State Review Framework Washington Clean Water Act Clean Air Act and Resource Conservation and Recovery Act Implementation in Federal Fiscal Year 2015


State Review Framework

Washington

Clean Water Act, Clean Air Act, and
Resource Conservation and Recovery Act
Implementation in Federal Fiscal Year 2015

U.S. Environmental Protection Agency
Region 10, Seattle

Final Report
December 1,2017

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Executive Summary

Introduction

EPA Region 10 enforcement staff conducted a State Review Framework (SRF) enforcement
program oversight review of the Washington Department of Ecology (ECY), Washington
Department of Health (DOH), Northwest Clean Air Agency (NWCAA), Olympic Regional
Clean Air Agency (ORCAA), and Benton Clean Air Agency (BCAA) The local air agencies are
partly funded by ECY with limited to no oversight.

EPA bases SRF findings on data and file review metrics, and conversations with program
management and staff. EPA will track recommended actions from the review in the SRF Tracker
and publish reports and recommendations on EPA's ECHO web site.

Areas of Strong Performance

• For all programs that were reviewed, penalty-related documentation was very good.
National goals were met for almost all penalty-related metrics.

• For RCRA, Ecology exceeded national averages regarding inspection coverage for
generators and meets the national goal of 100% for TSD inspections.

• Ecology met or exceeded all of its CWA inspection goals.

• Northwest Clean Air Agency met or exceeded expectations in every element of the
review.

Priority Issues to Address

The following are the top-priority issues affecting the state program's performance:

• CWA: Significant data errors were found related to major facilities in significant
noncompliance (SNC). EPA recommends ECY develop and deliver to EPA a plan to
screen major facilities for SNC (or utilize EPA's ICIS database) and ensure that ECY
takes proper formal enforcement actions in a timely manner for those that continue in
SNC.

• CAA: ECY and DOH's work at the Hanford site needs improvement across every
element of the review. Among the recommendations provided by EPA is that EPA, ECY
and DOH should develop an interagency working group tasked with conducting a
comprehensive review and assessment of inspection policies and practices. ECY and
DOH should also collaborate with EPA Region 10's Office of Compliance and
Enforcement (OCE) to appropriately address and resolve the current HPV consistent with
national HPV policy and guidance.

• RCRA: Inspection reports often lack sufficient documentation to support the findings.
EPA recommends separating the inspection narrative from the Notice to Comply (treating
them as separate documents rather than one) to ensure consistency between the
documents and ensure evidence is accurately and completely documented.

State Review Framework Report | Washington | Executive Summary | Page 1

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Most Significant CWA-NPDES Program Issues1

•	Significant data errors were found related to major facilities in significant noncompliance
(SNC).

•	There was only one formal enforcement action taken against the 35 major facilities that
should have received formal enforcement in the SRF review period.

•	Not all inspection reports were completed in a timely manner.

Most Significant CAA Stationary Source Program Issues

•	ECY and DOH's work at the Hanford site needs improvement in every element of the
review.

•	All Ecology offices in the review had data problems including files with inaccurate data
and/or missing documents.

•	Benton Clean Air Agency's compliance documentation was incomplete or it lacked
sufficient detail to reliably determine the compliance status of a source.

Most Significant RCRA Subtitle C Program Issues

•	Inspection reports often lack sufficient documentation to support the findings.

•	The reviewers found multiple reports where violations were missed or incorrectly cited
resulting in the state failing to make accurate SNC determinations. It is the State's
practice to make a SNC determination only after they have determined they will pursue
formal enforcement rather than first making a SNC determination and then deciding the
appropriate enforcement response based on that determination.

•	Multiple data errors were found. Since the type of data error varied from case file to case
file it appears this is a quality control issue versus a lack of understanding the data
requirements.

1 EPA's "National Strategy for Improving Oversight of State Enforcement Performance" identifies the following as
significant recurrent issues: "Widespread and persistent data inaccuracy and incompleteness, which make it hard to
identify when serious problems exist or to track state actions; routine failure of states to identify and report
significant noncompliance; routine failure of states to take timely or appropriate enforcement actions to return
violating facilities to compliance, potentially allowing pollution to continue unabated; failure of states to take
appropriate penalty actions, which results in ineffective deterrence for noncompliance and an unlevel playing field
for companies that do comply; use of enforcement orders to circumvent standards or to extend permits without
appropriate notice and comment; and failure to inspect and enforce in some regulated sectors."

State Review Framework Report | Washington | Executive Summary | Page 2

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Table of Contents

I.	Background on the State Review Framework	1

II.	SRF Review Process	2

III.	SRF Findings	4

Clean Water Act Findings	5

Clean Air Act Findings - Department of Ecology (ECY)	18

Clean Air Act Findings - Ecology and Department of Health: Hanford	26

Clean Air Act Findings Northwest Clean Air Agency (NWCAA)	39

Clean Air Act Findings - Olympic Regional Clean Air Agency (ORCAA)	44

Clean Air Act Findings - Benton Clean Air Agency (BCAA)	49

Resource Conservation and Recovery Act Findings	58

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I. Background on the State Review Framework

The State Review Framework (SRF) is designed to ensure that EPA conducts nationally
consistent oversight. It reviews the following local, state, and EPA compliance and enforcement
programs:

•	Clean Water Act National Pollutant Discharge Elimination System

•	Clean Air Act Stationary Sources (Title V)

•	Resource Conservation and Recovery Act Subtitle C

Reviews cover:

•	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, determination of significant noncompliance
(SNC) for the CWA and RCRA programs and high priority violators (HPV) for the CAA
program, and accuracy of compliance determinations

•	Enforcement — timeliness and appropriateness, returning facilities to compliance

•	Penalties — calculation including gravity and economic benefit components, assessment,
and collection

EPA conducts SRF reviews in three phases:

•	Analyzing information from the national data systems in the form of data metrics

•	Reviewing facility files and compiling file metrics

•	Development of findings and recommendations

EPA builds consultation into the SRF to ensure that EPA and the state understand the causes of
issues and agree, to the degree possible, on actions needed to address them. SRF reports capture
the agreements developed during the review process in order to facilitate program improvements.
EPA also uses the information in the reports to develop a better understanding of enforcement
and compliance nationwide, and to identify issues that require a national response.

Reports provide factual information. They do not include determinations of overall program
adequacy, nor are they used to compare or rank state programs.

Each state's programs are reviewed once every five years. The first round of SRF reviews began
in FY 2004. The third round of reviews began in FY 2013 and will continue through FY 2017.

State Review Framework Report | Washington | Page 1

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II. SRF Review Process

Review period: FFY2015 data and activities were the focus of this review.

Note: The CAA review for ECY included statewide data metrics and file reviews from the
Industrial Office, the Eastern Regional Office and Hanford. Due to the unique nature of the
Hanford site, its findings are detailed in a separate chapter for both ECY and DOH.

Key dates:

•	Kick off letter sent to State on July 01,2016

•	Data Metric Analyses and File Selection Lists sent to State and LAAs

o CWA on July 20, 2016
o ORCAA on July 5, 2016
o ECY Industrial - July 6, 2016
o NWCAA on August 22, 2016
o Benton on September 19, 2016
o ECY ERO on September 19, 2016
o RCRAon July 06, 2016

•	On-Site File Reviews Conducted

o CWA - September 22, 2016, October 13-14, 2016, November 3-4, 2016
o ORCAA on July 19, 2016
o ECY Industrial on July 20, 2016
o NWCAA on October 12, 2016
o Hanford - ECY and DOH on October 17, 2016
o Benton on October 19, 2016
o ECY ERO on October 19,2016
o RCRA - N/A

•	Draft Report Sent to State and LAAs on September 5, 2017

•	LAA comments and State comments received on October 26, 2017

•	Report Finalized on December 1, 2017

State and EPA key contacts for review:

Donna Smith, Ecology CWA Program
Jolaine Johnson, Ecology CAA Program
Brenda Smits, Ecology CAA Program
Holly Martin, Ecology CAA Program

Kim Wigfield, Ecology Industrial Office (EIO) CAA Program

Stephanie Ogle, EIO CAA Program

Ewa Kotwicka, EIO CAA Program

John Martell, DOH - Hanford CAA Program

John Schmidt, DOH- Hanford CAA Program

Randy Utlex, DOH- Hanford CAA Program

Shawna Breven, DOH- Hanford CAA Program

Crystal Matthey, DOH- Hanford CAA Program

Philip Gent, Ecology - Hanford CAA Program

State Review Framework Report | Washington | Page 2

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Daniel Heuston, Ecology - Hanford CAA Program
Robin Priddy, BCAA CAA Program
Rob Rodger, BCAA CAA Program
Toby Mahar, NWCAA CAA Program
Robert Moody, ORCAA CAA Program
Mike Shults, ORCAA CAA Program
Jennifer Demay, ORCAA CAA Program
Aaron Manley, ORCAA CAA Program
Mark Goodin, ORCAA CAA Program
Jim Pearson, Ecology RCRA Program
Michelle Underwood. Ecology RCRA Program
Rob Grandinetti, Region 10 NPDES Reviewer
Aaron Lambert, Region 10 CAA Reviewer
Paul Koprowski, Region 10 CAA Reviewer
Cheryl Williams, Region 10 RCRA Reviewer
Jack Boiler, Region 10 RCRA Reviewer
Scott Wilder, SRF Coordinator

State Review Framework Report | Washington | Page 3

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III. SRF Findings

Findings represent EPA's conclusions regarding state performance and are based on findings
made during the data and/or file reviews and may also be informed by:

• Annual data metric reviews conducted since the state's last SRF review

• Follow-up conversations with state agency personnel

• Review of previous SRF reports, Memoranda of Agreement, or other data sources

• Additional information collected to determine an issue's severity and root causes

There are three categories of findings:

Meets or Exceeds Expectations: The SRF was established to define a base level or floor for
enforcement program performance. This rating describes a situation where the base level is met
and no performance deficiency is identified, or a state performs above national program
expectations.

Area for State Attention: An activity, process, or policy that one or more SRF metrics show as
a minor problem. Where appropriate, the state should correct the issue without additional EPA
oversight. EPA may make recommendations to improve performance, but it will not monitor
these recommendations for completion between SRF reviews. These areas are not highlighted as
significant in an executive summary.

Area for State Improvement: An activity, process, or policy that one or more SRF metrics
show as a significant problem that the agency is required to address. Recommendations should
address root causes. These recommendations must have well-defined timelines and milestones
for completion, and EPA will monitor them for completion between SRF reviews in the SRF
Tracker.

Whenever a metric indicates a major performance issue, EPA will write up a finding of Area for
State Improvement, regardless of other metric values pertaining to a particular element.

The relevant SRF metrics are listed within each finding. The following information is provided
for each metric:

• Metric ID Number and Description: The metric's SRF identification number and a
description of what the metric measures.

• Natl Goal: The national goal, if applicable, of the metric, or the CMS commitment that
the state has made.

• Natl Avg: The national average across all states, territories, and the District of Columbia.

• State N: For metrics expressed as percentages, the numerator.

• State D: The denominator.

• State % or #: The percentage, or if the metric is expressed as a whole number, the count.

State Review Framework Report | Washington | Page 4

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Clean Water Act Findings

CWA Element 1 — Data

Finding 1-1

Meets or Exceeds Expectations

Summary

The metrics in the table below all met or exceeded the metrics when
evaluated

Explanation	This metric ensures that the appropriate Water Enforcement National Data

Base (WENDB) elements are entered into ICIS-NPDES correctly and
completely. This element shows that the state successfully entered the
WENDB data that is required.

Relevant metrics

Metric ID Number and Description

Natl Goal

Natl
Avg

Sialc
\

Siale
1)

Sialc

% or#

lb 1 Permit limit rate for major facilities

>=95%

90.9".,

(ilj

/

5".,

Vol DMR entry rate for major facilities

>=95%

96.7".,

V,S(.

U2"

<>X X"„

2b Files reviewed where data are accurately
reflected in the national data system



100°,.,

:x

:x



5al Inspection coverage of NPDES majors

100% or
CMS

55.3".,

1(1

/

452

14

7al Number of major facilities with single
event violations











7fl Non-major facilities in Category 1
noncompliance











7gl Non-major facilities in Category 2
noncompliance









l(>5

8c Percentage of SEVs identified as SNC
reported timely at major facilities



100°,.,

5

s



State response

N/A

Recommendation

State Review Framework Report | Washington | Page 5

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CWA Element 1 — Data

Finding 1-2 Area for State Attention

Summary Major facilities in noncompliance, SNC or failing to initiate timely

enforcement actions.

Explanation EPA and Washington Department of Ecology performed an investigation

of the 38 majors in noncompliance, and in SNC. After reviewing all of the
facilities it was determined that there are significant errors in the data. Of
the 38 facilities: 7 showed no violations in either PARIS, or ICIS-NPDES;
10 had some violations in ICIS-NPDES, but the list did not match the list
in PARIS, in which PARIS showed no violations; 17 had violations in
ICIS-NPDES, but did not match the violations in PARIS, the violations in
PARIS that did show in the facilities were all addressed and the addressing
action was either not linked to the violations, or the link did not flow to
ICIS-NPDES; and the remaining 4 were for late submittals that were
received by Ecology, entered into PARIS, but that was not reflected as
received in ICIS-NPDES. The State should provide EPA with a schedule to
ensure the 2017 annual data metric analysis (DMA) will address the major
facilities that are in noncompliance, ensuring that future data flow from
PARIS to ICIS-NPDES is corrected, and addressing actions for violations
are linked to the violations in PARIS, and that the addressing action link
flows to ICIS-NPDES

Relevant metrics

Metric ID Number and Description

m «i n i N;ltl
Nail Goal .

Avg

Sialc
\

Suite
1)

Sialc
".,or ¦

7dl Major facilities in noncompliance

74.2".,

(¦(¦

'Jo 4".,

8a2 Percentage of major facilities in SNC

19.2".,

5()

lOal Major facilities with timely action as

>=98%

:
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Ecology and EPA will conduct the next annual data metric analysis in
December of 2017, and review existing data in ICIS up to the date the
report for the analysis is extracted, but prior to the data being frozen in
order to complete any correction. Priority will be major facilities that are in
noncompliance.

Recommendation

State Review Framework Report | Washington | Page 7

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CWA Element 2

Inspections

Mild ill" 2-1

Meets or Exceeds Expectations

Summary

All of the state's inspection goals were met for fiscal year 2015.

Explanation

The sanitary sewer overflow inspections are not explicitly called out for the
state. These inspections simply occur during the regular major and minor
inspections of each municipality. The rest of Washington's Compliance
Monitoring plan was found to conform to EPA's Compliance Monitoring
Strategy, and in some instances exceeded the national CMS.

Relevant metrics

Metric ID Number and Description

National CMS Siale Siale

Goal

Siale

% or #

4a 1 Pretreatment compliance inspections and
audits

20% a

iall>

-»

i: :5".,

4a4 Major CSO inspections

20% a

iall>

|()(>"

4a5 SSO inspections

N/A

4a7 Phase I & IIMS4 audits or inspections

20% a

iall>

(i (I-",,

4a8 Industrial stormwater inspections

10% a

iall>

v,x

1.55'J 22".,

4a9 Phase I and II stormwater construction
inspections

10% a

iall>

"51

I.'XT iS".,

4al0 Medium and large NPDES CAFO
inspections

20% a

iall>

:i i

211 1

5al Inspection coverage of NPDES majors

50% a

iall>

1(1

4ir„

5b 1 Inspection coverage of NPDES non-majors
with individual permits

20% a

iall>

i:u

'52 U".,

5b2 Inspection coverage of NPDES non-majors
with general permits

10% a

iall>

4.(.52 14".,

6a Inspection reports complete and sufficient to
determine compliance at the facility

100%

2S loll"

State response N/A

Recommendation

CWA Element 2 — Inspections

State Review Framework Report | Washington | Page 8

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Finding 2-2

Area for State Improvement

Summary

The State did not meet the CMS goal for the SIU inspections.

Explanation The State does not meet the CMS criteria of 100% inspections of all SIUs

discharging to non-authorized POTWs.

Relevant metrics

Metric ID Number and Description

National CMS Male Stale Slate
Goal N D %or#

4a2 Significant Industrial User inspections for
SIUs discharging to non-authorized POTWs

100% annualK SI 5<> <>2"..

State response Staff turnover and vacancies contributed to the failure to meet inspection
criteria, and several POTWs are in the process of seeking pre-treatment
delegation. The expected delegation will reduce the number of required
inspections and better position Ecology to meet inspection criteria.
Additionally, Ecology works proactively to ensure POTWs are designed
and operated adequately to treat waste streams from SIU's, and is in
contact with permittees on a regular basis for consultation and technical
assistance. This proactive approach to addressing inspections of SIU's
discharging to POTWs was shared with the EPA in response to their 1999
audit of Ecology's pre-treatment program. At that time, the EPA accepted
Ecology's strategy with the understanding that not all SIU's would be
inspected every year. Going forward, Ecology will provide an alternate
plan to the EPA annually, and maintain a proactive approach to pre-
treatment while focusing on new permit applications at an inspection
frequency of no less than once per every five years.

Recommendation Ensure the State meets the 100% inspection criteria, or provide an alternate
plan to EPA by August 31 of each year.

State Review Framework Report | Washington | Page 9

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CWA Element 2

Inspections

Mild ill" 2-3

Area for State Improvement

Summary

Not all inspection reports are completed in a timely manner.

Explanation

The requirement is to have inspection reports completed in 30 days for a
compliance inspection without sampling, and 45 days for compliance
inspections with sampling. The state failed to meet the deadline in 4 out of
the 19 inspections.

Relevant metrics

,. . .... , Natl Natl Sialc Slate Stale
Metric ID Number and Description

Goal Avjj N D %or#

6b Inspection reports completed within prescribed ^ _(J11
timeframe /(>

State response Staff turnover and vacancies contributed to 4 inspection reports failing to
meet report deadlines. Ecology will educate new staff on both inspection
with sampling and inspection without sampling deadlines and continue to
reinforce these requirements through recurring unit and section meetings,
as well as state-wide Enforcement Workgroups.

Recommendation The state shall come up with a plan to routinely remind their inspectors to
complete their inspection reports within 30 days for compliance
inspections without sampling, and 45 days for compliance inspections with
sampling.

State Review Framework Report | Washington | Page 10

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CWA Element 3

Violations

Finding 3-1 Meets or Exceeds Expectations

Summary This metric applies to violations found during inspections.

Explanation The inspection reports reviewed allowed an accurate compliance

determination to be made, and the state made the appropriate determination
in all inspections. The single event violations (SEVs) were all accurately
identified and reported in a timely manner.

Relevant metrics . Natl Natl Siaic sum- Siaic

Metric ID Number and Description _ , . .

Goal Avij N D %or#

7fl Non-major facilities in Category 1
noncompliance

n/a :: v*: <¦

7e Inspection reports reviewed that led to an
accurate compliance determination

100% :i :i I <)<)"„

8b Single-event violations accurately identified
as SNC or non-SNC

100% <> <> I no",,

8c Percentage of SEVs identified as SNC
reported timely at major facilities

100% 5 5 I ()()"„

State response N/A

Recommendation

State Review Framework Report | Washington | Page 11

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CWA Element 3

Violations

Mild ill" 3-2

Area for State Improvement

Summary

Number of facilities in the state that are in noncompliance.

This metric does not have any goals associated with them, however, there
are national averages to compare to Washington. The metric pull for
Washington shows a large number of facilities in Washington that are in
noncompliance. Refer to Finding 1-2.

Explanation

Relevant metrics

Metric ID Number and Description

Natl Natl
Goal Avij

Sialc Siale Sialc

N D % or#

7dl Major facilities in noncompliance

7gl Non-major facilities in Category 2
noncompliance

N/A 74.2% (¦(¦ l>u.4".,

N/A l
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for necessary corrections to be made timely. Our priority will be major
facilities that are in noncompliance.

Recommendation The State should provide EPA with a schedule to ensure the 2017 annual
data metric analysis (DMA) will address the major facilities that are in
noncompliance, ensuring that future data flow from PARIS to ICIS-
NPDES is corrected, and addressing actions for violations are linked to the
violations in PARIS, and that the addressing action link flows to ICIS-
NPDES.

State Review Framework Report | Washington | Page 13

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CWA Element 4 — Enforcement

Finding 4-1 Meets or Exceeds Expectations

Summary Review of the enforcement actions during Fiscal Year 2015

Explanation The enforcement actions that EPA reviewed were both penalty actions, and

informal enforcement actions during Fiscal Year 2015. According to the
files reviewed, the state met the criteria for the number of enforcement
actions that will bring a source in violation into compliance. Furthermore,
the state met the criteria for appropriate enforcement responses that
addressed the violations.

-t . j ^ Natl Natl Male Male Slate

Metric ID Number and Description „ , . .

Goal Avjj N D % or #

9a Percentage of enforcement responses that

return or will return source in violation to 100% 2i> 2<> |u<)"„
compliance

10b Enforcement responses reviewed that
address violations in an appropriate manner

100% 2" I oil",,

State response N/A

Recommendation

State Review Framework Report | Washington | Page 14

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CWA Element 4 — Enforcement

Finding 4-2 Area for State Improvement

Summary Lack of Formal Enforcement action taken at major facilities in significant

non-compliance.

Explanation The data show that there was only one formal enforcement action taken

against the 35 major facilities that should have received formal
enforcement in the SRF review period. All of the 35 facilities were in
significant non-compliance (SNC) during the reporting period. EPA
enforcement guidance, Clarification o/NPDESEMS Guidance on Timely
and Appropriate Response to Significant Noncompliance Violations, date
May 29, 2008, states "Administrating agencies are expected to take formal
enforcement action before the violation appears on the second Quarterly
Noncompliance Report, generally within 60 days of the first QNCR." The
only mechanism available to address SNC is for the permit authority to
take a formal enforcement action against the permittee.

Refer to Finding 1-2.

Relevant metrics Natl stale siaie stale

Metric ID Number and Description Natl Goal . . ..

Avjj N D %or#

lOal Major facilities with timely action as -wy \ \ | ,r,

appropriate " /(> /n

State response Data errors currently exist in the current version of PARIS. One area of
primary focus in the development and deployment of PARIS 3.0 is to
analyze current data and identify inconsistent or inaccurate data. Post
PARIS 3.0 deployment, existing SNC data will be reviewed for accuracy,
and verified either by utilizing EPA's ICIS database or through facility
screening. At which point PARIS 3.0 is deployed and functionally stable,
Ecology enforcement staff will review and verify existing data and provide
the EPA a "get-well" enforcement plan for major facilities in SNC.

Recommendation As detailed in the explanation for Finding 1-2, EPA recognizes that due to
data errors not all of the facilities listed as needing formal enforcement in
this element are actually in SNC. However, the State should still issue
formal enforcement per the Clarification ofNPDES EMS Guidance on
Timely and Appropriate Response to Significant Noncompliance Violations
for those that are. Within 180 days of receipt of this report, the State shall
develop and deliver to EPA a plan to screen major facilities for SNC (or
utilize EPA's ICIS database) and ensure that the State takes proper formal
enforcement actions against the permittee in a timely manner for those that
continue in SNC.

State Review Framework Report | Washington | Page 15

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State Review Framework Report | Washington | Page 16

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CWA Element 5

Penalties

Mild ill" 5-1

Meets or Exceeds Expectations

Summary

Penalty actions taken in Fiscal Year 2015

Explanation

This metric evaluates whether the state has taken into consideration the
economic benefit gained by any facility not complying in a timely manner.
The metric also evaluates that the state documented the difference from the
initial penalty amount and the final penalty amount with appropriate
rationale. Lastly this metric evaluates if the state to documented in the file
that the penalties were collected. The state met these criteria in all of the
penalty actions reviewed during the review time period.

Relevant metrics

Metric ID Number and Description

Natl Natl Siale Sialc Sialc
Goal Avg N D %or#

11a Penalty calculations reviewed that consider
and include gravity and economic benefit

100% 4 4 1 oil",,

12a Documentation of the difference between
initial and final penalty and rationale

100% 4 4 lull",,

12b Penalties collected

100% 4 4 K id".,

State response N/A

Recommendation

State Review Framework Report | Washington | Page 17

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Clean Air Act Findings - Department of Ecology (ECY)

CAA Element 1 — Data

Finding 1-1 Area for State Improvement

Summary Twelve of the twenty-one files reviewed contained inaccurate data or

were missing documents.

Explanation The following file review issues related to metric 2b were identified:

1. In four files the date of the inspection was entered as the date the
inspection reports were entered into ICIS, not the date when the
inspections actually took place.

2. A file identified one source as a Synthetic Minor (SM80), when ICIS
indicated the source was an Operating Major.

3. A file did not include a copy of the Title V Certification or a record of
it being reviewed, although, it was entered into ICIS as received and
reviewed.

4. In one of the files the Title V Certification review date was entered
into ICIS as the date the report was received, not the date it was
reviewed.

5. Two of the files did not contain a copies of the FCE inspection
reports, even though the reports were entered into ICIS.

6. One of the files was missing documentation of multiple source tests
that were entered into ICIS, and in the same file copies of source tests
that were included in the file were not entered into ICIS.

7. One file was missing documentation related to two NOVs and one file
was missing documentation for a warning letter that was entered into
ICIS.

8. One of the files had an incorrect FCE date entered into ICIS of

11/3/2014 when the FCE in the file indicated the FCE was actually not
conducted until 10/15/2015.

State Review Framework Report | Washington | Page 18

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Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl

Avjj

Sialc
\

Siale
1)

Siale

% or#

2b Accurate MDR data in ICIS-AIR

5" 4".,

3a2 Timely reporting of HPV determinations

100%

99.6%

|()()"„

3b 1 Timely reporting of compliance
monitoring MDRs

100%

64.4%

2')

3b2 Timely reporting of stack tests and stack
test results

100%

65.2%

5l>

14 X"„

3b3 Timely reporting of enforcement MDRs

100%

56.6%

1 ^

i'j

(.X 4".,

State response

Under explanation item #7 EPA notes that there was an ICIS entry for a
warning letter on 4/7/2015 that could not be verified. ECY checked the
files and concur with this finding, so we do not have a comment related
to that finding. ECY was able to locate a PDF of the letter in our
electronic folder where we store all of correspondence, etc that we
issue. A copy of the letter is available for EPA review upon request.

ECY recognizes the need to update regional processes for recording data
to insure that deadlines are met.

ECY recognizes the need to provide standardized training to staff
currently tasked with entering data.

ECY recognizes the need to develop internal reference document for
ICIS database and continue to develop Registration database. ECY
should insure that current databases and future database development are
compatible and mutually supportive.

In response to the 2011 SRF CAA recommendations, Ecology proposed
and implemented a plan to improve MDR information entered into AFS.
Since 2013, data management systems have evolved (AFS replaced by
ISIS) and employees have moved-on or retired. Ecology proposes to
update the plan submitted and approved by EPA in 2013 to improve data
entry and file management practices moving forward. Within 180 days
of the completion of this report, ECY would review the SRF MDR and
stack test requirements and evaluate it against its current data entry and
management practices to identify the root causes of data entry practices
that adversely impact the accuracy of data entry. ECY would develop an
updated plan based on this review, and provide the plan to EPA for
review at the end of the 180-day period. Staff training would be
completed within 90 days of plan approval to ensure the updated data
entry and management practices are being implemented and that the
accuracy of data entry improves.

State Review Framework Report | Washington | Page 19

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Recommendation Within 180 days of the completion of this report, ECY should review the
SRF MDR and stack test requirements and evaluate it against its current
data entry and management practices to identify the root causes of data
entry practices that adversely impact the accuracy of data entry. A
revised data entry management policy based on this review should be
provided to EPA for review at the end of the 180-day period. Staff
training should be completed within 90 days of the issuance of the
revised policy to ensure the updated data entry and management
practices are being implemented and that the accuracy of data entry
improves.

State Review Framework Report | Washington | Page 20

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CAA Element 2 — Inspections

Finding 2-1

Area for State Attention

Summary ECY generally meets its FCE commitments as delineated in EPA's

Compliance Monitoring Strategy (CMS) Policy

Explanation For both metrics 6a and 6b three files were missing copies of inspection

reports that had been entered into ICIS. One of the files was missing
copies of two PCE inspection reports, and neither of which were entered
into ICIS. ECY should review its file management practices and ensure
that copies of all CMR documents are included in its files

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl
Avj;

Siale
\

Siale
1)

Siale

% or #

5a FCE coverage: majors and mega-sites

100%

63.2".,

1 1

XI X"„

5b FCE coverage: SM-80s

100%

79.5".,

1 1

1 <)<)"„

5c FCE coverage: minor and synthetics minor
(non-SM80s) sources that are part of a CMS
plan and Alternative CMS Facilities

100%

42.6",,

:u"„

5e Reviews of Title V annual compliance
certifications completed

100%

39.1".,

"i".,

6a Documentation of FCE elements

100%

i'j

X'J

6b Compliance monitoring reports (CMRs) or
facility files reviewed that provide sufficient
documentation to determine compliance of the
facility

100%

S5".,

State response ECY will review its file management practices and ensure that copies of
all CMR documents are included in its files.

Recommendation

State Review Framework Report | Washington | Page 21

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CAA Element 3 —

Violations

Finding 3-1 Area for State Attention

Summary ECY compliance determinations are mostly accurate however, three files

had issues that should be reviewed.

Explanation For one of the files reviewed, Region 10 could not establish compliance

with a specific permit condition. In this instance, it appears the source's
pollution control device was operating below the permitted range during
an inspection, but documents in the file and the inspection report did not
include enough information or data to establish compliance with the
permit condition.

A second file included enough information and data to establish the
source was in compliance, but the compliance status was entered into
ICIS as Unknown or N/A.

The third file documented violations at a source, but there was no entry
in ICIS indicating that the source was in violation. Notes in the file also
pointed to an NOV that had been issued, but a copy of the NOV was not
included in the file.

ECY should ensure that sufficient information and data are included in
its files to determine compliance. Inspection reports could be subjected
to a peer review process to ensure they include sufficient information
and data to determine compliance. ECY needs to improve adherence to
the FRV policy

Relevant metrics . Natl Natl Stale Male Stale

Metric ID Number and Description _ , . .

Goal Avjj N D %or#

7a Accuracy of compliance determinations IS 21 85

8c Accuracy of HP V determinations N/A 1% 5 5 luu",,

13 Timeliness of HPVidentification 100% 82.6% " " lull",,

State response ECY will endeavor to ensure that sufficient information and data are
included in its files to determine compliance. Ecology will ensure
inspection reports include sufficient information and data to determine
compliance. ECY will improve adherence to the FRV policy.

Recommendation

State Review Framework Report | Washington | Page 22

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CAA Element 4 — Enforcement

Finding 4-1

Area for State Attention

Summary

HPVs are not always appropriately or timely addressed by ECY.

Explanation For (Metric 10a) a HPV was not resolved and addressed within the

timeframe required by the August 2014 HPV Policy. In this instance it
took 861 days to address and resolve the HPV. The Case Development
and Resolution Timeline (Metric 14) also was not developed for this
HPV until day 791.

For Metric 10b a HPV violation was resolved in 92 days, but remains as
unaddressed in ICIS. This HPV also appears to have been resolved and
addressed without the assessment of any penalty which is inconsistent
with the policy

In addition to continuing regular HPV calls with Region 10, ECY should
coordinate with Region 10 to conduct a joint review and training session
on the August 2014 HPV policy to ensure that all future HPVs are
addressed and resolved accordingly.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl

A vij

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.

10a Timeliness of addressing HPVs or
alternatively having a case development and
resolution timeline in place.

10b Percent of HPVs that have been have been
addressed or removed consistent with the HPV
Policy.

14 HPV Case Development and Resolution
Timeline In Place When Required that Contains
Required Policy Elements

Siale Sialc
N I)

4 5

Sialc

% or#

S()"„

State response

ECY will coordinate with Region 10 to conduct a joint review and
training session on the August 2014 HPV policy to ensure that all future
HPVs are addressed and resolved accordingly.

State Review Framework Report | Washington | Page 23

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State Review Framework Report | Washington | Page 24

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CAA Element 5 — Penalties

Finding 5-1

Meets or Exceeds Expectations

Summary ECY documented the consideration of economic benefit and gravity, the

rationale for reduction of penalties, and the collection of penalties.

Explanation No discrepancies or other issues were identified in the files that were

reviewed against metrics 11a, 12a, and 12b.

Relevant metrics

Metric ID Number and Description

Natl Nail
Goal Avi*

11a Penalty calculations reviewed that
document gravity and economic benefit

12a Documentation of rationale for difference
between initial penalty calculation and final
penalty

12b Penalties collected

Siale Siale Siale

N D % or#

: : iuo",,

I |UU"„

: loo".,

State response

N/A

Recommendation

State Review Framework Report | Washington | Page 25

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Clean Air Act Findings - Ecology and Department of Health: Hanford

CAA Element 1 — Data

Finding 1-1 Area for State Improvement

Summary

ECY does not enter timely data into ICIS. DOH consistently enters
accurate but not always timely data in to ICIS

Explanation The Hanford Nuclear facility is a Department of Energy (DOE) Mega-

Site that encompasses an area of nearly 540 square miles and includes
approximately 1000 radionuclide air emission sources. ECY has
responsibility for conducting oversight of all non-radionuclide air
emission sources and DOH has sole responsibility for conducting
oversight of all radionuclide sources at the Hanford Nuclear Complex.
Based on conversations with ECY staff and the records reviewed during
the onsite visit, EPA believes that the timeliness of MDR data entered
into ICIS is insufficient due to a period of up to one-year when no ECY
CAA inspector was on staff to conduct inspections or enter compliance
and enforcement related data. Based on conversations with DOH staff
and records that were reviewed EPA determined that the timeliness of
DOH's MDR data entry into ICIS was not consistent. Specifically, the
entry of source test data and results into ICIS does not appear to be
occurring.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl Siale Siale

Avjj N 1)

Siale

% or#

2b Accurate MDR data in ICIS-AIR

ii 5

on",,

3a2 Timely reporting of HPV determinations

100%

99.60% u 5

on",,

3b 1 Timely reporting of compliance
monitoring MDRs

100%

64.20% u 1

on",,

3b2 Timely reporting of stack test dates and
results

100%

\ \

3b3 Timely reporting of enforcement MDRs 100% 56.40%

on",,

State response ECY: Ecology disagrees that the timeliness of MDR data entered into

ICIS is insufficient due to a period of up to one-year when no ECY CAA
inspector was on staff to conduct inspections or enter compliance and
enforcement related data.

Ecology (Nuclear Waste Program) prioritized resources during a period
when an existing CAA inspector accepted a different position and the
hiring of a new inspector. During this time period, no inspections were

State Review Framework Report | Washington | Page 26

-------
being performed. The decision was based on the fact that Ecology has
three years to perform a full compliance evaluation of the Hanford
Mega-Site and the existing inspector left near the start of this period.
Ecology had time to defer inspections initially and make-up this time
later. A new inspector was hired with approximately a year and a half
left in the period. As no inspections were being performed, no data
existed to input into ICIS were generated.

Ecology did complete the FCE on time and entered the PCE and FCE
data into ICIS.

The recommendation for an interagency working group to develop or
update SOPs to improve data management practices is an issue that
needs to be addressed at a State-Wide level and not at a specific site
level. The Nuclear Waste Program agrees with the response from the
Air Quality Program in the CAA - Data "Department of Ecology"
section (as opposed to this Ecology: Hanford section) where the
Department of Ecology proposes to update the plan submitted and
approved by EPA in 2013 to improve data entry and file management
practices moving forward.

The Ecology Nuclear Waste Program agrees that training needs related
to ICIS data entry and use will help further ICIS data entry and
management. The updated State-Wide Plan will provide a basis to
evaluate and prepare this training.

DOH: Prior to 2014, ECY was entering the necessary information into
AFS which is now ICIS-AIR. In 2014 and the start of the ICIS-AIR
system, Ecology entered into discussions with DOH to have DOH enter
inspection and compliance data directly into ICIS-AIR. DOH staff
received training on the ICIS-AIR system, and with the beginning of a
new three-year Full Compliance Inspection (FCE) period beginning
Januaryl, 2015, began to enter inspection data into the database. Wilde
not all inspections had been entered into ICIS-AIR at the time of the
audit in 2015, we had completed approximately 60 inspections on the
Hanford site, and by the completion of the last three-year cycle ending
September 30, 2017, we had conducted approximately 550 inspections
encompassing all 609 emissions units at least once. These reviews
successfully met the conditions of performing FCE within three years for
the Hanford Mega-Site. I should also be noted that in some cases
emission units were inspected several times over, and some inspections
consisted of looking at multiple emission units concurrently.

As far as specific stack test data that is required to be entered into ICIS-
AIR for radionuclide emissions, we are unclear of EPA's expectations. If

State Review Framework Report | Washington | Page 27

-------
this is referring to the source reporting requirements of 40 CFR 60.10, 40
CFR 61 Subpart H is exempt from those requirements as called out in 40
CFR 61.97 "Exemption from the reporting and testing requirements of
40 CFR 61.19".

Recommendation Within 90 days of the date of this report, EPA, ECY and DOH should

develop an interagency working group2 tasked with conducting a review
and assessment of past and current MDR data entry practices for non-
radionuclide and radionuclide emission sources at the Hanford Mega-
Site. The review should be complete 120 days after the workgroup is
formed. The results of that review should be developed into
recommendations within 60 days of the completion of the review that
can be used by ECY and DOH to establish updated SOPs to improve
data management practices and policies. The review will also identify
the training needs ECY and/or DOH has for ICIS so that EPA can
provide specific ICIS training before the end of calendar year 2018 to
help further ensure MDR data entry and maintenance is accurate and
timely.

2 ECY and DOH Hanford programs are interconnected and work closely together under the same permit mechanisms and or requirements. As such, for purposes of efficiency and
to avoid duplication of efforts the interagency working group should be comprised of both ECY and DOH.

State Review Framework Report | Washington | Page 28

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CAA Element 2 — Inspections

Finding 2-1 Area for State Improvement

Summary ECY/DOH has a period of 3 years to complete a comprehensive Full

Compliance Inspection (FCE) of the Hanford Nuclear Complex. ECY
indicated to EPA file reviewers that it was not certain when the last
comprehensive FCE of all of the non-radionuclide air emission sources
located at the Hanford Complex was completed. It was also unclear to
EPA file reviewers if and when the last comprehensive FCE of all of the
radionuclide air emission sources was completed

Explanation Based on conversations with ECY staff indicating that there was a period

of up to one-year when no ECY CAA inspector was on staff to conduct
inspections or enter compliance and enforcement related data for non-
radionuclide sources at the Complex, EPA was not able to establish the
consistency or comprehensiveness of past and present FCE inspections
conducted at the Hanford Nuclear Complex. The DFR for Hanford does
indicate that DOH has conducted several years of onsite PCEs at the
Complex. However, no offsite FCE entry appears in the DFR, indicating
that the entire complex of approximately 1000 radionuclide air emission
sources has been inspected as required within the 3-year period allotted
for a Mega-Site. FCEs at Mega-Sites are completed by multiple onsite
PCEs being conducted over time at multiple sources within the Mega-
Site that are then combined together to comprise single comprehensive
FCE evaluation of the entire Complex.

Relevant metrics

-t . j ^ Natl Natl Sialc

Metric ID Number and Description _ , .

Goal Avu N

100% 63.20% I)

5a FCE coverage: majors and mega-
sites

5b FCE coverage: SM-80s

5c FCE coverage: minors and
synthetic minors (non-SM 80s) that
are part of CMS plan or alternative
CMS Plan.

5e Review of Title V annual
compliance certifications

6a Documentation of FCE elements

6b Compliance monitoring reports
(CMRs) or facility files reviewed that
provide sufficient documentation to
determine compliance of the facility

\ \

100% 39.10% u

Slale Sialic

D % or#

2 no",,

: on",,
u \ \

u \ \

State Review Framework Report | Washington | Page 29

-------
State response ECY: When EPA conducted the audit, they discovered the date of the
last FCE was not in the database. Ecology and Department of Health
(DOH) investigated the issue and corrected the coding of the
corresponding compliance evaluation in the database from PCE to FCE
(it was incorrectly coded as PCE). With this correction, the FCE was
dated as December 31, 2014. The next FCE was due to be completed on
September 30, 2017, and Ecology and DOH were only half way through
the 3-year inspection timeframe window at the time of the audit. As
discussed above, a new inspector was hired by Ecology to complete all
required inspections within the 3-year window. The inspector has since
completed all AOP discharge point inspections within the required 3-
year period and entered the appropriate data/results into EPA's ICIS
database.

The inspector provided compressive evaluations for the latest 3-year
round of FCE inspections through inspection close-out letters which
provide detailed information regarding determination of compliance.
The EPA was included in the distribution of these letters. Ecology is
open to any feedback from the EPA regarding the depth and breadth of
their inspection close out letters content and would be happy to invite
EPA on inspections.

It is recommended that any SOP discussions be returned to the general
CAA section as it is a State wide issue. As discussed in the response to
Element 1, The Ecology Nuclear Waste Program agrees with the
response from the Air Quality Program in the CAA - Data "Department
of Ecology" section (as opposed to this Ecology: Hanford section) where
The Department of Ecology proposes to update the plan submitted and
approved by EPA in 2013 to improve data entry and file management
practices moving forward.

Ecology's Hanford Air Section uses the Department of Ecology's
procedures and guidance in the performance of inspections. Any
changes or modifications to these SOPs would need to be performed in
coordination with the State-wide Air Quality Program.

DOH: As stated in Finding 1-1, prior to 2014 DOH did not enter data
into what was previously AFS and is now ICIS-AIR. It was our
understanding that ECY was entering the necessary information into
AFS. In 2014 and the start of the ICIS-AIR system, ECY entered into
discussions with DOH for the purpose of having DOH enter inspection
and compliance data directly into ICIS-AIR. DOH staff received training
on the ICIS-AIR system, and with the beginning of the new three-year
FCE beginning January 1, 2015, began to enter the inspections data into
the database. While not all inspections have been entered into ICIS-AIR,

State Review Framework Report | Washington | Page 30

-------
at the time of the audit in 2015, we had completed approximately 60
inspections on the Hanford Site, and by the completion of the last three-
year cycle ending September 30, 2017, we had conducted approximately
550 inspections inspecting all 609 emissions units at least once. This
successfully met the conditions of performing a FCE within three years
for the Hanford Mega-Site. I should also be noted that in some cases
emission units were inspected several times over, and some inspections
consisted of looking at multiple emission units concurrently.

We invite EPA to review the history of radionuclide air emission
inspections completed by DOH in our existing database which identifies
all inspections going back to the 1990s.

DOH inspections are rigorous, comprehensive, and time intensive. They
are drive by the Emission Units (EU) license conditions, monitoring and
abatement technology requirements developed specifically for that EU's
unique proves, and potential to emit. The release of emission documents
take additional time at the Hanford Site as the United States Department
of Energy (USDOE) has to evaluate all documents provided to DOH to
ensure they do not contain control information. It is also DOH's practice
to not close an inspection and issue a report until all issues are addressed.

DOH has performed numerous joint inspections of Hanford EUs with
EPA Region 10 radiation health physicists for several years. During this
time, no issues on National Emission Standards for Hazardous Air
Pollutants (NESHAP) inspections were ever identified to DOH by EPA.

DOH looks forward to meeting with EPA and ECY to determine EPAs
expectations as they relate to the SRF, as well as, the inspection
responsibilities for NESHAP facilities in which the State has been
delegated.

Recommendation As part of the interagency working group developed to assess MDR data
entry practices and issues addressed in the element above, EPA and
ECY/DOH should also use the resources of that working group to
conduct a comprehensive review and assessment of ECY and DOH
inspection policies and practices. In addition, ECY and DOH will invite
EPA to attend CAA inspections at the Hanford facility for at least one
year of the 3-year FCE inspection cycle. After completing the review,
assessment, and conducting joint inspections, EPA and ECY/DOH will
review the data, findings and best practices generated from that effort
and use that information to develop a list of recommendations, policies,
and practices that ECY/DOH can adopt and utilize as SOPs to ensure the
consistency and comprehensiveness of all of its FCE inspection efforts at
the Hanford facility. Within 90 days of completing this effort ECY/DOH

State Review Framework Report | Washington | Page 31

-------
will submit a draft report to EPA that identifies the root causes of these
issues and details the corrective actions that will be taken.

State Review Framework Report | Washington | Page 32

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CAA Element 3 —

Violations

Finding 3-1 Area for State Improvement

Summary Issues regarding the accuracy of compliance determinations and

timeliness of HPV determinations were identified.

Explanation Based on conversations with ECY and DOH staff regarding the

development, processing and managerial review of violations alleged at
the Hanford Nuclear Complex, EPA is concerned that past and present
compliance determinations are inconsistent with ECY, DOH and EPA
enforcement policies, guidance, and the Clean Air Act stationary source
civil penalty policy. Currently, there are four (4) HPVs that have been
identified by DOH and one (1) HPV correctly identified by ECY, but all
of them remain unaddressed after two or more years. It also appears that
both ECY and DOH intend to resolve the HPVs without assessing a
penalty. Such a resolution could be contrary to the CAA stationary
source penalty policy and more likely than not would be inconsistent
with EPA's historic practices and HPV policy when resolving similar
HPVs at large complex facilities.

Relevant metrics . Natl Natl Siaic Siaic Siaic

Metric ID Number and Description _ , . .

Goal Avjj N D %or#

7a Accuracy of compliance determinations 4 5 X<)"„

8c Accuracy of HPV determinations 5 5 I < n

13 Timeliness of HPV determinations o 5 no",,

State response ECY: The HPVs in question were the first HPVs issued by Ecology's
Nuclear Waste Program. Previous HPV guidance would not have
classified them as HPVs. Ecology, DOH and United States Department
of Energy (the Permittee) were learning the HPV process for the first
time and all levels of management, inspectors, compliance, and permit
writers were part of the learning process.

Ecology has no objection to collaborating with EPA Region 10's Office
of Compliance and Enforcement to address all future HPVs consistently
with EPA's guidance.

State Review Framework Report | Washington | Page 33

-------
only occurred when a violation in a Title V permit occurred for the
constituents that required the Site to obtain a Title V permit. As the
radiological NESHAPS that ECY contracts DOH to manage are not a
constituent that required the Hanford site to obtain a Title V permit, no
HPV for radiological only violation could occur.

With the new guidance document inclusion of NESHAP violations, a
system has been put in place by DOH to review all notifications to
determine if they trigger an HPV/FPV criteria. The system also evaluates
all issues identified during an inspection. The new guidance on HPVs
resulted in four HPVs being identified in 2015. We agree that the
timeliness identified in the policies were not met for the Hanford Site,
however part of the difficulties is due to the length of time it takes to
deal with the USDOE. At this time, three of the HPVs can be closed out
and there is a corrective action plan to correct the final HPV which is
due to be completed in March 2018.

It is DOH's opinion that compliance and protection of public health is
sometimes better served by prevention of releases through licensing
requirements and inspections. Even when an issue is found the finding
does not necessarily mean that the EUS license limit has been exceeded.
We have not had a finding at Hanford where the Ambient Air standard
of 10 mrem/yr has been exceeded. Issues identified generally equate to a
putlic dose several orders of magnitude lower than the Ambient Air
standard of 10 mrem/yr which is still a conservative limit.

In regards to issuing penalties, the DOH preference is to work with the
licensee to gain compliance and only use monetary penalties as a last
resort.

We look forward to meeting with EPA and ECY to discuss the
HPV/FRV policy. Based on the outcome of those meetings, we will
update our procedures, as appropriate, to clearly identify our processes
for issuing penalties.

Recommendation ECY should collaborate with EPA Region 10's Office of Compliance

and Enforcement (OCE) to appropriately address and resolve the current
HPV consistent with national HPV policy and guidance within 90 days
of the finalization of the SRF report. All future HPVs should be
addressed consistent with national policy and guidance by the authorized
state agency or EPA, if necessary.

State Review Framework Report | Washington | Page 34

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CAA Element 4 — Enforcement

Finding 4-1

Area for State Improvement

Summary

ECY has not timely addressed the one HPV identified and DOH has
not addressed 4 HP Vs. Additionally, both were late in developing
CD&R timelines. Based on periodic HPV conferences, ECY staff
have indicated that the HPV identified for the Hanford Nuclear
Complex will not be addressed with a civil penalty. Note that ECY
has not yet requested to resolve the HPV without penalty at this time,
though staff have indicated that this is anticipated in the future.

Explanation ECY currently has 1 HPV and DOH has 4 4at the Hanford Nuclear

Complex, and all remain unaddressed after more than 2 years. The
violations of the engine NESHAP are relatively straightforward and
should not require such an extended period of time to address and
resolve.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl

A vij

Siale
N

Siale
I)

10a Timeliness of addressing HPVs or
alternatively having a case development and
resolution timeline in place.

10b Percent of HPVs that have been have been
addressed or removed consistent with the HPV
Policy.

14 HPV Case Development and Resolution
Timeline In Place When Required that
Contains Required Policy Elements

Siale

% or#

DO"

()()",

()()"

State response

ECY: The HPVs in question were the first HPVs issued by Ecology's
Nuclear Waste Program. Previous HPV guidance would not have
classified them as HPVs. Ecology, DOH and United States Department
of Energy (the Permittee) were learning the HPV process for the first
time and all levels of management, inspectors, compliance, and permit
writers were part of the learning process.

State Review Framework Report | Washington | Page 35

-------
Ecology has no objection to collaborating with EPA Region 10's Office
of Compliance and Enforcement to address all future HPVs consistently
with EPA's guidance.

DOH: Until late 2014, DOH was unaware of the EPA policies regarding
High Priority Violations and Federal Reportable Violations (HPV/FRV).
As a result, we were not evaluating our inspection findings and
notifications against those policies. Once we became aware of the
policies, our evaluations were consistent with your procedures. It should
be noted that up until the new HPV/FRV policy was issued, an HPV
only occurred when a violation in a Title V permit occurred for the
constituents that required the Site to obtain a Title V permit. As the
radiological NESHAPS that ECY contracts DOH to manage are not a
constituent that required the Hanford site to obtain a Title V permit, no
HPV for radiological only violation could occur.

In regards to issuing penalties, the DOH preference is to work with the
licensee to gain compliance and only use monetary penalties as a last
resort.

State Review Framework Report | Washington | Page 36

-------
Recommendation 1. ECY and DOH should address and resolve the existing HPVs within

90 days of the finalization of the SRF Report.

2. ECY and DOH should also review national HPV policy, guidance,
and the CAA stationary source civil penalty policy and develop a
draft SOP within 90 days of this report to ensure all future HPVs
identified at the facility are addressed and resolved consistent with
HPV policy and guidance.

A draft HPV SOP should be completed and submitted to EPA within

180 days of the finalization of the SRF report.

State Review Framework Report | Washington | Page 37

-------
CAA Element 5 — Penalties

Finding 5-1

N/A

Summary

Explanation

Relevant metrics

Metric ID Number and Description

Natl Natl Stale Stale Stale
Goal Avij N D %or#

11a Penalty calculations reviewed that
document gravity and economic benefit

12a Documentation of rationale for difference
between initial penalty calculation and final
penalty

12b Penalties collected

no",,

on",,

nu"„

State response

N/A

Recommendation

State Review Framework Report | Washington | Page 38

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Clean Air Act Findings Northwest Clean Air Agency (NWCAA)

CAA Element 1

— Data

Finding 1-1

Meets or Exceeds Expectations

Summary

NWCAA provides accurate and timely data entry into ICIS

Explanation NWCAA utilizes an electronic data base for file management that is

frequently updated and well managed. Use of this data base allows
NWCAA to maintain consistently accurate and up to date MDR data
entry in to ICIS.

For Metric 3b 1, 3b2 and 3b3 it was believed that the low percentages for
these metrics was being caused because NWCAA had accidentally been
entering data into the ICIS test platform after ICIS production went
online. During the file review NWCAA pointed out this issue to EPA
and indicated that the data had been correctly entered into ICIS since
then. A subsequent review of the same data metrics for 2017 verify that
data entry errors for these metrics have been corrected. Therefore, EPA
recommends these data metric percentages be revised using the 2017
data metrics to reflect the corrections.

Relevant metrics

Metric ID Number and Description

2b Accurate MDR data in ICIS-AIR

3a2 Timely reporting of HPV determinations

100%

99.6%

3b 1 Timely reporting of compliance
monitoring MDRs (Revised)

100%

64.4%

3b2 Timely reporting of stack tests and stack
test results (Revised)

100%

65.2%

3b3 Timely reporting of enforcement MDRs
(Revised)

Natl .. . Siaie Siaie Siaic

„ . NatlAvji .

Goal N D %or#

I (i0%
N/A

86.7%
100%
87.5%

100% 56.6%

State response N/A

Recommendation None Required

State Review Framework Report | Washington | Page 39

-------
CAA Element 2 — Inspections

Finding 2-1 Meets or Exceeds Expectations

Summary NWCAA clearly documents FCE elements and the files include ample

CMR documentation

Explanation Inspection reports and supporting CMR documents were immediately

and easily accessed using NWCAA's electronic file system. For each of
the files reviewed, it was easy for the reviewer to locate and review the
supporting documents, and file contained sufficient data and documents
to accurately determine the compliance of the facility.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl

Avjj

Siale
\

Sialic
D

Sialc

% or#

6a Documentation of FCE elements

1 <)<>"„

6b Compliance monitoring reports (CMRs) or
facility files reviewed that provide sufficient
documentation to determine compliance of the
facility

5a FCE coverage: majors and mega-sites

100%

63.2%

1
-------
CAA Element 3 —

Violations

Finding 3-1 Meets or Exceeds Expectations

Summary NWCAA makes consistent and accurate compliance and HPV

determinations.

Explanation Compliance determinations were based on the information contained in

the source file, and the compliance determinations were accurately
reported into ICIS. The HPV status was accurately determined using the
August 2014 HPV Policy. NWCAA still needs to improve its adherence
to the FRV policy. NWCAA contacted EPA after the file review was
completed and informed EPA that it had identified some FRVs that had
not been correctly entered. NWCAA indicated that it had taken steps to
ensure the reporting of all FRVs and that it had successfully entered
those FRVs into ICIS.

Relevant metrics

Metric ID Number and Description

Natl Natl
Goal Avjj

8a Accuracy of HPV determinations

N/A

8c Accuracy of HPV determinations

Siale Sialic Sialc

N D % or#

7a Accuracy of compliance determinations

13 Timeliness of HPV identification

100% 82.6% u

15 lull",,

2u d".,

I |n<)"„

0 \ \

State response

N/A

Recommendation None Required

State Review Framework Report | Washington | Page 41

-------
CAA Element 4 — Enforcement

Finding 4-1

Meets or Exceeds Expectations

Summary NWCAA uses formal enforcement responses to return facilities to

compliance in a specified time frame. HPVs are addressed or removed
according to the timing requirements of the August 2014 HPV Policy

Explanation All of the formal enforcement responses reviewed included a document

such as an order or consent decree with requirements that a source return
to compliance within a specified timeframe. The HPV that was reviewed
was addressed according to the August 2014 HPV policy.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl
Avti

Siale
\

Sialic
I)

10a Timeliness of addressing HPVs or
alternatively having a case development and
resolution timeline in place.

10b Percent of HPVs that have been have been
addressed or removed consistent with the HPV
Policy.

Sialc

% or#

I DO",

I ()()"„

I DO",

State response

N/A

Recommendation None Required

State Review Framework Report | Washington | Page 42

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CAA Element 5 — Penalties

Finding 5-1

Meets or Exceeds Expectations

Summary

All but one of the files reviewed documented consideration of economic
benefit and gravity, the rationale for reduction of penalties, and the
collection of penalties.

Explanation For one penalty that was issued there was not any supporting

documentation discussing gravity and economic benefit, and there was
no rationale for how the penalty amount was established. According to
NWCAA in this particular instance no penalty calculations were made
because the penalty was derived through a settlement process.

Relevant metrics

Metric ID Number and Description

Natl Natl
Goal Avi*

11a Penalty calculations reviewed that
document gravity and economic benefit

12a Documentation of rationale for difference
between initial penalty calculation and final
penalty

12b Penalties collected

Siale Siale Siale

N D % or#

4 5 Si)",,

11 )()"„
I ()()"„

State response N/A

Recommendation None Required

State Review Framework Report | Washington | Page 43

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Clean Air Act Findings - Olympic Regional Clean Air Agency (ORCAA)

CAA Element 1

— Data

Finding 1-1

Area for State Attention

Summary

ORCAA generally enters accurate and timely data into ICIS

Explanation

Only one of the files reviewed contained MDR data that was not entered

into ICIS. The file contained two source test reports but only one of the

reports was entered into ICIS.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl

Avjj

Siale
N

Siale
1)

Siale

% or #

2b Accurate MDR data in ICIS-AIR

3a2 Timely reporting of HPV determinations

100%

99.6".,

\ \

3b 1 Timely reporting of compliance
monitoring MDRs

100%

64.4".,

l(>

5'J

3b2 Timely reporting of stack tests and tack
test results

100%

65.2".,

:<)".,

3b3 Timely reporting of enforcement MDRs

100%

56.6".,

\ \

State response

N/A

Recommendation None Required

State Review Framework Report | Washington | Page 44

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CAA Element 2 — Inspections

Finding Choose
an item.

Meets or Exceeds Expectations

Summary ORCAA carefully documents FCE elements and compliance monitoring

reports are included in its files are sufficient to determine facility
compliance

Explanation For both Metrics 6a and 6b one file indicted that a FCE inspection was

conducted, but it appears that two significant permit conditions related to
facility compliance were not evaluated or considered during the FCE
inspection.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl

Avg

Siale
\

Siale
1)

Siale

% or#

5a FCE coverage: majors and mega-sites

100%

63.2%

5b FCE coverage: SM-80s

100%

79.5%

5c FCE coverage: minor and synthetics minor
(non-SM80s) sources that are part of a CMS
plan and Alternative CMS Facilities

N/A

\ \

5e Reviews of Title V annual compliance
certifications completed

100%

39.1%

45 5".,

6a Documentation of FCE elements

T. V,,

6b Compliance monitoring reports (CMRs) or
facility files reviewed that provide sufficient
documentation to determine compliance of the
facility

')? V',,

State response

N/A

Recommendation None Required

State Review Framework Report | Washington | Page 45

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CAA Element 3 —

Violations

Finding 3-1

Meets or Exceeds Expectations

Summary

ORCAA makes accurate compliance determinations

Explanation Compliance determinations in the 15 files reviewed were accurately

determined and supported by the documents and data included in the
files. No HPVs were identified during the review period, so metric 8a is
not applicable.

Relevant metrics

Metric ID Number and Description

Natl Natl
Goal Avu

Siale Siale Slale

7a Accuracy of compliance determinations

8c Accuracy of HPV determinations

N/A 1%

13 Timeliness of HPV identification

100% 82.6% 0

% or#

1 ^

<)"„

V \

State response N/A

Recommendation None Required

State Review Framework Report | Washington | Page 46

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CAA Element 4 — Enforcement

Finding 4-1 Meets or Exceeds Expectations

Summary ORCAA mostly uses formal enforcement mechanisms that include

specifics corrective actions and a timeline to return a facility to
compliance

Explanation ORCAA had one formal enforcement response during the review period

and the formal enforcement response required corrective action within a
specified time frame to return the facility to compliance. No HPVs were
identified during the review period, so metrics 10a, 10b and 14 are not
applicable.

Relevant metrics

Metric ID Number and Description

Natl Natl
Goal Avi*

Siale Siale Sialc

N D % or#

I ()()"„

State response

N/A

Recommendation None Required

State Review Framework Report | Washington | Page 47

-------
CAA Element 5 — Penalties

Finding Choose
an item.

Area for State Attention

Summary ORCAA did not document consideration of gravity and economic

benefit in its penalty calculation.

Explanation Two minor issues were identified regarding the penalty calculation.

First, ORCAA's civil penalty worksheet states there was no economic
benefit resulting from the instance of noncompliance, however, it does
not explain and justify why no economic benefit was assessed as part of
the penalty. Second, the civil penalty worksheet also has a section asking
if there were previous violations at the facility in the last five years, and
the worksheet is checked no indicating that there were not any
violations, however, ICIS data indicates that an Agreed Order (AO) was
issued to the facility in 2014 indicating that at least one prior violation
existed. There was no difference between the initial and final penalty
calculation so Metric 12a is not applicable, and a copy of the check used
to pay the penalty was included in the file. ORCAA needs to ensure that
penalty calculations include a written justification and rationale in the
file, when the economic benefit component of a penalty is not assessed.

Relevant metrics

Metric ID Number and Description

Natl Natl
Goal Avu

Stale Stale Stale

N D % or#

11a Penalty calculations reviewed that
document gravity and economic benefit

12b Penalties collected

I <)<)"„
I Iihi"„

State response

N/A

Recommendation None required

State Review Framework Report | Washington | Page 48

-------
Clean Air Act Findings - Benton Clean Air Agency (BCAA)

CAA Element 1

— Data

Finding 1-1

Area for State Attention

Summary

Information reported into ICIS was mostly consistent with the

information contained in all of the files reviewed.

Explanation

BCAA enters accurate MDR data into ICIS. However, it appears that

stack test data is not being entered into ICIS at all.

Relevant metrics

Metric ID Number and

Natl

Nail Sialc

Siale

Slale

Description

Goal

Avji N

% or#

2b Accurate MDR data in ICIS-

II HI".,

AIR

3a2 Timely reporting of HPV
determinations

100%

99.
-------
CAA Element 2 — Inspections

Finding 2-1 Area for State Improvement

Summary BCAA compliance documentation was incomplete or it lacked sufficient

analysis and detail to determine the compliance status of a source.

Explanation 1. One DFR indicated that stack tests were entered into ICIS as

reviewed, when they were not. Records of the stack test results and data
were not provided to BCAA and they were not included in the source
file. According to BCAA the source conducts its own internal source
testing, but it does not submit copies of the stack test results and data to
BCAA, because the permit originally issued in 1995 does include a
requirement for the submission of stack test records and data to BCAA.

2. For one source the FCE inspection was not completed within the five-
year period required by the CMS plan. According to BCAA the inability
to conduct this FCE was caused by a shortage of travel dollars, and the
FCE for this source will be completed October 1, 2017.

3. In the remaining files FCE Inspection Reports only contained general
statements regarding the source's records that were reviewed, but did not
indicate explicitly what the records determined with regard to
compliance. Documentation of FCE elements in this regard were
consistently insufficient to determine compliance. For example; in one
instance, general comments were made about process operating
conditions in the inspection report, such as; permit condition 2.1.7. limits
SO2 emissions < lOOOppm @ 7% O2 (60-minute average) the FCE report
mentions the documentation the source submits to show compliance with
this condition, however, the FCE report does not indicate whether or not
the SO2 content of the Natural Gas met the requirement. In another
instance, Region 10 was not able to determine compliance because the
inspection report did not contain sufficient details regarding exactly how
BCAA determined compliance during and after the inspection. Finally,
in other instances, FCE files included an annual inspection checklist
spreadsheet with notes, however, the notes that were included were not
detailed enough to draw conclusions regarding compliance. Also in
many instances the checklists were not completely filled out.

Relevant metrics . Natl Natl Siaio Sisiie Siau-

Metric ID Number and Description _ , .

Goal Avjj N D %or#

5a FCE coverage: majors and mega-sites 100% 63.2% I I |uu"„

5b FCE coverage: SM-80s 100% 79.5% t) ' t>"

State Review Framework Report | Washington | Page 50

-------
5c FCE coverage: minor and synthetics minor

(non-SM80s) sources that are part of a CMS N/A N/A \ \ \ \ \ \
plan and Alternative CMS Facilities

5e Reviews of Title V annual compliance mno/ ,«,«/ ,,

, • • | j X 00 /o J y, 1 /o 0 O On

certifications completed

6a Documentation of FCE elements 2 5 4<)".,

6b Compliance monitoring reports (CMRs) or

facility files reviewed that provide sufficient , . ^()11

documentation to determine compliance of the

facility

State response N/A

Recommendation 1. Within 120 days of the finalization of the SRF report BCAA should
amend the 1995 AOP to ensure the submission of stack test results, in
addition to any other applicable compliance data and/or information in
the future. Region 10 also recommends that BCAA provide Region 10
monthly progress reports detailing its efforts to renew or amend the
existing permit to Region 10 until such efforts are successfully
concluded.

2. BCAA and EPA should develop a strategy within 90 days of
finalizing this report for Region 10 to provide support to BCAA when
needed to ensure that all CMS commitments are met within the required
timeframe. BCAA should also develop internal policy and/or guidance
that requires notification of Region 10 as soon as possible whenever any
circumstances arise that may prevent BCAA from meeting the
requirements of the CMS plan in a timely manner.

3. Within 180 days of the completion of this report, BCAA needs to
develop a draft revised inspection report template for regional review
that includes permit terms and clear concise statements regarding how
and why compliance is determined. The inspectors need to include in
the inspection reports the "basic elements" as identified in the CMS
Policy. Also within 180 days, an SOP needs to be developed for the
supervisor of the inspectors to review and approve all inspection reports.
Inspectors should receive training on drafting inspection reports within a
year of this report.

4. For a period of at least 1 year after BCAA begins utilizing the new
inspection report template and conducting supervisory review and
approval of inspection reports. BCAA should submit copies of each
inspection report and supervisor approval to EPA for peer review and
discussion. EPA will review each report and provide feedback to BCAA
on inspection report completeness and adequacy within 30 days.

State Review Framework Report | Washington | Page 51

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State Review Framework Report | Washington | Page 52

-------
CAA Element 3 —

Violations

Finding Choose Area for State Improvement

an item.

Summary BCAA compliance documentation was incomplete or it lacked sufficient

detail to reliably determine the compliance status of a source.

Explanation Two of the four files reviewed lacked sufficient information and data to

accurately determine compliance.

In two of files FCE Inspection Reports only contained general statements
regarding the source's records that were reviewed, but did not indicate
explicitly what the records determined with regard to compliance.
Documentation of FCE elements in this regard were consistently
insufficient to determine compliance. For example; in one instance,
general comments were made about process operating conditions in the
inspection report, such as; permit condition 2.1.7. limits S02 emissions
< lOOOppm @ 7% 02 (60-minute average) the FCE report mentions the
documentation the source submits to show compliance with this
condition, however, the FCE report does not indicate whether or not the
S02 content of the Natural Gas was meeting the requirement. In the
other instance, Region 10 was not able to determine compliance because
the inspection report did not contain sufficient enough details regarding
exactly how BCAA determined compliance during and after the
inspection.

Relevant metrics

Metric ID Number and Description

8a Accuracy of HPV determinations

13 Timeliness of HPV identification

Natl Natl
Goal Avij

7a Accuracy of compliance determinations

N/A

100% 82.6% ()

Siale Siale Siale

N D % or#

5 <>u"„
() 2 <>"„

u NT/A

State response

N/A

Recommendation

Within 180 days of the completion of this report, BCAA needs to develop
a draft revised inspection report template for regional review that includes
permit terms and clear concise statements regarding how and why
compliance is determined. The inspectors need to include in the inspection
reports the "basic elements" as identified in the CMS Policy. Also within
180 days, an SOP needs to be developed for the supervisor of the
inspectors to review and approve all inspection reports. Inspectors should

State Review Framework Report | Washington | Page 53

-------
receive training on drafting inspection reports within a year of this report.
For a period of at least 1 year after BCAA begins utilizing the new
inspection report template and conducting supervisory review and
approval of inspection reports. BCAA should submit copies of each
inspection report and supervisor approval to EPA for peer review and
discussion. EPA will review each report and provide feedback to BCAA
on inspection report completeness and adequacy within 30 days.

State Review Framework Report | Washington | Page 54

-------
CAA Element 4 —

Enforcement

Finding 4-1

Area for State Improvement

Summary

BCAA did not conduct any enforcement responses during the review

period.

Explanation

See Explanation for Finding 5-1 as it also applies to these metrics as

well.

Relevant metrics

Metric ID Number and Description

Natl Nail
Goal Avu

Siale Siale Siale

or #

10a Timeliness of addressing HPVs or
alternatively having a case development and
resolution timeline in place.

10b Percent of HPVs that have been have been
addressed or removed consistent with the HPV
Policy.

14 HPV Case Development and Resolution
Timeline In Place When Required that
Contains Required Policy Elements

\ \

State response N/A

Recommendation See Recommendation for Finding 5-1 as it applies to these metrics also.

State Review Framework Report | Washington | Page 55

-------
CAA Element 5 — Penalties

Finding 5-1 Area for State Improvement

Summary BCAA did not conduct any enforcement responses during the review

period and therefore no penalties were assessed or collected.

Explanation It should be noted, that the BCAA source universe consists of a total of

six sources; two of which are Title V Major and four are Synthetic
Minor (SM80) sources. Thus, BCAA's work load is significantly less
than most other state and local agencies in Region 10. For the BCAA
SRF review only one source file had an activity within the review
period, and as such, Region 10 elected to conduct a review of all of
BCAA's source files. The only activity that took place during the review
period was an FCE inspection at one of BCAA's two Title V major
sources. It also appears that BCAA has not reported any HPV or FRV
violations before or after the updated HPV and FRV policies came into
effect. In addition, to conducting a review of all of the BCAA source
files, Region 10 also decided to review the ICIS State Enforcement
Activities Report covering the period from 2008 to the present.
According to this report, BCAA has not taken an informal or formal
enforcement actions against any of its major or minor sources for at least
9 years. Based on discussions with BCAA staff, it also appears that when
instances of non-compliance are identified that BCAA chooses to utilize
non-enforcement actions to address most instances of non-compliance.
Reliance on non-enforcement actions that do not conclude in formal
enforceable orders and the evaluation of penalties concerns EPA,
because, the sole use of non-enforcement actions to return to compliance
and deter future non-compliance is inconsistent with existing EPA
enforcement policy(s), guidance and practices in that the reliance on
such mechanisms does not create a fair and level playing field.

Relevant metrics . Natl Natl Siaic Siaic Siaic

Metric ID Number and Description „ , . .

Goal Avg N D %or#

0 0 N/A

11a Penalty calculations reviewed that
document gravity and economic benefit

12a Documentation of rationale for difference

between initial penalty calculation and final < i < i \ \

penalty

12b Penalties collected u u \ \

State response N/A

Recommendation por a perj0(j 0f jeas^ \ year after BCAA begins utilizing the new

State Review Framework Report | Washington | Page 56

-------
inspection report template and conducting supervisory review and
approval of inspection reports. BCAA should submit copies of each
inspection report and supervisor approval to EPA for peer review and
discussion. EPA will review each report and provide feedback to BCAA
on inspection report completeness and adequacy within 30 days.

State Review Framework Report | Washington | Page 57

-------
Resource Conservation and Recovery Act Findings

RCRA Element 1 — Data

Finding Choose Area for State Improvement

an item.

Summary Multiple errors in data were found.

Explanation Since the type of data error varied from case file to case file it appears this

is a quality control issue versus a lack of understanding the data
requirements. In some instances, the database elements did not match the
documents in the file and in other instances the errors appeared to be
typographical in nature. Accurate data is necessary for EPA to verify work
the State does as part of the Grant and Performance Partnership
Agreement. Accurate date is also the primary way that the public is able to
evaluate the status of any particular facility.

Relevant metrics

Metric ID Number and Description

Natl .. . Siaie Stale Sinic

„ . Natl Avji . „

Goal N D %or#

2b Complete and accurate entry of mandatory data

State response Ecology has re-instituted regular meetings for RCRAInfo data entry staff.

The first meeting occurred in September 2017. Future meetings will occur
at least quarterly and focus on answering questions, resolving problems,
and expanding knowledge of RCRAInfo in general. Program experts for
financial assurance, permitting, and corrective action data will lead
sessions and share knowledge.

Quality Assurance/Quality Control (QA/QC) reports are available and
updated monthly. RCRAInfo data entry staff have been regularly informed
of the updates. Beginning December 2017, Ecology inspectors and field
staff supervisors will be notified as the monthly updates to the QA/QC
reports occur. Ecology will coordinate with EPA Region 10 staff and
develop customized reports to allow better review by Ecology.

Ecology will review the data and files that EPA examined in this State
Review Framework (SRF), looking for common patterns that might be
corrected to improve data quality. Staff supervisors will be informed of
any recurring data entry issues, so correction can occur with supervisory
support and intervention if needed.

State Review Framework Report | Washington | Page 58

-------
EPA is updating RCRAInfo for better and more consistent data entry. The
Compliance Monitoring module in RCRAInfo is expected to become
available within the next year, and should allow more accurate data entry.

This SRF cycle was the first time Ecology primarily provided documents
electronically for review. Previously, EPA staff traveled to Ecology
offices to review most documents. Some discrepancies between Ecology
documentation and RCRAInfo data appear to be the result of incomplete
delivery of documents to EPA. EPA did not ask for documents that were
missing in all cases, resulting in incomplete information in some cases. A
plan for better communication in the future will help with this time saving
aspect of the review.

Recommendation All data entered into the database must be supported by a corresponding
document in the facility file; all data entered must be accurate. Ecology
will ensure data quality by instituting a quality control procedure into its
data entry process and ensure that all employees doing responsible for data
have been trained on data entry requirements and quality control
procedures. EPA and State will negotiate an agreeable timeframe for all
data to go through quality control and to ensure all employees responsible
for data entry are thoroughly training in data entry and quality control once
findings are shared with the State.

RCRA Element 2

— Inspections

Finding Choose

Area for State Improvement

an item.

Summary

Quality and completeness of inspection reports appears to be sacrificed

for quantity and timeliness.

Explanation

The State exceeds national averages regarding inspection coverage for

generators and meets the national goal of 100% for TSD inspections.

State Review Framework Report | Washington | Page 59

-------
The state was very timely in completing inspection reports and notifying
the facility of the inspection outcome (violations). On average, the state
completed the inspection reports and sent the report documenting
violations that needed correcting approximately 56 days after the
inspection occurred. However, it appears that the state's emphasis on
increased inspection coverage and timely inspection reports has been at
the expense of well written reports that have sufficient documentation to
support the findings. Only 59.5% of the inspection reports were found to
be complete and sufficient enough to determine compliance. For
example, in some instances the reports and the compliance letters did not
match, photos were not linked to the narrative evidence, regulations were
inaccurately quoted, and inspectors decided at the time of the inspection
without adequate reason, to hold a facility to more stringent generator
conditions than required by the regulations.

Relevant metrics Natl Natl Sialc Sialc Sialc

Metric ID Number and Description „ , . .

Goal Av;j N D % or #

5a Two-year inspection coverage of operating
TSDFs

100%

90.6°/,,

n n luo"

5b Annual inspection coverage of LQGs

20%

18,3'}..

115 45" 25 211"

5c Five-year inspection coverage of LQGs

100%

52.50%

i2~ 45" "I (>D"

5d Five-year inspection coverage of active
SQGs

10.20%

i.'K. 5v(>n"

6a Inspection reports complete and sufficient to
determine compliance

25 42 5'J 5"

6b Timeliness of inspection report completion 42 42 I ()()"„

State response The SRF review examined work completed in federal fiscal year 2015.

The most recent report reviewed is over two years old. Ecology,
including hazardous waste inspectors, has had significant employee
turnover. Twenty-five percent of current HWTR program inspectors
have been DW inspectors for less than 2 years. One third of the reports
reviewed were of inspections done by now former inspectors.

Our current inspection document package that we send to facilities has
been developed with EPA assistance to address multiple purposes. Our
focus has been to meet our inspection count obligations per the findings
in the SRF Round 3 2013 Report, which we have accomplished. Having
achieved that regularly, Ecology is committed to improving the quality
of our reports. Since the timeframe of the reports reviewed, Ecology has
instituted certain protocols to improve the quality of inspection reports.
Further improvements will be identified during the root cause analysis
by the Compliance Network, with EPA participation, in January 2018.

State Review Framework Report | Washington | Page 60

-------
We will consider EPA's recommendation on separation of our inspection
report and decision tree for verifying generator status at that time. We
will identify issues, develop a plan, and implement it no later than
October 1 2018.

We have an inspector training curriculum that we are reviewing and
revising to address the deficiencies identified by EPA as well as other
emerging program needs. It will include training on how to conduct a
thorough compliance evaluation inspection, how to gather evidence to
support violations found, how to write a defensible report, and the proper
citation of violations according to generator status.

Recommendation State will provide inspector training that addresses documenting

evidence and properly citing violations no later than October 1, 2018.
The training should also address exclusions, and exemptions, and
include a decision tree or some similar tool that helps the inspectors
verify generator size and appropriate regulations applicable at the time of
inspection. Finally, the training should address what inspectors may
require a facility to do in the compliance letters.

EPA will defer to Ecology on the format of inspection reports and will
instead work with Ecology to improve the quality of the information
documented in reports by conducting periodic, real-time reviews by
randomly selecting eight (seven LQGs* and one operating TSD)
inspection reports to review, twice each year. The reviewers (including
one Ecology person, if Ecology elects to participate) will provide the
results of the review to Ecology within three months. These reviews will
take place in January and July each year and will be selected from the
previous six-month timeframe. EPA will continue to randomly review
inspection reports until the next SRF review of Ecology is conducted, or
no later than September 30, 2021. However, the number of reports and
or the number of reviews may be decreased over time as improvements
are made.

inspection reports will be selected for review as follows: NWRO-2,
SWRO-2, CRO-1, ERO-1, and one report from either the Industrial
Section or Nuclear Waste Program.

State Review Framework Report | Washington | Page 61

-------
RCRA Element 3

— Violations

Finding Choose

Area for State Improvement

an item.

Summary

Although the State finds more violations than the national average the

accuracy of those determinations and the rate of determining SNCs is

lower that would be expected.

Explanation The State aggressively looks for violations during inspections as is

indicated by the significantly higher than national average number of
violations found during inspections (73.4% versus 36.5%). However, the
reviewers found multiple reports where violations were missed or mis-
cited or as importantly the state failed to make accurate SNC
determinations based on those violations. The low SNC rate is likely
related to the State's misunderstanding that a SNC determination is a
separate (but related) decision from the enforcement response. It is the
State's practice make a SNC determination only after they have
determined they will pursue formal enforcement rather than first making
a SNC determination and then deciding the appropriate enforcement
response based on that determination.

Relevant metrics

Metric ID Number and Description

Natl
Goal

Natl
Avii

Sialc
\

Sialc
D

Sialc

% or#

7a Accurate compliance determinations

2(1

(.1 <>()"„

7b Violations found during inspections

36.5%

2'JU

v>5

40"„

8a SNC identification rate

2.2%

'•J 5

UNO",,

8c Appropriate SNC determinations

<>5 lu"„

State response See Element 4 response

Recommendation See Element 4 Recommendation

State Review Framework Report | Washington | Page 62

-------
RCRA Element 4 — Enforcement

Finding Choose Area for State Improvement

an item.

Summary Most of the enforcement actions taken by the state are timely and return

the facility to compliance, at least in the short term.

Explanation Although the State is very timely in addressing all violations (and

documents that the majority of the time the violations that have been
found are returned to compliance), the data does not seem to support
sustained compliance when compared to the number of handlers from
each universe that are inspected each year and the number of violations
found.

Rather the lack of formal enforcement appears to indicate facilities in the
state are using state inspectors as consultants to point out violations and
potential violations

Relevant metrics Natl Nail sum-sum- Si sue

Metric ID Number and Description _ . . .

Goal Av;j N D % or #

9a Enforcement that returns violators to ^ V1
compliance

10a Timely enforcement taken to address SNC 80% 81,4'}.. 5 <>

10b Appropriate enforcement taken to address ,

violations " 4' "

State response Ecology's agency-wide enforcement process is being revised. The
Hazardous Waste and Toxics Reduction Program will update its
enforcement process to be consistent with the revised agency
enforcement policy as soon as possible.

Ecology issues formal enforcement in accordance with Ecology's
Compliance Assurance Manual and individual program policies.
Enforcement of the Dangerous Waste regulations is determined by the
HWTR Compliance Assurance Policy 3-1. Ecology's Nuclear Waste
Program and Waste 2 Resources Program Industrial Section use HWTR
Policy 3-1 when developing formal enforcement of the dangerous waste
regulations.

Of the sites reviewed, EPA suggests that over 20% should have been
identified as SNCs. This far exceeds the current national average of 2%
SNC identification. The resultant expectation of formal enforcement is
neither reasonable nor achievable. Ecology will revise its SNC
identification and tracking process, which will increase the rate of SNC

State Review Framework Report | Washington | Page 63

-------
identification. Decisions to issue formal enforcement will continue to be
made using existing agency standards.

Most of the content of EPA's tool recommendation already exists in
Ecology processes. Through root cause analysis based on objective
criteria, Ecology will determine an appropriate enforcement response
that conforms with existing Ecology processes. Ecology regional section
supervisors have already begun to vet enforcement state-wide during bi-
monthly calls. These reviews focus on regulatory issues, and
consistency with similar enforcement actions at other locations.

Additionally, inspector training as discussed in the response to RCRA
Element 2 will result in better violation documentation which will in turn
support enforcement actions.

We plan to implement these changes before July 1, 2018.

Recommendation EPA recommends that the State develop an enforcement evaluation tool
that will be used across all Regions no later than July 1, 2018..

Similar to the Finding 2 recommendation, twice each year EPA will
randomly select one enforcement action to review and will provide the
results of the review to Ecology within three months. These reviews will
take place in January and July each year and the enforcement actions
will be from the previous six-month timeframe. The number of reviews
may be decreased over time as improvements are made. Reviews will
conclude no later than September 30, 2021

RCRA Element 5

— Penalties

Finding Choose

Area for State Attention

an item.

Summary

State has procedures for documenting penalty determinations and

collections

Explanation Although the state has put into place procedures for calculating,

documenting, and collecting penalties it appears that at times the state
chooses not to calculate or collect economic benefit. In one instance the
recommendation for enforcement (RFE) indicates that the EB could not
be quantified (EPA disagrees) and in another although calculated chose
not to collect because didn't want to take money away from cleaning up
the contamination.

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Relevant metrics

Metric ID Number and Description

Natl
Goal

Nail Siale Siale Siale

Avjj N D %or#

11a Penalty calculations include gravity and ^ |,,

economic benefit

12a Documentation on difference between .

^ (> O ^ ^ II

initial and final penalty

12b Penalties collected 5 " "14".,

State response Ecology's Hazardous Waste and Toxics Reduction Program will review
the Economic Benefit determination process as identified in the
Performance Partnership Agreement and Hazardous Waste and Toxics
Reduction Program Assurance Policy 3-1. In consultation with the EPA,
the Program will review relevant language and processes. Ecology
management will also review these requirements with inspectors to
better ensure compliance with these agreements. This topic will be
included in the inspector training proposed in response to Element 2 of
this SRF.

Recommendation

State Review Framework Report | Washington | Page 65

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