STATE REVIEW FRAMEWORK
Forsyth County, North Carolina
Clean Air Act
Implementation in Federal Fiscal Year 2017
U.S. Environmental Protection Agency
Region 4
Final Report
July 5, 2019
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I. Introduction
A. Overview of the State Review Framework
The State Review Framework (SRF) is a key mechanism for EPA oversight, providing a
nationally consistent process for reviewing the performance of state delegated compliance and
enforcement programs under three core federal statutes: Clean Air Act, Clean Water Act, and
Resource Conservation and Recovery Act. Through SRF, EPA periodically reviews such
programs using a standardized set of metrics to evaluate their performance against performance
standards laid out in federal statute, EPA regulations, policy, and guidance. When states do not
achieve standards, the EPA will work with them to improve performance.
Established in 2004, the review was developed jointly by EPA and Environmental Council of the
States (ECOS) in response to calls both inside and outside the agency for improved, more
consistent oversight of state delegated programs. The goals of the review that were agreed upon
at its formation remain relevant and unchanged today:
1. Ensure delegated and EPA-run programs meet federal policy and baseline performance
standards
2. Promote fair and consistent enforcement necessary to protect human health and the
environment
3. Promote equitable treatment and level interstate playing field for business
4. Provide transparency with publicly available data and reports
B. The Review Process
The review is conducted on a rolling five-year cycle such that all programs are reviewed
approximately once every five years. The EPA evaluates programs on a one-year period of
performance, typically the one-year prior to review, using a standard set of metrics to make
findings on performance in five areas (elements) around which the report is organized: data,
inspections, violations, enforcement, and penalties. Wherever program performance is found to
deviate significantly from federal policy or standards, the EPA will issue recommendations for
corrective action which are monitored by EPA until completed and program performance
improves.
The SRF is currently in its 4th Round (FY2018-2022) of reviews, preceded by Round 3
(FY2012-2017), Round 2 (2008-2011), and Round 1 (FY2004-2007). Additional information
and final reports can be found at the EPA website under State Review Framework.
II. Navigating the Report
The final report contains the results and relevant information from the review including EPA and
program contact information, metric values, performance findings and explanations, program
responses, and EPA recommendations for corrective action where any significant deficiencies in
performance were found.
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A. Metrics
There are two general types of metrics used to assess program performance. The first are data
metrics, which reflect verified inspection and enforcement data from the national data systems
of each media, or statute. The second, and generally more significant, are file metrics, which are
derived from the review of individual facility files in order to determine if the program is
performing their compliance and enforcement responsibilities adequately.
Other information considered by EPA to make performance findings in addition to the metrics
includes results from previous SRF reviews, data metrics from the years in-between reviews,
multi-year metric trends.
B. Performance Findings
The EPA makes findings on performance in five program areas:
• Data - completeness, accuracy, and timeliness of data entry into national data systems
• Inspections - meeting inspection and coverage commitments, inspection report quality,
and report timeliness
• Violations - identification of violations, accuracy of compliance determinations, and
determination of significant noncompliance (SNC) or high priority violators (HPV)
• Enforcement - timeliness and appropriateness of enforcement, returning facilities to
compliance
• Penalties - calculation including gravity and economic benefit components, assessment,
and collection
Though performance generally varies across a spectrum, for the purposes of conducting a
standardized review, SRF categorizes performance into three findings levels:
Meets or Exceeds: No issues are found. Base standards of performance are met or exceeded.
Area for Attention: Minor issues are found. One or more metrics indicates performance
issues related to quality, process, or policy. The implementing agency is considered able to
correct the issue without additional EPA oversight.
Area for Improvement: Significant issues are found. One or more metrics indicates routine
and/or widespread performance issues related to quality, process, or policy. A
recommendation for corrective action is issued which contains specific actions and schedule
for completion. The EPA monitors implementation until completion.
C. Recommendations for Corrective Action
Whenever the EPA makes a finding on performance of Area for Improvement, the EPA will
include a recommendation for corrective action, or recommendation, in the report. The purpose
of recommendations is to address significant performance issues and bring program performance
back in line with federal policy and standards. All recommendations should include specific
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actions and a schedule for completion, and their implementation is monitored by the EPA until
completion.
III. Review Process Information
Clean Air Act (CAA)
Key dates:
• August 20,2018, Round 4 kick-off letter sent to Local program
• September 4, 2018, DMA and file selection sent to county
• November 5-8, 2018, on-site file review for CAA
• December 21, 2018, file review spreadsheet provided to county
Local Program and EPA key contacts for review:
• Forsyth County: SRF Coordinator, Minor Barnette; CAA Contact: Peter Lloyd
• EPA Region 4: SRF Coordinator, William Bush; CAA Contacts: Mark Fite, OEC;
Wendell Reed, APTMD
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Executive Summary
Areas of Strong Performance
The following are aspects of the program that, according to the review, are being implemented at
a high level:
Clean Air Act (CAA)
Forsyth County Environmental Assistance & Protection (FCEAP) met the negotiated frequency
for inspection of sources, reviewed Title V Annual Compliance Certifications, and included all
required elements in their Full Compliance Evaluations (FCEs) and Compliance Monitoring
Reports (CMRs).
Enforcement actions bring sources back into compliance within a specified timeframe, and HPVs
are addressed in a timely and appropriate manner.
Priority Issues to Address
The following are aspects of the program that, according to the review, are not meeting federal
standards and should be prioritized for management attention:
Clean Air Act (CAA)
Minimum data requirements (MDRs) were not entered into ICIS-Air within the required
timeframes, and discrepancies between the files and ICIS-Air were identified in about 45% of
the files reviewed.
FCEAP documented the consideration of gravity in their penalty calculations, but the
consideration of economic benefit was not documented.
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Clean Air Act Findings
CAA Element 1 - Data
Finding 1-1
Area for Improvement
Summary:
Minimum data requirements (MDRs) were not entered into ICIS-Air within the required
timeframes, and discrepancies between the files and ICIS-Air were identified in about 45% of
the files reviewed.
Explanation:
File Review Metric 2b indicated that 55% (11 of 20) of the files reviewed reflected accurate
entry of all MDRs into ICIS-Air. The remaining nine files had one or more discrepancies
between information in the files and data entered in ICIS-Air. Eight sources had missing or
inaccurate activity or violation data. Three sources had missing Air Program subparts (e.g.
MACT ZZZZ), and two sources had inaccurate facility information. Incorrect data has the
potential to hinder EPA's oversight and targeting efforts and may result in inaccurate
information being released to the public. Metric 3a2 (0%) indicated that FCEAP did not report
any HPVs into ICIS-Air in FY17. Metrics 3b 1 {6.1%), 3b2 (0%) and 3b3 (0%) indicated that
MDRs for compliance monitoring, stack tests and enforcement activities were not entered timely.
Local Agency Response:
FCEAP agrees that improvement is needed in this area. The root cause for these reporting
deficiencies was the separation of the reporting duties in the data management group of our
organization from the compliance monitoring personnel as well as a lack of training with the
ICIS-Air reporting system. FCEAP will provide EPA a written certification with the measures
and procedures that have been implemented to ensure accurate and timely reporting to ICIS-Air.
The reporting deficiencies were identified prior to the SRF and reporting responsibilities were
transitioned to the Compliance Coordinator in the compliance monitoring group. This change
will be reflected in the revised Compliance Monitoring Quality Assurance Plan. During the SRF
review, FCEAP staff became aware of routine errors during data entry that resulted in
incomplete data reported in ICIS Air. Assistance from the SRF review staff and subsequent
online training has corrected the routine data entry errors. FCEAP believes these steps have
resolved this issue and will verify progress by reviewing SRF metrics annually.
Recommendation:
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Due Date Recommendation
By September 30, 2019, FCEAP should identify the root causes for late
and inaccurate data entry, certify in writing to EPA what measures and/or
procedures have been implemented to ensure accurate and timely entry of
1 04/30/2020 MDRs into ICIS-Air, and provide to EPA a written description or copy of
any such measures or procedures. By April 30, 2020, following data
verification, EPA will review the relevant data metrics to ensure
implementation is taking place and timely data entry has improved.
Relevant metrics:
Metric ID Number and Description
Natl
Goal
Natl
Avg
State
N
State
D
State
%
2b Files reviewed where data are accurately
reflected in the national data system [GOAL]
| 100%
-
11
20
55%
3a2 Timely reporting of HPV determinations
[GOAL]
| 100%
40.5%
0
0
3b 1 Timely reporting of compliance monitoring
MDRs [GOAL]
| 100%
82.3%
2
30
6.67%
3b2 Timely reporting of stack test dates and
results [GOAL]
I 100%
67.1%
0
27
0%
3b3 Timely reporting of enforcement MDRs
[GOAL]
I 100%
77.6%
0
6
0%
CAA Element 2 - Inspections
Finding 2-1
Meets or Exceeds Expectations
Summary:
FCEAP met the negotiated frequency for inspection of sources, reviewed Title V Annual
Compliance Certifications, and included all required elements in their Full Compliance
Evaluations (FCEs) and Compliance Monitoring Reports (CMRs).
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Explanation:
Metrics 5a (100%) and Metric 5b (93.3%) indicated that FCEAP provided adequate inspection
coverage for major and SM-80 sources during FY17 by ensuring that each major source was
inspected at least every 2 years, and each SM-80 source was inspected at least every 5 years. In
addition, Metric 5e (87.5%) documented that FCEAP reviewed Title V annual compliance
certifications submitted by major sources and recorded these reviews in ICIS-Air. Finally, Metric
6a (100%>) and Metric 6b (100%) confirmed that all elements of an FCE and CMR required by
the Clean Air Act Stationary Source Compliance Monitoring Strategy (CMS Guidance) were
addressed in facility files reviewed.
Local Agency Response:
This metric is the best measure of the actual performance of compliance monitoring programs in
protecting public health and the environment. FCEAP has, and continues, to consider compliance
monitoring and assurance to be the number one priority. We are pleased that this review of our
program has demonstrated that it meets or exceeds national expectations.
Relevant metrics:
Metric ID Number and Description
Natl Natl
Goal Avg
State
N
State
D
State
%
5a FCE coverage: majors and mega-sites
[GOAL]
100% | 88.7%
5
5
100%
5b FCE coverage: SM-80s [GOAL]
100% ' 93.7%
14
15
93.33%
5e Reviews of Title V annual compliance
certifications completed [GOAL]
100% 1 76.7%
7
8
87.5%
6a Documentation of FCE elements [GOAL]
100% !
20
20
100%
6b Compliance monitoring reports (CMRs) or
facility files reviewed that provide sufficient
documentation to determine compliance of the
facility [GOAL]
100% |
20
20
100%
CAA Element 3 - Violations
Finding 3-1
Area for Attention
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Summary:
FCEAP made accurate compliance determinations. FRV and HPV violations were documented
in the files, but they were not reported into ICIS-Air.
Explanation:
Metric 7a indicated that FCEAP made accurate compliance determinations in 18 of 20 files
reviewed (90%). Metric 8c indicated that FCEAP's HPV determinations for 12 of 13 files
reviewed (92.3%) were accurate. Metric 13 indicated that FCEAP did not identify any HPVs
during the review year. Although violations were accurately identified in the file, FRVs and
HPVs were not recorded in ICIS-Air, so EPA provided training during the review for entering
violations into ICIS-Air. In addition, EPA recommends that the checklists FCEAP uses to
document FRV and HPV determinations be updated to reflect current policy and guidance and
delete references to AFS. A review of FY2018 production data in ECHO indicates that FCEAP
has self-corrected this issue and is now reporting HPVs and FRVs into ICIS-Air.
Local Agency Response: FCEAP strives to accurately identify violations and return facilities to
compliance in a timely manner. We have reviewed our legislatively mandated, tiered
enforcement policy to better align it with EPA's FRV policy and guidance. We have also revised
our violation data form and integrated it with our other violation processing tools to reflect
current EPA policy and guidance and improve internal oversight. FCEAP anticipates making
analogous changes in our internal data systems once adequate resources are available in our data
management group.
Relevant metrics:
Metric ID Number and Description
Natl
Goal
Natl
Avg
State
N
State
D
State
%
13 Timeliness of HPV Identification [GOAL]
loo0,,
-
0
0 |
7a Accurate compliance determinations [GOAL]
1
-
18
20
90%
8c Accuracy of HPV determinations [GOAL]
| 100%
-
12
13
92.31%
CAA Element 4 - Enforcement
Finding 4-1
Meets or Exceeds Expectations
Summary:
Enforcement actions bring sources back into compliance within a specified timeframe, and HPVs
are addressed in a timely and appropriate manner.
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Explanation:
Metric 9a indicated that all ten formal enforcement actions reviewed (100%) brought the sources
back into compliance through corrective actions in the order, or compliance was achieved prior
to issuance of the order. Since there were only three enforcement actions reported in the review
year (FY17), additional actions from FY16 and FY18 were also included in the review. Metric
10a (100%) indicated that all three HPV actions reviewed were either addressed within 180 days
or a case development and resolution timeline (CDRT) was discuss with EPA. Metric 14 (100%)
indicated that one CDRT was developed and contained the required policy elements. Finally,
Metric 10b (100%) indicated that appropriate enforcement action was taken to address these
HPVs.
Local Agency Response:
Again FCEAP is pleased that this measure of our compliance and enforcement program meets or
exceeds national expectations. We consider compliance monitoring and assurance to be our
number one priority and strive to return facilities to compliance in a timely manner.
Relevant metrics:
Metric ID Number and Description
Natl
Goal
Natl State
Avg N
State
D
State
%
10a Timeliness of addressing HPVs or alternatively
having a case development and resolution timeline
in place
| 100%
- | 3
3
100%
10b Percent of HPVs that have been have been
addressed or removed consistent with the HPV
Policy [GOAL]
| 100%
- | 3
3
100%
14 HPV case development and resolution timeline in
place when required that contains required policy
elements [GOAL]
| 100%
1
1
100%
9a Formal enforcement responses that include
required corrective action that will return the facility
to compliance in a specified time frame or the
facility fixed the problem without a compliance
schedule [GOAL]
I 100%
-
10
10
....
100%
CAA Element 5 - Penalties
Finding 5-1
Meets or Exceeds Expectations
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Summary:
The collection of penalties was adequately documented in the file, and any difference between
initial and final penalties was also documented.
Explanation:
Metric 12a indicated that all ten penalty calculations reviewed (100%) documented any
differences between the initial and final penalties. In addition, Metric 12b confirmed that
documentation of all penalty payments made by sources was included in the file (100%).
Local Agency Response:
Relevant metrics:
Metric ID Number and Description
Natl
Goal
Natl
Avg
State
N
State
D
State
%
12a Documentation of rationale for difference
between initial penalty calculation and final penalty
[GOAL]
100%
-
10
10
100%
12b Penalties collected [GOAL]
100%
-
10
10
100%
Finding 5-2
Area for Improvement
Summary:
FCEAP documented the consideration of gravity in their penalty calculations, but the
consideration of economic benefit was not documented.
Explanation:
Metric 11a (0%) indicated that none of the penalty calculations reviewed documented the
consideration of economic benefit. FCEAP's penalty worksheet template has a place for
recording both the value of any economic benefit and any rationale for its inclusion or exclusion.
However, $0 was usually all that was recorded, with no rationale or discussion provided
concerning why no economic benefit was realized or included. EPA's expectation that state and
local enforcement agencies document the consideration and assessment of both gravity and
economic benefit is outlined in the 1993 Steve Herman memo entitled "Oversight of State and
Local Penalty Assessments: Revisions to the Policy Framework from State/EPA Enforcement
Agreements". Region 4 recommends that if no economic benefit is realized or it is de minimis,
the county should document this rationale in the penalty worksheet.
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Local Agency Response:
EPA found that none of the penalties reviewed documented economic benefit. While FCEAP
does not dispute this finding, none of the penalties reviewed resulted in economic benefits.
FCEAP's Tier Assignment and Gravity forms are completed for all enforcement actions. This
form includes a specific area for documenting economic benefit. FCEAP considers economic
benefit during penalty calculations, however, the basis for economic benefit has previously only
been documented when an economic benefit has been identified.
FCEAP understands EPA's expectation to provide some analysis of whether a facility gains an
economic benefit by violating air quality requirements. This process will be addressed in the
revision to our Compliance Monitoring Quality Assurance Plan. We have integrated our
violation processing tools to ensure economic benefit is always addressed and improve internal
oversight. We also anticipate tracking economic benefit determinations using our internal data
systems once adequate resources are available in our data management group. FCEAP will
provide EPA a written certification with the measures and procedures that have been
implemented to document economic benefit in penalty calculations and provide sample penalty
calculations demonstrating their implementation.
Recommendation:
Rec
#
Due Date
Recommendation
1
04/30/2020
By September 30, 2019, FCEAP should certify in writing to EPA what
revised procedures have been implemented to document penalty
calculations in accordance with EPA policy and provide EPA a copy of
such revised procedures. These procedures should address the
documentation and consideration of economic benefit in all future penalty
calculations. By April 30, 2020, FCEAP should submit and EPA will
review sample penalty calculations to ensure that implementation of the
revised procedures is taking place and the calculation of EB is either being
included, or an explanation for not including it has been provided.
Relevant metrics:
Metric ID Number and Description
Natl
Goal
Natl
Avg
State
N
State
D
State
%
1 la Penalty calculations reviewed that document
gravity and economic benefit [GOAL]
100%
0
10
0%
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