives
  Merbromin/water solution
  Nasal spray with thimerosal,
          phenylmercuric acetate or
          phenylmercuric nitrate
  Vaccines with thimerosal (primarily in
          hemophilus, hepatitis, rabies,
          tetanus, influenza, diphtheria and
  	pertussis vaccines)	
Batteries for medical use
Alarms
Blood analyzers
Defibrillators
ECG monitors
Fetal monitors
Hearing aids
Hofler monitor
Meters
Monitors
Oxygen monitors
Pacemakers
Pumps
Scales
Telemetry transmitters
Ultrasound
Ventilators
                                             Lamps
Fluorescent
Germicidal
High-intensity discharge (high pressure
    sodium, mercury vapor, metal halide)
Ultraviolet
Tilt switches
Air flow/fan limit control
Building security systems
Chest freezer lids
Fire alarm box switches
Lap top computer screen shut-off
Pressure control (mounted on bourdon
       tube or diaphragm)
Silent light switches (single pole and
       three way)
Temperature control
Washing machine power shut off	
Click here to return to page 78.
                                         - 153-
-------
   Float control
   Septic tanks
   Sump pumps
   Thermostats (nondigital)
   Thermostat probes in electrical
          equipment
   Reed Relays (low voltage, high precision
          analytical equip)
   Plunger or displacement relays (high
         current/high voltage)
   Thermostat probes
   Gas Appliances
   Flame sensors
   Gas safety valves
   Pressure gauges
   Barometers
   Manometers
   Vacuum gauges
   Chemicals that contain mercury
   Acetic Acid
   Alum hematoxylin (Solution A)
   Ammonium reagent/Stone Analysis kit
   Antibody test kits
   Antigens
   Antiserums
   B5 fixative
   Buffers
   Bleach solutions containing sodium
   hypochlorite
   Cajal's
   Calibration kits
   Calibrators
   Cameo
   Carbol Gentain violet
   Chloride
   Carnoy-Lebrun solution
   Diluents
   Enzyme Immunoassay test kits
   Enzyme tracers
   Ethanol
   Extraction enzymes
   Fixatives
   Gomori's
   Golgi's
Chemicals that contain mercury cont.
Gram Iodine
Helly solution
Hematology reagents
Hitergent
Hormones
Immunoelectrophoresis reagents
Immunofixationphoresis reagents
Immun-sal
Mercury chloride
Mercurochrome
Mercurophyline
Mercury iodide
Mercury nitrate
Mercury sulfate
Merthiolate
Million's reagent
Mucolex
Negative control kits
Nessler's solution
Ohlamacher
Phenobarbital reageant
Phenol Mercuric Acetate
Phenytoin reagent
Positive control kits
Potassium hydroxide
Pregnancy test kits
Rabbit serum
Shardin Solution
Shigella bacteria
Sodium hypochlorite
Stains
Stabilur Tablets
Standards
Takata's reagent
Thimerosal
Tracer kits
Urine analysis reagents
Wash solutions
Zenker solution
Other
Devices, such as personal computers that
       utilize a printed wire board
Blood gas analyzer reference electrode
       (Radiometer brand)
Cathode-ray oscilloscope
Click here to return to page 78.
                                         - 154-
-------
   Other continued
   DC watt hour meters (Duncan)
   Electron microscope (mercury may be
         used as a damper)
   Flow meters
   Generators
   Hitachi Chem Analyzer reagent
   Lead analyzer electrode (ESA model
         301 OB)
   Sequential Multi-Channel Autoanalyzer
   (SCMA) AU 2000
   Vibration Meters
Click here to return to page 78.                  - 15 5 -
-------
                 Polyvinyl Chloride (PVC) Products in Hospitals

Blood Products and Transfusions: apheresis circuits, blood bags and tubing,
extracorporeal membrane oxygenation ciruits
Collection of Bodily Fluids: dialysis, peritoneal: drainage bags, urinary collection
bags, urological catheters, and irrigation sets, wound drainage systems
Enteric Feeding Products:  enteric feeding sets, nasogastric tubes, tubing for breast
pumps
Gloves
Intravenous (IV) Therapy Products:  catheters, solution bags, tubing
Kidney (Renal Disease) Therapy Products: hemodialysis: blood lines and catheters,
peritoneal dialysis
Packaging, Medical Products: film wrap, thermoformed trays for admission and
diagnostic kits, and medical devices
Patient Products:  bedpans, cold  and heat packs and heating pads, inflatable splints and
injury support packs, patient ID cards and bracelets, sequential compression devices
Respiratory Therapy Products:  aerosol and oxygen masks, tents, and tubing,
endotracheal and tracheostomy tubes, humidifiers, sterile water bags and tubing, nasal
cannulas and catheters, resuscitator bags, suction catheters.
Office Supplies:  notebook binders, plastic dividers in patient charts
Durable Medical Products: testing and diagnostic equipment, including instrument
housings
Furniture Products and Furnishings: bed  casters, rails and wheels, floor coverings,
furniture upholstery, inflatable mattresses and pads, mattress covers, pillowcase covers,
shower curtains, thermal blankets, wallpaper, window blinds and shades
Construction Products: doors, electrical wire sheathing, water and vent pipes, roofing
membranes, and windows
Click here to return to page 80.
-------
                           - APPENDIX B -
                    ADDITIONAL RESOURCES
                              Table of Contents
                                                                   PAGE No.

I.     Compliance Resources                                        158
      Web sites                                                       158
•     Other Compliance Resources                                         158

II.    Environmentally Preferable Purchasing (EPP) Resources        159
      Web sites                                                       159

III.   Energy Efficiency Resources                                   160
      Web sites                                                       160

IV.   Environmental Management Accounting Resources              161
•     Guides, Articles and Manuals                                         161
      Web sites                                                       161

V.    Small Business Resources                                     162

VI.   General Pollution Prevention Resources                        170
      Check Lists                                                     170
      Fact Sheets                                                     170
      Guides                                                        170
•     Manuals                                                       171
      Reports                                                        172
•     Compact Disc                                                    173
      Web sites                                                       173

VII.  Water Permits/Effluent Limits                                 176
•     Factor 2 Screening Level Information on the Health Care Industry                176
•     U.S. Department of the Interior Geological Survey                           180
Click here to return to Table of Contents.          - 157 -
-------
                                I.  Compliance Resources
Web sites

Health Care Compliance Association
HCCA's mission is to champion ethical practice and
compliance standards in the health care community
and to provide the necessary resources for
compliance.
http: //www.hcca-info .org/

Health Care Corporate Compliance Supersite
Complianceinfo.com provides compliance news,
newsletters and other resources to covering a variety
of general hospital compliance issues.
http://www.hcpro.com/corporate-compliance/

National Compliance Assistance Centers
The U.S. EPA sponsors partnerships with industry,
academic institutions, environmental groups and
other agencies to launch sector-specific Compliance
Assistance Centers. Each Compliance Assistance
Center addresses real-world issues in language that
speaks to the regulated entities.
http://www.assistancecenters.net/
A new compliance assistance center for the health
care sector will be available in the first quarter of
2005. http ://www.hercenter.org

National Environmental Assistance Clearinghouse
This Web site provides easy access to compliance
assistance tools, contacts and planned activities from
the U.S. EPA, its partners and other compliance
assistance providers.
http://cfpub.epa.gov/clearinghouse/

U.S. EPA's Oil Spill Program Web site
The U.S. EPA's program for preventing, preparing
for and responding to oil spills that occur in and
around inland waters of the United States.
http://www.epa.gov/oilspill/

U.S. EPA's NPDES Web site
Provides technical and regulatory information about
the National Pollutant Discharge Elimination System
(NPDES) permit program, which controls water
pollution by regulating point sources (e.g., pipe,
ditch) that discharge pollutants into waters of the
United States, http://cfbub.epa.gov/npdes/
Code of Federal Regulations
Database of the Code of Federal Regulations (CFR)
http://www.gpoaccess.gov/ecfr/

Other Compliance Resources

American Hospital Association (AHA)
    The American Hospital Association (AHA) is a
national trade organization that represents hospitals,
health care networks, patients and the communities
they serve. As many as 5,000 institutions and 40,000
individuals belong to  the AHA. The AHA's mission
is to advance the health of individuals and
communities.
    AHA provides representation and advocacy
activities to ensure that members' perspectives are
addressed in national  health policy development,
legislative and regulatory  debates and judicial
matters. In addition, AHA provides resources to help
health care leaders implement change at the
community level. The AHA helps hospitals and
other health care providers form networks for patient
care. AHA conducts research and demonstration
projects; provides educational programs; performs
data gathering and information analysis to support
policy development and track trends and keeps
members informed of national developments and
trends and their impact on local communities.
    The AHA also works for its membership to track
international and federal rule-making to educate
members of the health care community on the
potential impact of new legislation and regulatory
initiatives, http://www.aha.org

Clean Air Technology Center (CATC)
    The Clean Air Technology Center (CATC)
serves as a resource in all  areas of emerging and
existing air pollution prevention and control
technologies and provides public access to data and
information on their use, effectiveness and cost. The
CATC also provides technical support, including
access to the U.S. EPA and other government
agencies as resources allow, related to the technical
and economic feasibility, operation and maintenance
of these technologies, http: //www.epa. gov/ttn/catc/
or call 919-541-0800. For publications, call 919-
541-2777.
Click here to return to start of Appendix B.
                                              - 158-
-------
Hospitals for a Healthy Environment (H2E)
    The Hospitals for a Healthy Environment (H2E)
is a voluntary program, which was formed as a result
of the American Hospital Association and the U.S.
EPA's Memorandum of Understanding (MOU) dated
June 24, 1998.
    This landmark agreement calls for:
•      Elimination of mercury-containing waste
       from health care facilities' waste streams by
       2005.
•      Reduction of the overall volume of waste
       (both regulated and nonregulated waste) by
       33 percent by 2005 and by 50 percent by
       2010.
•      Identification of hazardous substances for
       pollution prevention and waste reduction
       opportunities, including hazardous chemicals
       and persistent, bioaccumulative and toxic
       pollutants (PBT).
    The Hospitals for a Healthy Environment
program helps health care facilities enhance
workplace safety, reduce waste and waste disposal
costs and become better environmental stewards and
neighbors. This is done by educating health care
professionals about pollution prevention
opportunities in hospitals and health care systems.
    Through such activities as the development of
best practices, model plans for total waste
management, resource directories and case studies,
H2E provides hospitals and health care systems with
enhanced tools for minimizing the volumes of waste
generated and the use of persistent, bioaccumulative
and toxic chemicals (PBT). Such reductions are
beneficial to the environment and community health.
Furthermore, improved waste management practices
reduce industry waste disposal costs.
    To take advantage of the opportunities the H2E
program offers, visit the H2E Web site http://
www.h2e-online.org and/or participate in one of the
H2E programs as either a partner or champion.
    Partners are health care facilities who commit to
making changes in their facilities that protect
community and environmental health. Champions
are organizations that encourage and aid health care
facilities to participate as H2E partners and/or who
make changes in their own institutions that support
the goals of the H2E program. Partners and
champions receive local and national recognition for
the work they do to reduce waste and protect the
environment through the H2E recognition and
awards program.
    Visit the H2E Web site for a complete list of
current partners and champions; tools and resources
including many items such as mercury, green
buildings and green purchasing; environmental
management systems; technical resources with links
to mercury recyclers and consultants and vendors;
news and events; videos and much more.
http://www.h2e-online.org
        II.  Environmentally Preferred Purchasing (EPP) Resources
Web sites
APIC Guideline For Selection/Use of
Disinfectants
The Association for Professionals in Infection
Control and Epidemiology (APIC) assists health care
professionals in selecting and using specific
disinfectants.
http://www.apic.org

U.S. EPA's Environmentally Preferable
Purchasing (EPP) Web site
Among the tools on this Web page include EPP
general training tools, a database of information of
contacts for environmentally preferable products and
services and a practices guide for "greener"
contracts.
http: //www. epa. go v/oppt/epp/
EPP Database
A tool to make it easier to purchase products and
services with reduced environmental impacts.
Environmental information on more than 600
products and services is included in this database.
http ://yosemite .epa. gov

EPP Newsletter
This monthly newsletter provides updates on health
care environmental purchasing innovations from
across the country.
http://www.epa.gov/epp/pubs/
update 13_final_l 24 .pdf

Health Care Purchasing News Online
http://www.hpnonline.com/
Click here to return to start of Appendix B.
                                             - 159-
-------
Green Seal Standard
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: //www. greenseal. org/standards .htm

INFORM, Inc
Provides a report on changing to green janitorial
products.  Has large list of green cleaning products
that are reviewed by existing state or local
government green cleaning programs.  Contains
vendor information.
http://www.informinc.org/cleanforhealth.php
The Nightingale Institute for Health and the
Environment
This Web page provides resources including
manuals, news and tools for environmentally
preferable health care purchasing called the HCEPT
Tool.
http://www.nihe.org/

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. Such products are referred to as "sustainable"
or "eco-effective."
http://www.zerowaste.org/ugca.htm
                          III.  Energy Efficiency Resources
Web sites
Energy Efficiency in Health Care Facilities: A
Hot Opportunity to Chill
Philip J. Kercher.  September 1999.  Available
through the American Hospital Association (800)-
242-2626 or the hyperlink below.  The manual
describes preventive maintenance, performance
contracting and energy management teams as
component of successful energy management.
Reviews three programs along with costs and
benefits.
http://www.ahaonlinestore .com/

Managing Utility Cost in a Health Care Facility
Michael Brian Cotton. August 1999. Available
through the American Hospital Association (800)
242-2626 or visit the American Hospital Association
Web site at the hyperlink below. The manual
describes energy controls and management
opportunities  available to hospital facility managers.
http: //www. ahaonline store .com/
Energy Savings in Hospitals
Caddett Analyses Series 20. June 1996. Available
for purchase through the American Council for an
Energy Efficient Economy.
http://www.aceee.org/index.htm

EnergyStar for Hospitals
An easy way to evaluate and compare energy
performance against others across the country.
http://www.energystar.gov/
index.cfm?c=healthcare.bus healthcare
 Click here to return to start of Appendix B.
                                             - 160-
-------
           IV. Environmental Management Accounting Resources
Guides, Articles and Manuals
Accounting and Capital Budgeting for Pollution
Prevention
Martin A. Spitzer, Robert Pojasek, Francis L.
Robertaccio, Judith Nelson. Pollution Prevention in
South Carolina. Winter 1996
http: //www.umich. edu/~nppcpub/re sources/Re sLists/
acctlistl.html

An Introduction to Environmental Accounting as
a Business Management Tool: Key Concepts and
Terms
U.S. EPA, Design for the Environment Program,
Environmental Accounting Project
http://www.greenbiz.com/toolbox/
reports Jhird.cfm?LinkAdvID=13759

Total Cost Assessment: Accelerating Industrial
Pollution Prevention Through Innovative Project
Financial Analysis
U.S. EPA Office of Pollution Prevention. May 1992
http://www.epa.gov/reg3rcei/genlib/pollprev.htmtfTB
Web sites
Environmental Management Accounting Network
A network of researchers, consultants,
businesspeople and policy advisors interested in
environmental management accounting as a tool for
corporate environmental management.
http://www.emawebsite.org/

Environmental Management Accounting
Research and Information Center
A source of comprehensive information in
environmental management accounting for the
international  community.
http://www.emawebsite.org/about_emaric.htm

Tellus Institute, Business and Sustainability to
Environmental Management Accounting
Tellus environmental management accounting
projects have covered booth the materials and cost
accounting aspects of environmental management
accounting for a wide variety of applications such as:
Capital Budgeting and Project Profitability
Assessment; Pollution Prevention and Cleaner
Production; Environmental Supply Chain
Management; Environmentally Preferable
Purchasing; and Environmental Management
Systems.
http: //www.tellus. org/

United Nations Sustainable Development
Environmental Accounting Initiative
Background information on environmental
management accounting.
http://www.un.org/esa/sustdev/sdissues/technology/
estemal.htm

U.S. EPA's Design for the Environment
One of the U.S. EPA's premier partnership programs,
working with individual industry sectors to compare
and improve the performance, human health,
environmental risks and costs of existing and
alternative products, processes and practices.
http: //www.epa. gov/dfe/

EMS Primer for Federal Facilities
Informative guide on EMS for federal facilities.
http://nepa.fhwa.dot.gOv/ReNEPA/ReNepa.nsf/0/
a6399e41bab0239085256fl5004e2562?QpenDocument
Click here to return to start of Appendix B.
                                           - 161 -
-------
                           V. Small Business Resources
ALABAMA
Gary Ellis, (SBO)
Office of Education and Outreach
AL Department of Environmental
   Management
P.O. Box 301463
Montgomery, AL 36130-1463
(334) 394-4352
(334) 394-4383 (F)
(800)533-2336
mailto:gle@adem.state.al.us

Mike Sherman (SBAP)
Air Division
AL Department of Environmental
   Management
P.O. Box 301463
Montgomery, AL 36130-1463
(334)271-7873
(334) 279-3044 (F)
(800)533-2336
mailto:mhs@adem.state.al.us

ALASKA
Bill Smyth (SBO)
AKDEC
610 University Avenue
Fairbanks, AK 99709
(907)451-2177
(907) 451-2188 (F)
(800) 520-2332
mailto :Bill_smy th@dec. state .ak.us

ARIZONA
Brian Davidson (SBO)
Deputy Director
Air Quality Division
1110 West Washington Street
Phoenix, AZ  85007
(602) 771-2365
(800) 234-5677
mailto:domsky.ira(S!ev.state.az.us
Emily Bonanni (SBAP)
Compliance Section
Air Quality Division
1110 West Washington Street
Phoenix, AZ 85007
(602)771-2324
(800)234-5677
mailto:Ebl@state.az.us

MARICOPA COUNTY
Richard Polito (SBAP)
Maricopa County SBEAP
1001 N. Central, Suite 500
Phoenix, AZ 85004
(602)506-5102
(602) 506-7303  (F)
mailto :rpolito@mail.maricopa.gov

ARKANSAS
Ron Alexander (SBO)
Department of
Environmental Quality
P.O. Box 8913
8001 National Drive
Little Rock, AR 72219-8913
(501)682-0866
(501) 682-0880 (F)
(888)233-0326
mailto: alexander@arb .ca.gov

CALIFORNIA
Kathleen Tschogl (SBO)
Ombudsman
Air Resources Board
10011 Street
P.O. Box 2815
Sacramento, CA 95814
(916)323-6791
(916) 322-4737 (F)
(800) 272-4572
mailto:ktschogl@arb.ca.gov
Terrell D. Feirra (SBAP)
Air Resources Board
10011 Street
P.O. Box 2815
Sacramento, CA 95 814
(916)322-2467
(916) 322-4737 (F)
mailto :tferreir@arb .ca.gov

SOUTH COAST
Anupom Ganguli (SBO)
Public Advisor
South Coast Management District
Small Business Ombudsman
21865 E.Copley Drive
Diamond Bar, CA 91765
(909)396-3185
(909) 396-3335 (F)
(800)388-2121

Larry Kolczak (SBAP)
Community Relations Manager
South Coast Air
Management District
Small Business Assistance Office
21865 E.Copley Drive
Diamond Bar, CA 91765
(909)396-3215
(909) 396-3638 (F)
(800)388-2121
(800) CUTSMOG
mailto: Lkolczak@aqmd .gov

COLORADO
Nick Melliadis (SBO)
CDPHE
OCSINFA1
4300 Cherry Creek Drive
South Denver, CO 80246-1530
(303)692-2135
(303) 691-1979 (F)
(800)886-7689
mailto:nick.melliadis@state.co.us
 Click here to return to start of Appendix B.
                                          - 162-
-------
Joni Canterbury (SBAP)
CDPHE
APCD/55/B1
4300 Cherry Creek Drive
South Denver, CO 80246-1530
(303)692-3175
(303) 782-0278 (F)
mailto:joni.canterbury@state.co.us

CONNECTICUT
Robert Kaliszewski (SBO)
Small Business Ombudsman
Department of Environmental
   Protection
79 Elm Street
Hartford, CT  06106-5127
(860) 424-3003
(860) 424-4153 (F)
mailto:robert.kaliszewski@po.state.ct.us

JoAnn Smith (SBAP)
Permit Assistance Office
CT Department of Environmental
   Protection
79 Elm Street
Hartford, CT  06106-5127
(860) 424-3003
(860)424-4153
mailto:joann.smith@po.state.ct.us

DELAWARE
Kim Finch (SBO)
DE DNRC
89 Kings Highway
Dover, DE  19901
(302) 739-6400
(302) 739-6242 (F)
mailto :kimberly. fmch@state. de .us

DISTRICT OF COLUMBIA
Sandra Handon (SBO)
DC Dept. of Health/EHA
Air Quality Division
51 N Street, N.E., 5th Floor
Washington, DC 20002
(202)535-1722
(202)535-1371(F)
mailto: sandra.handon@dc.gov
Olivia Achuko (SBAP)
Air Quality Division
EHA/Department of Health
51 N Street, NE, 5th Floor
Washington, DC 20002
(202)535-2997
(202)535-1371(F)
mailto:olivia.achuko@dc.gov

FLORIDA
William Davis (SBO)
Small Business Ombudsman
Bureau of Air Monitoring and
    Mobile Sources
Division of Air Resources
    Management
2600 Blair Stone Road, MS5510
Tallahassee, FL 32399-2400
(850)921-9580
(850) 922-6979 (F)
(800) 722-7457
mailto:william.davis@dep.state.fl.us

Stephen McKeough (SBAP)
FL SBAP Technical Advisor
Division of Air Resources
    Management
2600 Blair Stone Road, MS5510
Tallahassee, FL 32399-2400
(850)921-9539
(850) 922-6979 (F)
(800) 722-7457
mailto:stephen.mckeough@dep.state.n.us

GEORGIA
Anita DorseyWord (SBO)
GA SBAP
DNR/EPD
4244 International Parkway
Suite 120
Atlanta, GA 30354
(404) 362-4842
(877) 427-6255 (Toll Free)
(404) 363-7100 (F)
mailto: adword@mail.dnr. state .ga.us
Lee Tate (SBAP)
GA SBAP
DNR/EPD
4244 International Parkway
Suite 120
(404) 362-4854
(404) 463-7100 (F)
mailto: lee_tate@mail .dnr.ga.us

HAWAII
Patrick Felling (SBO)
Environmental Ombudsman
Compliance Assistance Office
Hawaii Department of Health
P.O. Box 3378
Honolulu, HI 96801
(808) 586-4528
(808) 586-7236 (F)
mailto:cao@eha.health.state.hi.us

Robert Tarn (SBAP)
HI Department of Health
Clean Air Branch
P.O. Box 3378
Honolulu, HI 96801
(808)586-4200
(808) 586-4359 (F)
mailto: rtam@emd .health. state .hi .us

IDAHO
Sally Tarowsky,
Environmental Assistance
    Coordinator
Idaho Small Business
    Development Center
Boise State University
1910 University Drive
Boise, Idaho 83725-1655
(208)426-1839
(208) 426-3877 (F)
mailto: starowsk(3>boise state .edu
Click here to return to start of Appendix B.
                                            - 163-
-------
ILLINOIS
Donald Squires (SBO)
Illinois EPA/DAPC
Small Business Ombudsman
P.O. Box 19276
Springfield, IL 62794-9276
(217) 785-1625
(217) 785-8346 (F)
(888) 372-1996
mailto:don.squires@epa.gov

Roslyn Jackson (SBAP)
Small Business Env.
    Assistance Program
Dept of Commerce and
    Economic Opportunity
620 East Adams, 4th Floor
Springfield, IL 62701
(217) 524-0169
(217)557-2853(F)
(800) 252-3998
mailto:roslynjackson@illinoisbiz.biz
INDIANA
GaylaMcCarty(SBO)
Program Director
IDEM  CTAP
ISTA Building
150 W. Market Street
Suite 703
Indianapolis, IN 46204-2811
(317)233-1046
(317) 233-5627 (F)
(800) 988-7901
mailto:gkmccart@dem.state.in.us

Marc Hancock (SBAP)
IDEM  CTAP
ISTA Building
150 W. Market Street
Suite 703
Indianapolis, IN 46204-2811
(317)233-6663
(317) 233-5627 (F)
(800) 988-7901
mailto:mhancock(3)/dem.state.in.us
IOWA
Wendy Walker (SBO)
Small Business Air Quality
    Liaison
Iowa Department of Economic
    Development
200 E. Grand Avenue
Des Moines, IA  50309
(515)242-4761
(800)351-4668
(515)  242-4795 (F)
mailto:wendy.walker@ided.state.ia.us

John Konefes  (SBAP)
IA Waste Reduction Center
University of Northern Iowa
1005 Technology Parkway
Cedar Falls, IA 50613-0185
(319)273-8905
(319)  268-3733 (F)
(800)422-3109
mailto: konefe s@uni. edu

KANSAS
Cathy Colglazier (SBO)
Environmental Ombudsman
Kansas Dept. of Health and
    Environment
1000 SW Jackson St., Suite 430
Topeka, KS  66612
(785)  296-0669
(785)  291-3266 (F)
(800)357-6087
mailto:ccolglaz@kdhe.state.ks.us

Nancy Larson (SBAP)
P2 Specialist
K. State Pollution
Prevention Institute
7001W. 21st St. North
Wichita, KS  67205
(316)722-7721
(316)  722-7727 (F)
(800)578-8898
mailto:nlarson@ksu.edu
KENTUCKY
Rose Marie Wilmoth (SBO)
Air Quality Representative for
   Small Business
Office of Commissioner
Department for Environmental
   Protection
14 Reilly Road
Frankfort, KY 40601
(502)564-2150, x!28
(502) 564-4245 (F)
(800)926-8111
mailto:RosdVlarie.Wilmo1r@mail.statE.ky.us

Gregory C. Copley (SBAP)
Director
Kentucky Business Environmental
   Assistance Program
Gatton College of Business and
   Economics
University of Kentucky
Lexington, KY 40506-0034
(859)257-1131
(859) 323-1907 (F)
(800) 562-2327
mailto:gccopll@uky.edu

Cam Metcalf
Executive Director
Kentucky Pollution
    Prevention Center
420 Lutz Hall
University of Louisville
Louisville, KY 40292
(502)852-0965
(800) 334-8635, Ext. 0965
(502) 852-0964 (F)
mailto:cam.metcalf@louisville.edu

LOUISIANA
Roger Ward (SBO)
LADEQ
P.O. Box 4301
Baton Rouge, LA  70821
(225)219-3956
(225)219-3971 (F)
(800)259-2890
mailto: roger.ward@LA.Gov
 Click here to return to start of Appendix B.
            - 164-
-------
Dick Lehr (SBAP)
Environmental Assistance
    Division
Small Business Assistance
    Program
Baton Rouge, LA 70821-4313
(225)219-3258
(225) 219-3309 (F)
(800) 259-2890
mailto:dick.lehr@LA.Gov

MAINE
Ron Dyer (SBO)
Department of Environmental
    Protection
Office of Innovation and
    Assistance
State House Station 17
Augusta, ME 04333
(207)287-4152
(207) 287-2814 (F)
(800) 789-9802
mailto:ron.e.dyer@maine.gov

Julie M. Churchill (SBAP)
Small Business Assistance
    Program
State House Station 17
Augusta, ME 04333
(207)287-7881
(207) 287-2814 (F)
(800) 789-9802
mailto:julie.m.churchill@maine.gov

MARYLAND
Andrew Gosden (SBO)
MD Dept. of the Environment
1800 Washington Blvd., Suite 735
Baltimore, MD 21230-1720
(410)537-4158
(410) 5 3 7-4477 (F)
(800) 633-6101
mailto: agosden@mde. state .md.us
MASSACHUSETTS
Robert Donaldson (SBO)
MA Department of Environmental
   Protection
1 Winter Street, 8th Floor
Boston, MA 02108
(617)292-5619
mailto:robert.donaldson@state.ma.us

William McGowan (SBAP)
EOEA/ Office of
    TechnicalAssistance
251 Causeway Street
Suite 900, 8th Floor
Boston, MA 02114
(617)626-1078
(617) 626-1095 (F)
mailto :william.mcgowan@state.ma.us

MICHIGAN
Susan Holben (SBO)
Business Services
Michigan Economic Development
   Corporation
300 North Washington Square
Lansing, Michigan  48913
(517)335-2168
mailto:holbens@michigan.org

Dave Fiedler (SBAP)
MDEQ Env Science and Services
   Division
P.O. Box 30457
Lansing, MI  48909
(517)373-0607
(517) 335-4729 (F)
(800) 662-9278
mailto: fiedlerd@michigan .gov

MINNESOTA
Troy Johnson (SBAP)
MPCA/MAR/SBAP
520 Lafayette Road
St. Paul, MN 55155
(651)296-7767
(651)297-8701 (F)
(800) 657-3938
mailto :troy.j ohnson@pca. state .mn.us
MISSISSIPPI
Jesse Thompson (SBO)
Small Business Ombudsman
MSDEQ
2380 Hwy. 80 West
P.O. Box 20305
Jackson, MS 39289-1305
(601)961-5167
(601) 961-5541 (F)
(800)7256112
mailto :jesse_thompson@deq.state.ms.us

Randy Wolfe (SBAP)
Small Business Technical
   Assistance Director
MSDEQ
2380 Hwy. 80 West
P.O. Box 20305
Jackson, MS 39289-1305
(601)961-5166
(601) 961-5541 (F)
(800)725-6112
mailto:randy_wolfe@deq.state.ms.us

MISSOURI
Byron Shaw (SBAP)
Missouri DNR
1659 E. Elm Street
P.O. Box 176
Jefferson City, MO  65102
(573) 526-6627
(573) 526-5808 (F)
(800)361-4827
mailto:nrshawb@mail.dnr.state.mo.us

MONTANA
Bonnie Rouse (SBO)/(SBAP)
MTDEQ
P.O. Box 200901
1520 E. 6th Avenue
Helena, MT 596200901
(406)444-3641
(406) 444-6836 (F)
(800)433-8773
mailto:brouse@ateat.mt.us
Click here to return to start of Appendix B.
                                           - 165-
-------
Brian Spangler (SBAP)
Manager of Business and
    Assistant Prog. Pollution
    Prevention Bureau
Montana Dept. of Environ Qlty.
1520 E. 6th Ave
P.O. Box 200901
Helena, MT 5 9620-0901
(406) 444-5307
(406) 444-6836 (F)
(800)433-8773
mailto:bspangler@state.mt.us

NEBRASKA
Tom Franklin (SBO)/(SBAP)
Small Business and Public
    Assistance
NEDEQ
P.O. Box 98922
Lincoln, NE  68509-8922
(402)471-8697
(402) 471-2909 (F)
(877)253-2603
mailto :tom.franklin@ndeq. state.ne.us

NEVADA
Marcia Manley (SBO)
NV Division of Environmental
   Protection
333 West Nye Lane
Carson City, NV 89706-0851
(775) 687-9309
(775) 687-5856 (F)
(800) 992-0900, x4670
mailto: mmanley @ndep .nv.gov

NEW HAMPSHIRE
Rudolph Cartier (SBO)
Air Resources Division
Department of Environmental
    Services
6 Hazen Drive
Concord, NH 03301-2033
(603)271-1379
(603)271-1381(F)
(800) 837-0656
mailto: rcartier@des. state .nh.us
NEW JERSEY
Joe Constance (SBO)
Small Business Ombudsman
20 West State Street
P. O. Box 820
Trenton, NJ  08625-0820
(609)984-6922
(609) 777-4097 (F)
(800) 643-6090
mailto:ceacons@commerce.state.nj.us

KyAsral(SBAP)
Small Business Assistance
    Program Manager
NJDEP/SBAP
P.O. Box 423
Trenton, NJ  08625-0423
(609) 292-3600
(609) 777-1330 (F)
(877)753-1151
mailto:kasral@dep.state.nj .us

NEW MEXICO
Rita Trujillo  (SBO)
NMED AQB
2048 Galisteo Street
P.O. Box 26110
Santa Fe,NM 87505
(505)955-8091
(505) 827-1523 (F)
(800) 224-7009
mailto:rita_trujillo@nmenv.state.nm.us

Steve Dubyk (SBAP)
NMEDAQB
2044 Galisteo
Santa Fe,NM 87505
(505)955-8025
(505) 827-1543 (F)
(800) 224-7009
mailto:steve dubyk@nmenv.state.nm.us
NEW YORK
Keith Lashway (SBO)
Environmental Service Unit
SBEO Director
Environmental Ombudsman Unit
30 S. Pearl Street
Albany, NY  12245
(518)292-5340
(518) 292-5886 (F)
(800)782-8369
mailto:klashway@empire.state.ny.us

John P. McKeon (SBAP)
Technical Advisory Services
    Division
Business Assistance Unit
NYS Environmental Facilities
    Corporation
625 Broadway
Albany, NY  12207-2997
(518)402-7461
(518) 486-9248 (F)
(800)780-7227
mailto:mckeon@nysefc.org

NORTH CAROLINA
Edythe McKinney (SBO)
NC DENR Cust. Service Center
Small Business Assistance
    Program
1640 Mail Service Center
Raleigh, NC  27699-1640
(919)733-0823
(919) 715-7468 (F)
(877)623-6748
mailto: edythe .mckinney @ncmail .net

Tony Pendola (SBAP)
NC DENR Cust. Service Center
Small Business Assistance
    Program
1640 Mail Service Center
Raleigh, NC  27699-1640
(919)733-0824
(919) 715-7468 (F)
(877)623-6748
mailto :tony.pendola@ncmail .net
 Click here to return to start of Appendix B.
            - 166-
-------
NORTH DAKOTA
Dana Mount (SBO)
ND Department of Health
1200 Missouri Avenue
P.O. Box 5520
Bismarck, ND 58506
(701)328-5150
(701) 328-5200 (F)
(800) 755-1625
mailto: dmount@state .nd.us

Tom Bachman (SBAP)
ND Department of Health
1200 Missouri Avenue
Division of Air Quality
P.O. Box 5520
Bismarck, ND 58506
(701)328-5188
(701) 328-5200 (F)
(800) 755-1625
mailto :tbachman@state .nd .us

OHIO
Mark Shanahan (SBO)
Clean Air Resource Center
50 West Broad Street, Room 1901
Columbus, OH 43215-5985
(614) 728-3540
(614) 752-9188(F)
(800)225-5051
mailto:mark.shanahan@aqda.state.oh.us

Rick Carleski (SBAP)
Ohio EPA/DAPC
Lazarus Government Center
P.O. Box 1049
Columbus, OH 43216
(614) 728-1742
(614) 644-3681 (F)
mailto:rick.carleski@epa.state.oh.us

OKLAHOMA
Judy Duncan (SBO)
Director Customer Service
P.O. Box 1677
Oklahoma City, OK 73101-1677
(405) 702-1000
(405)702-1001(F)
(800) 869-1400
mailto:judy.duncan@deq.state.ok.us
Kyle Arthur (SBAP)
Dept. of Environmental Quality
P.O. 1677
Oklahoma City, OK 73101-1677
(405)702-9132
(405) 702-1000 (F)
(800) 869-1400
mailto:kyle.arthur@deq.state.ok.us

OREGON
Rich Grant (SBO)
Small Business Ombudsman
Office of Compliance and
   Enforcement
OR Department of Environmental
    Quality
811 SW 6th Avenue
Portland, OR  97204
(503) 229-6839
(800)452-4011
mailto:grant.richard@deq.state.or.us

Linda Hayes-Gorman (SBAP)
Air Quality Business Assistance
   Program
Oregon Department of
   Environmental Quality
2146 NE 4th Street
Bend, OR  97701
(541)388-6146x274
(541) 388-8283 (F)
(800)452-4011
mailto :hyes-
gorman.linda@deq.state.or.us

PENNSYLVANIA
Jeanne Dworetzky (SBO)
Small Business Ombudsman
PA Department of Environmental
   Protection
Office of Pollution Prevention and
   Compliance Assistance
RCSOB, 15th Floor
P.O. Box 8772
Harrisburg, PA 17105-8772
(717)772-5942
(717) 783-2703 (F)
mailto: Jdoretzky@state .pa.us
Jon Miller (SBAP)
PA Dept. Bureau of Air Quality
400 Market Street
Harrisburg, PA 17105-8468
(717)787-7019
(717) 772-2302 (F)
(800) 722-4743
mailto:Jonmiller@state.pa.us

PUERTO RICO
Evelyn Rodriguez (SBAP)
Environmental Quality Board
Air Quality Program Director
PO Box 11488
Santurce, PR  00919
(787) 767-8025
(787) 756-5906

RHODE ISLAND
NO SBO/SBAP

SOUTH CAROLINA
Phyllis T. Copeland, (SBO)
Small Business Ombudsam
SCDHEC EQC Administration
2600 Bull Street
Columbia, SC 29201-1708
(803) 896-8982
(803) 896-8999 (F)
(800)819-9001
mailto:copelapt@dhec.sc.gov

James Robinson (SBAP)
Technical Assistance Engineer
SCDHEC - EQC Administration
2600 Bull St
Columbia, SC 29201-1708
(803) 896-8984
(800)819-9001
(803) 896-8999 (F)
mailto: robinsj c@dhec. sc.gov
 Click here to return to start of Appendix B.
            - 167-
-------
SOUTH DAKOTA
Joe D. Nadenicek (SBO)
Small Business Ombudsman
Department of Environment and
   Natural Resources
Joe Foss Building
523 East Capitol
Pierre, SD 57501
(605) 773-3836
(605) 773-6035 (F)
(800) 438-3367
mailto: j oe .nadenicek@state. sd .us

Rick Boddicker (SBAP)
Department of Environment and
   Natural Resources
Joe Foss Building
523 East Capitol
Pierre, SD  57501
(605) 773-6706
(605) 773-5286 (F)
(800) 438-3367
mailto:rick.boddicker@state.sd.us

TENNESSEE
Linda Sadler (SBO)
Small Business Environmental
   Assistance Program
L&C Annex, 8th Floor
401 Church Street
Nashville, TN 37243-1551
(615)532-0779
(615) 532-8007 (F)
(800) 734-3619
mailto:linda.sadler@state.tn.us

TEXAS
Israel Anderson (SBO)
Small Business Advocate
TCEQ (Mail Code 112)
P.O. Box  13087
Austin, TX 78711-3087
(512)239-5319
(512) 239-3165 (F)
(800) 447-2827
mailto:ianderso@tceq.state.tx.us
Tamra ShaeOatman (SBAP)
Small Business and Local
    Govt. Asst. Section Mgr.
TCEQ (Mail Code 106)
P.O. Box 13087
Austin, TX  78711-3087
(512)239-1066
(512) 239-1065 (F)
(800) 447-2827
mailto:toatman@tceq.state.tx.us

UTAH
Renette Anderson (SBO)
UT Dept. of Environmental Qlty.
Office of the Small Business
    Ombudsman
168 North 1950 West
Salt Lake City, UT 84114-4810
(801)536-4478
(801) 536-4457 (F)
(800)458-0145
mailto: renetteanderson@utah .gov

Ron Reece (SBAP)
Environmental Engineer
UT Dept. of Environmental Qlty.
Division of Air Quality
150 North 1950 West
P.O. Box 144820
Salt Lake City, UT 84114-4820
(801)536-4091
(801) 536-4099 (F)
(800) 270-4440
mailto: rreece @utah .gov

VERMONT
Judy Mirro (SBAP)
SB Compliance Assistance
    Program
VT DEC Environmental
    Assistance Division
Laundry Building
103 South Main Street
Waterbury,VT 05671
(802)241-3745
(802) 241-3273 (F)
(800) 974-9559
mailto:junym@dec.anr.state.vt.us
VIRGINIA
John Daniel (SBO)
Programs Coordinator
VA Dept. of Environmental Qlty.
629 E. Main Street
P.O. Box 10009
Richmond, VA 23240
(804)698-4311
(804) 698-4510 (F)
(800) 592-5482
mailto:jmdaniel@deq.state.va.us

Richard Rasmussen (SBAP)
Director
Small Business Assistance Prog.
Air Division
VA Dept. of Environmental Qlty.
629 E. Main Street
P.O. Box 10009
Richmond, VA 23240
(804) 698-4394
(804) 698-4510 (F)
(800) 592-5482, Ext. 4394
mailto:rgrassmussen@deq.state.va.us

VIRGIN ISLANDS
MarylynA. Stapleton
   (SBO/SBAP)
SBTAP Program Adm.
V.I. Department of Planning and
   Natural Resources
Environmental Protection
   Division, SBAP
Terminal Bldg, 2nd Floor
Cyril E. King Airport
St. Thomas, VI 00802
(340)774-3320, Ext. 5167
(340) 714-9528 or 9549 (F)
(340)714-9529
mailto: envprotj @viacce ss .net

WASHINGTON
Bernard Brady (SBO/SBAP)
WA Department of Ecology
Air Quality Program
P.O. Box 47600
Olympia,WA  98504-7600
(360) 407-6803
(360) 407-7534 (F)
mailto:bbra461@ecy.wa.gov
 Click here to return to start of Appendix B.
                                            - 168-
-------
WEST VIRGINIA
Terry L. Polen PE, QEP (SBO)
WV Department of Environmental
    Protection
10 McJunkin Road
Nitro,WV  25143
(304)759-0510, Ext. 341
mailto:tpolen@dep.state.wv.us

Gene M. Coccari (SBAP)
Technical Specialist
Small Business Assistance
    Program
WV DEP, Division of Air Quality
7012 MacCorkle Avenue, SW
Charleston, WV 25304
(304)926-3731
(304) 926-3637 (F)
(800) 982-2474
mailto:gcoccari@mail.dep.state.wv.us

WISCONSIN
Pam Christenson (SBO)
WI Small Business
Clean Air Assistance Program
P.O. Box 7970  6th Floor
201 West Washington Avenue
Madison, WI 53707-7970
(608) 267-9384
(608) 267-0436 (F)
(800) 435-7287
mailto:pchristenson@commeice.statE.wi.us

Renee Lesjak Bashel (SBAP)
WI Department of Commerce
PO Box 7970 6th Floor
201 West Washington Avenue
Madison, WI 53707-7970
(608)264-6153
(608) 267-0436 (F)
(800) 435-7287
mailto:rlesjakbashel@commerce.state.wi.us
WYOMING
Dan Clark (SBO/SBAP)
Dept. of Environmental Qlty.
Small Business Ombudsman
Herschler Building 4W
122 W. 25th Street
Cheyenne, WY 82002
(307) 777-7388
(307) 777-3610 (F)
mailto: dclark@state. wy.us

Brian Lovett (SBAP)
Dept. of Environmental Qlty.
Technical Assistance Program
    Coordinator
Herschler Building 4W
122 W. 25th Street
Cheyenne, WY 82002
(307) 777-7347
(307) 777-3610 (F)
mailto: blovet@state .wy.us
 Click here to return to start of Appendix B.
                                             - 169-
-------
                   VI.  General Pollution Prevention Resources
Check Lists

Environmental Self-Assessment for Health Care
Facilities
New York State Department of Environmental
Conservation Pollution Prevention Unit.  February
2000. A checklist of pollution prevention measures
for health care  facilities.
http://www.dec.state.ny.us/website/ppu/esahcf.pdf

Fact Sheets

Best Management Practices for Hospitals and
Medical Facilities
Palo Alto Regional Water Quality Control Plant.  Ken
Torke. September 1994. These best management
practices encompass the metal pollutants of concern
in hospitals from the South San Francisco Bay Area.
http://www.city.palo-alto.ca.us/cleanbay/pdf/hosp.pdf

Case Studies in Hospital Solid Waste Reduction
and Recycling: Reusable Totes, Blue Bag Wrap
Recycling and Composting: Environmental Best
Practices for Health Care Facilities
Spring 2002. U.S. EPA. Contains three hospital case
studies, which cover reusable totes, blue sterile wrap
and plastic film recycling and composting.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/totes .pdf

Eliminating Mercury in Hospitals: Environmental
Best Practices for Health Care  Facilities
Spring 2002. U.S. EPA fact sheet that outlines
sources of mercury in hospitals, efficiency and cost
data for mercury-free sphygmomanometers as well as
three case studies that summarize successes, costs
and lessons learned by hospitals accomplishing
mercury reduction.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/mercury.pdf

Right to Know Hazardous Substances Fact Sheets
New Jersey Department of Health and Senior
Services.
http ://www. state .ni .us/health/eoh/rtkweb/rtkhsfs .htm
Replacing Ethylene Oxide and Glutaraldehyde
with Environmentally Preferable Sterilants/
Disinfectants: Environmental Best Practices for
Health Care Facilities
Spring 2002.  U.S. EPA.  Contains case studies on
hospitals reducing use of ethylene oxide and
glutaraldehyde.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/glutareth.pdf

Using Microfiber Mops in Hospitals:
Environmental Best Practices for Health Care
Facilities
Spring 2002.  U.S. EPA.  Provides focus on an often
overlooked aspect of hospital pollution prevention:
janitorial cleaning products.  Hospital case studies
provide cost data from water and chemical savings
associated with switching to microfiber mops in
hospitals. Labor savings included.
http://www.epa.gov/region09/cross_pr/p2/projects/
hospital/mops.pdf

Guides

Environmental Management Guide for Small
Laboratories
U.S. EPA Small Business Division. Washington, DC.
May 2000.
http://www.epa.gov/sbo/smalllabguide_500.pdf

Guide to Mercury Assessment and Elimination in
Health Care Facilities
Medical Waste Management Program, Department of
Health Services:  State of California. 2000.
http://www.getf.org/file/toolmanager/O16F8459.pdf

Guide to Pollution Prevention: Selected Hospital
Waste Streams; Risk Reduction Engineering
Laboratory. The Center for Environmental Research
Information, June 1990, EPA/625/7/-90/009.
http ://www.p2pavs .org/ref/02/01059 .pdf

Mercury Pollution Prevention in Health Care
National  Wildlife Federation. Guy Williams. 1997.
A guide to help hospitals and their employees in their
effort to become mercury free.
http://www.nwf.org
Click here to return to start of Appendix B.
                                             - 170-
-------
Guidebook for Hospital Waste Reduction
Planning and Program Implementation
American Society for Health Care Environmental
Services of the American Hospital Association.
Chicago, IL. 1996.
http://www.ahaonlinestore.com/
Rq]iicOisph^?Ra]iic^

H2E guide to EPP Guide for Hospital
Environmentally Preferable Purchasing
http://www.geocities.com/EPP_how_to_guide/

Mercury: In Your Community and the
Environment
Wisconsin Department of Natural Resources.
October 1998.
http://www.epa.gov/glnpo/bnsdocs/merccomm/
merccomm.pdf

NYC WasteLe$$: Hospital Waste Prevention  and
Energy Conservation Guidance Document
City of New York Department of Sanitation, U.S.
EPA, New York State Energy Research and
Development Authority. February 2001.
http://www.nycwasteless.com/bus/businesstour/
healthcare.html

2000 PBT Program Accomplishments
Office of Pollution Prevention and Toxics.  U.S.
EPA. EPA-742-R-01-003. November 2001.
http://www.epa.gov/pbt/PBT2000annualreport.pdf

Pollution Prevention Guide for Hospitals
(excluding medical wastes)
California Environmental Protection Agency,
Department of Toxic Substances Control, Office of
Pollution Prevention and Technology Development.
May 1998.
http://www.getf.org/file/toolmanager/O16F4754.pdf

Environmental Management Systems Managers
Guide
Office of the Federal Environmental Executive
document provides information on EMS
implementation at federal facilities. April 2004
http://www.ofee.gov/ems/training/manguide.pdf
Cleaning for Health:  Products and Practices for
Safer Indoor Environment
Alicia Culver, Marian Feinberg, David Klebenov,
Judy Muskinow, Lara Sutherland
ISBN 0-918780-79-9. August 2002. Guide to
environmentally preferable cleaning products and
methods that have been effectively used in office
buildings, schools, hospitals and other facilities in
the United States and Canada. It describes pioneering
product evaluation programs and lists the brands that
were chosen based on environmental and
performance criteria. It also provides a model
specification, as well as manufacturer contacts and
other resources for those who want to develop a safer
cleaning program for their buildings.
http://www.informinc.org/cleanforhealth.php

Profile of the Health Care Industry
Includes information on various services provided by
the health care facilities and the pollutants and
environmental regulations associated with each.
Information about pollution prevention opportunities,
compliance history and related organizations and
initiatives also included. October 2004.
http: //www.epa. gov/compliance/


Manuals

An Organizational Guide to Pollution Prevention
CD-ROM. U.S. EPA. Office of Research and
Development. EPA/625/C-01/003. August 2001.
http: //www. epa.gov/ttbnrmrl

Code Green P2 Strategies for Health Care
This  manual provides hospitals with an overview of
important pollution prevention areas based on
Canadian resources.
http ://www.cornet.nf.ca/web/acapha/proj ects/
documents/hospital_book.pdf

Greener Hospitals
Bristol-Meyers Squibb Company.  ISBN 3-00-
012582-5. December 2002. This manual explains
how to implement Environmental Management
Systems for environmentally friendly activities in
hospitals, doctors' offices, clinics and other health
care facilities.
http://www.bms.com/static/ehs/sideba/data/
greenh.pdf
 Click here to return to start of Appendix B.
                                             - 171 -
-------
U.S. EPA Buy Clean Training Manual for Eastern
Kentucky School Districts
Developed by the Kentucky Pollution Prevention
Center.  October 2001.
http://www.epa.gov/oppt/buy_clean/docs/schools-
regional .htm#region4

Waste Management Strategies for Hospitals and
Clinical Laboratories
Pollution Prevention Program, North Carolina Dept.
of Environment, Health and Natural Resources.  May
1992.
http://www.p2pays.org/

Reducing Mercury Use in Health Care:
Promoting a Healthier Environment A "How-to"
Manual
Monroe County Department of Health and the
Monroe County Department of Environmental
Services, NY. Manual addresses how to establish a
mercury pollution prevention program in hospitals.
http://www.epa.gov/glnpo/bnsdocs/merchealth/

Writing a Waste Reduction Plan for Health Care
Organization
The University of Tennessee Center for Industrial
Services. A handbook designed to help hospitals
comply with the Tennessee Hazardous Waste
Reduction Act of 1990, Resource Conservation and
Recovery Act (RCRA), and help identify and assess
pollution prevention and waste reduction options.
http://www.cis.utk.edu/EHSP/hospman.pdf

Reports

Scientific Report on APE Surfactants
Troubling Bubbles: The Case for Replacing
Alkylphenol Ethoxylate Surfactants.
Philip Dickey, Washington Toxics Coalition,  1997.
This 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. Available by mail at Washington
Toxics Coalition Web site.
http://www.watoxics.org/pages/root.aspx
    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.
    http://www.ewg.org/reports/greening/greenpr.html

    Healthy Hospitals: Controlling Pests without
    Harmful Pesticides
    This November 2003 survey, released by health
    advocate groups Health Care Without Harm and
    Beyond Pesticides, found that many major hospitals
    regularly spray with toxic pesticides. The good news,
    according to the report, is that some hospitals have
    great success managing pests with no or few
    hazardous pesticides by using proven, safer
    integrated pest management (IPM) techniques. The
    report concludes with tips and resources on how
    hospitals can manage pests while also protecting the
    health  of people and the environment.
    http: //www.noharm. org/
    details.cfm?ID=864&type=document

    Environmentally Preferable Purchasing
    This report highlights the variety of approaches
    organizations use to incorporate environmental and
    social factors into procurement activities. Based on
    interviews with representatives from 18 public and
    private sector organizations, the report describes (1)
    how the organizations choose product categories and
    attributes for EPP initiatives, (2) how integrated EPP
    is into  everyday purchasing decisions, (3) common
    challenges, and (4) the positive outcomes produced
    by the  organizations' EPP efforts. Synopses of the
    participating organizations' EPP strategies and
    programs are included.
    http://www.pprc.org/pubs/pubslist.cfm

    HealthSystem  Minnesota Mercury Reduction
    Holly J. Baron. Minnesota Technical Assistance
    Program.  2000.
    http://www.cleanmed.org/2002/presentations/
    saturday/gonyon_tice/gonyon_tice_files/
    frame .htm#slideOOO 1 .htm
 Click here to return to start of Appendix B.
- 172-
-------
Compact Disc

Compliance Assistance & Pollution Prevention
Hospitals
Provided free of charge from the U.S. EPA - Region
2, 290 Broadway, 21 Floor, New York, NY 10007
(212) 637-4050. This CD includes presentations,
documents, resources and Web sites.
http://www.epa.gov/region02/healthcare/

Web sites

American Hospital Association
The American Hospital Association (AHA) provides
education for health care leaders and is a source of
information on health care issues and trends. AHA
leads, represents and serves health care provider
organizations that are accountable to the community
and committed to health improvement.
http://www.hospitalconnect.com/hospitalconnect/
index.jsp

California Department of Health Services,
Medical Waste Management Program
This Web page provides guidelines for proper
handling and disposal of medical waste in California.
http://www.dhs.ca. gov/ps/ddwem/environmental/
med_waste/default.htm

California Integrated Waste Management Board -
Waste Preventions Information Exchange Health
Care Waste
A comprehensive list of publications, fact sheets and
Web links to information on health care waste.
http://www.ciwmb.ca. gov/wpie/healthcare/

The Canadian Centre for Pollution Prevention,
Health Care Environet
Health Care Environet offers information on
management tools including audits, environmental
management systems, health and safety programs,
pollution prevention plans, emergency response
plans, numerous case studies as well as networks and
programs.
http://www.c2p2online.com/

PCB homepage Information on Polychlorinated
Biphenyls (PCBs)
http://www.epa.gov/opptintr/pcb/
    The Canadian Coalition for Green Health Care
    Includes case studies, an environmentally preferred
    list of PVC-free and mercury suppliers and links to
    additional green health care Web sites.
    http: //www. greenhealthcare .ca/

    EPP Database of Vendors
    http ://www.epa. gov/oppt/epp/database .htm

    EPP Update Newsletter
    http://www.epa.gov/epp/pubs/updatel3_final_124.pdf

    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
    natural resources and promote positive changes in the
    way goods are produced and consumed.
    http://www.newdream.org/procure/products/
    approved.html

    Disinfection Best Management Practices
    Using best management practices helps ensure proper
    use of disinfectants. It illustrates only the amount of
    disinfectant necessary to do the job. Ultimately, best
    management practices protect patients, employees
    and the environment.
    http://www.mntap.umn.edu/health/disinfection.htm

    Environmental Working Group
    Environmental Working Group (EWG) is a nonprofit
    environmental research organization dedicated to
    improving public health and protecting the
    environment by reducing pollution in air, water and
    food.
    http://www.ewg.org/

    U.S. EPA Design for the Environment Program
    The Design for the Environment (DfE) program is
    one of the U.S. EPA's premier partnership programs,
    working with individual industry sectors to compare
    and improve the performance and human health and
    environmental risks and costs of existing and
    alternative products, processes and practices.
    http: //www. epa. gov/opptintr/dfe/
 Click here to return to start of Appendix B.
- 173-
-------
PBT/Mercury Reduction Resources
Resources are accessible under Technical Resource
Links P2 for Health Care Organizations.
http: //www.kppc .org/

Health Care Case Studies in Oregon
Several documented case studies of pollution
prevention and cost savings in Oregon.
http: //www. deq. state .or.us/wmc/solwaste/cwrc/
cstudy/healthcare .html

U.S. EPA Disinfectant Web site
A list of EPA registered disinfectants. These strong
disinfectants do not need to be used all the time, just
where cleaning blood or other bodily fluids.  They
are strong disinfectants and are used  in hospital
settings.  For disinfectant needs other than in blood
and bodily fluids covered by OSHA's regulations, a
regular environmentally preferable disinfectant can
be used.
http://www.epa.gov/oppad001/chemregindex.htm

Health Care Without Harm
This Web site features new resources including
"Going Green: A Resource Kit for Pollution
Prevention in Health Care" and links to PVC and
mercury publications, videos and web resources.
http: //www.noharm .org/

Hospitals for a Healthy Environment
H2E is a voluntary partnership of the U.S. EPA,
American Hospital Association, Health Care Without
Harm and the American Nurses Association pledged
to eliminate mercury use by 2005 and reduce all
hospital waste by 50 percent by 2010. The Web site
offers resources to achieve these objectives including
lists of mercury-containing items, persistent
bioaccumulative toxins, green cleaning products and
links to pollution prevention providers, consultants,
mercury recyclers and many other resources.
http://www.h2e-online.org/

Hotlines and Clearinghouses
Request technical information, reports and
documents or ask questions about environmental
issues.
http://www.epa.gov/epahome/hotline.htm
Kentucky Hospital Association
The Kentucky Hospital Association provides
information for Kentucky Hospitals.
Medical and Scientific Community Organization
Mercury Work Group
http://www.kyha.com/

MASCO
MASCO has mercury management and mercury-free
resources including a mercury management
guidebook and a searchable database of mercury-free
products.
http://www.masco.org/mercury/index.htm

Minnesota Technical Assistance Program
Answers to questions regarding disposal of some
common medical-related waste streams.
http: //www.mntap .umn. edu/

Northwest Guide to Pollution Prevention by the
Health Care Sector
This Web site features  a list of resources for pollution
prevention in hospitals.
http://www.pprc.org/pubs/healthcare.cfm

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.epa. gov/tri/chemical/
appendixc 1999pdr.pdf

Pollution Prevention Tips for Health Care
Providers
This Montana Pollution Prevention Program lists
tips, additional resources and more information about
pollution prevention.
http://www.montana.edu/~wwwated/healthcare.htm

Rechargeable Battery Recycling Corporation
The Rechargeable Battery Recycling Corporation
(RBRC) offers information on how to recycle
portable rechargeable batteries.
http ://www.rbrc .org/
index.html?sp=true&h=400&w=275

U.S. EPA's Office of Solid Waste
Provides link to state solid waste programs.
http ://www.epa. gov/epaoswer/osw/stateweb .htm
Click here to return to start of Appendix B.
                                              - 174-
-------
Small Business Assistance Programs
SBAPs provide free, nonregulatory environmental
compliance and pollution prevention assistance to
small businesses.  This site provides a list of state
contacts for compliance assistance.
http://www.epa.gov/reg3ecej/compliance_assistance/
hospitals.htm

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.sustainablehospitals.org/cgi-bin/
DB_Index.cgi

The Sustainable Hospitals Web site
Provides technical support to the health care industry
for selecting products and work practices that reduce
occupational and environmental hazards, maintain
quality patient care and contain costs.
http://www.sustainablehospitals.org/cgi-bin/
DB_Index.cgi

U.S. EPA - Information  on Antimicrobial
Pesticide Products
Nearly 50 percent of antimicrobial products are
registered to control infectious microorganisms in
hospitals and other health care environments.
However, public health antimicrobial  products tend
to be low-volume products, and thus constitute less
than 5 percent of the estimated total market for
antimicrobial products.
http://www.epa.gov/pesticides/factsheets/antimic.htm

U.S. EPA's Mercury  Web site
This site provides background information and
agency actions taken on mercury, fish advisory
information, as well as downloadable research and
technical materials.
http://www.epa.gov/mercury/

U.S. EPA's Mercury in Medical Facilities
This is an interactive environmental education
software program that provides information on the
proper handling and disposal of mercury wastes
produced by medical facilities.
http://www.epa.gov/seahome/mercury/src/
outmerc.htm
Waste Reduction Activities for Hospitals
This Web site provides information on waste
reduction activities for hospitals as well as statistics
on hospitals' success in waste reduction.
http://www.ciwmb.ca.gov/BIZWASTE/factsheets/
hospital.htm

U.S. EPA's Office of Pollution Prevention and
Toxics (OPPT) PBT Web site
Information on U.S. EPA initiatives, goals, regulatory
activities, voluntary partnerships and links to
technical materials and environmental/health effects
associated with PBT's.
http: //www.epa. gov/pbt/

The U.S. EPA sponsors approximately 89 hotlines
and clearinghouses that provide free and convenient
avenues to obtain assistance with environmental
requirements. Key hotlines that may be of interest to
include the following:
RCRA/UST/CERCLAHotline:  (800) 424-9346
Toxic Substances and Asbestos Information:
                               (202)554-1404
Stratospheric Ozone/CFC Information:
                               (800) 296-1996
Clean Air Technical Center:      (919) 541-0800

The Waste Reduction Resource Center
Provides resources for hospitals and medical
facilities including Web sites, manuals, articles and
reports, fact sheets, videotapes and case studies.
http: //wrrc .p2pays. org/industry/hospital .htm

Waste Reduction Tips for Health Care/Medical
Provides waste reduction tips in the pharmacy, X-ray,
custodial, purchasing, supplies and cafeteria. There
are also recycling and composting tips.
http: //www. deq. state .or.us/wmc/solwaste/cwrc/
wrstrategy/healthcarestrategy.html

Pollution Prevention Information for Health Care
Facilities
Contains links that provide information on how to
comply with environmental regulations, apply P2
techniques and achieve better environmental
performance at a lower cost.
http://www.dec.state.nv.us/website/ppu/p2shlth.html
 Click here to return to start of Appendix B.
                                               - 175-
-------
                   VII.  Hospital Water Permits/Effluent Limits

Memorandum
From: Carey A. Johnston, P.E.
       USEPA/OW/OST
       ph: (202) 566-1014
       mailto:johnston.carey@epa.gov

To:    Public Record for the Effluent Guidelines Program Plan for 2004/2005
       DCN XXX, Section 2.2.3
       EPA Docket Number OW20030074 (http://www.epa.gov/edockets/)

Date:  December 30, 2003

Re:    Factor 2 Screening Level Information on the Health Care Industry
Overview

     Under the Clean Water Act (CWA), the U.S. EPA establishes technology-based national regulations,

termed "effluent guidelines," to reduce pollutant discharges from industrial facilities to waters of the United

States. Section 304(m) of the Clean Water Act (CWA) requires the U.S. EPA to publish an Effluent

Guidelines Program Plan every two years. CWA Section 304(m)(l)(A) also requires the U.S. EPA to

establish a schedule for the annual review and revision of all existing effluent guidelines. Additionally, CWA

Section 304(m)(l)(B) requires the U.S. EPA to identify categories of point sources discharging toxic or

nonconventional pollutants for which the U.S. EPA has not published effluent guidelines.

     The preliminary Effluent Guidelines Program Plan for 2004/20051 describes the four factors the U.S.

EPA considered during its screening-level analyses.  Factor 2 (Technology Advances and Process Changes)

considers applicable and demonstrated technologies, process changes or pollution prevention alternatives that

can effectively reduce the pollutants remaining in an industry category's wastewater and thereby substantially

reduce any identified risk to human health or the environment associated with those pollutants.  This memo

summarizes the Factor 2 screening level information gathered on the health care industry. Sectors  of this

industry were identified in the U.S. EPA's outreach activities, however, this industry was not identified for

further data collection in the current effluent guidelines planning cycle.2
Click here to return to start of Appendix B.
-------
Health Services Industry



     The health services industry is one of the many service industries that have recently experienced a large



percent increase in revenue and value of receipts.  Unlike many other service industries, the health services



industry discharges wastewaters that contain a variety of pollutants such as pathogenic microorganisms,



radioactive elements and other toxic chemicals such as mercury. The health services industry (SIC 80)



consists of the following eight segments: 1) hospitals, 2) nursing and personal care facilities, 3) offices and



clinics of physicians, 4) home health care services, 5) offices and clinics of dentists, 6) offices and clinics of



other practitioners, 7) health and allied services, and 8) medical and dental laboratories.  However, hospitals



are the only segment of the health services industry currently subject to any effluent limitations guidelines



(ELGs). Direct discharges from hospitals are subject to the requirements of the ELG for the Hospital Point



Source Category (40 CFR 460) established in 1976. Most hospitals discharge to POTWs and are not subject



to these effluent guidelines.



     Hospitals generate wastewater from food service operations, cleaning of exam and surgical suits,



equipment sterilization, laundries, sanitary waste (toilets, sinks and showers), medical laboratories, cooling



towers and heating systems (boiler blow-down). Approximately 242 gallons of wastewater are generated per



bed per day in the average hospital. Wastewater from hospitals is characterized by BOD5 (50 to 400  mg/L),



chemical oxygen demand (150 to 800 mg/L), total suspended solids (60 to 200 mg/L), and total organic



carbon (50 to 300 mg/L).



     The current BPT effluent limits for hospitals are based on biological treatment with sludge handling



facilities.  BPT effluent limits are based on multimedia filtration following biological treatment to remove



residual solids. Regulated pollutants include BOD5, TSS and pH.  Sampling data from hospitals with



treatment systems indicate BOD5 and TSS removals are approximately 93 percent and 86 percent



respectively.



     Other possible pollutants in hospital waste include  solvents, radioisotopes and body fluids (considered



to be infectious).  Solvents include alcohols, acetone, xylenes, formalin, some halogenated compounds and



toluene. The continued increase in the use of pharmaceuticals may also affect the composition of wastewater



from health service facilities.  Drugs such as antibiotics, antidepressants, birth control pills, seizure



medication, cancer treatment, pain killers, tranquilizers and cholesterol-lowering compounds have been



detected in various water sources. These drugs can pass through conventional sewage treatment facilities



intact, and end up in waterways, lakes and even aquifers. For example, data from Tucson, Arizona, show







Click here to return to start of Appendix B.            - 177 -
-------
approximately 3.4 mg/L of Ibuprofen and 6.3 mg/L Naproxen in effluent from the city's activated sludge



treatment plant.



     Medical procedures as well as research utilize radioactive dyes. For example, radioactive sodium iodide



(Na 131-1) is a common compound used in medical treatment for thyroid  disease. About 750,000 diagnostic



thyroid scans are performed each year in the United States. Each procedure utilizes about 0.01-0.1 millicuries



of I-131. Patients who have been inj ected with the iodine will eventually excrete the material in their urine or



feces mostly while in the hospital.  Radioactive discharges from a hospital to a POTW may result in



radioactive particles suspended in effluent and entrapped in sewage sludge. These discharges are regulated by



the U.S. Nuclear Regulatory Commission.3



     Recent studies have shown a variety of pathogenic pollutants present in hospital wastewater, including



bacteria,  fungi and viruses. Ozonation has been shown to be  a suitable treatment process for the control of



such pollutants prior to the discharge of wastewater from a hospital.



     Internationally, high concentrations of AOX (halogenated organic compounds adsorbable on activated



carbon) have been detected in hospital wastewater. In Germany, iodized X-ray contrast media used for



medical applications have been linked to these high concentrations. Photochemical oxidation with hydrogen



peroxide was investigated as a method to reduce concentrations of AOX.  Studies demonstrate that complete



removal of the organically bonded iodine and partial mineralization is feasible. The degradation in the UV



reactor was enhanced by adding hydrogen peroxide and by using a bubble column to remove the formed



elemental iodine from the solution by stripping.



     The disposal of mercury, a persistent bioaccumulative toxin, is a problem for many health care facilities.



Mercury can accumulate in waste traps and discharge in small amounts each time water is used. Many



hospitals already take steps to reduce or eliminate mercury use. There are many mercury-free products (e.g.,



thermometers, sphygmomanometers) that can be used in place of the conventional mercury-containing



products. Mercury may also originate in laboratory reagents  and laundry bleach. Hospitals have begun



testing these products and reagents to quantify the mercury content and investigate product substitution to



reduce mercury use.



     The dental industry, which uses mercury amalgam fillings, has also been receiving pressure to reduce



their use  of mercury and develop effective techniques for removing mercury from their liquid wastewater



streams.  The larger particles of amalgam captured by the chair side dental vacuum system during the



placement or removal of amalgam fillings  get caught in the chair side trap. This trap is periodically cleaned,







Click here to return to start of Appendix B.            - 178 -
-------
and any pieces of amalgam are recycled. However, most of the vacuumed amalgam material is in smaller

particles or slurry, which passes through the chair side trap and enters the wastewater line which eventually

leads to the municipal sewage system. There are several different commercially available amalgam separators

that can remove more than 99 percent of amalgam from dental wastewater streams, however, in most states,

dentists are not required to use amalgam separators.

     Composite resin fillings are becoming a popular alternative to conventional amalgam fillings. While the

number of new amalgam restorations is declining, there are still billions of amalgam restorations currently in

place, which will eventually need to be removed.  Consequently, the process of removing amalgam

restorations will continue to serve as a source of mercury discharges for many years to come and may

necessitate the implementation of pollution prevention techniques to control the  release of mercury from

dental offices.
 'This preliminary Plan was signed by EPA
 's Assistant Administrator for Water on December 23, 2003. It is expected to be published in the Federal Register on
 December 31,2003.
 2See "Description and Results of EPA Methodology to Synthesize Screening Level Results for the Effluent Guidelines
 Program Plan for 2004/2005," DCN 548, Section 3.0.
 3See http://www.nrc.gov/.


 Click here to return to start of Appendix B.            - 179 -
-------
science fora changing world
Pharmaceuticals,  Hormones,  and Other Organic Wastewater

Contaminants  in U.S. Streams

     A recent study by the Toxic Substances Hydrology Program of the U.S. Geological Survey (USGS) shows that a broad range
     of chemicals found in residential, industrial, and agricultural wastewaters commonly occurs in mixtures at low concentrations
      downstream from areas of intense urbanization and animal production. The chemicals include human and veterinary drugs
      (including antibiotics), natural and synthetic hormones, detergent metabolites, plasticizers, insecticides, and fire retardants.
      One or more of these chemicals were found in 80 percent of the streams sampled. Half of the streams contained 7 or more
       of these chemicals, and about one-third of the streams contained 10 or more of these chemicals. This study is the first
     national-scale examination of these organic wastewater contaminants in streams and supports the USGS mission to assess
       the quantity and quality of the Nation's water resources. A more complete analysis of these and other emerging water-
                                              quality issues is ongoing.
Background: Chemicals, used everyday in homes, industry
and agriculture, can enter the environment in wastewater.
These chemicals include human and veterinary drugs (including
antibiotics), hormones, detergents, disinfectants, plasticizers,
fire retardants, insecticides, and antioxidants. To assess whether
these chemicals are entering our Nation's streams, the Toxic
Substances Hydrology Program of the U.S. Geological Survey
(USGS) collected and analyzed water samples from 139 streams
Household chemicals can enter streams through wastewater
discharges. A wastewater treatment facility near Atlanta,
Georgia, is shown above. (Photograph by Daniel J. Hippe,
U.S. Geological Survey)
                                                         Pharmaceuticals, hormones, and other organic wastewater
                                                         contaminants were measured in 139 streams during 1999 and
                                                         2000.
in 30 states during 1999 and 2000. Streams were sampled that
were considered susceptible to contamination from various
wastewater sources, such as those downstream from intense
urbanization or livestock production. Thus, the results of this study
are not considered representative of all streams.

Although each of the 95 chemicals is used extensively, there
is little information about the extent or occurrence of many of
these compounds in the environment. Some may be indicators
of certain classes of contamination sources, such as livestock
or human waste, and some have human or environmental
health implications. The results of this study are a starting point
for investigation of the transport of a wide  range of organic
wastewater contaminants  in the Nation's waters.

New laboratory methods were developed in several USGS
research laboratories to provide the analytical capability to
measure concentrations of 95 wastewater-related organic
chemicals in water. Uniform sample-collection protocols and field
and laboratory quality-assurance programs were followed to
ensure that results are comparable and representative of actual
stream conditions.
U.S. Department of the Interior
U.S. Geological Survey
      Click here to return to start of Appendix B.
                                                    - 180-
                              USGS Fact Sheet FS-027-02
                                              June 2002
-------
Findings: One or more chemicals were detected in 80 percent of
the streams sampled, and 82 of the 95 chemicals were detected
at least once. Generally, these chemicals were found at very
low concentrations (in most cases, less than 1 part per billion).
Mixtures of the chemicals were common; 75 percent of the
streams had more than one, 50 percent had 7 or more, and 34
percent had 10 or more.

The most frequently detected chemicals (found in more than
half of the streams) were coprostanol (fecal steroid), cholesterol
(plant and animal steroid), N-N-diethyltoluamide (insect repellent),
caffeine (stimulant), triclosan (antimicrobial disinfectant), tri
(2-chloroethyl) phosphate (fire retardant), and 4-nonylphenol
(nonionic detergent metabolite). Steroids, nonprescription drugs,
and insect repellent were the chemical groups most frequently
detected. Detergent metabolites, steroids, and plasticizers
generally were measured at the highest concentrations.
                                                   Veterinary Pharmaceuticals used in animal agriculture can
                                                   enter streams through runoff or infiltration. A swine facility
                                                   near the South Fork Iowa River, Iowa, is shown above.
                                                   (Photograph by Doug Schnoebelen, U.S. Geological Survey)
                DETECTION FREQUENCY, IN PERCENT
QC
LU
H
QC 2.5 -
LLJ
D.
, 1 , , , , 1
O LO
c\i ^
WHOOHOIIAI r>
zf
O
tr 1.0 -
F-
i i i i
LO
0
N30NOC
_i
P :






II
i





!,


1
1












i





•
1





r
i i i















[





1
i
-
-
-
-
-
-
       /
 
-------
-------
                         - APPENDIX C -

     KENTUCKY POLLUTION PREVENTION CENTER
  ENVIRONMENTAL  MANAGEMENT  SYSTEMS (EMS)
                        AUDITING TOOL
                                                 Kentucky
                                                 Pollution
                                                 Prevention
                                                 Center



 This auditing tool is for the sole use of health care professionals and health care organizations. Further use,
 duplication or distribution of this auditing tool without expressed written consent of the Kentucky Pollution
                        Prevention Center is unauthorized.

The Kentucky Pollution Prevention Center (KPPC) is the Commonwealth of Kentucky's primary resource for
  pollution prevention technical assistance, training and applied research. The Center helps organizations
 increase efficiency and profitability by identifying opportunities for waste reduction and other methods of
                       improving environmental management.

    For more information, call toll-free at (800) 334-8635, extension 0965 or direct at (502) 852-0965.
          Fax KPPC at (502) 852- 0964 or visit KPPC's Web site at http://www.kppc.org.
Click here to return to Table of Contents.
                                - 183-
-------
                      Kentucky
                      Pollution
                      Prevention
                      Center
                            Kentucky Pollution Prevention Center
                            Environmental Management Systems
                             (EMS) Auditing Tool
oo
     Date:
     Audit Team:
     Lead Auditor:
                               . Facility Name:	
                               . Facility Location:	
                               .Facility Representative:
Opening meeting:
•  Brief introduction and background of auditors
•  Review scope (this plant)
•  Intent is to collect objective evidence to assess whether organization has a EMS.
   •  Does the system conform to the ISO 14001 standard?
   •  Is the system documented where required?
   •  Does the work agree with the documented/undocumented system?
   •  Do records show the system works?
•  Review audit plan and timetable. There will be a closing meeting each day of the audit to review the sections covered. At the end of the audit.
   there will be a final closing meeting with a preliminary written report for the plant before the audit team leaves.
•  Establish communication links between audit team and auditee.
•  Confirm needed resources and facilities are available.
•  Confirm date and time of closing meeting.
•  Review relevant site safety and emergency procedures with audit team.
      KPPC EMS/ISO 14001 AUDITING TOOL
    © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      ISO 14001 Section 4.2 - Environmental Policy: Top management shall define the organization's environmental policy and ensure that it:
      a) is appropriate to the nature, scale and environmental impacts of its activities, products or services; b) includes a commitment to
      continual improvement and prevention of pollution; c) includes a commitment to comply with relevant environmental legislation and
      regulations, and with other requirements to which the organization subscribes; d) provides the framework for setting and reviewing
      environmental objectives and targets; e) is documented, implemented, maintained and communicated to all employees; f) is available to
      the public.
      4.2 Environmental policy


      This section requires the organization's top management to define, document, maintain, implement, and communicate an environmental policy that
      includes a commitment to continual improvement, prevention of pollution, and a commitment to comply with legal and other requirements.


      1.1   Has top management defined the organization's environmental policy?

      Note(s)	Observations and Recommendations	Score	

      Who is top management?  Has it been defined in system?
1      Objective evidence includes meeting minutes showing top
oo    management attendees and policy review and approval.
^    Signature(s) by top manager(s) on written policy.
      1.2  Is the policy appropriate to the nature and scale of the organization's activities, products, and services?
      Note(s)	Observations and Recommendations	Score

      Corporate policies handed down to the facility may not
      be appropriate to organization's activities, products, or services.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
        1.3   Check to ensure the policy includes:

        a)   A commitment to continual improvement.

        b)   A commitment to prevention of pollution.

        c) A commitment to comply with relevant environmental legislation and regulations and other requirements to which the organization subscribes, that are

            applicable to the environmental aspects of its activities, products, or services?
        Note(s)
Observations and Recommendations
Score
        1.4   Does the policy provide a framework for setting and reviewing the organization's environmental objectives and targets?
        Note(s)
Observations and Recommendations
 Score
        Score 0=environmental policy does not guide setting
        of objectives and targets. Policy written in a way that
        leaves readers confused.
        Score l=Policy is specific enough to guide setting of
        environmental objectives and targets for most aspects;
^      most of policy understandable to interested parties
oo      Score 2=policy clear and specific to guide setting of
,        environmental objectives and targets; policy
        understandable to interested parties.
        1.5    Is the policy documented?

        Note(s)	
Observations and Recommendations
Score
          KPPC EMS/ISO 14001 AUDITING TOOL
        © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
1.6   Is the policy implemented and maintained?

Note(s)	Observations and Recommendations	Score

Is there evidence of discussion of possible need to change
policy? Organization may review policy and progress toward
objectives and targets annually as part of management
review (4.6).  Review meetings may have documented
agendas and minutes indicating preventive and corrective
action.
1.7   Is the policy communicated to all employees?

Note(s)	Observations and Recommendations	Score

Objective evidence that the policy has been
communicated would include employee answers to
questions under 4.4.2 training, awareness, and
competence.  Others include documented training
agendas and course materials, policy postings on bulletin
boards throughout production and common areas,
electronic access from workstations, publications, hardhat
stickers, policy on back of ID badges.
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
        1.8   How do you make the policy available to the public?
        Note(s)
Observations and Recommendations
Score
oo
oo
        Objective evidence would include policy posted in lobby,
        on brochure in lobby, newspaper clippings, handouts at
        community events, etc.
         KPPC EMS/ISO 14001 AUDITING TOOL
        © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
       ISO 14001  4.3 - Planning:  Section 4.3.1 - Environmental Aspects: The organization shall establish and maintain (a) procedure(s) to
       identify the environmental aspects of its activities, products or services that it can control and over which it can be expected to have an
       influence, in order to determine those which have or can have significant impacts on the environment.  The organization shall ensure that
       the impacts related to these significant aspects are considered in setting its environmental objectives. The organization shall keep this
       information up-to-date.
       4.3.1 Environmental aspects
       This section requires the organization to establish and maintain a procedure for the identification of environmental aspects that could have a
       significant impact on the environment.  Aspect information is required to be kept up-to-date.
       2.1   Does the organization have a procedure to identify environmental aspects of plant's activities, products and services, which it can control
             and have influence over?
       Note(s)
                                                     Observations and Recommendations
Score
oo
VO
1)   If no written procedure present, ask how organization
    identifies its aspects and assess whether the process
    could be duplicated in a controlled and consistent
    manner.
2)   Relevant records demonstrating application of
    procedure include aspect identification worksheets,
    meeting minutes from departmental teams identifying
    environmental aspects, etc.
3)   Are there design, procurement, distribution, product
    use and end-of-life issues mentioned in the aspects
    procedure?
         KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
2.2   How do you determine significance of aspects/impacts?
Note(s)
Observations and Recommendations
Score
Was significance of aspects determined in
conformance with the procedure?
2.3   Have environmental aspects which have significant environmental impacts been considered in setting objectives?

Note(s)	Observations and Recommendations	
                                                                          Score
2.4 Is aspect information up-to-date?
Note(s)
Observations and Recommendations
Score
1)  How frequently is it reviewed (at least annually)?
    How are new activities, products, and services
    handled within the EMS?
2)  Look to see review is occurring as stated and as often
    as stated. Examples of objective evidence includes
    records of periodic review. This review is commonly
    done by environmental staffer functional areas or
    Management Review (4.6).
3)  New activities, products, and services may be
    handled through periodic reviews performed by
    environmental staff or functional areas or
    Management Review (4.6).
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
       ISO 14001 4.3 Planning: Section 4.3.2 - Legal and other requirements: The organization shall establish and maintain a procedure to
       identify and have access to legal and other requirements which the organization subscribes, that are applicable to the environmental
       aspects of its activities, products or services.
       4.3.2 Legal and other requirements

       Section 4.3.2 requires the organization to have procedures in place to identify and have access to legal and "other" requirements to which the
       organization subscribes.  'Other' requirements include industry codes of practice, voluntary waste minimization/pollution prevention programs
       such as Project XL, and corporate policies.


       3.1   Does the organization have a procedure to identify/have access to legal requirements that relate to environmental aspects of organization's
             activities, products, and services?
       Note(s)
Observations and Recommendations
Score
       1)  If no written procedure present, ask how organization
           identifies its legal requirements and assess whether
           the process could be duplicated in a controlled and
1           consistent manner.
vo     2)  Choose a requirement that the organization
h]~'         determined was not applicable.  Ask them to show
           how they made this determination.
       3)  Objective evidence that legal requirements have been
           identified may include a list/matrix of applicable
           regulatory requirements.  Pick 2 or 3 legal
           requirements and ask auditee to show regulatory text
           that is applicable. Is it done how the procedure says
           it would be done? Objective evidence for access to
           legal requirements includes corporate counsel,
           ongoing subscriptions to BNA, CD-ROM's, Internet
           bookmarks, corporate headquarters legal staff, CFRs
           present during audit, and EPA compliance audits and
           results.
         KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
        3.2   Does the organization have a procedure to identify/have access to other requirements (relating to environmental aspects of activities,
             products, services) to which the organization may subscribe?
        Note(s)
Observations and Recommendations
Score
to
         KPPC EMS/ISO 14001 AUDITING TOOL
        © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
ISO 14001 Section 4.3.3 - Objectives and Targets: The organization shall establish and maintain documented environmental objectives
and targets, at each relevant function and level within the organization. When establishing and reviewing its objectives, an organization
shall consider the legal and other requirements, its significant environmental aspects, its technological options and its financial,
operational and business requirements, and the views of interested parties.  The objectives and targets shall be consistent with the
environmental policy, including the commitment to prevention of pollution.
4.3.3 Objectives and targets

Section 4.3.3 specifies several factors that must be considered for setting objectives and targets. These include, significant environmental aspects,
legal and other requirements, views of stakeholders, technology, financial, operational and other business issues.  ISO 14001 also requires the
objectives and targets to link to the environmental policy, and be established at every relevant function and level in the organization.
4.1  Does the organization have documented objectives and targets?

Note(s)	Observations and Recommendations
                                                                    Score
4.2   Are the objectives and targets established at each relevant function and level within the organization?
Note(s)
Observations and Recommendations
Score
This requirement is most commonly addressed in the
documentation through a statement indicating that
objectives and targets apply throughout the organization.
Objective evidence will come through questioning
employees on their knowledge.
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
VO
       4.3  How were each of the following considered in establishing and reviewing objectives:



       a)  Legal requirements?



       b)  Other requirements?



       c)  Significant environmental aspects?



       d)  Technological options?



       e)  Financial requirements?



       f)  Operational requirements?



       g)  Business requirements?



       h)  Views of interested parties?



       Note(s)	Observations and Recommendations	Score
       4.4  Who are the organization's external interested parties? How did you consider their views in setting your objectives and targets?



       Note(s)	Observations and Recommendations	Score
         KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
4.5   Has responsibility for establishing and maintaining documented objectives and targets been assigned?

Note(s)	Observations and Recommendations	Score

1)  Tell me how you review your objectives and targets.
    How frequently are they reviewed? Who reviews and
    approves the objectives and targets?
2)  Look to see review is occurring as stated and as often
    as stated.  Examples of objective evidence includes
    records of periodic review of the procedure. This
    review is commonly done by environmental staffer
    Management Review (4.6) but frequency of review
    should be specified.
4.6   Are objectives and targets consistent with the environmental policy, including commitment to prevention of pollution?

Note(s)	Observations and Recommendations	Score
4.7   Is reasonable progress being made in accomplishing objectives and targets?

Note(s)	Observations and Recommendations	Score

1)  Review quarterly or annual reports on objectives and
    targets when auditing Management Review 4.6. Have
    they been reviewed by management? Are corrective
    actions being implemented that improve the chances
    of meeting targets for the objectives?
2)  Progress toward objectives and targets may provide
    objective evidence of 4.2 Environmental Policy
    continual improvement.
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
4.8   As objectives and targets are met, are new ones established?

Note(s)	Observations and Recommendations	Score

1)  As objectives and targets are achieved, are new ones
    established? This would be objective evidence for
    continual improvement under 4.2(b) and (d).
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
VO
       ISO 14001 Section 4.3.4 - Environmental Management Program (s): The organization shall establish and maintain (a) program(s) for
       achieving its objectives and targets.  It shall include: a) designation of responsibility for achieving objectives and targets at each relevant
       function and level of the organization; b) the means and time frame by which they are to be achieved. If a project relates to new
       developments and new or modified activities, products or services, program(s) shall be amended where relevant to ensure that
       environmental management applies to such projects.
       4.3.4 Environmental management program(s)

       This section requires the organization to establish programs for achieving its objectives and targets. The program requirement specifically includes
       designation of responsibility at each relevant function and level in the organization, and the means and time frame by which these objectives are to
       be achieved. The program is also required to address new activities, products, or services.

       5.1   Has the organization established an environmental management program(s) for achieving its objectives and targets?

       Note(s)	Observations and Recommendations	Score	
       5.2   Has responsibility for achieving objectives and targets at each relevant function and level of the organization been established in the BMP?

       Note(s)	Observations and Recommendations	Score	

       Pick 2 or 3 objectives and ask auditee to describe which
       plant areas are affected by each target/objective.
        KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
VO
oo
        5.3   Has the organization specified the time frames by which objectives and targets will be achieved?

        Note(s)	Observations and Recommendations	Score

        Do key personnel know relevant timeframes for achieving
        objectives and targets? This can be objective evidence of
        4.4.2 (d) and 4.4.3 (a).
        5.4   Has the organization specified how objectives and targets will be achieved?

        Note(s)	Observations and Recommendations	Score

        Objective evidence can include work instructions.
        Objective evidence of financial means would include
        budgets for EMPs, line item in accounting budget for EMS
        or EMP expenditures, staffing plans and vacancies in the
        environmental programs.
        5.5   How is progress toward objectives and targets measured?

        Note(s)	Observations and Recommendations	Score
          KPPC EMS/ISO 14001 AUDITING TOOL
        © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
VO
VO
       5.6   Does the organization maintain/review programs for achieving objectives and targets?

       Note(s)	Observations and Recommendations	Score

       This review may be mentioned under 4.3.3 Objectives and
       targets. Examples of objective evidence include records
       of periodic review. This review is commonly done by
       environmental staffer Management Review (4.6). Look to
       see how often review will be conducted.
       5.7   When new or modified activities, products or services are implemented, how do you ensure that environmental management applies to these
       projects?

       Note(s)	Observations and Recommendations	Score	
         KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      ISO 14001 4.4 Implementation and Operation:  Section 4.4.1 - Structure and Responsibility: Roles, responsibilities and authorities shall
      be defined, documented and communicated in order to facilitate effective environmental management.  Management shall provide
      resources essential to the implementation and control of the environmental management system. Resources include human resources and
      specialized skills, technology and financial resources. The organization's top management shall appoint (a) specific management
      representative(s) who, irrespective of other responsibilities, shall have defined roles, responsibilities and authorities for: a) ensuring that
      environmental management system requirements are established, implemented and maintained in accordance with this standard; b)
      reporting on the performance of the environmental management system to top management for review and as a basis for improvement of
      the environmental management system.
      4.4.1 Structure and responsibility

      This section requires the organization to formally and clearly define, document, and communicate environmental responsibilities, and to assign a
      management representative with responsibility for overseeing the overall implementation of the EMS.

      6.1   Are environmental roles (what has to get done), responsibilities (who gets it done), and authorities (who sees that it gets done) documented?
           If not documented, have environmental roles been defined?

g    Note(s)	Observations and Recommendations	Score	
o
      6.2   Are environmental roles (what has to get done), responsibilities (who gets it done), and authorities (who sees that it gets done)
           communicated?

      Note(s)	Observations and Recommendations	Score
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
        6.3   Have adequate resources (human, skills, technology, and financial) been provided for the implementation and control of the EMS?

        Note(s)	Observations and Recommendations	Score

        How are human, financial, and technological resources
        allocated/provided to the EMS? Objective evidence of
        financial support would include line item in accounting
        budget or an account number for EMS expenditures.
        6.4   Has top management appointed an EMS management representative?

        Note(s)	Observations and Recommendations	Score

        Be sure to look for documentation/record of appointment
        of top management representative (e.g., in a letter or
        memo of commitment from President/General Manager or
        an organization chart that shows roles and
        responsibilities).
o      6.5   Do the roles and responsibilities of the management's representative(s) fulfill the duties described in Section 4.4.1 a) and b) of the Standard?

        Note(s)	Observations and Recommendations	Score	

        Top management shall appoint representatives who ensure
        EMS requirements are established, implemented, and
        maintained"  (a) and who report the performance of the EMS
        to top management (b).  See 6.4 above.
          KPPC EMS/ISO 14001 AUDITING TOOL
        ©Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
      ISO 14001 Section 4.4.2 - Training, Awareness and Competence:  The organization shall identify training needs. It shall require that all
      personnel, whose work may create a significant impact upon the environment, receive appropriate training. It shall establish and
      maintain procedures to make its employees or members at all relevant levels aware of: a) the importance of conformance with the
      environmental policy and procedures and with the requirements of the environmental management system; b) the significant
      environmental impacts, actual or potential, of their work activities and the environmental benefits of improved personal performance; c)
      their roles and responsibilities in achieving conformance with the environmental policy and procedures, and with the requirements of the
      environmental management system including emergency preparedness and response requirements; d) the potential consequences of
      departure from specific operating procedures.

      Personnel performing tasks which can cause significant environmental impacts shall be competent on the basis of appropriate education,
      training and/or experience.
      4.4.2 Training, awareness, and competence


      This section requires the organization to evaluate and implement specific training activities for those personnel at each relevant function and level,
      whose job activities could have a significant impact on the environment. Training is required to include general environmental awareness, and job
i      specific training.
o    7.1  Has the organization identified what job functions may have a significant impact on the environment? How does organization identify EMS
,          training needs?

      Note(s)	Observations and Recommendations	Score	

      1)   Sample-check that personnel (preferably a key line
          operator, manager, and supervisor) whose work can
          have a significant impact on the environment have
          been identified.
      2)   Objective evidence can include lists of positions
          within the organization and associated training needs,
          procedures for training, as well as organization charts.
      3)   Documentation should link personnel whose work can
          have a significant impact on the environment to the
          training they receive.
      4)   Was the training delivered? Look at training records
          (4.5.3), agendas, class materials/training curricula to
          verify what was covered in the training.
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
o
       7.2   Has the organization established a procedure to make its employees aware of the following?

       a)  The importance of conformance with the environmental policy, procedures, and requirements of the EMS.

       b)  The significant actual and potential impacts of their work and the benefits of improved personal performance.

       c)  Their roles and responsibilities in achieving conformance with the environmental policy, procedures, EMS, and emergency preparedness and
          response procedures.

       d)  The potential consequences of departure from specified operating procedures.

       Note(s)	Observations and Recommendations	Score	
       7.3   How does the organization assess competence of personnel whose work can cause significant environmental impacts?

       Note(s)	Observations and Recommendations	Score
       7.4   Have training needs for the EMS representative been determined?

       Note(s)	Observations and Recommendations	Score

       Verify whether the EMS representative received this
       training? Ask for EMS representative's training records
       (4.5.3).
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
o
      7.5   Who else provides training that is required? How were they trained or qualified to be a trainer?

      Note(s)	Observations and Recommendations	Score

      a)  Ask to see objective evidence of training received and
          competency.
      b)  If experience is called out as the basis of competency,
          follow up with questions: how many years of
          experience required? How do you decide 'how much'
          experience is enough? What qualifies as experience?
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      ISO 14001 Section 4.4.3 - Communication: With regard to its environmental aspects and environmental management system, the
      organization shall establish and maintain procedures for: a) internal communication between various functions and levels of the
      organization; b) receiving, documenting and responding to relevant communication from external interested parties.

      The organization shall consider processes for external communication on its significant environmental aspects and record its decision.
      4.4.3 Communication


      This section requires the organization to establish and maintain procedures for communicating its aspects and elements of the environmental
      management system to external interested parties. It also requires the organization to consider a process for communicating to external parties
      about its significant aspects, and record its decision.


      8.1   Is there a procedure for internal communication of the EMS and the environmental aspects between the various levels and functions of the
            organization?

^j    Note(s)	Observations and Recommendations	Score	
o
,      1)  If yes, is communication occurred as indicated in the
          procedure?
      2)  Any of the following may be sample items that a
          facility may point to as examples of how internal
          communication occurs: training-related materials,
          agendas, sign-up sheets, and overheads from
          environmental meetings.
      3)  A common nonconformance is that documented
          internal communications were required under the
          Standard but transmitted verbally.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
       8.2   Is there a procedure for receiving, documenting and responding to communications from external interested parties regarding the
             organization's environmental aspects and EMS?

       Note(s)	Observations and Recommendations	Score

       1)   There are three things to look for: how it receives,
           documents, and responds to the request.
       2)   Have you received any external requests for
           information? If yes, ask/look to see how these have
           been handled in the system. Is it how they said it
           would be handled? Was it documented? Responded
           to in the required or reasonable period of time?  One
           test would be to call ahead to ask for significant
           aspects. When on-site, verify that your request has
           been handled within the system.  A common example
           of an external request is a sister facility calling for
           information on the EMS.
       8.3   Has the organization has documented a decision as to whether or not it will communicate information on its aspects and EMS to external
             interested parties.

       Note(s)	Observations and Recommendations	Score	
to
o
         KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
to
o
      ISO 14001 Section 4.4.4 - Environmental Management System Documentation: The organization shall establish and maintain
      information, in paper or electronic form, to: a) describe the requirements of the management system and their interaction, b) provide
      direction to related documentation.
      4.4.4   Environmental management system documentation


      This section requires the organization to maintain documentation (electronically or written) which describes the core elements of the EMS, their
      interaction, and directions to related documentation.


      9.1   Is there documentation describing the core elements of the EMS and their interaction?

      Note(s)	Observations and Recommendations	Score	

      There are a variety of ways to show interaction among the
      elements: references within the procedures (probably
      most common), flowcharts, procedural matrices, EMS
      table of contents or Master Document Control List.
      9.2   Does the scope of the EMS documentation and related documents cover all elements of the ISO 14001 standard? Does documentation
            provide direction to related documents?

      Note(s)	Observations and Recommendations	Score

      Related documentation may include internal standards
      and operational procedures, process information, site
      emergency plans, etc.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      ISO 14001 Section 4.4.5 - Document Control: The organization shall establish and maintain procedures for controlling all documents
      required by this standard to ensure that: a) they can be located; b) they are periodically reviewed, revised as necessary and approved for
      adequacy by authorized personnel; c) the current versions of relevant documents are available at all locations where operations essential
      to the effective functioning of the system are performed; d) obsolete documents are promptly removed from all points of issue and points
      of use or otherwise assured against unintended use; e) any obsolete documents retained for legal and/or knowledge preservation purposes
      are suitably identified. Documentation shall be legible, dated (with dates of revision) and readily identifiable, maintained in an orderly
      manner and retained for  a specified period.  Procedures and responsibilities shall be established and maintained concerning the creation
      and modification of the various types of documents.
      4.4.5 Document control

      This section requires the organization to establish and maintain procedures for controlling documentation related to the EMS.

      This section is largely audited while looking at other system requirements.
      Generally speaking, if a paper/reference is being used to answer an auditor question, to support the system or to communicate information
      regarding the system, it should be in document control and meet document control requirements.
to
oo    10.1  Does the organization have a procedure for controlling documents required by ISO 14001?

      Note(s)	Observations and Recommendations	Score
      10.2   Does the procedure ensure that:
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
       a)  Documents are locatable?


       b)  Documents are periodically reviewed, revised as necessary, and approved for adequacy by authorized personnel?


       c)  Current versions of relevant documents are available at all locations where operations essential to the effective functioning of the EMS are

          performed?


       d)  Obsolete documents are promptly removed from all points of issue and use, or otherwise protected from unintended use?


       e)  Obsolete documents retained for legal and/or knowledge preservation purposes are suitably identified?


       Note(s)	Observations and Recommendations	Score	
       10.3   Has responsibility for fulfilling document control responsibilities been assigned?

to
o     Note(s)	Observations and Recommendations	Score
       10.4   Is documentation legible?


       Note(s)	Observations and Recommendations	Score
       10.5   Does documentation have dates of revision?
        KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
o
      Note(s)	Observations and Recommendations	Score
      10.6  Is documentation readily identifiable?

      Note(s)	Observations and Recommendations	Score
      10.7  Is documentation maintained in an orderly manner?

      Note(s)	Observations and Recommendations	Score
      10.8  Is documentation retained for a specific period?

      Note(s)	Observations and Recommendations	Score
      10.9  Are there assigned responsibilities for creating and modifying EMS documents?
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
Note(s)	Observations and Recommendations	Score
10.10 Is there/are there procedure(s) for creating and modifying EMS documents?



Note(s)	Observations and Recommendations	Score
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
      ISO 14001 Section 4.4.6 - Operational Control: The organization shall identify those operations and activities that are associated with the
      identified significant environmental aspects, in line with its policy, objectives and targets. The organization shall plan these activities,
      including maintenance, to ensure that they are carried out under specified conditions by: a) establishing and maintaining documented
      procedures to cover situations where their absence could lead to deviations from the environmental policy and the objectives and targets
      b) stipulating operating criteria in the procedures; c) establishing and maintaining procedures related to the significant environmental
      aspects of goods and services used by the organization and communicating relevant procedures and requirements to suppliers and
      contractors.
      4.4.6 Operational control

      This section requires the organization to identify operations and activities that are associated with the significant aspects, then document
      procedures whenever the absence of documented procedures could result in deviations from the environmental policy and objectives and targets.
      All operational control procedures should have operating criteria spelled out. There should be procedure(s) for communicating applicable and
      relevant operational procedures and requirements to suppliers and contractors.

      11.1 Has the organization identified operations and activities associated with its identified significant environmental aspects?

      Note(s) _ Observations and Recommendations _ Score _
      11.2  Has the organization established documented work instructions and procedures to cover situations where their absence could lead to
           deviations from the environmental policy, objectives and targets?

      Note(s)	Observations and Recommendations	Score

      Sample several operations and activities associated with
      significant aspects. Verify that the procedures tell
      "how-to".
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
       11.3  Has the organization established operating criteria in the work instructions and procedures?

       Note(s)	Observations and Recommendations	Score
       11.4  Are relevant documented procedures available at locations where these operations and activities are performed?

       Note(s)	Observations and Recommendations	Score

       Is maintenance crew on spill response team? Is
       emergency preparedness and response procedure
       available at this workstation?
       11.5  Has responsibility for implementing these work instructions and procedures been assigned?

       Note(s)	Observations and Recommendations	Score
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
11.6  Has responsibility for periodically reviewing and updating these work instructions and procedures been assigned?

Note(s)	Observations and Recommendations	Score

Tell me how you maintain the procedure. How frequently
is it maintained/reviewed? Look to see review is
occurring as stated and as often as stated. Examples of
objective evidence include records of periodic review.
This review is commonly done by environmental staffer
Management Review (4.6) but frequency of review should
be specified.
11.7  Has the organization established and maintained procedure(s) related to the identifiable significant environmental aspects of goods and
      services used by the organization?  How are these communicated to suppliers and contractors?

Note(s)	Observations and Recommendations	Score

1)  Show me some of the relevant procedures and
    requirements you have for your suppliers and
    contractors.
2)  Organization should have a procedure that identifies
    suppliers (i.e. those whose goods and services are
    related to significant aspects) and provides for
    communicating relevant procedures and requirements
    to these suppliers.
3)  Record of this training/external communication could
    include mailing of aspect/impact/objectives and
    targets/sheet with signed confirmation back to
    organization.
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
       ISO 14001 Section 4.4.7 - Emergency Preparedness and Response: The organization shall establish and maintain procedures to identify
       potential for and respond to accidents and emergency situations, and for preventing and mitigating the environmental impacts that may
       be associated with them. The organization shall review and revise, where necessary, its emergency preparedness and response
       procedures, in particular, after the occurrence of accidents or emergency situations. The organization shall also periodically test such
       procedures where applicable.
       4.4.7 Emergency preparedness and response

       This section requires the organization to establish and maintain procedures for identifying and responding to potential accidents and emergency
       situations; preventing and mitigating associated environmental impacts. The organization shall review procedures especially after accidents and
       emergency, and revise procedures where necessary.

       12.1 Has the organization established a procedure to identify the potential for accidents and emergency situations?

       Note(s)	Observations and Recommendations	Score	

       Has the organization defined accidents and emergencies?
to
       12.2  Does the procedure address how the organization will respond to accidents and emergency situations so as to prevent and mitigate the
            associated environmental impacts?

       Note(s)	Observations and Recommendations	Score

       Objective evidence of how the organization would respond
       include referenced SPCC Plans, RCRA Hazardous Waste
       plans, Stormwater Pollution Prevention Plans, etc.
        KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
       12.3  Are emergency preparedness and response procedures available in applicable operational areas?

       Note(s)	Observations and Recommendations	Score

       Check during tour, while interviewing key employees.
       12.4  Are the procedures maintained, reviewed and updated regularly and when necessary, particularly after the occurrence of accidents or
             emergency situations?

       Note(s)	Observations and Recommendations	Score

       Have any accidents or emergencies occurred? If so, may
       want to see if organization reviewed its procedures. What
       would guide decision to review and update the procedure?
       Look at incident investigation results and corrective
       actions. If one of the potential accidents occurred, what
       would be the steps that would be followed for reviewing
       and revising the procedures.
       12.5  Does the organization periodically test these procedures where practicable?  Has responsibility been assigned in these circumstances?

       Note(s)	Observations and Recommendations	Score

       Some organizations say: "The organization shall
       periodically test such procedures where practicable." How
       do you determine if it is practicable to test the procedure?
       If practicable, when were they last tested.  Look for log of
       last test date and time.
         KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      ISO 14001 4.5 Checking and Corrective Action:  Section 4.5.1 - Monitoring And Measurement:  The organization shall establish and
      maintain documented procedures to monitor and measure, on a regular basis, the key characteristics of its operations and activities that
      can have a significant impact on the environment. This shall include the recording of information to track performance, relevant
      operational controls and conformance with the organization's objectives and targets. Monitoring equipment shall be calibrated and
      maintained, and records of this process shall be retained according to the organization's procedures.  The organization shall establish and
      maintain a documented procedure for periodically evaluating compliance with relevant environmental legislation and regulations.
      4.5.1    Monitoring and measurement

      This section requires the organization to establish and maintain documented procedures to monitor and measure the key characteristics of
      operations and activities that are related to the significant aspects. This should include a requirement for documented procedures for compliance
      auditing and monitoring equipment maintenance and calibration.

      13.1  Has the organization established documented procedures to monitor and measure on a regular basis the key characteristics (as determined in
            4.4.6) of its operations and activities that can have a significant impact on the environment?

,      Note(s)	Observations and Recommendations	Score	
to
^    How do you monitor and measure operations and activities
i      that can have a significant impact on the environment?
      What are the measurements you use that show you are
      making progress toward your objectives and targets?
      13.2  Does the procedure include requirements for recording information to track performance, relevant operational controls, and conformance
            with the organization's objectives and targets?

      Note(s)	Observations and Recommendations	Score	
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
       13.3  Is there a procedure for calibrating and maintaining monitoring equipment?

      Note(s)	Observations and Recommendations	Score
       13.4  Are records of calibration and maintenance retained according to the organization's procedures?

      Note(s)	Observations and Recommendations	Score
       13.5  Has the organization established a documented procedure for periodically evaluating compliance with relevant environmental legislation and
       regulations?

•       Note(s)	Observations and Recommendations	Score	
to
oo     1)  Procedure should specify how and when compliance
1          will be evaluated.
       2)  Verify that compliance evaluations have been
          performed as described and at specified time
          intervals. Objective evidence includes internal and
          external compliance audit reports.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
ISO 14001 Section 4.5.2 - Nonconformance, Corrective and Preventative Action: The organization shall establish and maintain
procedures for defining responsibility and authority, for handling and investigating nonconformance, taking action to mitigate any
impacts caused by non-conformances and for initiating and completing corrective and preventative action. Any corrective or
preventative action taken to eliminate the causes of actual and potential non-conformances shall be appropriate to the magnitude of
problems and commensurate with the environmental impact encountered.
4.5.2   Nonconformance and corrective and preventive action

This section of the ISO 14001 requires that the organization identify the causes of nonconformance, identify and implement the necessary
corrective action, implement or modify controls necessary to avoid repeating the nonconformance, and record any changes in written procedures
resulting from the corrective action.

14.1 Does the organization have a procedure that defines responsibility and authority for:

a)  Handling and investigating nonconformance, including determining root cause of the nonconformance?

b)  Taking action to mitigate impacts caused by non-conformances?

c)  Initiating and completing corrective and preventive action?

Note(s)	Observations and Recommendations	Score	
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
14.2  Has corrective or preventive action (if any) taken been appropriate to the magnitude of the problem and commensurate with the
      environmental impacts?

Note(s)	Observations and Recommendations	Score

If so, was the nonconformance/suggestion handled
according to procedure? Has the organization
implemented and recorded any changes in the
documented procedures resulting from the corrective and
preventive action?
14.3  Has the organization implemented and recorded any changes in the documented procedures resulting from the corrective and preventive
      action?

Note(s)	Observations and Recommendations	Score	

1)  Have appropriate changes have been carried through
    the system and made in documented procedures,
    training, relevant work instructions/procedures, etc.
2)  If no non-conformances, have there been any
    suggestions brought forward to improve the system?
    Is there a mechanism, perhaps  as part of 4.4.3
    Communication, whereby employees can bring
    forward suggestions for the EMS? Suggestions
    brought forward and handled appropriately in the
    system can be objective evidence of a procedure in
    place to handle corrective and preventive action. Ask
    to see related forms and records.  Related records
    could include action request forms, action request
    logs, etc.
  KPPC EMS/ISO 14001  AUDITING TOOL
© Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
to
to
      14.4  Has responsibility for the following been assigned?


      a)  Handling and investigating nonconformance's


      b)  Taking action to mitigate impacts of nonconformance's


      c)  Initiating and completing corrective and preventive action


      Note(s)	Observations and Recommendations	Score
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      ISO 14001 Section 4.5.3 - Records: The organization shall establish and maintain procedures for the identification, maintenance and
      disposition of environmental records.  These records shall include training records and the results of audits and reviews. Environmental
      records shall be legible, identifiable and traceable to the activity, product or service involved. Environmental records shall be stored and
      maintained in such a way that they are readily retrievable and protected against damage, deterioration or loss. Their retention times
      shall be established and recorded. Records shall be maintained, as appropriate to the system and to the organization, to demonstrate
      conformance to the requirements of this standard.
      4.5.3   Records


      This section requires the organization to establish and maintain procedures for handling environmental records. Records are used to show that the
      organization is doing what procedures said would be done.


      15.1  Has the organization established procedures to identify, maintain and dispose of environmental records?

      Note(s)	Observations and Recommendations	Score	

      Training records, EMS audit records, and management
1      review records are the minimum system records that must
fo    be kept. See that these are referenced from the
^    Record(s) procedure.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
to
to
        15.2 Has responsibility for maintenance and disposition of records been assigned?

       Note(s)	Observations and Recommendations	Score

        1.  Are records identified, maintained, and disposed of as
           indicated in the procedure?
           Note: Sample check records to verify that records
           are being kept in accordance with the written
           retention times.
       2.  How frequently is it maintained/reviewed? Look
           to see review is occurring as stated and as often as
           stated.  Examples of objective evidence include
           records of periodic. This review is commonly done
           by environmental staffer Management Review (4.6)
           but frequency of review should be specified.
        15.3  Do environmental records in the procedure include training records and the results of audits and reviews?

       Note(s)	Observations and Recommendations	Score
         KPPC EMS/ISO 14001  AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
to
to
       15.4  Are environmental records:


       a)  Legible?


       b)  Identifiable?


       c)  Traceable to the activity, product, or service involved?


       d)  Readily retrievable?


       e)  Protected against damage, deterioration, or loss?


       Note(s)	Observations and Recommendations	Score
        KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
to
      ISO 14001 Section 4.5.4 - Environmental Management System Audit: The organization shall establish and maintain programs and
      procedures for periodic environmental management system audits to be carried out, in order to: (a) determine whether or not the
      environmental management system: 1) conforms to planned arrangements for environmental management including the requirements of
      this standard; 2) has been properly implemented and maintained; (b) provide information on the results of audits to management. The
      audit program, including any schedule, shall be based on the environmental importance of the activity concerned and the results of
      previous audits. In order to be comprehensive, the audit procedures shall cover the audit scope, frequency and methodologies, as well as
      the responsibilities and requirements for conducting audits and reporting results.
      4.5.4 Environmental management system audits

      This section requires the organization to establish and maintain procedures and programs for periodic audits of the EMS.

      16.1  Has the organization established a procedure/program for periodic EMS audits?

      Note(s)	Observations and Recommendations	Score
      16.2  Does the audit procedure/program:

      a)  Determine whether or not the EMS conforms to planned arrangements for environmental management including ISO 14001?

      b)  Determine whether the EMS has been properly implemented and maintained?

      c)  Address how audit information is provided to management?

      Note(s)	Observations and Recommendations	Score
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
to
to
       16.3  Do audit procedures address the following:

       a)  Audit scope?

       b)  Audit frequency? (Note: Does the audit program and procedure provide for audit frequency and scope appropriate to the importance of the
          activity concerned and results of previous audits?  A follow-up question may ask how the organization takes importance of the activity and
          results of previous audits into consideration when determining audit frequency.)

       c)  Audit methodologies?

       d)  Responsibilities and requirements for conducting and reporting audit results?

       Note(s)	Observations and Recommendations	Score	
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
to
      ISO 14001 4.6 Management Review:  The organization's top management shall, at intervals it determines, review the environmental
      management system, to ensure its continuing suitability, adequacy and effectiveness. The management review process shall ensure that
      the necessary information is collected to allow management to carry out this evaluation. This review shall be documented. The
      management review shall address the possible need for changes to policy, objectives and other elements of the EMS, in the light of
      environmental management system audit results, changing circumstances and the commitment to continual improvement.



      4.6 Management review

      This section requires the organization's top management to periodically review the EMS for suitability and effectiveness, and to make changes to
      the system where appropriate. This review must be documented.

      17.1 Is there a procedure for top management review to ensure EMS suitability, adequacy, and effectiveness?

      Note(s)	Observations and Recommendations	Score	
      17.2 Does the procedure address what will be reviewed?

      Note(s) _ Observations and Recommendations _ Score
      17.3 Has top management determined the frequency of the reviews?

      Note(s)	Observations and Recommendations	Score

      Look to see where top management determined how often
      it meets for management review.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
      17.4  Are EMS audit results reviewed during management review?

      Note(s)	Observations and Recommendations	Score
      17.5  Does management review address possible need for changes to the environmental policy, objectives, and other elements of the EMS?

      Note(s)	Observations and Recommendations	Score
      17.6  Has top management participated in the review?

      Note(s)	Observations and Recommendations	Score

,      Verify that all procedures to be reviewed during
to    management review are in fact reviewed at this time.
oo    Verify that possible need for changes to policy, objectives,
1      etc., have been considered.  Make sure these are
      documented as having been considered.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
Position/of person interviewed:




Department/work area;





1. What do you do? (What are your job responsibilities?)



Note(s)	Observations and Recommendations	Score
2. What is the environmental policy?  What does policy mean to you?



Note(s)	Observations and Recommendations	Score
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
OJ
o
      3.  How does your work impact the environment? What do you do to reduce these impacts, to protect the environment?  Listen for mention of
            significant impacts, objectives and targets and work instructions. How did you know to do this?

      Note(s)	Observations and Recommendations	Score	

      Answers to this can provide objective evidence of 4.3.4 (a).
      4. How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
      environment?  Where do you look for this information?  (Are there operating procedures/work instructions that relate to the environment you
      follow?) Do you have to record any information? Ask to see.

      Note(s)	Observations and Recommendations	Score

      Answers to this can provide objective evidence for
      4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
      5. How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?

      Note(s)	Observations and Recommendations	Score
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
       6.  What environmental training have you had? When was it?
       Note(s)
                                                       Observations and Recommendations
Score
       7.  What is the worst-case environmental scenario in this work area?  What would you do if it happened?  What would you do if there were an
       emergency?  A spill? Have you had drills lately? When?  (4.4.7)
       Note(s)
                                                       Observations and Recommendations
Score
to
oo
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
       Objective evidence of 4.4.5 (c) Reasonable for members
       of emergency response/action team to have copy of plan
       at their workstation.  Competency (4.4.2) demonstrated
       through question and answer acceptable.
         KPPC EMS/ISO 14001 AUDITING TOOL
       © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      8. Can you provide example of something that's improved environmentally here over the last couple of years?


      Note(s)	Observations and Recommendations	Score
      9. What would you like to see improve environmentally here in the future?


      Note(s)	Observations and Recommendations	Score
to
OJ
to
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
oo
      Position/of person interviewed:



      Department/work area;




      1. What do you do? (What are your job responsibilities?)



      Note(s)	Observations and Recommendations	Score
      2. What is the environmental policy?  What does policy mean to you?



      Note(s)	Observations and Recommendations	Score
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      3.  How does your work impact the environment?  What do you do to reduce these impacts, to protect the environment? Listen for mention of
           significant impacts, objectives and targets and work instructions. How did you know to do this?

      Note(s)	Observations and Recommendations	Score	
      Answers to this can provide objective evidence of 4.3.4 (a).
      4.  How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
      environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
      follow?)  Do you have to record any information? Ask to see.

      Note(s)	Observations and Recommendations	Score

^    Answers to this can provide objective evidence for
<->->    4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
      5.  How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?

      Note(s)	Observations and Recommendations	Score
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      6. What environmental training have you had? When was it?
      Note(s)
                                                       Observations and Recommendations
Score
      7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
      emergency? A spill? Have you had drills lately? When? (4.4.7)
      Note(s)
                                                       Observations and Recommendations
Score
to
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
      Objective evidence of 4.4.5 (c) Reasonable for members
      of emergency response/action team to have copy of plan
      at their workstation. Competency (4.4.2) demonstrated
      through question and answer acceptable.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
to
      8.  Can you provide example of something that's improved environmentally here over the last couple of years?



      Note(s)	Observations and Recommendations	Score
      9.  What would you like to see improve environmentally here in the future?



      Note(s)	Observations and Recommendations	Score
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
Position/of person interviewed:




Department/work area;





1. What do you do? (What are your job responsibilities?)



Note(s)	Observations and Recommendations	Score
2. What is the environmental policy?  What does policy mean to you?



Note(s)	Observations and Recommendations	Score
  KPPC EMS/ISO 14001 AUDITING TOOL
© Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
to
oo
oo
      3.  How does your work impact the environment?  What do you do to reduce these impacts, to protect the environment? Listen for mention of
           significant impacts, objectives and targets and work instructions. How did you know to do this?

      Note(s)	Observations and Recommendations	Score	
      Answers to this can provide objective evidence of 4.3.4 (a).
      4.  How do you know if you're doing your job in an environmentally-friendly way? What do you watch to make sure you don't impact the
      environment? Where do you look for this information? (Are there operating procedures/work instructions that relate to the environment you
      follow?)  Do you have to record any information? Ask to see.

      Note(s)	Observations and Recommendations	Score
      Answers to this can provide objective evidence for
      4.3.4 (b), Structure and Responsibility, and 4.4.2 Training.
      5.  How do you find things out? (Communication 4.4.3) How do you know if you're doing a good job environmentally?

      Note(s)	Observations and Recommendations	Score
       KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville. All Rights Reserved.
-------
      6. What environmental training have you had? When was it?
      Note(s)
                                                       Observations and Recommendations
Score
      7. What is the worst-case environmental scenario in this work area? What would you do if it happened? What would you do if there were an
      emergency? A spill? Have you had drills lately? When? (4.4.7)
      Note(s)
                                                       Observations and Recommendations
Score
to
oo
VO
Ask employees who would reasonably be expected to
actively respond to an emergency and check for
consistency of response. Ask this to employees who
would be expected to leave the situation and check for
consistency of response.
      Objective evidence of 4.4.5 (c) Reasonable for members
      of emergency response/action team to have copy of plan
      at their workstation. Competency (4.4.2) demonstrated
      through question and answer acceptable.
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
      8. Can you provide example of something that's improved environmentally here over the last couple of years?


      Note(s)	Observations and Recommendations	Score
      9. What would you like to see improve environmentally here in the future?


      Note(s)	Observations and Recommendations	Score
to
j^.
o
        KPPC EMS/ISO 14001 AUDITING TOOL
      © Copyright 1998, 2000 University of Louisville.  All Rights Reserved.
-------
                  - APPENDIX D -


                U.S. EPA REGION 1
           COMPLIANCE AUDITING TOOL
                        United States
                        Environmental Protection
                        Agency
Click here to return to Table of Contents.      - 241 -
-------
     AEPAi
'•niintl VMtal
Civ ii MtnttriM PI yl
                  EPA New England- Hospit.il Environmental Assessment Template
                                An SHW'rownental compliance and pollution piweniion tool
Introduction
Tni» too! wss developed foi in Office of Environmental Compliance mid Assistance (OECA) grant which was giveu to the University
af New Hampshire Polhuion Prevention Program.  The leal was modified tnto three state specific took- for CT. RI Mid NH.  The
mteira collected and compiled information from s total of 25 hospilils in the three states.  A copy of the finil report can be found it
bttp: 'ivT.wv.uah.gtin p2 'Ehppc'12003 jitmi.  This tool »s not all-inclusive and tt doe1; not include all Federal hospital requirements or
preferable practices.. If you are a VA there are additional requirements thai will apply to you that are not covered in this template  IE
addition, vou ^herald aiio atwav^ cheek with vmir state for any additional state requirements.  If vou would like a word version of this
document to ciwtoinize for your state or EPA Regsoa, please email Janef Bowen of EPA Region 1 at Boweii.JanetiS'epa ,go^r or call hei
directly at 1617)918-1795 '

Section I:  General FacMit\"
1.1   Number of Hosps tal Bedi

1.2   Wtar state are vou located in*1
                                                         200
1.3   What departments) are nK-poasible for enviromneatal compliance at your hospital1 (Check ill that apply)
        	Health and Safety         	Maintenance.'Facility            	Industrial Hygteuisc
        	Environmentzl            	Nur&mg                       	Other (Specify)	
1.4  Has Y3ur hospital u*ed t?A technical resonrces*1 (Check al! that apply)
	Accessed H2E website
	Participate H2E teleconferences
__H2E fact sheets
	j-Zl-'fil Hospital workshop in CT
	Accessed Region I website
   SPCC Amendment fact sheet
                                      	Participate on Hit Liits-erv
                                         Participate EuergyStar internet traminE
                                      	H2E Asses sineQt
                                         EPA presecraiion
                                      	11,6'02 SPCC training in CT
                                         EPCRA fact sheet
                                                         	.eiepiiC'iie assistance from tPA
                                                            lafomuiion from EPA at event
                                                         __Accessed EPA website
                                                            EBei'gvrStaf Bejichmai'iano infonnanou
                                                         	Mercury ClsalIejiE:e Paitneia
                                                         	Other (Speciryj
1.5  What changes or actions [if -any) have you nude as a result of EPA/H2E -asM-itaiice'1 [Check all that apply)
   	.Filed notification                         	Became H2E Partnei                    Improved-evaluated water
   	Obtained permit                             Inventoried mercury nse-'equipment        efficiency
   	Provided employee training                	BendimarJced'increase energy efficiency	Reduced'replaced mercury items
   	Submitted dccuniematioc to EPA, Staff          Minimized infectious waste              lasamted-iiicreased recycling reuse
   	Adopted fomul purchasing policy           	Came sntc compliance                	Othei (Specifyl	

 Section II: Compliance Self Assessment
1.0 Resource Conservation and Recovery Act CRC'RA) (40 CFR 251. 262, 165)
1 1
1 2
1.3
1 4
1 5
What ii vow hospital'^ generator status? (Please checfc")
No HazaidoHs Waae CESQG1 SQC-- LQGJ Don't Know (DK)

Does your hcspital osve in EPA hazardoiis waste eenerator number1
Storage
Is all hazardous waste slored m either a satellite acciiamlation area and,'or i separate hazardous fluste
storaee area11
Aie the satellite accunaijatiou area? clearly identified^
Are all hazardous waste conwjners fcepi closed except when filling or adding waste1*
Y





K





Some





DK





KA





                                                       -242-
-------
1.0 Resource Conservation and Recovery Act (RCRA) (40 CFR 261, 262, 265)
1.6
l:l
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
Are all hazardous waste containers in good condition9
Is there a secondary containment system in the hazardous waste storage area11
Does the storage area have an impervious surface and no floor drain?
Does your hospital maintain emergency and safety equipment within the hazardous waste storage
area? (spill kits, eye wash, personal protective equipment (PPE). etc.)
Does your hazardous waste storage area have a communication device"1 (telephone, alarm, etc.)
Labeling
Are hazardous wastes stored in labeled containers with:
the words "'Hazardous Waste"
the name of waste
the EPA waste code 	
the date container was placed in storage''

Inspections
Is the hazardous waste storage area inspected weekly for signs of spills or container deterioration'!'
Axe the inspections documented*7
Is there a hazardous waste determination on file for all wastes'1
Contingency Plan
Is there an updated RCRA Contingency Plan including accurate phone numbers?
Was a copy of the RCRA Contingency Plan sent to the local fire department?
Training
Do employees receive hazardous waste management training related to their job duties?
Are these training records maintained?
Manifests
Does the hospital maintain its manifests for at least three years?
Does the hospital maintain Land Disposal Restriction notices with the manifests that they are
providing the Notice for?
Y















N















Some















DK















NA















2.0 Universal Waste" (40 CFR 273)
2.1
2.2
2.3
2.4
Does your hospital handle Universal Waste separately from your other hazardous waste?
Tip: For moi'is information on Universal Waste visit
htty:t<\ww.epa.gov/epaoswer/1ia:wastefidSiinfvH'ast.ktns
If yes to 2.1, does your hospital label its Universal Waste and specify type (e.g.. lamps, batteries)?
If yes to 2.1. does your hospital store Universal Waste in appropriate containers that prevent releases
to the environment1!'
If yes to 2.1. does your hospital have a system to document the length of time that the Universal Waste
has been accumulating?
Y




N




DK




NA




-243-
-------
3.0 Spill Prevention Control Countermeasure Plans (SPCC) (40 CFR 112)
3.1
3.2
3.3
3.4
Is oil of any kind stored above ground in containers or equipment thai have a capacity of 55 gallons or
greater and a total aggregate capacity of over 1.320 gallons9
Tip: For more information visit EPA '5 Oil Program 'website at hTtp:--'sw\w.epa.go\'~bikpill::in\tffi
as a helpjiil, comprehensive tool to identify compliance lapses
Y





N





DK





NA





6.0 Community Right to Know SARA Title IH - EPCRA (Sections 302-304, 31 land 312)
6.1
6.2
6.3
6.4
Does the hospital have on-site. at any time during the calendar year, a listed Extremely Hazardous
Substance (EHS) in an amount over the threshold reporting quantify?
Tip: Find This listai ^ffp.v^»j«H%ji2c3j[OT^
If yes to 6.1, has your hospital submitted a notification letter identifying the EHS and facility
emergency coordinator to the Local Emergency Planning Committee (LEPC)/State Emergency
Response Committee (SERC)?
Does the hospital have oa-site at any time during the calendar year 10,0001bs of any product/material
requiring a Material Safety Data Sheet (MSDS)?
If yes to 6.1 or 6.3, have Tier n chemical inventory forms (Tier 2 Submit for electronic submissions)
been filed annually with the local fire department, LEPC and SERC?
Tip: For electronic Tier II Submit go to
http:.''.-"vose)'iiite. epa. ^or:oswer-';Ceppo We b. ,< is f "con tst i t-'tier2. htm %2/cirm>;
Y




N




DK




NA




7.0 Clean Air Act (CAA)
7.1
7 ~>
7.4
Does your hospital have a Title V operating permit?
If no to 7.1 , does your hospital have a State air permit?
Hospital/Medic al/Infectious Waste Incinerators - 40 CFR Part 62 Subpart HHH
Does your hospital operate a medical waste incinerator on-site?
Y



N



DK



NA



-244-
-------
7.0 Clean Air Act (CAA)

"7 >
1.6
1 1
7.8
7.9
7.10
7.11
7.12
7.13
7,14
7.15
7,16
7.17
7.18
Tip: For more information visit EPA '; Air Toxic website,
ktfp ;.''>v/ww. eoa. FOV ft?? /a nv/J 29/'"km iwi/tikm ml. kntil
If yes to 7.4. has EPA.-' State been notified and the incinerator tested?
New Source Performance Standards - 40 CFR Part 60
Does your hospital have boilers constructed (manufactured) or modified after June 9, 1989 with heat
input between 10-100 MMBTU'nr or larger"1
If yes to 7.6, did your hospital notify EPA and.'or the State that you are subject to the New Source
Performance Standard (NSPS)n
Chlorofluorocarbon (CFC)
Does your hospital use a certified technician to service your refrigeration units with freon?
If your hospital uses in-house certified technicians, is your recovery ''recycling equipment registered
with EPA9
Are annual CFC leak rate records and maintenance and repair records maintained for the refrigeration
arid air conditioning system having over 50 Ibs of CFC normal refrigerant charge for a period of three
years0
Mobile Sources
Does your hospital have vehicle gasoline dispensing units on-site?
Specify annual throughput gal/vr

If yes to 7.11, are these units equipped with Stage 2 vapor recovery equipment?
Does your hospital prohibit hospital operated vehicles from idling?
Asbestos - 40 CFR Part 61
Has your hospital undergone any demolition-renovation within the last IS months?
Tip: For more information asbestos, visit kttp:/ywww.epa.gov/asbesToz!
Has the hospital removed any asbestos from any facility components within the last 18 months?
If yes to either 7.14 or 7. 15. was notification for the project provided fo your1 State asbestos regulatory
agency?
If yes to 7.15 and 7.16, was the area where the renovation/demolition occurred "thoroughly inspected"
for the presence of asbestos prior to carnrneneetnent of the renovation/demolition activity?
Other
If you have a helicopter landing site, is exhaust prevented from entering the hospital?
Y















N















DK















NA















8.0 Federal Insecticide, Fungicide & Rodeaticide Act (FIFRA)
8.1
8.2
8.3
8.4
8,5
Does your hospital mix/blend your own pesticides? (Pesticides include: disinfectants, sterilants. germicides,
algicides, virucides. swimming pool compounds, insecticides, fungicides, herbicides, etc.)
If your hospital uses your own janitorial employees to apply disinfectants and other pesticides, do you
offer/provide training as to the proper use of pesticides?
Does your hospital use any "Restricted Use" pesticides9 (Note: Refer to the label)
If yes to 8.3. is the pesticide applied by a certified applicator or under direct supervision of a certified
applicator''
Are your hospital pest control operators licensed/certified by the state to apply pesticides?
Y





N





DK





-245-
-------
9.0 Clean Water Act (CWA)
9.1
9.2
9.3
Have all the wastewater discharges been identified and evaluated to determine whether they are being properly
managed? (Note: If the hospital discharges wastewater into a municipal sewer system you should check with
local publicly owned treatment works (POTW) for regulatory requirements.)
Is, your hospital's wastewater directly discharged iato surface water or groundwater?
If yes to 9.2, does your hospital have a National Pollutant Discharge Elimination System (NPDES) permit?
Y



N



BK



10.0 Toxic Substances Control Act (TSC A) (40 CFR 761) - Potychlorinated Biphenyl (PCB)
10.1
10.2
10.3
Does the hospital have any PCB-containing electrical equipment ou-site?
If yes to 10.1, is the PCB-coutainmg equipment properly identified"
If yes to 10.1, does your hospital inspect PCB-containing equipment regularly for leaks and keep records of
the inspections?
Y



N



DK



11.0 Lead Paint
11.1
11.2
11.3
11.4
Has your hospital sold or leased housing built before 1978?
If yes to 11.1. did your hospital disclose potential and known lead-based paint and lead-based paint
hazardous?
If yes to 11.1. did your hospital give buyerv'renters the pamphlet titled "Protect Your Family from
Lead in Tow Home".
If yes to 11.2. are disclosures documented and the records kept for three years?
Y




N




DK




KA




Section III: Pollution Prevention
This section includes additional voluntary actions your facility can consider That may reduce environmental
liability, waste disposal costs, and worker exposure.

Tip: H2E or Hospitals for a Healthy Environment is national vohmtaty program, which has set goals for mercun- toxics elimination and
solid waste reductions specifically for tke. healthcare industiy. This program provides technical support and recognition for the indusny.
Read more about H2E or join as art H2Eparti\er by reading more ®t Ml3L±ij2£±Jl2nxw. k2e~
£!lli[JL2DiiLj!££i^^
Have you replaced mercury thermometers (If yes. specify alternatives in the notes section)
"in lab?
hospital patients9
in dispensing to outpatients including newborns1?
Have vou replaced mercury blood pressure units? If ves. specify alternative

Have you replaced other mercury containing cantor tubes, dilators, etc?
Have you identified which iab chemicals you use that contain mercury?
Have you replaced lab chemicals containing mercury?
Do you still purchase any equipment containing mercury?
Y







N







Some







DK







NA







                                                    -246-
-------
2.0 Solid Waste
Tip: For more information on Waste Reduction visit http:Vwww. h2e-online.org/iooh/vaste,htm

2.1 Do you donate/cooipost any of the following (Check all that apply)?
    _Food scrap/plate waste
    _Laudscape waste
                    _ Edible food
                     Medical device/equipment
                                        _ Office equipment
                                         Linen
2.2 Do you recycle any of the following materials?  (Check all that apply)
  	Paper, white
  	Paper, color
  	Cardboard
  	Newspaper
  	Boxboard
   Baiteiies
  _ Nickel cadmium
  _  Alkaline
  _  Mercury
     Lead acid
    _Tyvek
    Mattresses
	Lead aprons
Plastics
	  #1 PET
	S2HDPE
	«PVC
	#4LDPE
	£5 Polypropiene
     #6 PS"
_Toner cartridges
_Ink jet cartridges
_Printer ribbons
_Ccfflputers
_Ice packs/coolers
_Fluorescent lamps
_Scrap metal
_Motor oil                   	Expired Pharmaceuticals (reverse
_ Construction/demolition waste    distribution)
_Other (Please specify)	
Xray films
Silver recovery
Solvents/fixers
Foam peanuts
Shrink wrap
Mercurv
Sharps
Wood
Pallets
Cookine oil
Glass
Steel cans
Aluminum cans
Grass/leaves
2.3 Does, your hospital reuse any of the following materials?
If you do not reuse enter 0; otherwise specify either < 50?% 50%, >50% or 100%.  Write DK if you do not know and NA if not applicable.
Dietary
Dishware, patient
Dishware, employee
Glassware
Cutlery
Baking pans
Metal travs

Other






Reusable
(%)














Patient care
Bath basins
Mattress overlays
Water pitchers
Bed pans
Urinals
Pillows

Towels

Underpads (Chux)
Exam gowns
Linens
Other

Reusable
(%)














Surgerv
Instrument pans
Splash basins
Medicine cups
Gowns
Towels
Drapes

Other






Reusable
(%}














Equipment
Ventilator tubing
Ambu bags
Pulse oximeters
Suture removal kit
Vaginal speculnms
Other








Reusable
(%}














2.4  How much solid waste does your hospital generate per year (tons/year)?	
2.5  How many tons/year did your hospital recycle?	for calendar year
2.6  What percentage of your hospital's waste is medical red bag waste?   	
                                                             for calendar year
                                                        % for calendar vear
2.7  How does your hospital dispose of your medical red bag waste? (Please check)
	incinerate (offsife)  	incinerate fonsite)   	autoclave (offsite)   	autoclave (onsite)
	Other( specify)	
                                                        -247-
-------
3.0 Purchasing
Tip: To read more about green purchasing visit hfip:/,-'\vww.h2e-online.org/tooh/gmpi!rch/epp.htm
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
Has your hospital instituted purchasing policies in any of the following areas0 (Check all that apply)
	 "Green" Product 	 Low VOC products 	 PVC products and DEHP products
	 Energy Star products 	 Latex 	 Specifying recycled content in products
Less toxic materials Mercury' Other (Specify)

Has your hospital called upon vendors and your Group Purchasing Organization (GPO) to identify and
develop alternatives for harmful and/or wasteful products and materials'1
Has your hospital worked with suppliers to minimize wasteful packaging?
Does your hospital receive supplies in reusable shipping containers';1
Does your hospital use office paper with at least 30° i recycled content0
Has your hospital evaluated alternatives- to Polyvinyl Chloride (PVC) and DEHP containing products?
Does your hospital purchase non-toxic/less toxic alternatives for janitorial chemicals'1
Do you use Ethyleue Oxide at your hospital'1
If yes to 3.3. have you evaluated alternatives?
Does your hospital have a central system in place for tracking and quantifying the amount of chemicals
purchased, dispensed and disposed of
Does your hospital track the quantity or amount of green products and services used11
Y











N











DK











4,0 Energy/Water Conservation
Tip: To view Energ)>Star information for Healthcare visit hnp://20S. 254.22. 6/index.cfhi?c=healthcare. bus healthcare
4,1
4.2
4.3
4.4
4.5
4,6
4.7
Have you created a baseline of energy performance for your hospital using the EPA's benchmarking tool0
Tip: To view the Energy Star hospital benchmarking fool visit
hftp:/s208. 254.22. 6/iHdex.cfni?c=eligibility\bu5^ortfoliomanagerjitigibilit}'_kospitak
Has your hospital done aa energy management review within the last 3 years?
Has your hospital implemented \vithiu the last three years any of the following? (Check all that apply)
Heating/ventilation upgrades Control ventilation rates to minimum requirements
Ail' side cooling economizer cycle Energy efficient lighting upgrades
Prcgramable thermostats Lighting occupancy sensors

Does your hospital purchase EnergyStar equipment? (Check all that apply)
Computers Fax machines Roofing Products
Monitors Printers Transformers
Copiers TVs Dishwashers
Scanners Exit sisns. Commercial refrigerator.'freezers
Multifunction devices Water coolers Other (Specify)

Has your hospital assessed its water usage?
Tip to read about water conservation visit http:-''Aww.h2f:-online.org/took'Vt'ate>'-ktjn
Have you implemented a water conservation program?
Does your hospital use any of the following water-efficient equipment or practices0 (Check all that apply)
Low flow toilets Flow control mechanisms Regular inspection and repair of leaks
Low flow faucets Recirculating coolins water LaadscapinE-irripation
Automatic faucet shut off Recirculate sterilizer water Low water Xray process
Low flow showerheads Kitchen Other (Specify)
Y







N







DK







-248-
-------
Section TV: General

4.1 Does your hospital have an Integrated Pest Management (IPM) program?
                                                                             Yes
                                                                                       No
Don't Know
4.2 What environmental topics, would you like more training in? (Check all that apply)

                                                       	Solid waste recycling
                              	CAA               	Solid waste recycling    	Energy Management Systems
                              	SPCC                   Red bag waste reduction   	Energy conservation
                              	EPA Audit Program 	Resource management   	Green buildings
	                           	Mercury            	Wafer conservation      	Environmental Management System
	Integrated Pest Management  	Green purchasing     	Other (Specify)	
_General compliance
_RCRA - hazardous waste
_Universal Waste
 EPCRA
4.3 What are your top three training needs?
    Priority 1	Priority 2
                                                                           Priority 3
4.4 Has your hovpital taken any action not covered above to improve environmental performance?  Please specify.
Notes on any questions above:

Question number
                                                           Comments
 Conditionally Exempt Small Quantity Generator (CESQG) i? a generator who- generate; less than 100 kg'month (about 220 Ibsonouth) and ne\"er
acainmlates more than 1000 kg (22001bs) or more. (Note220Ibs is about half a 55 gallon drum)

''Small Quantity Generator (SQG) is a generator who generates more than  100 kg/mondi (2201bsviuonth) but less than 1000 kg/month (2200 Ibs'month))

3 Large Quantity Generator (LQG) is a generator who generates more than 1000 Ig/rnontfa (2200 Ibsv'month) or generates 1 kg (2.2 Ibs) or more of an
acutely hazardous or severely toxic waste.

 Federal definition includes battenes( eg. nickel cadmium), pesticides, lamps, and thermostats
                                                       -249-
-------
-------
                                - APPENDIX E -
                 COMPLIANCE: A SUPPLEMENT TO
               LEGAL AND OTHER REQUIREMENTS
    This resource compendium provides a starting point for identifying and maintaining compliance
requirements. Be sure to check with state and local regulators to determine final requirements.*


                   Federal Regulation of Medical Waste
    Each federal agency develops regulations related to its direct responsibilities. For example, the U.S.
Environmental Protection Agency (US. EPA) is charged with protecting the air, land and water from improper

management practices while the Department of Transportation is responsible for the safe transport of
infectious and hazardous waste over the nation's roadways.
    Regulation of hazardous waste is the responsibility of multiple, separate agencies of the federal
government including the following:
       U.S. Environmental Protection Agency (http://www.epa.gov)
       National Institutes of Health, Centers for Disease Control (http://www.cdc.gov)
       U.S. Department of Health and Human Services (http://www.hhs.gov)
       U.S. Food and Drug Administration (http://www.fda.gov)
       U.S. Department of Labor, Occupational Safety and Health Administration (http://www.osha.gov)
       U.S. Department of Transportation (http://www.dot.gov)
       U.S. Coast Guard (http://www.uscg.mil/USCG.shtm)
       U.S. Postal Service (http://www.usps.com)
       U.S. Department of Energy, Nuclear Regulatory Commission (http://www.energy.gov)
     * While the U.S EPA has made every effort to ensure the accuracy of this information, a regulated entity's legal obligations are
also determined by the terms of its applicable environmental facility-specific permits, underlying statutes and applicable state and
local law. States and local regulating bodies may impose more stringent requirements than those established by the U.S. EPA and
other federal agencies. It is beyond the scope of this compliance chapter to list the requirements of all federal,  state and local
regulatory bodies.
Click here to return to Table of Contents.
-------
Code of Federal Regulations (CFR) and the Federal Register

     The Code of Federal Regulations (CFR) is referenced throughout this compliance chapter at the end of

each act. To search the CFR, go to the Electronic Code of Federal Regulations (e-CFR) at

http://www.gpoaccess.gov/ecfr/. The e-CFR consists of two linked databases: the "current code" and

"amendment files." The Office of Federal Register updates the current code database according to the

effective dates of amendments published in the Federal Register.  The Federal Register is the official daily

publication of rules, proposed rules and notices of federal agencies and organizations as well as executive

orders and other presidential documents. The Federal Register is available online at

http://www.gpoaccess.gov/fr/index.html.


                                      Clean Air Act

     Through the enforcement of the Clean Air Act (CAA), the U.S. EPA protects and enhances the quality of

the nation's air to promote public health and the environment. The CAA addresses permitting programs,

criteria pollutants, hazardous air pollutants, mobile sources, acid rain control and stratospheric ozone

protection.


Common CAA violations and problems found at hospitals:
•      Failure to use properly trained and accredited asbestos personnel
•      Failure to notify U.S. EPA of asbestos removal projects and to keep required documentation/record
       keeping
•      Failure to properly dispose of asbestos debris
•      Failure to have CFC leak rate records for chillers and air conditioning units more than 50 pounds of
       charge
•      Failure to have U.S. EPA certified technicians for CFC containing air conditioning and refrigeration
       systems
•      Failure to get boilers permitted with the state agency
•      Failure to apply for Title V operating permit

     The U.S. EPA Region 2 health care Web site lists common violations/problems found at hospitals and

fact sheets on environmental requirements for hospitals, http://www.epa.gov/region02/healthcare/


CAA Common Areas for Inspections

     For the most part, a U.S. EPA air inspector will primarily be interested in five areas of a hospital:  air

conditioning and refrigeration, asbestos, boilers, Title V operating permit and medical waste incinerators.
                                             -252-
-------
Air Conditioning and Refrigeration Service

     Under Section 608 of the Clean Air Act, the U.S. EPA has developed regulations to reduce the emissions

of environmentally harmful refrigerants into the environment to the "lowest achievable level" during the

servicing and disposal of air conditioning and refrigeration equipment. This site also contains CAA Section

608 fact sheets, http://www.epa.gov/region02/cfc/


Asbestos

     A hospital that performs demolition and renovation operations will be subject to the CAA National

Emission Standards for Hazardous Air Pollution (NESHAP) for asbestos. Asbestos must be removed prior to

demolition or renovation and proper precautions must be made, such as wetting down the materials to keep it

intact. No asbestos is to be striped, removed or otherwise handled or disturbed unless at least one authorized

representative trained in NESHAP asbestos regulations is present. A written notice of intention to demolish

or renovate must be submitted to the U.S. EPA at least 10 working days prior to start of construction.

     Also the Toxic Substance Control Act (TSCA) comes into play with asbestos removal under the

Asbestos Hazardous Emergency Response Act (AHERA) and the Asbestos Model Accreditation Plan (MAP),

which expands AHERA's training requirements to include not only schools but all public and commercial

buildings, including hospitals.  Under AHERA, a facility must have personnel, trained by the U.S. EPA or

state approved instructors, conducting the asbestos removal..

     "Public and commercial building" means the interior space of any building which is not a school

building, except that the term does not include any residential apartment building of fewer than 10  units or

detached single-family homes. The term includes, but is not limited to: industrial and office buildings,

residential apartment buildings and condominiums of 10 or more dwelling units, government-owned

buildings, colleges, museums, airports, hospitals, churches, preschools, stores, warehouses and factories.

Interior space includes exterior hallways connecting buildings, porticos and mechanical systems used to

condition interior space.
     http://www.epa.gov/asbestos/
     http://www.epa.gov/region02/ahera/


Boilers

     Most hospital boilers are subject to the Federal New Source Performance Standards (NSPS) regulations.

The applicable regulations can be found at 40 CFR Part 60 Subparts Db and DC. Subpart Db applies to the


                                             -253-
-------
larger boilers (greater than 100 million BTU/hr), which were constructed after June 19, 1984, whereas
Subpart DC applies to the smaller boilers (between 10 and 100 million BTU/hr), which were built after June
8, 1989. Depending on the type of fuel combusted, the regulations have emission standards for sulfur
dioxide, nitrogen oxide and particulate matter. The NSPS also have requirements for monitoring and record
keeping.
     http://www.epa.gov/ttn/atw/boiler/boilerpg.html


CAA Title V Operating Permit
     Existing major industrial sources (including hospitals) are required to obtain a legally enforceable Title
V operating permit. The operating permit program is a national permitting system that consolidates all of the
air pollution control requirements into a single, comprehensive "operating permit" that covers all aspects of a
source's yearly air pollution activities after the source has begun to operate. A Title V operating permit grants
a source permission to operate. The permit includes  all air pollution requirements that apply to the source,
including emissions limits and monitoring, record keeping and reporting requirements. State and local
permitting authorities issue most of the permits required by Title V of the Clean Air Act. (40 CFR part 70
permits). However, the U.S. EPA issues Title V permits (40 CFR part 71 permits) to sources in Indian country
and in other situations as needed.
     http://www.epa.gov/air/oaqps/permits/whogets.html
     http://www.epa.gov/air/oaqps/permjmp.html


Medical Waste Incinerators
     Under the CAA, the U.S. EPA regulates air emissions from hospital and/or medical/infectious wastes
incinerators (HMIWI).  When burned, medical waste may emit air pollutants, including hydrochloric acid
(HC1), dioxins and  furans and metals, such as lead (Pb), cadmium (Cd) and mercury (Hg).  Therefore, the
U.S. EPA has developed emission standards that apply to incinerators used by hospitals and health care
facilities as well as those used by commercial waste treatment and disposal companies to treat medical waste.
The emission guidelines are intended to meet the requirements of the CAA, and states must establish
standards that are at least as protective. These standards will result in reductions in the air emissions of
concern from HMIWI.
     http: //www. epa.gov/ttn/atw/129/hmiwi/rihmiwi .html
                                              -254-
-------
Clean Air Technology Center (CATC)

     The Clean Air Technology Center (CATC) serves as a resource for all areas of emerging and existing air

pollution prevention and control technologies and provides public access to data and information on use,

effectiveness and cost. In addition, the CATC provides technical support, including access to the U.S. EPA's

knowledge base, government agencies and others, as resources allow, related to the technical and economic

feasibility, operation and maintenance of these technologies. Go to http://www.epa.gov/ttn/catc/ or call (919)

541-0800. For publications, call (919) 541-2777.
     For more information on the CAA visit the Web links below.
     CAAhttp://www.epa.gov/oar/oaq_caa.html
     CAA http://www.epa.gov/region5/defs/html/caa.htm
     CAA http://www.epa.gov/ebtpages/air.html
Federal CAA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Part 50-99

     * Also look at the Federal TSCA regulations under Appendix C to Subpart E of Part 763 Asbestos Model

Accreditation Plan, (http://www.epa.gov/compliance/civil/programs/tsca/tscaenfprog.html)
                                     Clean Water Act

     The Clean Water Act (CWA) is the primary federal statute regulating the protection of the nation's

waters.  The CWA established national programs for prevention, reduction and elimination of pollution in

navigable water and groundwater, including a water quality standards program, a permit program for

discharge and treatment of wastewater and stormwater and an oil pollution prevention program.

     The U.S. EPA protects water resources primarily through the National Pollution Discharge Elimination

System (NPDES), the regulatory program reinforcing the CWA, which restores and maintains the chemical,

physical and biological integrity of the nation's waters. The CWA eliminates the discharge of pollutants,

including contaminated stormwater, solid waste, biological materials, sewage, chemical wastes and

radioactive materials to surface waters through dredge and fill prohibitions and end-of-the-pipe effluent

limits.
                                              -255-
-------
Common CWA violations and problems found at hospitals:
•      No permit for or noncompliance with wastewater discharges
•      Failure to know about local treatment plant sewer use regulations and possible prohibited discharges
       for indirect dischargers
•      No or inadequate secondary containment of storage tanks
•      Improper disposal down floor drains
•      Failure to have a Spill Prevention Control Countermeasure (SPCC) plan in place
CWA common areas for inspections

     Generally, a U.S. EPA water inspector will primarily be interested in three areas of a hospital:

wastewater discharges, stormwater discharges and any aboveground or underground oil storage containers.


Wastewater Discharges

     The water regulations establish two different permitting programs for wastewater discharges.  Facilities

that discharge directly to waters (e.g., rivers, lakes, oceans) of the United States are covered by the National

Pollutant Discharge Elimination System (NPDES) Permit Program. These facilities are known as direct

dischargers.  Facilities that discharge to municipal wastewater treatment plants are covered by the

Pretreatment Program.  These facilities are known as indirect dischargers. Most hospitals are indirect

dischargers.

Indirect Dischargers

     Hospitals, which are indirect dischargers, are subject to regulations by the local sewer authority.

Currently, about 1,500 of the nation's largest municipalities are required to implement industrial pretreatment

programs, which include issuing industrial user permits to significant industrial users. Some municipalities

have determined hospitals to be significant industrial users.

     Most municipalities have established local prohibitions that apply specifically to medical waste

discharges. For example, some municipalities have set a prohibition on "all medical waste." Other

prohibitions include, for example, no discharge of discernible body parts, no human remains greater than 0.5

inches in diameter, and/or no radioactive wastes. The ability of municipalities to establish prohibitions to

meet their specific needs/interests is very flexible.

     Federal pretreatment regulations prohibit discharges of fire or explosion hazards; corrosive discharges

(pH < 5.0); solid or viscous pollutants; heat (in amounts that cause the treatment plant influent to exceed 104

degrees F); pollutants that cause toxic gases, fumes or vapors; and any  other pollutant (including oil and


                                              -256-
-------
grease) that will interfere with or pass through the treatment plant.






Direct Dischargers



     Hospitals, which are direct dischargers of process and sewer wastes, must be permitted (e.g., obtain a



permit) for any point source discharge of pollutants to waters of the United States. These permits are issued



either by the U.S. EPA or the state, where the state has been authorized to implement the NPDES Permit



Program.  The federal  regulations establish the permit application and permit requirements. Specific numeric



limitations that apply to a medical facility depend on the receiving stream of the discharge. For detailed



information on numeric limitations, contact your U.S. EPA Regional pretreatment coordinator. Contact



information can be found at the following Web site:



     http ://cfpub .epa.gov/npdes/contacts .cfm?program_id=3 &type=REGION.






Stormwater Discharges



     U.S.  EPA's NPDES Web site, http://cfpub.epa.gov/npdes, provides technical and regulatory information



about the National Pollutant Discharge Elimination System (NPDES) Permit Program, which controls water



pollution by regulating point sources (e.g. pipe, ditch) that discharge pollutants into waters of the United



States. The stormwater program is part of the NPDES Permit Program and is designed to prevent the



discharge of contaminated stormwater into navigable waters.



     http://cfpub.epa.gov/npdes/home.cfm?program_id=6



     Phase I of the stormwater program was promulgated in 1990 and applied to medium and large municipal



separate storm sewer systems (MS4), certain industrial facilities (not hospitals) and any construction activity



disturbing greater than five acres (large construction sites).



     Phase II of the stormwater program was promulgated in 1999 and applies to small municipal separate



storm sewer systems (MS4) and construction activity greater than one acre and less than five acres (small



construction sites). Public hospitals located in urbanized areas are regulated under this new rule. Any



hospital located in urbanized or rural areas that plan construction activities should look into obtaining a



stormwater NPDES permit for construction.



     The term MS4 does not solely refer to municipally owned storm sewer systems, but rather  is a term with



a much broader application that can include, in addition to local jurisdictions, state departments of



transportation, universities, local sewer districts, hospitals, military bases and prisons. An MS4 is not always
                                              -257-
-------
just a system of underground pipes; it can also include roads with drainage systems, gutters and ditches.

Hospitals in urbanized areas should consult with the state NPDES authority to evaluate whether a permit

authorization is required.

     The regulatory definition of an MS4 is provided in 40 CFR 122.26(b)(8).  General stormwater

information can be found at http://cfpub.epa.gov/npdes/home.cfm?program_id=6, and the Stormwater Phase

II Compliance Assistance Guide at http://www.epa.gov/npdes/pubs/comguide.pdf.

Aboveground or Underground Oil Storage Containers

     The U.S.  EPA's oil spill program (http://www.epa.gov/oilspill/) provides information about the U.S.

EPA's program for preventing, preparing for and responding to oil spills that occur in and around inland

waters of the United States.  If a hospital uses or stores oil, it may be subject to the Spill Prevention Control

Countermeasure (SPCC) rule.  Hospitals with an aboveground oil storage capacity of greater than 1,320

gallons, or total completely buried oil storage capacity greater than 42,000 gallons must prepare and

implement a SPCC Plan to prevent any discharge of oil into or upon navigable waters of the United States or

adjoining shorelines.

     On July 16, 2002, the U.S. EPA promulgated a revised final SPCC regulation, which became effective

August 17,  2002.  The U.S. EPA subsequently extended the regulatory compliance schedule included in the

new SPCC  rule. The current compliance dates for the new rule are as follows:

•       August 17, 2004: Facilities must prepare and P.E. (professional engineer) certify an SPCC Plan in
        accordance with the new SPCC rule by this date;
•       February 18, 2005: The revised SPCC Plan must be implemented.


     In the interim, facilities are required to maintain the existing SPCC Plans and amend in accordance with

40 CFR §112.5.
Typical records that a U.S. EPA inspector may ask to review under the CWA are:
       Industrial User permit (IU permit) for discharges to the local municipality (indirect discharge). Most
       hospitals are indirect dischargers.
       Spill Prevention, Control and Countermeasure (SPCC) Plan. The plan is to prevent any discharge of
       oil into or upon navigable waters of the United States or adjoining shorelines.
•      Phase II stormwater permits under the National Pollution Discharge Elimination System (NPDES)
       program for public hospitals located in an urbanized area.
•      NPDES construction stormwater permits (Phase I and Phase II) are also required for any construction
                                              -258-
-------
       activity greater than one acre for any hospital located in urban or rural areas.
•      National Pollution Discharge Elimination System (NPDES) general permit for discharging directly to
       a water body (direct discharge).
     For more information on the CWA, visit the following Web site: http://www.epa.gov/r5water/cwa.htm

Federal CWA regulations are  set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts:
        100-136
        140
       230-233
       401-471
       501-503


                            Emergency Planning and

                Community Right to  Know Act (EPCRA)

     This act, also known as Superfund Amendments and Reauthorization Act (SARA) Title III, was

designed to promote emergency planning and preparedness at both the state and local levels. It provides

citizens, local governments and local response authorities with information regarding the potential hazards in

their community.  EPCRA requires the use of emergency planning and designates state and local governments

as recipients of information regarding certain chemicals used in the community. SARA Title III, better known

as EPCRA, originated from the Comprehensive Environmental Response, Compensation and Liability Act

(CERCLA, or better known as the Superfund Law).  Like EPCRA Section 304, CERCLA also has hazardous

substance release reporting  regulations under CERCLA Section 103; 40 CFR Part 302. Under CERCLA, the

person in charge of a facility is required to report to the National Response Center (800-424-8802 or http://

www.nrc.uscg.mil) "immediately upon knowledge of a reportable release," any environmental release of a

listed hazardous substance that equals or exceeds a reportable quantity.


EPCRA has four major components:
       Emergency planning (EPCRA Sections 301-303 corresponds to 40 CFR 355.30)
       Emergency release  notification (EPCRA Section 304 corresponds to 40 CFR 355.40 and CERCLA
       Section 103 corresponds to 40 CFR 302)
•      Community right-to-know reporting (EPCRA Sections 311-312)
              Material Safety Data Sheet reporting (40 CFR 370.21)
              Inventory reporting (40 CFR 370.25; 370.40; 370.41)
              •       Report hazardous chemicals above 10,000 Ibs. and/or extremely hazardous
                     substances present at amounts 500 Ibs. or the threshold planning quantity whichever
                     is lower. Reporting mechanism is the annual emergency and hazardous chemical
                     inventory forms, Tier I and Tier II forms. Submit to state emergency response
                     commission and local emergency planning committee and local fire department.  Tier
                     I includes chemical categories, quantities and locations of hazardous chemicals on
                     site.  For a Tier I form, call the hotline at (800) 424-9346. Tier II is a more detailed

                                            -259-
-------
                      list and is recommended over Tier I by the U.S. EPA.  The Tier II form can be
                      downloaded at: http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/tier2.htm/.
                      Hospitals will typically have more than 10,000 pounds of heating fuel and/or
                      gasoline for vehicles; also look at lab quantities (e.g., formaldehyde).
       Toxic chemical release reporting (EPCRA Section 313 corresponds to 40 CFR 372)
       •       Toxic Release Inventory Form R only applies to federal facilities (e.g., Veterans
               Administration hospitals; military health care units).  Public and private hospitals are exempt
               from EPCRA Section 313 reporting.
Common EPCRA violations and problems found at hospitals:
•      Failure to report certain accidental chemical releases that occur.
•      Chemicals are stored on-site above threshold [hazardous chemicals above 10,000 Ibs. and/or
       extremely hazardous substances present at amounts 500 Ibs. or the threshold planning quantity,
       whichever is lower (e.g., heating oil, gasoline)].
Typical records a U.S. EPA inspector may ask to review under the EPCRA:
       Proof of notification for all environmental releases of a listed hazardous substance. "Failure to
       notify" violation will be sited if the National Response Center, state hotline and Local Emergency
       Planning Committee are not notified in a timely fashion.
•      Emergency Response Plans
       Material Safety Data Sheets (MSDS)
•      Tier I or Tier II inventory reporting forms. This inspection is done together with the MSDS. The
       inspector will look at what materials are stored and in what quantity and if subject to reporting
       requirements. The federal government prefers the more detailed Tier II inventory form.
•      U.S. EPA Toxic Release Inventory Form R for federal health care facilities report on every chemical
       manufactured, processed or used.  Form R contains facility identification information and chemical
       specific information (toxic chemical identity; mixture component; activity and uses; maximum
       amount of chemical on site during calendar year; quantity;  transfers; discharges; on-site waste
       treatment; on-site energy recovery; on-site recycling; source reduction/recycling).
Several compliance assistance tools that can help medical facilities comply with EPCRA:
       U.S. EPA Call Center RCRA, Superfund, EPCRA http://www.epa.gov/epaoswer/hotline/ (800) 424-
       9346 or D.C. area local (703) 412-9810, TDD (800) 553-7672 or TDD D.C. area (703) 412-
       3323 Monday - Friday 9:00 a.m. - 5:00 p.m. Eastern time. Closed federal holidays.
       mail to:epacallcenter@bah.com. Note that the call center cannot provide regulatory interpretations.
•      U.S. EPA Document Protocol for Conducting Environmental Compliance Audits under the
       Emergency Planning and Community Right-to-Know Act and CERCLA Section 103 at
       http://www.epa.gov/compliance/resources/policies/incentives/auditing/epcra.pdf
•      U.S. EPA Toxic Release Inventory Web site: http://www.epa.gov/tri/. The Toxic Release Inventory
       (TRI) is a publicly available U.S. EPA database that contains information on toxic chemical releases
       and other waste management activities reported annually by certain covered industry groups as well
       as federal facilities.
•      U.S. EPA Superfund Web site: http://www.epa.gov/superfund/ Links to tools such as Enviromapper,
       which maps hazardous waste sites in your community, guidance documents, current news events,
       success stories and more.
                                              -260-
-------
For more information on EPCRA visit the following Web sites:
•      http://www4.law.cornell.edu/uscode/42/chl 16.html
       http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/epcraOverview.htm
•      http://yosemite.epa.gov/oswer/ceppoweb .nsf/content/result.htm?OpenDocument&list%20of%201ists
       http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/epcra_law.htm
•      http://www.epa.gov/region5/defs/html/epcra.htm
"List of Lists" - Consolidated list of chemicals subject to EPCRA and CAA Section 112(r). Used to help

facilities handling chemicals determine whether they need to submit reports under sections 302, 304, 311,

312, or 313 of EPCRA and, for a specific chemical, what reports may need to be submitted. It will also help

facilities determine whether they will be subject to accident prevention regulations under CAA section 112(r)

and lists "unlisted hazardous wastes" under RCRA: http://www.epa.gov/ceppo/pubs/title3.pdf

Federal EPCRA regulations are set forth in the Code of Federal Regulations (CFR) in 40 CFR Parts:
       302
       55
       370
       372


  Federal Insecticide, Fungicide and Rodenticide Act (FIFRA)

     The U.S. EPA has established requirements under the Federal Insecticide, Fungicide and Rodenticide

Act (FIFRA) for medical waste treatment technologies that use chemicals for treating waste.  In hospitals,

chemical pest control helps contain the spread of infection, reduces infestations with vermin and is used in

kitchens, cafeterias, patient rooms, public areas and offices. Under FIFRA, alternative medical waste

treatments that use chemicals are considered pesticides and require registration by the U.S. EPA. Cleaning

disinfectants are also considered pesticides under FIFRA and require registration. Check labels to make sure

they have a U.S. EPA registration number and are used properly as the label indicates.  Registration is a

scientific, legal and administrative process where the chemical ingredients are carefully examined to

determine the amount, frequency and timing of use, storage and disposal practices. The U.S. EPA assesses a

wide variety of potential environmental and human health effects associated with use of the product including

adverse effects on humans, wildlife, fish and plants, as well as possible contamination of surface water or

groundwater.
                                             -261 -
-------
Common violations and problems found at hospitals for FIFRA issues include:
•       Misuse of a registered pesticide product
•       Use of an unregistered product
•       Lack of proper records concerning pest control application within the hospital and/or on the hospital
        grounds
•       Failure to report pesticide poisonings incidents either occurring within the hospital or of admitted
        patients.

Typical physical features to inspect for under FIFRA include:
•       Personnel protection equipment
•       Pesticide application equipment
•       Pesticide storage areas, including storage containers
•       Cleaning disinfectants and labels

Typical records a U.S. EPA inspector may ask to review under the FIFRA include:
•       Records of pesticides purchased (purchase orders, inventory)
•       Pesticide application records
•       Description of the pest control program
•       Certification status of pesticide applicators
•       Pesticide disposal manifests
•       Contract files
•       Recent ventilation rating for pesticide fume hood and pesticide mixing/storage areas

FIFRA compliance  assistance tools include the following:
•       U.S. EPA Office of Pesticides Programs Web site provides information and resources to help
        facilities comply with regulations regarding pesticide use and implement safer means of pest control.
        http://www.epa.gov/pesticides/
•       Registering pesticides for use in the United States at
        http://www.epa.gov/pesticides/regulating/index.htm
•       Pesticides Consumer Alert U.S. EPA fact sheet for all pesticide industry organizations, facilities and
        handlers as a precaution during this heightened state  of security awareness.  This alert highlights
        some general security areas that companies may want to review to ensure that appropriate measures
        are being implemented. http://www.epa.gov/pesticides/factsheets/pest_secu_alert.htm
•       National Pesticide Information Center (NPIC) is a cooperative effort of Oregon State University and
        the U.S. EPA. NPIC provides objective, science-based information about a variety of pesticide
        related subjects, including pesticide products, recognition and management of pesticide poisonings,
        toxicology and environmental chemistry. NPIC also  lists state pesticide regulatory agencies and
        provides links to their Web sites,  http://www.npic.orst.edu/
•       U.S. EPA Document Protocol for Conduction Environmental Compliance Audits under Federal
        Insecticide, Fungicide and Rodenticide Act was developed by the  U.S. EPA to provide guidance to
        regulated entities conducting a review of facility conditions to determine their compliance with
        FIFRA. http://www.epa.gov/compliance/resources/policies/incentives/auditing/fifra.pdf
•       Pest Management in New York State Hospitals, Risk Reduction and Health Promotion: The major
        finding from this report is that pesticides are used widely in New York's hospitals. More than 30
        different pesticide preparations are currently applied  in hospitals across the state. They are used as
        fogs, sprays and powders. They are applied in virtually all areas of hospitals, including areas that
        contain patients, http://www.oag.state.ny.us/environment/hospital95.html
•       Healthy Hospitals-Controlling Pests Without Harmful Pesticides report by Healthcare Without Harm
                                               -262-
-------
       and Beyond Pesticides.  http://www.noharm.org/details.cfin?ID=864&type=document





For more information on FIFRA, go to http://www.epa.gov/region5/defs/html/fifra.htm.



Federal pesticide regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts 150-189







             Resource  Conservation Recovery Act (RCRA)



     The regulation of land-based waste management activity is achieved primarily through the federal



Resource Conservation and Recovery Act (RCRA). The primary goals of RCRA are to protect the



environment and human health from the potential hazards of waste disposal, to conserve energy and natural



resources, to reduce the amount of waste generated and to ensure that wastes are managed in an



environmentally sound manner.  RCRA regulates the management of solid waste, hazardous waste and



underground storage tanks holding petroleum products or certain chemicals. Of concern for health care



facilities is the hazard associated with the land disposal of untreated, infectious or hazardous wastes.



     RCRA Subtitle D regulations focus on state and local governments as the primary planning, regulating



and implementing entities for the management of nonhazardous solid waste, such as household garbage and



nonhazardous industrial solid waste. The U.S. EPA provides state and local agencies with information,



guidance, policy and regulations to help them and the regulated community make sound decisions concerning



waste issues.  To  promote the use of safer units for solid waste  disposal, the U.S. EPA developed federal



criteria for the proper design and operation of municipal solid waste landfills and other solid waste disposal



facilities. Many states have adopted these criteria and have required upgrading or closure  of all



environmentally unsound disposal units.



     RCRA Subtitle C regulations first identify the criteria to determine which solid wastes are  hazardous.



They then establish various requirements for the three categories of hazardous waste handlers: 1) generators,



2) transporters and 3)  treatment, storage and disposal facilities  (TSDFs).  In addition, Subtitle C regulations



set technical standards for the design and safe operation of TSDFs. These standards are designed to minimize



the release of hazardous waste into the environment.  Furthermore, the regulations for TSDFs serve as a basis



for developing and issuing the permits required by the RCRA for each facility. Permits are essential to



making the Subtitle C regulatory program work, since it is through the permitting process that the U.S. EPA or



the state applies standards to TSDFs.  The U.S. EPA conducts compliance evaluation inspections to ensure



that hazardous waste is managed in accordance with applicable laws, regulations and safe handling practices;



works with state agencies to enforce hazardous waste laws where violations are observed;  and helps state and





                                             -263-
-------
local agencies develop and administer hazardous waste management programs.

Common violations and problems found at hospitals for RCRA issues include:
•      Failure to comply with hazardous waste generator regulations and lack of documentation
•      Failure to comply with underground storage tank regulations and lack of documentation
•      Improper or lack of hazardous waste labeling
•      Failure to have waste batteries/fluorescent lamps stored in proper universal waste containers and
       labeled
•      Infrequent or no weekly inspections of hazardous wastes storage/satellite areas
•      Open containers of hazardous wastes
•      Improper disposal of chemotherapy drugs
•      Failure to have hazardous waste determinations on file for all wastes (e.g., some pharmaceutical
       wastes are classified as RCRA hazardous wastes)
•      No or inadequate hazardous waste manifests
•      Throwing hazardous wastes down the drain
•      Failure to have procedure in place to ensure spent aerosol containers are empty before disposal as
       solid waste
•      Improper management of expired pharmaceuticals, paints, etc.
•      Lack of hazardous waste contingency  plan
•      Lack of or inadequate  training of employees in hazardous waste management, handling and
       emergency preparedness
•      Failure to ensure that hazardous waste meets land disposal restrictions
•      Failure to upgrade or close underground storage tanks (USTs) by 12/22/98
•      Malfunctioning leak detection systems on underground storage tanks
•      Improper consolidation of wastes from nearby facilities


Typical physical features to inspect under RCRA:
•      Universal waste storage area
•      Used oil  storage areas
•      Vehicle maintenance facilities
•      Battery storage areas
•      Building maintenance and repair shops
•      Laboratories
•      Bulk storage tank farms
•      Transfer  terminals
•      Secondary containment structures
•      Tank peripheral piping, manifolds, filling and dispensing areas
•      Dispenser pumps and check valves
•      Tank sumps, manway areas
•      Leak detection equipment
•      Overflow alarms or other audible and  visual alarms, sight gauges
•      Fill ports, catchment basins
•      Oil/water separators
•      Clean-up equipment (e.g., absorbent materials, fuel recovery pumps, personal protective gear)
•      Hazardous waste generation sites (e.g., x-ray, chemotherapy, morgue, pathology, etc.)
•      Waste storage areas
•      Satellite  accumulation points
•      Vehicles  used for transport

                                              -264-
-------
•      Container storage areas
•      Shop activities

Typical records an inspector may ask to review under RCRA:
       Notification of Hazardous Waste Activity (U.S. EPA ID No.)
•      Hazardous waste manifests
•      Manifest exception reports
•      Biennial reports
•      Inspection logs
•      Land disposal restriction certifications
•      Employee training documentation
•      Hazardous substance spill control and contingency plan
       Material Safety Data Sheets (MSDSs)
•      Inventory records
•      Spill records - Spill Prevention Control and Countermeasure (SPCC) plans
•      Emergency plan documents
•      Placarding of hazardous waste and hazardous materials
•      Permits, if issued
•      Waste analysis plan(s)
•      Operating record
•      Universal waste transportation/shipping records
•      Used oil analysis records
•      Used oil transportation related documentation
•      Underground Storage Tanks (UST) regarding leak detection performance and maintenance including
       the following:
       •      Monitoring results over the last 12 months
       •      Most recent tank tightness test(s)
       •      Manual tank gauging records
       •      Copies of performance claims provided by leak detection equipment manufacturers
       •      Records of recent maintenance, repair and calibration of on-site leak detection equipment
•      Records of required inspections and test of corrosion protection systems
•      Records of repairs or upgrades of UST systems
•      Site assessment results of closed USTs
•      Results of AST integrity assessments,  sampling, monitoring, inspection and repair work
•      Notification forms and registration records for all in-service, temporarily out-of service and
       permanently closed tanks
•      Waste determinations
Several compliance assistance tools that can help medical facilities comply with RCRA:
•      U.S. EPA's RCRA Web site enables users to locate documents, including publications and other
       outreach materials, that cover a wide range of RCRA issues and topics.
       http: //www. epa.gov/rcraonline/
•      The U.S. EPA RCRA, Superfund and EPCRA call center, http://www.epa.gov/epaoswer/hotline/
       (800) 424 9346 or DC Area Local (703) 412-9810 or TDD (800) 553-7672 or TDD D.C. area local
       (703) 412 3323 Monday - Friday 9:00 a.m. - 5:00 p.m. Eastern time. Closed Federal Holidays.
       mailto:epacallcenter@bah.com. Note that the call center cannot provide regulatory interpretations.
•      RCRA wastes A-Z. http://www.epa.gov/osw/topics.htm
•      Nuclear Regulatory Commission radioactive wastes Web site, http://www.nrc.gov/waste.html
                                             -265-
-------
•      U.S. EPA Document Protocol for Conducting Environmental Compliance Audits of Hazardous Waste
       Generators Under RCRA.
       http://www.epa.gov/compliance/resources/policies/incentives/auditing/hazardous.pdf
•      U.S. EPA Document Protocol for Conducting Environmental Compliance Audits of Treatment
       Storage and Disposal Facilities Under RCRA.
       http://www.epa.gov/compliance/resources/policiesincentives/auditing/rcra.pdf
•      U.S. EPA Document Protocol for Conducting Environmental Compliance Audits for Used Oil and
       Universal Waste Generators Under RCRA.
       http://www.epa.gov/compliance/resources/policies/incentives/auditing/oil.pdf
•      U.S. EPA Document Protocol for Conducting Environmental Compliance Audits of Storage Tanks
       Under RCRA.
       http://www.epa.gov/Compliance/resources/policies/civil/rcra/audstankrcra-rpt.pdf
•      Expired pharmaceuticals and reverse distribution concept. One way of handling outdated
       Pharmaceuticals is by sending them back to their place of origin. There are more than 40
       organizations that will take outdated pharmaceuticals, reprocess them when possible, and properly
       discard them if they cannot be used.  More information is available at the Returns Industry
       Association Web site at http://www.returnsindustry.com.


For more information on RCRA:
•      RCRA: http://www.epa.gov/region5/defs/html/rcra.htm
•      RCRA Subtitle D: http://www.epa.gov/epaoswer/osw/non7hw.htm
•      RCRA Subtitle C: http://www.epa.gov/epaoswer/osw/hazwaste.htm
"List of Lists" - Consolidated list of chemicals subject to EPCRA and CAA Section 112(r). Used to help

facilities that handle chemicals determine whether they need to submit reports under sections 302, 304, 311,

312 or 313 of EPCRA and, for a specific chemical, what reports may need to be submitted. It also helps

facilities determine whether they will be subject to accident prevention regulations under CAA Section 112(r)

and lists "unlisted hazardous wastes" under RCRA at http://www.epa.gov/ceppo/pubs/title3.pdfRCRA.


Federal RCRA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts: 240-282


                       Safe Drinking Water Act  (SDWA)

     The Safe Drinking Water Act (SDWA) protects public health by requiring public water systems to

monitor for specified contaminants on a periodic basis and by mandating underground injection requirements

for waste disposal into underground injection wells.  It does this by directing the U.S. EPA to set maximum

contaminant levels for regulated contaminants found in public water supply systems, establishing

underground injection control and sole-source aquifer/wellhead protection programs and prohibiting the use

of lead pipes, solder or flux in the installation and  repair of any public water systems or any plumbing in a
                                             -266-
-------
residential or nonresidential facility providing water for human consumption.

     The SDWA established the Underground Injection Control (UIC) Program to provide safeguards so that

injection wells do not endanger current and future underground sources of drinking water.  The most

accessible fresh water is stored in shallow geological formations called aquifers and is the most vulnerable to

contamination. Aquifers feed our lakes; provide recharge to our streams and rivers, particularly during dry

periods; and serve as resources for 92 percent of public water systems in the United States.  To assure that

underground injection will not endanger drinking water sources, the SDWA provides that all underground

injections are authorized by a permit. For a hospital an injection well can constitute any bored, drilled  or

driven shaft or a dug hole, where the depth is greater than the largest surface dimension that is used to

discharge fluids underground as well as any on-site drainage systems, such as septic systems, cesspools and

stormwater wells, that discharge fluids only a few feet underground. Hospitals and doctors' offices must make

sure that what they pour down a drain goes to a sewer, not a drywell or septic system.

     A hospital would be considered a non-transient noncommunity water system (e.g., a public water

system) if it regularly serves at least 25 of the same people six months per year from its own water source.

The hospital would thus be required to comply with SDWA monitoring and reporting requirements.

Typical physical features to  inspect under SDWA:
•       Safe drinking water inspectors will primarily be concerned with any underground injection control
        wells at the hospital.

Several  compliance assistance tools that can help medical facilities comply with SDWA:
•       U.S. EPA Safe Drinking Water Hotline provides up-to-date information on recently promulgated
        standards and regulations that have appeared in the Federal Register and answers questions.
        (800) 426-4791 or http://www.epa.gov/OGWDW/drinklink.html
•       U.S. EPA's Groundwater and Drinking Water Web site provides information and resources that help
        facilities ensure safe drinking water and protect ground water, http://www.epa.gov/ogwdw/
•       Safe Drinking Water Academy/The Drinking Water Academy (DWA) provides training and
        information to help  U.S. EPA, states, tribes and others increase their capability to implement the
        1996 Safe Drinking Water Act amendments. Training will, in turn, promote better compliance  and
        encourage greater public health protection.  The academy will develop courses designed to meet the
        training needs of the Public Water System Supervision, Underground Injection Control and Drinking
        Water Source Water Protection programs, http://www.epa.gov/safewater/dwa/
•       Safe Drinking Water Academy Underground Injection Control on-line training module.
        http://www.epa.gov/safewater/dwa/electronic/uic.html


For more information on SDWA:
•       http://www.epa.gov/region5/defs/html/sdwa.htm
•       Underground Injection Control general information, http://www.epa.gov/safewater/uic.html
                                              -267-
-------
Federal SDWA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts 141-149
       Also look at Underground Injection Control Program: Part C of the SDWA, 40 CFR Part 144-148


                    Toxic Substances Control Act (TSCA)

     The Toxic Substances Control Act (TSCA) protects human health and the environment by requiring the

testing of certain potentially hazardous chemicals and establishing regulations that restrict the manufacturing,

processing and use of such chemicals. Health care facilities may be subject to TSCA through the lead hazard

reduction regulations in the event of lead-based paint issues possibly at staff residential units, especially those

built before 1980 Note: Use of lead-based paint was outlawed in 1978. However, lead-based paint was still in

circulation and used after 1978.

Common violations and problems found at hospitals for TSCA issues:
TSCA inspectors will primarily be interested in any PCBs and lead-based paint at the hospital.
Typical staff residential area lead paint violations/issues:
•      Failure to notify residents of lead-based paint in the building or lack of knowledge of any lead hazard.
•      Failure to provide the U.S. EPA's pamphlet, "Protect Your Family from Lead in Your Home" as
       required under 40 CFR Part 745.107(a)(l). http://www.epa.gov/opptintr/lead/leadpdfe.pdf


Typical physical features to inspect for PCB 's, asbestos and lead-based paint under TSCA.
•      PCB storage areas
•      Equipment, fluids, and other items used or stored at the facility containing PCBs. PCBs are most
       likely to be found in electrical equipment such as transformers, capacitors, and possibly fluorescent
       light ballasts in older (pre-1980s)  fixtures.
•      Pipe, spray-on, duct, and troweled cementitious insulation and boiler lagging
•      Ceiling and floor tiles


Several compliance assistance tools that can help medical facilities comply with TSCA:
•      TSCA Hotline provides up-to-date technical assistance and information about programs implemented
       under TSCA, the Asbestos School Hazard Abatement Reauthorization Act, the Residential Lead-
       Based Paint Hazard Reduction Act and the Pollution Prevention Act.  In addition, the hotline
       provides a variety of documents, including Federal Register notices, reports, brochures and booklets.
       The hotline is a free service available to the public, state and local governments, federal agencies,
       environmental and public interest groups, and members of the United States Congress.
       Call (202) 554-1404 or mailto:tsca-hotline@epa.gov.
•      National Lead Information Center (NLIC) provides the general public and professionals with
       information about lead hazards  and their prevention. NLIC operates under a contract with funding
       from the U.S. EPA, the Centers for Disease Control and Prevention and the Department of Housing
       and Urban Development, http://www.epa.gov/opptintr/lead/nlic.htm
•      U.S. EPA's Lead Program Web site provides information and documents on how to comply with
       U.S. EPA's lead regulations and reduce  residential lead hazards, http://www.epa.gov/opptintr/lead/
•      U.S. EPA's Asbestos Web site provides information and resources to help facilities comply with the


                                              -268-
-------
       asbestos regulations under the Clean Air Act and the Toxic Substances Control Act.
       http://www.epa.gov/asbestos/
•      U.S. EPA's PCB Web site provides information on the federal program for regulating
       polychlorinated biphenyls (PCBs). http://www.epa.gov/opptintr/pcb/
•      U.S. EPA Regional PCB Program contacts, http://www.epa.gov/opptintr/pcb/coordin.html
•      U.S. EPA document protocol for conduction environmental compliance audits of facilities with
       PCB's, asbestos, and lead-based paint under TSCA.
       http://www.epa.gov/compliance/resources/policies/index.html

For more information on TSCA:
•      http://www.epa.gov/region5/defs/html/tsca.htm.

Federal TSCA regulations are set forth in the Code of Federal Regulations (CFR) at 40 CFR Parts 700-799
•      Lead hazard reduction regulations can be found at 40CFR Part 745.
•      Management requirements for polychlorinated biphenyls (PCBs) is found at 40CFR Part 761.
                        U.S. EPA Voluntary Audit Policy

     The U.S. Environmental Protection Agency (U.S. EPA) is responsible for ensuring that businesses and

organizations comply with federal laws that protect the public health and the environment. The U.S. EPA's

Office of Enforcement and Compliance (OEC) combines traditional enforcement activities with more

innovative compliance approaches including the provision of compliance assistance to the general public.

The OEC was established in 1994 to focus on compliance assistance-related activities. The U.S. EPA also

encourages the development of self-assessment programs at individual facilities.  Voluntary audit programs

play an important role in helping companies meet their obligation to comply with environmental

requirements. Such assessments can be a critical link, not only to improved compliance, but also to

improvements in other aspects of an organization's performance. For example, environmental audits may

identify pollution prevention opportunities that can substantially reduce an organization's operating costs.

Environmental audits can also serve as an  important diagnostic tool in evaluating a facility's overall

environmental management system or EMS.
Reasons to consider the voluntary audit program include the following:
•      Take proactive measures to find and address compliance problems before the U.S. EPA discovers
       them.
•      Take advantage of the penalty mitigation incentives under the audit policy.
       Conduct and publicize disclosures as evidence of good corporate citizenship and awareness of
       need to protect public health and the environment.

                                             -269-
-------
•       Obtain certainty by relying on predictable enforcement response under the audit policy.
        Obtain assurance from EPA that the violation(s) is being properly corrected and/or damage is
        properly remediated.
        Take advantage of the incentives regarding no recommendation for criminal prosecution under the
        audit policy.
Incentives for Self-Policing Under the Audit:
        No gravity-based penalties for disclosing entities that meet all nine policy conditions, including
        "systematic discovery" of the violation through an environmental audit or a compliance management
        system. Gravity-based penalties are that portion of the penalty over and above the economic benefit.
        In general, civil penalties that U.S. EPA assesses are comprised of two elements: the economic benefit
        component and the gravity-based component. The economic benefit component reflects the economic
        gain derived from a violator's illegal competitive  advantage. Gravity-based penalties are that portion
        of the penalty over and above the economic benefit. They reflect the egregiousness of the violator's
        behavior and constitute the punitive portion of the penalty. The U.S. EPA retains its discretion to
        collect any economic benefit that may have been realized as a result of noncompliance.
•       Reduction of gravity-based penalties by 75 percent may be granted to entities that meet all of the
        conditions except for "systematic discovery" of the violation through an environmental audit or a
        compliance management system.
•       No recommendation for criminal prosecution for entities  that disclose violations of criminal law and
        meet all  applicable conditions under the policy. "Systematic discovery" is not  required to be eligible
        for this incentive, although the entity must act in good faith and adopt a systematic approach to
        preventing recurring violations. The U.S. EPA generally does not focus its criminal enforcement
        resources on entities that voluntarily discover, promptly disclose and expeditiously correct violations,
        unless there is potentially culpable behavior that merits criminal investigation. When a disclosure that
        meets the terms and conditions under the audit policy results in a criminal investigation, the U.S. EPA
        generally will not recommend criminal prosecution for the disclosing entity, although the agency may
        recommend prosecution for culpable individuals and other entities.
•       No routine requests for audit reports from entities who disclose under the audit policy. In general, the
        U.S. EPA will refrain from routine  requests for audit reports. However, if the U.S. EPA has
        independent evidence of a violation, it may seek the information it needs to establish the extent and
        nature of the violation  and the degree of culpability.
     Under the audit program, the hospital can typically audit compliance with the following federal

regulatory programs:

Air Programs (CAA)
40 CFR Part 52 Section 21 (40 CFR 52.21)
        Prevention of Significant Deterioration of Air Quality
40 CFR Part 60
        Standards of Performance for New Stationary Sources
40 CFR Part 61
        National Emission Standards for Hazardous Air Pollutants, Subpart M, National Emission Standard
        for Asbestos
40 CFR Part 62 Subpart HHH
        Federal Plan Requirements for Hospital/Medical/Infectious Waste Incinerators
40 CFR Part 63
        National Emission Standards for Hazardous Air Pollutants for Source Categories (all applicable
        provisions)
40 CFR Part 68
                                               -270-
-------
       Chemical Accident Prevention Provisions
40 CFR Part 70
       State Operating Permit Programs
40 CFR Part 82
       Protection of Stratospheric Ozone

     All applicable provisions of the State Implementation Plan Regulations (promulgated pursuant to

Section 110 of the Clean Air Act) including the New Source Review regulations.


Water Programs (CWA)
40 CFR Part 112
       Oil Pollution Prevention
40 CFR Part 122
       EPA Administered Permit Programs:  The National Pollutant Discharge Elimination System
40 CFR Part 141
       National Primary Drinking Water Regulations
40 CFR Part 142
       National Primary Drinking Water Regulations Implementation
40 CFR Part 143
       National Secondary Drinking Water Regulations
40 CFR Part 144
       Underground Injection Control ("UIC") Program
40 CFR Part 145
       State UIC Program Requirements
40 CFR Part 146
       UIC Program: Criteria and Standards
40 CFR Part 147
       State UIC Programs
40 CFR Part 148
       Hazardous Waste Injection Restrictions
40 CFR Part 403
       General Pretreatment Regulations for Existing and New Sources of Pollution

Pesticide Programs (FIFRA)
40 CFR Part 160
       Good Laboratory Practice Standards
40 CFR Part 162
       State Registration of Pesticide Products
40 CFR Part 170
       Worker Protection Standard
40 CFR Part 171
       Certification of Pesticide Applicators
40 CFR Part 172
       Experimental Use Permits

Solid and Hazardous Wastes (RCRA)
40 CFR Part 260
                                             -271 -
-------
       Hazardous Waste Management System: General (Part 370, 6 New York  Code of Rules and
       Regulations)
40 CFR Part 261
       Identification and Listing of Hazardous Waste
40 CFR Part 262
       Standards Applicable to Generators of Hazardous Waste
40 CFR Part 263
       Standards Applicable to Transporters of Hazardous Waste
40 CFR Part 264
       Standards for Owners and Operators of Hazardous Waste Treatment, Storage and Disposal Facilities
40 CFR Part 265
       Interim Status Standards for Owners and Operators of Hazardous Waste Treatment, Storage and
       Disposal  Facilities
40 CFR Part 266
       Standards for the Management of Specific Hazardous Wastes and Specific Types of Hazardous Waste
       Management Facilities
40 CFR Part 268
       Land Disposal Restrictions
40 CFR Part 273
       Standards for Universal Waste Management
40 CFR Part 279
       Standards for the Management of Used Oil
40 CFR Part 280
       Technical Standards and Corrective Action Requirements for Owners and Operators of Underground
       Storage Tanks ("USTs")

Hazardous Substances and Chemicals, Environmental Response, Emergency Planning and Community

Right-to-Know Programs (EPCRA)
40 CFR Part 3 02
       Designation, Reportable Quantities and Notification
40 CFR Part 355
       Emergency Planning and Notification
40 CFR Part 3 70
       Hazardous Chemical Reporting: Community Right-to-Know
40 CFR Part 3 72
       Toxic Chemical Release Reporting: Community Right-to-Know

Toxic Substances (TSCA)
40 CFR Part 745
       Lead-Based Paint Poisoning Prevention in Certain Residential Structures
40 CFR Part 761
       Polychlorinated Biphenyls (PCBs) Manufacturing, Processing, Distribution in Commerce and Use
       Prohibitions
40 CFR Part 763
       Asbestos
     To learn more about the policy: http://www.epa.gov/compliance/incentives/auditing/auditpolicy.html
                                            -272-
-------
  U.S. EPA National Environmental Performance Track Program

                         www.epa.gov/performancetrack
                               (888) 339-PTRK (7875)
     Performance Track is a voluntary program in which the U.S. EPA rewards public and private facilities

that consistently exceed regulatory requirements, work closely with their communities, and excel in

protecting the environment and public health. A core principle of Performance Track is that companies with

a history of dedication to continuous improvement should be treated differently than other facilities. To foster

continuous improvement at member facilities, Performance Track offers incentives, such as recognition on

local and national levels, low inspection status, and regulatory changes, to help ease reporting requirements

and reduce administrative costs.

Standard Criteria for Program Eligibility
1.     Implementation of an Environmental Management System (EMS)
2.     Commitment to Continuous Improvement
3.     Community Outreach
4.     Sustained Compliance
5.     Standard Criteria for "Small Business" Applicants

Environmental Management System (EMS)

     During the application process, Performance Track organizations certify that they have adopted and

implemented an Environmental Management System (EMS). An EMS is an organization's systematic effort

to meet its environmental requirements and improve its overall performance. To participate, applicants must

complete at least one full cycle of implementation (NOTE: This "full cycle of implementation" could be one

year, less than one year or more than one year. The duration of the implementation cycle is best determined

by the originator/implementer of the individual EMS). Organizations that have adopted ISO 14001 or other

systems with a Plan-Do-Check-Act framework likely meet most of these elements.

     Because each organization is unique, the scope and formality of its EMS will vary according to its size,

sector and complexity.

     A qualifying EMS for Performance Track includes the following elements:
1.     Policy
2.     Planning
3.     Implementation and Operation
4.     Checking and Corrective Action
5.     Management Review
                                          -273-
-------
Continuous Improvement Performance Criteria

     To submit a successful application, organizations must demonstrate past environmental achievement

and commit to continued improvement in their performance.  Past achievements and future commitments are

in specific aspects of environmental categories. The categories are as follows:
       Energy Use
•      Water Use
       Materials Use
•      Air Emissions
       Waste Generation
•      Water Discharges
       Accidental Releases
•      Preservation and Restoration
       Product Performance

     Aspects are specific environmental impacts within these categories (e.g., discharge of heavy metals).

The Performance Track Application Instructions on the United States Environmental Protection Agency's

(U.S. EPA's) Web site (http://www.epa.gov/performancetrack/index.htm) lists the categories and their

associated aspects and measures.

     Performance Track  program applicants must demonstrate achievement in at least two environmental

aspects in any of the categories in the current and preceding year. Applicants must also commit to future

improvements in at least  four environmental aspects, drawn from two or more categories. Two of these

aspects may be in the same category, and they may be the same as those used to demonstrate past

performance.

     Organizations are encouraged to commit to more than the minimum. Aspects are chosen by the

organization, not by the U.S. EPA.  Commitments for improvement should relate to the organization's

significant environmental aspects identified in the EMS and should take into account local environmental

priorities and pollution prevention opportunities. In documenting past achievements and committing to

continued improvement,  organizations should not rely on any actions that represent compliance with existing

legal requirements at the  federal, state, tribal or local levels. Improvements  should represent actions beyond

existing legal requirements.


Community Outreach

     Performance Track  members demonstrate their commitment to public outreach and report periodically

on their performance in the program.  In addition, the U.S. EPA expects that applicants will already have
                                             -274-
-------
established a public outreach program (e.g., newsletters, sponsorship of community activities, performance

reporting) prior to submitting their applications. Public outreach activities may vary across organizations

depending on their size, setting and type of operation, but should include the following:
       Identifying and responding to community concerns. An organization should be able to
       demonstrate that it has established mechanisms for identifying and responding to local concerns
       regarding the environmental effects of its operations (e.g., emissions, odor).
•      Informing the community of important matters that affect it. Appropriate to an organization's size,
       operation and setting, each applicant should describe the mechanisms it uses to inform the
       community of important issues that relate to its environmental performance.
       Reporting on the organization's EMS and performance commitments. Whatever means an
       organization employs for community outreach, it should explain specifically how it provides the
       public with the environmental performance information that it is committed to reporting (e.g.,
       open houses, community meetings).

     Finally, organizations must provide a short list of community/local references that are familiar with the

facility and to list any ongoing citizen lawsuits against the facility.


Sustained Compliance

     Performance Track members have a record of compliance with environmental laws and are in

compliance with all applicable environmental requirements. They also commit to maintaining the level of

compliance necessary to qualify for the program.

     The U.S. EPA screens all applications consistent with U.S. EPA Compliance Screening Policy for U.S.

EPA Partnership  Programs.  See http://www.epa.gov/performancetrack/program/sustain.htm.  In evaluating an

applicant's compliance record, the U.S. EPA and its state partners will consult available databases and

enforcement information sources.  The U.S. EPA encourages applicants to assess their own compliance record

as they make decisions regarding participation in this program. Participation in the Performance Track is not

appropriate if the compliance screen shows any of the following, under federal or state law:

Criminal Activity
•      Corporate criminal conviction or plea for environmentally-related violations involving the
       corporation or a corporate officer within the past five years.
•      Criminal conviction or plea of employee at the same facility for environmentally-related violations
       within the past five years.
•      Ongoing criminal investigation/prosecution of corporation, corporate officer or employee at the same
       facility for violations of environmental law.
Civil Activity
       Three or more significant violations at the organization in the past three years.
•      Unresolved, unaddressed Significant Noncompliance (SNC) or Significant Violations (SV) at the
       facility.
                                               -275-
-------
       Planned but not yet filed judicial or administrative action at the organization.
•      Ongoing U.S. EPA- or state-initiated litigation at the organization.
       Situation where a facility is not in compliance with the schedule and terms of an order or decree.

"Small Business" Criteria (for Performance Track Eligibility)

     For the purposes of this program, an organization is considered to be a "small" organization if the

company as a whole is a small business as defined by the Small Business Administration [see "National

Environmental Performance Track Program: Final Program Changes for 2004" May 15, 2000 (http://

www.epa.gov/performancetrack/events/program_changes_web_version.pdf)] and if the organization itself

employs fewer than 50 full-time employees.

     Small businesses are active participants in innovative programs such as the U.S. EPA Sustainable

Industries Program, Design for the Environment, voluntary partnership programs and EMS projects with local

governments. Qualified small businesses, organizations and local governments are  encouraged to participate

in the National Environmental Performance Track as well.

     Based on input from small business representatives, certain provisions were designed to meet their

special needs:
•      Environmental Management Systems. The scope and level of formality of the EMS will vary,
       depending on the nature, size and complexity of the facility. U.S. EPA's experience with a variety
       of programs suggests that these EMS elements are within the capability of small organizations
       and can be met through different approaches. To help small organizations implement an EMS, the
       U.S. EPA makes guidance documents and assistance materials available.
•      Continuous Improvement. Small businesses have the option of documenting improvement for at
       least one environmental aspect from any category.  In making future performance commitments,
       small organizations should select at least two aspects from two or more categories.
       Community Outreach and Reporting. There is no standard set of outreach activities beyond the
       Annual Performance Report (APR). Each organization's approach to community reporting
       beyond the annual performance report will depend on its  size, scale of operations and setting. At a
       minimum, a small organization should be able to document that it has designated a point of
       contact with direct access to facility management and has adopted procedures for responding to
       local residents' questions or concerns.
       Sustained Compliance. Small organizations must have a record of sustained compliance in the
       same manner as other organizations participating in Performance Track.
•      Annual Performance Reporting to EPA. EPA is considering providing specialized assistance in
       this area for small organizations. A facility should maintain onsite the  supporting documentation
       used to prepare its Annual Performance Report and make this documentation available to EPA
       upon EPA's request.
     EPA has held numerous  discussions with representatives of small business interests and is encouraging

participation by qualified small businesses and their organizations. In addition, EPA may create a more active

and focused development program for small businesses and other small entities with the goal of helping to

expand their capacities for participation in Performance Track.	

                                              -276-
-------
                                Other Organizations


American Hospital Association (AHA)

    In the United States, private businesses including health care facilities and health care providers joined

together to form an organization that represents their interests and assists their efforts to work with the

government on a variety of health care issues. The American Hospital Association (AHA) is a national trade

organization that represents all types of hospitals, health care networks, their patients and the communities

they serve. As many as 5,000 institutions and 40,000 individuals belong to the AHA. The AHA's mission is

to advance the health of individuals and communities.

    AHA provides representation and advocacy activities to ensure that members' perspectives are addressed

in national health policy development, legislative and regulatory debates and judicial matters. In addition,

AHA provides resources to help health care leaders implement change at the community level. The AHA

helps hospitals and other health care providers form networks for patient care. They conduct research and

demonstration projects; provide educational programs; perform data gathering and information analysis to

support policy development and track trends and keep members informed of national developments and

trends and their impact on local communities.

    The AHA works for its membership to track international and federal rule-making to  educate members of

the health care community on the potential impact of new legislation and regulatory initiatives.

http://www.aha.org

Hospitals for a Healthy Environment (H2E)

    The Hospitals for a Healthy Environment (H2E) is a voluntary program, which was formed as a result of

the American Hospital Association and the U.S. EPA's Memorandum of Understanding (MOU) dated June

24,  1998.

    This landmark agreement calls for:
       Elimination of mercury-containing waste from health care facilities' waste streams by 2005.
•      Reduction of the overall volume of waste (both regulated and nonregulated waste) by 33  percent by
       2005 and by 50 percent by 2010.
•      Identification of hazardous substances for pollution prevention and waste reduction opportunities,
       including hazardous chemicals and persistent, bioaccumulative and toxic pollutants (PBT).
     The Hospitals for a Healthy Environment program helps health care facilities enhance workplace

safety, reduce waste and waste disposal costs and become better environmental stewards and neighbors. This
                                             -277-
-------
is done by educating health care professionals about pollution prevention opportunities in hospitals and
health care systems.
    Through activities, such as the development of best practices, model plans for total waste management,
resource directories and case studies, H2E provides hospitals and health care systems with enhanced tools
for minimizing the volumes  of waste generated and the use of persistent, bioaccumulative and toxic
chemicals (PBT).  Such reductions are beneficial to the environment and health of our communities.
Furthermore, improved waste management practices will reduce the waste disposal costs incurred by the
health care industry.
    To take advantage of the opportunities the H2E program offers, visit the H2E Web site www.h2e-
online.org and/or participate in one of the H2E programs as either a partner or champion.
    Partners are health care facilities who commit to making changes in their facilities that protect
community and environmental health. Champions are organizations that encourage and aid health care
facilities to participate as H2E partners and/or who make changes in their own institutions that support the
goals of the H2E program. Partners and champions receive local and national recognition for the work they
do to reduce waste and protect the environment through the H2E recognition and awards program.
    Visit the H2E  Web site for a complete list of current partners and champions; tools and resources
including many items such as mercury, green buildings and green purchasing; Environmental Management
Systems; technical resources with links to mercury recyclers and consultants and vendors; news and events;
videos and much more.
www.h2e-online .org

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
     The Joint Commission on Accreditation of Healthcare Organizations (JCAHO "jayco" or Joint
Commission) is an independent, not-for-profit organization, and a leading health care standards-setting and
accrediting body. The Joint Commission strives to improve the safety and quality of care provided to the
public. The Joint Commission evaluates and accredits more than 19,500 health care organizations in the
United States, including hospitals and health care organizations that provide home care, long term care,
behavioral health care, laboratory and ambulatory care services.
     JCAHO enforces seven (7) standards. The environment of care standard will be the focus for
connecting Environmental Management Systems to related JCAHO requirements. The seven JCAHO
                                             -278-
-------
standards are:
     •         Environment of Care
     •         Improving Organizational Performance
     •         Leadership
              Governance
     •         Human Resource
     •         Management of Information
     •         Surveillance, Prevention and Control of Infection
     http://www.icaho.org
                                             -279-
-------
                                                   UNITED STATES ENVIRONMENTAL
                                                               PROTECTION AGENCY
                                                                           REGION 2
                                                                         MARCH 2004
                  DRAFT
Contents

Introduction     1

What is RCRA?   2

Who is Regulated? 2

What is
Hazardous Waste? 2

What is
Universal Waste?  3

How Are Generators
Defined?       3

Do Exclusions
Exist?          4

Examples of Healthcare
Facility Waste
Generation      5

Other Environmental
Laws Affecting
the Healthcare
Industry        7

Most Common
Hospital Hazardous
Waste Violations  10

Best Management
Practices       11

Partnerships and
Resources     13
      MANAGEMENT  OF
      HEALTHCARE
      HAZARDOUS  WASTE
      INTRODUCTION

      Healthcare facilities manage many types of waste, such as normal solid waste
      (paper), medical/infectious waste (red bag), hazardous waste, and radioactive
      waste. The purpose of this factsheet is to guide healthcare facilities in
      identifying and properly managing hazardous waste, in accordance with RCRA
      requirements. Healthcare facilities are also regulated by other federal, state, and
      local regulations, as referenced at the end of this factsheet.
Contacts and
Resources
14
    March 2004
    Printed on paper
   i containing at least 30%
    postconsumer materials
                    RCRA Hotline
                    FOR MORE INFORMATION CALL:
        U.S. Environmental Protection Agency at 800 424-9346 or TDD 800 553-7672.
        In the Washington, DC, area: 703 412-9810 or TDD 703 412-3323.
                                          www. epa. gov\region02\healthcare
-------