STATE REVIEW FRAMEWORK Oregon Clean Air Act Clean Water Act Resource Conservation and Recovery Act Implementation in Federal Fiscal Year 2018 U.S. Environmental Protection Agency Region 10 Final Report March 6, 2020 ------- I. Introduction A. Overview of the State Review Framework The State Review Framework (SRF) is a key mechanism for EPA oversight, providing a nationally consistent process for reviewing the performance of state delegated compliance and enforcement programs under three core federal statutes: Clean Air Act, Clean Water Act, and Resource Conservation and Recovery Act. Through SRF, EPA periodically reviews such programs using a standardized set of metrics to evaluate their performance against performance standards laid out in federal statute, EPA regulations, policy, and guidance. When states do not achieve standards, the EPA will work with them to improve performance. Established in 2004, the review was developed jointly by EPA and Environmental Council of the States (ECOS) in response to calls both inside and outside the agency for improved, more consistent oversight of state delegated programs. The goals of the review that were agreed upon at its formation remain relevant and unchanged today: 1. Ensure delegated and EPA-run programs meet federal policy and baseline performance standards 2. Promote fair and consistent enforcement necessary to protect human health and the environment 3. Promote equitable treatment and level interstate playing field for business 4. Provide transparency with publicly available data and reports B. The Review Process The review is conducted on a rolling five-year cycle such that all programs are reviewed approximately once every five years. The EPA evaluates programs on a one-year period of performance, typically the one-year prior to review, using a standard set of metrics to make findings on performance in five areas (elements) around which the report is organized: data, inspections, violations, enforcement, and penalties. Wherever program performance is found to deviate significantly from federal policy or standards, the EPA will issue recommendations for corrective action which are monitored by EPA until completed and program performance improves. The SRF is currently in its 4th Round (FY2018-2022) of reviews, preceded by Round 3 (FY2012-2017), Round 2 (2008-2011), and Round 1 (FY2004-2007). Additional information and final reports can be found at the EPA website under State Review Framework. II. Navigating the Report The final report contains the results and relevant information from the review including EPA and program contact information, metric values, performance findings and explanations, program responses, and EPA recommendations for corrective action where any significant deficiencies in performance were found. ------- A. Metrics There are two general types of metrics used to assess program performance. The first are data metrics, which reflect verified inspection and enforcement data from the national data systems of each media, or statute. The second, and generally more significant, are file metrics, which are derived from the review of individual facility files in order to determine if the program is performing their compliance and enforcement responsibilities adequately. Other information considered by EPA to make performance findings in addition to the metrics includes results from previous SRF reviews, data metrics from the years in-between reviews, multi-year metric trends. B. Performance Findings The EPA makes findings on performance in five program areas: • Data - completeness, accuracy, and timeliness of data entry into national data systems • Inspections - meeting inspection and coverage commitments, inspection report quality, and report timeliness • Violations - identification of violations, accuracy of compliance determinations, and determination of significant noncompliance (SNC) or high priority violators (HPV) • Enforcement - timeliness and appropriateness of enforcement, returning facilities to compliance • Penalties - calculation including gravity and economic benefit components, assessment, and collection Though performance generally varies across a spectrum, for the purposes of conducting a standardized review, SRF categorizes performance into three findings levels: Meets or Exceeds: No issues are found. Base standards of performance are met or exceeded. Area for Attention: Minor issues are found. One or more metrics indicates performance issues related to quality, process, or policy. The implementing agency is considered able to correct the issue without additional EPA oversight. Area for Improvement: Significant issues are found. One or more metrics indicates routine and/or widespread performance issues related to quality, process, or policy. A recommendation for corrective action is issued which contains specific actions and schedule for completion. The EPA monitors implementation until completion. C. Recommendations for Corrective Action Whenever the EPA makes a finding on performance of Area for Improvement, the EPA will include a recommendation for corrective action, or recommendation, in the report. The purpose of recommendations are to address significant performance issues and bring program performance back in line with federal policy and standards. All recommendations should include ------- specific actions and a schedule for completion, and their implementation is monitored by the EPA until completion. III. Review Process Information Kickoff meeting held: March 13, 2019 Data Metric Analysis and file selections sent to DEQ: April 11 and May 8„ 2019 File reviews completed: November 8, 2019 Draft report sent to DEQ: December 12, 2109 Comments from DEQ received by EPA: February 10, 2020 Report Finalized: March 6, 2020 DEQ and EPA key contacts: Becka Puskas, J.D., DEQ Office of Compliance and Enforcement Scott Wilder, EPA SRF Coordinator Clean Air Act (CAA) Jaclyn Palermo, DEQ Elizabeth Walters, EPA CAA file reviewer John Pavitt, EPA CAA file reviewer Clean Water Act (CWA) Martina Frey, DEQ Rob Grandinetti, EPA CWA file reviewer Resource Conservation and Recovery Act (RCRA) Jeannette Acomb, DEQ Cheryl Williams, EPA file reviewer ------- Executive Summary Introduction Clean Air Act (CAA) Areas of Strong Performance The following are aspects of the program that, according to the review, are being implemented at a high level: Clean Air Act (CAA) Formal enforcement responses consistently included the required corrective action to return the facility to compliance. Penalty calculations consistently documented gravity and economic benefit. Rationales for differences between initial penalty and final penalty were always documented. Penalties were consistently collected and documented. Priority Issues to Address The following are aspects of the program that, according to the review, are not meeting federal standards and should be prioritized for management attention: Clean Air Act (CAA) ICIS-Air is inaccurate and does not reliably match MDR in file documentation. FCE reports occasionally lacked enough information to determine compliance. The State frequently misidentified violations as non-HPV when it met the criteria in the HPV Policy. High Priority Violations (HPV) were mostly not addressed in a timely manner or alternatively did not have a Case Development Resolution Timeline (CDRT) in accordance with the HPV policy. ------- Clean Water Act (CWA) Areas of Strong Performance The following are aspects of the program that, according to the review, are being implemented at a high level: Clean Water Act (CWA) In the metrics for inspection report completeness, sufficient to determine compliance of the facility, and accuracy of compliance determination, Oregon did an outstanding job. Priority Issues to Address The following are aspects of the program that, according to the review, are not meeting federal standards and should be prioritized for management attention: Clean Water Act (CWA) Oregon's data issues continue to be an area of concern during the SRF review period. Oregon relies on several municipalities and districts as its agents to conduct inspections of sources regulated by some stormwater and other general permits. However, ODEQ does not routinely collect data from these agents regarding inspections that are planned, inspections that have been conducted, and violations found during these inspections. EPA recognizes that Oregon has provided an MOA update for one of their agents, the Oregon Department of Geology and Mineral Industries. By June 30, 2021 Oregon shall provide a plan and timeline to get the remaining MO As to EPA for review and comment. Resource Conservation and Recovery Act (RCRA) Areas of Strong Performance The following are aspects of the program that, according to the review, are being implemented at a high level: Resource Conservation and Recovery Act (RCRA) ------- Appropriate SNC determination. Timely and appropriate enforcement. Economic benefit included in all penalty calculations/justifications. Priority Issues to Address The following are aspects of the program that, according to the review, are not meeting federal standards and should be prioritized for management attention: Resource Conservation and Recovery Act (RCRA) Missing Data Elements Inspection Report Accuracy/Completeness ------- Clean Air Act Findings CAA Element 1 - Data Finding 1-1 Area for Improvement Summary: ICIS-Air is very inaccurate and does not reliably match MDR in file documentation. Explanation: Facility identifiers such as programmatic ID, address, zip code, type of ownership and NAICS code were consistently inaccurate or missing in FCE reports. Stack tests and stack tests results were generally not reported in a timely manner. 60% of stack tests and stack test results were reporting in a timely manner. Stack tests were also frequently inaccurate in ICIS-Air and did not match file documentation. Most stack tests were submitted to ICIS-Air with incorrect dates, pollutants measured, and test results. For example, Boise Cascade Medford performed a stack test that was entered into ICIS-Air with a "PASS" for CO emissions, but file documentation showed that CO measurements were 2 times over the limit and that the results were actually a "FAIL." After preparing the draft report, EPA RIO learned from ODEQ that these examples were tests conducted for the purpose of verifying emission factors and were not for the purpose of making a compliance determination. State and local agencies are only required to report stack tests and their results for test performed for the purpose of making a compliance determination. Realizing that some agencies reported all stack tests performed, EPA gave agencies the ability to report the purpose (e.g., RATA, or "Other"). EPA does not require States to enter results for such tests for other purposes. A few stack tests were submitted to ICIS-Air twice, such as the 7/26/2016 stack test at Collins Products which also has the wrong pollutants listed. The 11/1/2017 Collins Pine Company, 10/16/2018 Interfor, 9/29/2017 and 11/16/2017 Stimson Lumber stack tests were not submitted to ICIS-Air. While air programs and subparts were generally accurate in ICIS-Air for the facilities, the applicable pollutants section often included "Pollutant X" and "FACIL." Out of the 26 facilities/files reviewed, only 1 facility had the CMS source category and frequency entered in ICIS-Air. Title V annual compliance certifications (ACC) were sometimes incorrectly coded into ICIS-Air as "Facility Reported No Deviations" when file documentation included deviations submitted by the facility such as Portland General Electric. JeldWen Bend also had a Title V ACC that was not submitted to ICIS-Air. Agency could also not produce the FCE report for Freres Lumber Co. Inc. While the Agency did report 94.7% of compliance monitoring MDRs in a timely manner, it reported 44.9% HPV determinations and 10.5% of enforcement MDRs in a timely manner into ICIS-Air. Relevant metrics: ------- Metric ID Number and Description Natl Goal Natl Avg State N State D State % 2b Files reviewed where data are accurately reflected in the national data system [GOAL] 100% 0 26 0% 3a2 Timely reporting of HPV determinations [GOAL] 100% 44.9% 0 2 0% 3b 1 Timely reporting of compliance monitoring MDRs [GOAL] 100% 85.2% 143 151 94.7% 3b2 Timely reporting of stack test dates and results [GOAL] 100% 65.1% 30 50 60% 3b3 Timely reporting of enforcement MDRs [GOAL] 100% 71.8% 2 19 10.5% State Response: In December 2019, DEQ identified a training need for source test data entry into ACES and trained source test coordinators. In addition, as of 12/31/2019 DEQ entered missing source/stack test information into ACES. Monthly updates are now sent to all source test coordinators to as a QA/QC step to help ensure the accuracy of data entry. DEQ is completing a thorough review of FY19 source/stack tests to compare with the data entry system and will update EPA with findings by 7/31/2020. In some cases, the facility name is different in ECHO than in ICIS-Air. DEQ's database (ACES) and ICIS-Air are correct, however ECHO reflects a different source name. DEQ is working with EPA to resolve this issue. In at least two instances (Boise Cascade Medford and Collins Pine Company), source test information reviewed by EPA was for emissions factors, which are not permit limits, and thus should not be considered a FAIL of a source test. DEQ will update its source test review memo template to more clearly differentiate between emission factors and emission limits. Currently, DEQ provides specific pollutant information, not a simple "pass" or "fail" for source/stack tests. DEQ is reviewing source test data entry to meet EPA's MDR. DEQ is also working to address the ACC findings. DEQ reviewed its FY18 CMS data and found that the DEQ ACES system transmitted the inspection information into ICIS-Air, which confirmed its acceptance. DEQ understands that EPA is working to address issues translating the information from ICIS-Air to ECHO. The DEQ's upcoming implementation of the Environmental Database Management System (EDMS) will help to resolve certain issues with source reporting. Sources will be able to upload their annual reports directly into the database, helping to streamline the reporting process for ------- DEQ staff. Internal testing of these modules is currently estimated to occur in April 2021, and the final release of EDMS for air quality permitting is projected for the end of 2nd QTR 2021. As part of EDMS development and testing, DEQ will work with the vendor to ensure that MDR information can be translated accurately from EDMS into ICIS-Air. Recommendation: U"' Due Dale # 1 07/31/2020 Recommendation State has informed EPA that they do not enter data directly into ICIS- Air, but into a separate database that is linked to ICIS-Air. State currently has a program in place to review the test reports, ID omissions and inaccurate data and results are entered into a database system that is linked to ICIS-Air. At this time, EPA does not know if the stack testing issues are related to incorrect data entry into the State's database system or a translating issue between the State's database system and ICIS-Air. State needs to determine if these stack testing issues are occurring at data entry, data transfer or both. By May 29, 2020, the State will conduct a thorough review on the FY19 stack tests and a data quality check in their database system. By July 31, 2020, State will provide an update EPA on the results as well as provide an update on the translating issues between their database system and ICIS-Air. EPA will also expect the State to develop a plan and timelines on resolving the stack testing issues and how they will ensure the new database system (EDMS) will translate accurately into ICIS-Air. CAA Element 2 - Inspections Finding 2-1 Area for Attention Summary: Inspection reports occasionally lacked required documentation of FCE elements. Explanation: Agency conducted FCE's at 91.8% of the major and mega-sites, and 83.3% of the SM-80s located within the state. However, inspection reports occasionally lacked the required documentation of FCE elements. Inspectors were generally thorough in their review of all required reports and included a summary of what was reviewed in their reports such as Title V self-certifications and excess emissions reports. A majority of FCE reports documented the required reports and records ------- reviewed. However, a few FCE reports did not include an assessment of or important facts from the underlying records. Boise Cascade Medford, for example, had a history of stack tests that had exceeded CO limits and the inspector did not discuss the stack tests in their report. A few FCE reports were lacking in detail. While inspectors listed what was reviewed on-site (i.e. facility records and operating records), the reports did not include an assessment of those records. Owens Brockway, for example, did not include assessments of process parameters or equipment performance as well as did not state whether other facility records were reviewed. Relevant metrics: Metric ID Number and Description 5a FCE coverage: majors and mega-sites [GOAL] Natl Goal 100% Natl Avg 88.1% State N 45 State D 49 State % 91.8% 5b FCE coverage: SM-80s [GOAL] 100% 93.7% 5 6 83.3% 5c FCE coverage: minors and synthetic minors (non-SM 80s) that are part of CMS plan or alternative CMS Plan [GOAL] 100% 70.1% 0 0 0 5e Reviews of Title V annual compliance certifications completed [GOAL] 100% 82.5% 97 106 91.5% 6a Documentation of FCE elements [GOAL] 100% 16 22 72.7% State Response: DEQ staff will be trained on the expectation of complete FCE reports, thorough review of supporting documents along with each report, and documentation of record assessment in reports. As discussed in Finding 2-2 below, DEQ recently convened an Air Quality Lead Inspectors Group. One task to be completed by this group includes updating inspection templates to help ensure that FCE information is complete. This task will be conducted with input from DEQ management, staff, and EPA. CAA Element 2 - Inspections Finding 2-2 Area for Improvement ------- Summary: FCE reports occasionally lacked enough information to determine compliance. Explanation: FCE reports generally documented the general information and facility information, but there was a recurring deficiency of information necessary to determine compliance of the facility. Many FCE reports were not thorough and did not include the federal requirements, inventory and description of regulated emission units and on-site observations. A few FCE reports also only listed the permit condition number without an explanation of what the permit condition or regulatory requirement was. Inspectors would also sometimes state that a facility was following permit conditions or regulatory requirements and did not document their observations or rationale for that determination. The FCE report for Evraz Inc. as well listed "N/A" for many permit conditions and did not explain what "N/A" meant or why the requirement was not applicable. FCE reports generally lacked the inspector's on-site observations of the facility during their compliance evaluation and did not always include what was relayed to the facility. For example, the inspector for the EP Minerals FCE did not document the observations or findings that were discussed with the facility and did not include federal regulatory requirements in the report. Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 6b Compliance monitoring reports (CMRs) or facility files reviewed that provide sufficient documentation to determine compliance of the facility [GOAL] 100% 14 22 63.6% | State Response: In an effort to improve inspections, templates, and procedures, DEQ recently formed an AQ Lead Inspector Group. One of the first tasks for this group is to improve DEQ's air quality inspection templates, in coordination with EPA Region 10. These templates will be used agency- wide for FCE reports. Going forward, DEQ will use these templates to help ensure that inspection reports are consistent, and include on-site observations, findings that were discussed with the facility, and other items of importance as determined by EPA. DEQ looks forward to working with EPA to improve these inspection templates, and that work will begin March 2020. DEQ air quality staff will be provided with the first iteration of the new inspection templates, presented by the AQ Lead Inspector group with assistance from EPA Region 10, at the April 22- 23, 2020 Permit Writer and Inspector Forum. During this event, training will take place for documentation and expectations for FCEs. Improvement of air inspections permits has been identified as an Air Division priority, and will undergo continuous improvement. As part of DEQ's process improvement efforts, this template will continue to be developed with input from AQ inspectors, and will be continually improved and adjusted as needed. ------- Recommendation: Ucc # Due Dale 06/26/2020 Recommendation By June 26, 2020, the State will create SOPs and provide training to inspectors on how to sufficiently document applicable requirements, observations and information in FCE reports for a case developer or attorney to be able to determine compliance. The State will also provide the SOPs and training documentation to EPA. CAA Element 3 - Violations Finding 3-1 Area for Attention Summary: Compliance determinations were generally accurate in cases where there was enough documentation. Explanation: The agency's compliance determinations were generally accurate in cases where there was enough documentation in the FCE report and other information in the source file. Compliance determinations were consistently reported to and accurate in ICIS-Air. Relevant metrics: mix - in v r u j rv • x- Natl Natl State State State Metric ID Number and Description , .. _ 1 Goal Avg N D % 7a Accurate compliance determinations [GOAL] t 100% i > 20 j 25 > 80% State Response: DEQ expects that compliance determinations will be further improved by updating inspection templates and conducting training on FCEs, as described above in Finding 2-2. CAA Element 3 - Violations ------- Finding 3-2 Area for Improvement Summary: The State frequently misidentified violations as non-HPV when it met the criteria in the HPV Policy. Explanation: High Priority Violations (HPVs) were frequently misidentified as non-HPV and were not addressed to the EPA in accordance with the HPV policy. Reviewers discovered many violations from stack tests, inspection reports, Title V ACCs, informal and formal enforcement actions that were never identified and addressed as HPVs. Several Federally Reportable Violations (FRVs) were also inaccurately determined by the agency as non-HPV. 11 files contained FRVs during the review period, of which 4 files were inaccurately determined as non-HPV. Relevant metrics: . . M n I I rv . 11*111 OUllC Julie 0 . ... Metric ID Number and Description ^ ^ State % 1 Goal Avg N D 13 Timeliness of HPV Identification [GOAL] 100% | 89.5% o o o 8c Accuracy of HPV determinations [GOAL] 100% 7 11 63.64% State Response: Training for all DEQ AQ inspectors will begin at the Permit Writer and Inspector Forum on April 22 - 23, 2020. It will include presentations by a representative from EPA Region 10 on HPVs/FRVs, the discovery process for these violations, and tracking and reporting expectations, including data entry. DEQ intends to work with EPA Region 10 throughout this process to ensure HPV training is effective, and templates will be continually improved with input from EPA and DEQ air quality staff. Updated templates and forms used for tracking and reporting FRVs and HPVs will be captured in the new database system (EDMS). Recommendation: ------- Ucc # Due Dale 05/01/2020 Recommendation Reviewers found a PDF at several of the State offices which was used to document the discovery of FRVs and HPVs. The PDF form included the criteria for HPV as outlined in the policy. By May 1, 2020, the State will standardize the HPV discovery process and the use of this form (or a similar form) across all offices to identify and document HPVs. CAA Element 4 - Enforcement Finding 4-1 Meets or Exceeds Expectations Summary: Formal enforcement responses consistently included the required corrective action to return the facility to compliance. Explanation: 7 out of 7 files that contained formal enforcement responses, during the review period, included the required corrective action that returned or will return the facility to compliance. Documentation of the facility's timeline to return to or had already returned to compliance was consistently included in the file. Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % 9a Formal enforcement responses that include required corrective action that will return the facility to compliance in a specified time frame or the facility fixed the problem without a compliance schedule [GOAL] 100% 100% State Response: No state response. ------- CAA Element 4 - Enforcement Finding 4-2 Area for Improvement Summary: High Priority Violations (HPV) were mostly not addressed in a timely manner or alternatively did not have a Case Development Resolution Timeline (CDRT) in accordance with the HPV policy. Explanation: The State did not follow the High Priority Violation (HPV) policy and frequently did not address HPVs in a timely manner. 8 files contained HPVs during the review period, of which Georgia- Pacific Consumer Operations, Interfor U.S., Boise Cascade Wood Products and Collins Pine Company were not addressed within 180 days or did not have a Case Development Resolution Timeline (CDRT) in place within 225 days. Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % 10a Timeliness of addressing HPVs or alternatively having a case development and resolution timeline in place 100% 50% State Response: DEQ agrees that the timely identification of and response to High Priority Violations (HPVs) is a priority, and appreciates the ongoing dialogue with EPA to improve DEQ's processes and procedures in this area. DEQ is requesting an extension until the end of April 2020 to begin full-staff training on HPVs. DEQ will hold its twice-annual Permit Writer and Inspector Forum on April 22 - 23, 2020. In collaboration with DEQ, a representative from EPA Region 10 will conduct training on the HPV policy during the April forum. DEQ recognizes that there may be a need for additional HPV training beyond the April forum and will keep EPA appraised if there are any additional needs. Based on prior discussions with EPA, DEQ has previously understood that the HPV list, along with the quarterly HPV calls held with EPA, are the mechanism for tracking HPVs that take more than 180 days to address. Based on this SRF review and recent conversations with EPA, DEQ understands that a written Case Review Development Timeline (CRDT) is needed in the file for cases that will take more than 180 days to address, even if the CRDT is not submitted to EPA. DEQ is considering the best way to include this information in the file, including adding ------- the CRDT to the updated HPV form referenced in Recommendation 3-2, and tracking this information in DEQ's new Environmental Data Management System (EDMS). Recommendation By April 30, 2020, the State will develop, plan and provide training on the EPA High Priority Violation policy to inspectors, case developers, attorneys and permit writers. EPA can also assist with the training. State will also provide confirmation of the completion of HPV training to EPA Region 10. CAA Element 4 - Enforcement Finding 4-3 Area for Attention Summary: High Priority Violations (HPV) were occasionally not addressed with the appropriate enforcement response in accordance with the HPV policy. Explanation: High Priority Violations (HPV) were generally removed or addressed in accordance with the EPA HPV policy. 7 files contained HPVs identified by the State and were not in the process of currently being addressed or not yet concluded. 5 of the 7 files contained HPVs that were appropriately addressed or removed by the State. Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 10b Percent of HPVs that have been addressed or removed consistent with the HPV Policy [GOAL] 100% 5 7 71.4% State Response: Recommendation: U"' Due Dale # 1 04/30/2020 ------- DEQ is working to improve its identification and timely response to HPVs, as described in Findings 3-2 and 4-2, above. CAA Element 5 - Penalties Finding 5-1 Meets or Exceeds Expectations Summary: Penalty calculations consistently documented gravity and economic benefit. Explanation: The State consistently documented how gravity and economic benefit values were assessed in the penalty. Penalty calculations always included a gravity component and the calculation of economic benefit. This documentation was in all the files reviewed where a penalty was assessed. Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % 1 la Penalty calculations reviewed that document gravity and economic benefit [GOAL] 100% 100% State Response: No state response. CAA Element 5 - Penalties Finding 5-2 Meets or Exceeds Expectations Summary: Rationales for differences between initial penalty and final penalty were always documented. Explanation: ------- The State consistently documented the rationale for differences between initial penalty calculations and final penalty calculations. Penalties were assessed in 7 files during the review period, and a memo or other documentation of penalty differences were included. Relevant metrics: Metric ID Number and Description 12a Documentation of rationale for difference Natl Natl State State State Goal Avg N D % between initial penalty calculation and final 100% I I 6 6 100% penalty [GOAL] State Response: No state response. CAA Element 5 - Penalties Finding 5-3 Meets or Exceeds Expectations Summary: Penalties were consistently collected and documented. Explanation: Photocopies of checks or other correspondence that documented check transmittal were consistently included in the files where a penalty was collected. The State also documented the costs, timelines and progress of Supplemental Environmental Projects (SEPs) if it was included in the penalty. Relevant metrics: , . Irk.. , , . . Natl Natl State State State Metric ID Number and Description „ , ; . .. _ ... 1 Goal Avg N I) % 12b Penalties collected [GOAL] I 100% I I 7 I 7 1 100% State Response: ------- No state response. Clean Water Act Findings CWA Element 1 - Data Finding 1-1 Area for Improvement Summary: Not all data in ICIS reflects the files that were reviewed. Explanation: There were many inspection reports that had the wrong dates in ICIS, and there were a couple of enforcement actions dates that were inconsistent with the dates in the enforcement action in the files. Some facilities had multiple inspections entered into ICIS, and the number in ICIS did not match the inspection reports in the files. The Rainier STP (OR0020389) enforcement action dates in ICIS did not match with the date in the file. The Tillamook County Creamery (OR0000141) did not have all of the enforcement actions entered into ICIS. Relevant metrics: .. , . , , „ . Natl Natl State State State Metric ID Number and Description „ , ... _ 1 Goal Avg N D % 2b Files reviewed where data are accurately , „„n/ n x j • .1 1 j , r/-^r\ a . n 100% 11 30 36.7% reflected in the national data system [GOAL] State Response: DEQ recently undertook a process improvement addressing how compliance and enforcement information is generated and tracked. New SOPs are drafted that dictate how enforcements will be entered into DEQ's compliance and enforcement database, ACES, to reflect the date on the letter. These SOPs will be provided to EPA as part of DEQ's plan for addressing data entry issues identified in the Recommendation below. Regarding inspections, DEQ will update its data flow specifications to correctly characterize inspection dates. Specifically, DEQ will populate the ICIS Actual End Date with the Inspection ------- Actual Date in ACES. Duplicate inspection records will be addressed through inspection staff training on ACES data entry. Recommendation: Ucc # Due Dale Recommendation 05/29/2020 By May 29, 2019, the State will provide a plan to EPA on creating standard operating procedures (SOPs) that will dictate which dates will be entered into ICIS, a process to enter the correct inspection dates, and a process to not create multiple inspection reports in ICIS. CWA Element 1 - Data Finding 1-2 Area for Improvement Summary: Discharge Monitoring Reports (DMRs) data entry rate for major and non-major facilities is 30% and the national goal is for this to be greater than 95%. Explanation: Oregon is not flowing all DMR data to ICIS from their database. This is a known issue by EPA and Oregon, and one in which they have been working on for a while now. Relevant metrics: Metric ID Number and Description Natl Natl Goal Avg State State State N D % lb5 Completeness of data entry on major and non-major permit limits. [GOAL] | 95% | 90.6% 327 327 100% lb6 Completeness of data entry on major and "I i non-major discharge monitoring reports. 95% 93.3% 1778 6058 29.3% [GOAL] State Response: ------- DEQ is in the process of configuring an Environmental Data Management System (EDMS) that will be deployed incrementally over the next two years. At this time, 85% of individual NPDES permit holders are reporting in NetDMR (State N = 5,215, State D = 6,155). DEQ expects to enroll the remaining individual NPDES facilities in the next few months. The remaining NPDES permit registrants (general permits and agent-administered permits) will begin electronic reporting when their program is deployed in EDMS. DEQ expects to develop and fully deploy EDMS for these water quality permits by mid-2021. Recommendation: Uec # Due Dale Recommendation By September 30, 2020, Oregon shall provide a plan to get a system in 09/30/2020 place to be able to flow data to ICIS. The plan shall have a time frame and proposed solution. CWA Element 2 - Inspections Finding 2-1 Meets or Exceeds Expectations Summary: In the metrics for inspection report completeness, sufficient to determine compliance of the facility, and accuracy of compliance determination, Oregon did an outstanding job. Explanation: Of all of the inspection reports reviewed during the file review all were of sufficient quality to determine compliance of the facility, the reports were complete, and were accurate in making a compliance determination. Relevant metrics: ------- Metric ID Number and Description Natl Goal Natl Avg State N State D State % 6a Inspection reports complete and sufficient to determine compliance at the facility. [GOAL] | 100% 17 17 100% | | | 6b Timeliness of inspection report completion [GOAL] 1 100% 16 17 94.1% | State Response: No state response. CWA Element 2 - Inspections Finding 2-2 Area for Improvement Summary: Oregon should be gathering inspection reports and providing oversight of the agents that perform inspections on behalf of them. Explanation: Oregon relies on several municipalities and districts as its agents to conduct inspections of sources regulated by some stormwater and other general permits. However, ODEQ does not routinely report data from these agents regarding inspections that are planned, inspections that have been conducted, and violations found during these inspections (except when they are referred to DEQ's Office of Compliance and Enforcement for formal enforcement). The agents that perform these inspections have Memorandums of Agreement (MO As) that specify that the agents have authority to implement the permit(s) on DEQ's behalf, which includes reviewing applications, performing inspections, setting inspection goals, and undertaking informal enforcement and referring formal enforcement to DEQ. Some of these MO As need to be updated. EPA acknowledges that Oregon has recently finalized an MOA with the Oregon Department of Geology and Mineral Industries (DOGAMI) in December 2019, following EPA review. Relevant metrics: Metric ID Number and Natl Natl State State State Description Goal Avg N D % State Response: ------- EPA recently closed out Recommendation 2-3 from the last SRF review regarding Oregon DEQ's administrative agents. Since March 2017, when DEQ realigned how our wastewater and stormwater programs are managed, DEQ has done a great deal of work with our agents to ensure the permits are implemented consistently throughout Oregon. Specifically, DEQ's oversight of stormwater agents includes hosting training sessions and conducting direct outreach with each of the stormwater agents regarding permit implementation, record-keeping, and compliance and enforcement actions. In addition, DEQ joins the agents on inspections periodically and works to ensure the permits are implemented consistently throughout the state. We have continued these communication actions throughout 2019 with all agents and hosted an in-person meeting with those that implement the 1200-Z industrial stormwater general permit in mid-2019 and meetings with each of the agents that implement the 1200-C construction stormwater general permit in December 2019 and January 2020. In 2019, DEQ worked with the Oregon Department of Geology and Mineral Industries (DOGAMI) to update the MO A for their implementation of the NPDES 1200-A industrial stormwater and mine dewatering discharge general permit and the WPCF-1000 general permit. EPA reviewed the MO A, and DEQ addressed EPA's comments prior to finalizing the MOA on December 2, 2019. The MOA includes all activities and information associated with inspection plans, inspection outcomes and compliance and enforcement activities. One specific condition of oversight is that the MOA requires DOGAMI to send DEQ'S Office of Compliance and Enforcement all informal enforcement letters, including warning letters, to ensure DOGAMI's consistent implementation of DEQ's enforcement guidance. Now that work on the DOGAMI MOA is completed, DEQ will begin work on updating the other Agent Agreements in coordination with DEQ's work to implement EDMS, which will serve as common platform by which both DEQ and Agents manage permit issuance, compliance, and enforcement with full transparency and oversight. The EDMS project for water quality general permits is currently scheduled to be implemented by June 30, 2021. Due to the anticipated timeline for EDMS, and the fact that EDMS will be a critical part of how DEQ shares information with and provides oversight for its agent partners, DEQ's plan for updating the MOA's needs to align with the timing of EDMS implementation. Thus, DEQ's plan for updating the MOA's will be completed and shared with EPA by June 30, 2021. Recommendation: Uec # Due Dale Recommendation 06/30/2021 EPA recognizes that Oregon has provided an MOA update for one of their agents, the Oregon Department of Geology and Mineral Industries. By June 30, 2021 Oregon shall provide a plan and timeline to get the remaining MO As to EPA for review and comment. ------- CWA Element 2 - Inspections Finding 2-3 Area for Improvement Summary: Oregon did not meet the 50% criteria for major inspections performed, or the 20% minor inspections performed during the review period. Explanation: The Clean Water Act monitoring strategy has annual inspection percentages that EPA expects each state to meet. The percentage for major NPDES permits is 50% annually. The percentage for minor NPDES permits is 20% annually. Oregon did not meet these percentages during the review period. The major NPDES inspections for Oregon was 26.7%, and the minor NPDES inspections was 14%. Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 5al Inspection coverage of NPDES majors. [GOAL] 100% 52.8% 20 75 26.7% 1 | | 5b 1 Inspections coverage of NPDES non- majors with individual permits [GOAL] 100% 22.6% 39 278 14% | ! 5b2 Inspections coverage of NPDES non- majors with general permits [GOAL] 100% 5.6% 120 2973 4% State Response: In 2018, DEQ directed significant resources toward permit issuance process improvements with the goal of reducing our NPDES individual permit backlog. At that time, 83% of permits were administratively continued - well behind most other states. DEQ reassigned several compliance staff to write permits and implemented permit writing process improvements. As a result, the backlog is now 75% and on track for further reductions. DEQ has also re-directed significant compliance staff resources for the purpose of transitioning NPDES permittees to electronic DMR reporting. Since 2017, when 21% of NPDES individual permittees were eReporting, now 85% of NPDES individual permittees are reporting electronically in NetDMR. As part of broad scale permitting process improvement efforts, DEQ successfully communicated the need for additional resources to the state legislature and stakeholders during the 2019 legislative session. The legislature granted 10 new positions for the Water Quality Permit ------- Program, three of which are allocated specifically to compliance monitoring and inspections. The positions will be phased in during 2020. Looking ahead, DEQ expects that these resources will contribute to improving inspections rates. In addition, DEQ anticipates requesting additional resources during the 2021 legislative session for compliance and inspection efforts during the 2021-2023 biennium. In 2019 the DEQ Water Quality Program examined our processes for managing compliance and enforcement data and identified several improvements that will streamline the way we capture reportable data. We expect these improvements to free up staff time for additional compliance monitoring work. Also, when DEQ deploys EDMS, we expect processes associated with permitting, compliance monitoring, and reporting to be streamlined significantly. Prior to EDMS deployment, DEQ plans to dedicate substantial staff resources to system development, testing, registration, and internal and external user training. As a result, DEQ may plan for a short-term reduction in compliance monitoring before the Agency can realize the multiple benefits of the more efficient permit and data management system. With regard to the recommendation below, DEQ requests more time to provide this plan to EPA, because it involves evaluating priorities across the water quality program, hiring and training new staff, and planning for additional staff resources in the coming budget cycle. DEQ requests that the deadline be moved to 12/31/2020. Recommendation By December 31, 2020 the state should put together a plan that will ensure the Clean Water Act monitoring strategy goals are met on an annual basis. This plan should be submitted to EPA for review. Recommendation: U"' Due Dale # 1 12/31/2020 CWA Element 3 - Violations Finding 3-1 Meets or Exceeds Expectations Summary: The files reviewed and the data metric analysis indicate the state is appropriately determining violations. Explanation: All of the primary metrics for this element were found to be satisfactory in the file review. ------- Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % 7e Accuracy of compliance determinations [GOAL] 100% 17 17 100% State Response: No state response. CWA Element 4 - Enforcement Finding 4-1 Area for Attention Summary: The percentage of major NPDES facilities in SNC with no formal actions initiated is low. Explanation: The data metric analysis shows three major NPDES facilities in SNC during the review period. Of those three none of them had formal enforcement actions initiated. When evaluating the frozen data to production data in ICIS, it shows only one of those facilities were actually in SNC status during the review period. This metric finding is both not initiating formal enforcement actions on facilitates in SNC, and that there are data errors from flowing data to ICIS. Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % lOal Percentage of major NPDES facilities with formal enforcement action taken in a 1 100% ) 15.4% | 0 [ 1 [ 0% timely manner in response to SNC violations State Response: DEQ recognizes the importance of significant non-compliers and continues to work with EPA Region 10 to address SNC rates in Oregon. DEQ plans to share SNC ratings on a monthly basis ------- with DEQ managers and compliance and enforcement staff so that SNC can be considered when prioritizing work. CWA Element 4 - Enforcement Finding 4-2 Meets or Exceeds Expectations Summary: Over 90% of the facilities reviewed for facilities returning into compliance, and enforcement responses addressed the violations in an appropriate manner Explanation: The state was able to return most facilities back into compliance with their effective enforcement actions. This shows the enforcement actions are making the desired result. Similarly, from the files reviewed EPA found that the enforcement actions taken were appropriate for the given violations. Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 10b Enforcement responses reviewed that address violations in an appropriate manner [GOAL] | 100% 19 21 90.5% 9a Percentage of enforcement responses that returned, or will return, a source in violation to compliance [GOAL] | 100% 19 21 90.5% State Response: No state response. CWA Element 5 - Penalties Finding 5-1 Meets or Exceeds Expectations ------- Summary: There was proper documentation to justify a difference in the penalty amount from the initial to the final settled amount, and documentation to show the penalty was paid. There was also justification of gravity and economic benefit. Explanation: Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 1 la Penalty calculations reviewed that document and include gravity and economic benefit [GOAL] 100% 9 9 100% 12a Documentation of rationale for difference between initial penalty calculation and final penalty [GOAL] 100% 9 9 100% 12b Penalties collected [GOAL] 100% 9 9 100% State Response: No state response. ------- Resource Conservation and Recovery Act Findings RCRA Element 1 - Data Finding 1-1 Area for Improvement Summary: Missing Data Elements Explanation: For all enforcement and penalty actions the State is not inputting all required data or is putting the data into the wrong fields. For example, when the State initially sends a compliance order and penalty assessment (either as a EEO or a formal action) to the facility they are coding this as a final action 314. This results in missing data such as the date the action becomes final, initial versus assessed penalty, etc. EPA and the State have already entered into discussions surrounding this finding. It appears that the State's current database (ACES), that translates into RCRAInfo, is not able to capture all the required data, or if it does, does not translate correctly. The State is currently building an Agency wide new data platform called EDMS. The State RCRA program will beginning using this new database in 2020. Relevant metrics: Natl Natl State State State Goal Avg N D % Metric ID Number and Description 2b Accurate entry of mandatory data [GOAL] 1 100% | [9 I 30 | 30% State Response: EPA and DEQ have already begun discussions on this finding. DEQ acknowledges the state database, Agency Compliance and Enforcement System (ACES) is currently not capable of capturing all the required data to translate correctly to RCRAInfo. Since DEQ is building a new Environmental Data Management System (EDMS) to launch for the hazardous waste program in 2020, DEQ will address these EPA-identified data elements in the new data system. Based on the current EDMS project timeline, DEQ anticipates that it will be able to meet the milestone for ensuring proper data flow between the new EDMS system and RCRAInfo as outlined in the Recommendations below. Based on the current EDMS project timeline, DEQ expects the data translation beta testing can begin by December 30, 2020. Specifically, improvements in the new EDMS system will: 1) Increase the data metric percentage by adjusting the data translation process in the new EDMS database. This will ensure the return to compliance qualifiers reflect the actual inspector compliance verifications; ------- 2) Include Oregon rule references in the new EDMS database; and 3) Within the new EDMS translation, include the: • Informal enforcement (Warning Letters and Pre-Enforcement Notices) (100 level); • Initial formal enforcement (Expedited Enforcement Offers (EEOs) and Notices of Civil Penalty Assessment and Orders (NCPOs) with proposed penalty (200 level) with the enforcement issued date, and • The final formal enforcement with final penalty assessed (including accepted EEOs, default orders, Mutual Agreement and Orders (MAOs), Remedial Action Orders (RAOs) and final orders obtained through appeals (by ALJ, EQC, courts) (300 level) to translate once the penalty is paid or date compliance is achieved. DEQ will conduct training for all field staff on the new data entry procedures after the 2020 launch of the EDMS hazardous waste module. Recommendation: Due Dale Recommendation 1 02/28/2020 No later than Feb 28, 2020, EPA and ODEQ will conclude discussions regarding the required compliance and enforcement elements in RCRAInfo, and the data flow between EDMS and RCRAInfo (including data entry in EDMS) to ensure proper translation into RCRAInfo. ODEQ will use this meeting/these meetings to provide information to the IT staff building the RCRA module of EDMS. 2 12/30/2020 No later than December 30, 2020, Oregon will begin beta testing EDMS translation into RCRAInfo and will seek EPA input to ensure data is translating correctly 3 12/30/2020 No later than December 30, 2020, Oregon will conduct refresher training on required data elements that will include how to accurately enter that data into EDMS. RCRA Element 2 - Inspections Finding 2-1 Area for Improvement Summary: Inspection Report Accuracy/Completeness ------- Explanation: It is evident that inspection reports have greatly improved from Round 3 however, there are a few lingering issues the impact report accuracy and/or completeness. Specifically: • The statement that one of the purposes of inspections is to evaluate compliance with federal rules • Referencing, linking supporting evidence such as photos to report narrative • Drawing conclusions in the report rather than citing observations Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 5a Two-year inspection coverage of operating TSDFs [GOAL] 100% 85% 2 3 66.7% 5b Annual inspection of LQGs using BR universe [GOAL] 20% 15.6% 37 252 14.7% 5b 1 Annual inspection coverage of LQGs using RCRAinfo universe [GOAL] 20% 9.9% 35 180 19.4% 6a Inspection reports complete and sufficient to determine compliance [GOAL] 100% 20 29 69% 6b Timeliness of inspection report completion [GOAL] 100% 24 29 82.8% State Response: EPA and DEQ have discussed these findings. Two of EPA's recommendations have already been achieved, as noted in EPA's Recommendations below. As indicated below, if appropriate, DEQ intends to conduct refresher training on revisions to the inspection reports in conjunction with EDMS training, by December 30, 2020. DEQ considers periodic refresher training on these elements will address EPA's identified concerns. DEQ has the following additional specific comments regarding the metrics below: 5a: This measure (two-year inspection coverage of operating TSDFs) included the Umatilla Military Depot facility, which ceased to have an operating unit prior to FY2018. Previous communication from EPA Region 10 indicates that EPA did not believe a CEI or any RCRA inspection is necessary based on the no wastes generated or stored onsite (see email from Scott Downey, EPA, to DEQ, April 20, 2016). Oregon is working to ensure RCRAInfo accurately reflects the current status for this facility. ------- 5b & 5b 1: DEQ understands we can use the biennial report (BR) LQG universe or the RCRAInfo LQG universe to meet the LQG inspection goals. The 2015 BR was used for FY2018 inspection goal review, which lags in updated information when compared to the current active LQGs in DEQ's RCRA hazardous waste universe. 6a: DEQ recently revised the hazardous waste inspection report template to remind inspectors of the following: 1) Use first-person to state facts and note observations; 2) Avoid using terms such as "identified" or "documented;" 3) The site inspection portion should focus on what is observed or what is seen; 4) Take pictures of what is being observed; 5) Link or reference the photo, if possible, to the narrative text in the inspection report; 6) State if the observation is a violation; 7) Emphasize: If observations show violations, take photos and reference the photos in the report write up. Recommendation: Uec # Due Dale Recommendation 1 07/30/2020 No later than July 30, 2020, the Oregon will change the purpose section of its inspection report template so that it no longer indicates that Oregon evaluated compliance with Federal regulation. This action item was completed by September 1, 2019. 2 01/31/2020 Oregon will identify and update all appropriate inspection templates, and guidance for Oregon statute and rule citations. This action item was completed by September 1, 2019. 3 12/30/2020 No later than December 30, 2020, in coordination with data base training, if appropriate, Oregon will conduct training on revisions to written inspection reports. The training will address, among other things: • Inspection report writing, • Updated templates • Oregon regulation citations • Inspection observations and documentation RCRA Element 3 - Violations Finding 3-1 Meets or Exceeds Expectations Summary: Appropriate SNC determination. ------- Explanation: EPA found two instances that a SNC determination at first appeared appropriate but, in review of the evidence and information provided agreed with the State's conclusion that evidence did not support a SNC. None the less in each instance Oregon took an appropriate enforcement action that returned the facility to compliance. Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 7a Accurate compliance determinations [GOAL] 100% 25 29 86.2% 1 | | | 8b Timeliness of SNC determinations [GOAL] 100% 76.5% 5 5 100% I 8c Appropriate SNC determinations [GOAL] 100% 27 29 93.1% | State Response: No state response. RCRA Element 4 - Enforcement Finding 4-1 Meets or Exceeds Expectations Summary: Timely and appropriate enforcement. Explanation: In all cases except one, the states chosen enforcement action returned the facility to compliance. In one case the facility did not immediately return to compliance and Oregon immediately issued a penalty for failure to comply; In another action the state issued a penalty for small violations at a small facility because the violations were repeat in nature. As part of this review, EPA looked for instances where Oregon deferred to their Technical Assistance program over their compliance program; EPA did not see any instance of this bias and instead saw a consistent use of both elements of their program without muddling the appropriate use of the tools. Relevant metrics: ------- Metric ID Number and Description Natl Goal Natl Avg State N State D State % 10a Timely enforcement taken to address SNC [GOAL] 100% 87.7% 1 2 50% 10b Appropriate enforcement taken to address violations [GOAL] 100% 28 28 100% 9a Enforcement that returns sites to compliance [GOAL] 100% 28 28 100% State Response: No state response. RCRA Element 5 - Penalties Finding 5-1 Meets or Exceeds Expectations Summary: Economic benefit included in all penalty calculations/justifications. Explanation: Oregon provided penalty justifications that include economic benefit in all instances. However, the justification for no economic benefit at times seemed to not be as thoroughly thought as may be necessary. EPA and Oregon have already engaged in conversations on this topic and Oregon is working on how better to explain no economic benefit. Relevant metrics: ------- Metric ID Number and Description Natl i Goal Natl Avg State N State D State % 1 la Gravity and economic benefit [GOAL] | 100% 12 15 80% 12a Documentation of rationale for difference between initial penalty calculation and final penalty [GOAL] I 100% 4 4 100% 12b Penalty collection [GOAL] 1 100% 15 15 100% State Response: No state response. ------- STATE REVIEW FRAMEWORK Oregon Clean Air Act Implementation in Federal Fiscal Year 2018 U.S. Environmental Protection Agency Region 10 Final Report March 10, 2020 ------- I. Introduction A. Overview of the State Review Framework The State Review Framework (SRF) is a key mechanism for EPA oversight, providing a nationally consistent process for reviewing the performance of state delegated compliance and enforcement programs under three core federal statutes: Clean Air Act, Clean Water Act, and Resource Conservation and Recovery Act. Through SRF, EPA periodically reviews such programs using a standardized set of metrics to evaluate their performance against performance standards laid out in federal statute, EPA regulations, policy, and guidance. When states do not achieve standards, the EPA will work with them to improve performance. Established in 2004, the review was developed jointly by EPA and Environmental Council of the States (ECOS) in response to calls both inside and outside the agency for improved, more consistent oversight of state delegated programs. The goals of the review that were agreed upon at its formation remain relevant and unchanged today: 1. Ensure delegated and EPA-run programs meet federal policy and baseline performance standards 2. Promote fair and consistent enforcement necessary to protect human health and the environment 3. Promote equitable treatment and level interstate playing field for business 4. Provide transparency with publicly available data and reports B. The Review Process The review is conducted on a rolling five-year cycle such that all programs are reviewed approximately once every five years. The EPA evaluates programs on a one-year period of performance, typically the one-year prior to review, using a standard set of metrics to make findings on performance in five areas (elements) around which the report is organized: data, inspections, violations, enforcement, and penalties. Wherever program performance is found to deviate significantly from federal policy or standards, the EPA will issue recommendations for corrective action which are monitored by EPA until completed and program performance improves. The SRF is currently in its 4th Round (FY2018-2022) of reviews, preceded by Round 3 (FY2012-2017), Round 2 (2008-2011), and Round 1 (FY2004-2007). Additional information and final reports can be found at the EPA website under State Review Framework. II. Navigating the Report The final report contains the results and relevant information from the review including EPA and program contact information, metric values, performance findings and explanations, program responses, and EPA recommendations for corrective action where any significant deficiencies in performance were found. ------- A. Metrics There are two general types of metrics used to assess program performance. The first are data metrics, which reflect verified inspection and enforcement data from the national data systems of each media, or statute. The second, and generally more significant, are file metrics, which are derived from the review of individual facility files in order to determine if the program is performing their compliance and enforcement responsibilities adequately. Other information considered by EPA to make performance findings in addition to the metrics includes results from previous SRF reviews, data metrics from the years in-between reviews, multi-year metric trends. B. Performance Findings The EPA makes findings on performance in five program areas: • Data - completeness, accuracy, and timeliness of data entry into national data systems • Inspections - meeting inspection and coverage commitments, inspection report quality, and report timeliness • Violations - identification of violations, accuracy of compliance determinations, and determination of significant noncompliance (SNC) or high priority violators (HPV) • Enforcement - timeliness and appropriateness of enforcement, returning facilities to compliance • Penalties - calculation including gravity and economic benefit components, assessment, and collection Though performance generally varies across a spectrum, for the purposes of conducting a standardized review, SRF categorizes performance into three findings levels: Meets or Exceeds: No issues are found. Base standards of performance are met or exceeded. Area for Attention: Minor issues are found. One or more metrics indicates performance issues related to quality, process, or policy. The implementing agency is considered able to correct the issue without additional EPA oversight. Area for Improvement: Significant issues are found. One or more metrics indicates routine and/or widespread performance issues related to quality, process, or policy. A recommendation for corrective action is issued which contains specific actions and schedule for completion. The EPA monitors implementation until completion. C. Recommendations for Corrective Action Whenever the EPA makes a finding on performance of Area for Improvement, the EPA will include a recommendation for corrective action, or recommendation, in the report. The purpose of recommendations are to address significant performance issues and bring program performance back in line with federal policy and standards. All recommendations should include ------- specific actions and a schedule for completion, and their implementation is monitored by the EPA until completion. III. Review Process Information Clean Air Act (CAA) Kickoff letter sent: April 2, 2019 Data Metric Analysis and file selections sent to LRAPA: September 18, 2019 File reviews completed: November 8, 2019 Draft report sent to LRAPA: December 16, 2019 Comments from LRAPA received by EPA: February 25, 2020 Report Finalized: March 10, 2020 LRAPA and EPA key contacts: Colleen Wagstaff, LRAPA Elizabeth Walters, EPA CAA file reviewer John Pavitt, EPA CAA file reviewer Scott Wilder, EPA SRF Coordinator ------- Executive Summary Introduction Clean Air Act (CAA) Areas of Strong Performance The following are aspects of the program that, according to the review, are being implemented at a high level: A Federally Reportable Violation (FRV) was accurately determined as non-HPV status. Penalties were collected and documented properly. Priority Issues to Address The following are aspects of the program that, according to the review, are not meeting federal standards and should be prioritized for management attention: Clean Air Act (CAA) Facility identifiers were consistently inaccurate, absent from facility files and/or did not match with ICIS-Air. Compliance determinations were generally inaccurate based on documentation in the FCE report and facility files. An HPV was not addressed in a timely manner or alternatively did not have a Case Development Resolution Timeline (CDRT) in accordance with the HPV policy. 1 out of 2 formal enforcement responses did not include the required corrective action to return the facility to compliance. ------- Clean Air Act Findings CAA Element 1 - Data Finding 1-1 Area for Improvement Summary: Facility identifiers were consistently inaccurate, absent from facility files and/or did not match with ICIS-Air. Explanation: Facility identifiers such as dates, programmatic ID, address, zip code and NAICS code were consistently inaccurate or not included in FCE reports. A few FCE reports lacked basic details such as the date(s) of inspection and whether it an announced or unannounced inspection. In reviewing metric 3b2 on stack test timeliness, it was found that several stack tests did not specify which pollutants were measured in ICIS-Air. While pollutants were generally accurate in ICIS- Air, 4 out of 12 facilities did not have the applicable air programs and subparts. Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 2b Files reviewed where data are accurately reflected in the national data system [GOAL] 100% 0 12 0% | LRAPA Response: LRAPA accepts EPA finding and agrees to, where deficient, implement the EPA recommendations by the dates specified. Recommendation: ------- Ucc # Due Dale Uecommemlalion 1 10/31/2020 The current FCE form used by LRAPA is a great template for completing a report. However, EPA recommends that LRAPA rework the front pages to include all of the necessary Minimum Data Requirements (MDRs) and share a draft of the re-worked template with EPA by March 31, 2020. Following FY20, EPA will review a selection of LRAPA inspection reports (also for Finding 3-1) and if EPA finds that the inspection reports include accurate facility information, this recommendation will be closed. 2 10/31/2020 EPA recommends that LRAPA develop a plan and timeline on how to input "pollutants measured" for source tests in ICIS-Air. Following FY20, EPA will review a selection of stack tests and if 85% or greater specify pollutants measure in ICIS-Air, this recommendation will be closed. CAA Element 1 - Data Finding 1-1 Meets or Exceeds Expectations Summary: Explanation: LRAPA reported 100% of stack tests and stack test results in a timely manner. However, several stack tests did not specify which pollutants were measured in ICIS-Air. While pollutants were generally accurate in ICIS-Air, 4 out of 12 facilities did not have the applicable air programs and subparts. CMS source category and frequency had also not been entered into ICIS-Air for all 12 facilities. LRAPA reported 100% of compliance monitoring MDRs and enforcement MDRs within a timely manner. Relevant metrics: ------- Metric ID Number and Description Natl Goal Natl Avg State N State D State % 3b 1 Timely reporting of compliance monitoring MDRs [GOAL] 100% 85.2% 41 46 89.1% 3b2 Timely reporting of stack test dates and results [GOAL] 100% 65.1% 11 11 100% 3b3 Timely reporting of enforcement MDRs [GOAL] 100% 71.8% 1 1 100% LRAPA Response: LRAPA accepts EPA finding and agrees to, where deficient, implement the EPA recommendations by the dates specified. Ucc # Due Dale Recommendation 1 04/17/2020 The current FCE form used by LRAPA is a great template for | completing a report. EPA is recommending that LRAPA rework the | front pages to include all of the necessary MDR and share a draft of the I re-worked template with EPA by March 31, 2020. The State will then 1 begin using the new template by April 17, 2020. 2 05/29/2020 | By May 29, 2020, the Agency must determine how to input "pollutants I measured" for source tests in ICIS-Air and provide a timeline/plan to EPA. CAA Element 2 - Inspections Finding 2-1 Area for Attention Summary: 2 out of 12 inspection reports did not document all the required FCE elements. Explanation: 2 out of 12 FCE reports lacked documentation of required FCE elements. Inspectors were generally thorough in their review of reports and documents and included a summary of the documents ------- reviewed in their reports. However, the 2 FCE reports did not review all the necessary underlying documents and reports and/or did not include an assessment of those documents. Relevant metrics: . ... .. . , „ • -• Natl ; Natl State State State Metric ID Number and Description , .. 1 Goal Avg N D % 6a Documentation of FCE elements [GOAL] . 100% : , 10 12 , 83.3% LRAPA Response: LRAPA accepts EPA finding and agrees to improve inspection reports so they document all the required FCE elements. CAA Element 2 - Inspections Finding 2-2 Area for Attention Summary: FCE reports occasionally lacked enough information to determine compliance. Explanation: The Agency conducted FCEs on 100% of the major, mega-site and SM-80 sources within their jurisdiction and 94.1% of Title V Annual Compliance Certification reviews were completed in FY18. FCE reports generally documented facility and regulatory information, but 3 out of 12 files lacked the necessary information in order to determine compliance of the facility. 3 FCE reports did not thoroughly assess the federal requirements, regulated emission units, or their on-site observations. There were also a few FCE reports that consisted of multiple inspections over a period of time. These multiple inspections are logged into what appears to be a database and is a narrative of the inspector's on-site observations, records review and discussions with the facility. However, this information often did not make it into the final FCE report. As a result, the final FCE report lacked a lot of information and major details. Additionally, a few of the final FCE reports also switched frequently between tenses (maintain, maintained, maintaining) and/or did not have the complete name of the inspector (i.e. initials only). Relevant metrics: ------- Metric ID Number and Description Natl Goal Natl Avg State N State D State % 5a FCE coverage: majors and mega-sites [GOAL] 100% 88.1% 11 11 100% 5b FCE coverage: SM-80s [GOAL] 100% 93.7% 2 2 100% 5c FCE coverage: minors and synthetic minors (non-SM 80s) that are part of CMS plan or alternative CMS Plan [GOAL] 100% 70.1% 0 0 0 5e Reviews of Title V annual compliance certifications completed [GOAL] 100% 82.5% 16 17 94.1% 6b Compliance monitoring reports (CMRs) or facility files reviewed that provide sufficient documentation to determine compliance of the facility [GOAL] 100% 9 12 75% LRAPA Response: LRAPA accepts EPA Finding and agrees to include sufficient information, including reference to Permit conditions, in the FCE reports, such that facility compliance status may be readily ascertained by EPA reviewer. CAA Element 3 - Violations Finding 3-1 Area for Improvement Summary: Compliance determinations were generally inaccurate based on documentation in the FCE report and facility files. Explanation: 6 out of 12 FCE reports had inaccurately determined that the facility was "in compliance" when they had violated permit conditions and/or permit requirements. FCE reports had identified a violation of a permit condition and/or federal requirements, but incorrectly determined that the facility was "in compliance." Overall, inspectors were not thorough in reviewing and assessing federal requirements during the FCE and in their final reports and did not make accurate compliance determinations. ------- Relevant metrics: mix - i tv vr u j rv • x- Natl Natl State State State Metric ID Number and Description 1 Goal Avg N D % 7a Accurate compliance determinations [GOAL] 100% 6 12 50% LRAPA Response: LRAPA accepts EPA finding, and will improve documentation of compliance status in the FCE reports. It is LRAPA understanding, that to remedy the Recommendation, an instance of non-compliance documented during the reporting period will be readily apparent to the EPA report reviewer, even though the facility may be "in- compliance" at the time of FCE report submittal. LRAPA will also observe the EPA-led inspections in Lane County and is anticipating EPA visit the week of March 30, 2019. LRAPA inspectors and compliance staff will review the HPV Policy and HPV training prior to the inspections. Recommendation: Ucc # Due Dale 07/31/2020 Recommendation By July 31, 2020, LRAPA will observe 3 EPA-lead FCEs in Lane County. EPA recommends that the LRAPA inspectors review the High Priority Violation Policy and the HPV training developed by EPA prior to each inspection. CAA Element 3 - Violations Finding 3-2 Meets or Exceeds Expectations Summary: 1 file included a Federally Reportable Violation (FRV) which was accurately determined as non- HP V status. Explanation: 1 facility file documented a Federally Reportable Violation (FRV). The FRV was accurately determined as non-High Priority Violation (HPV) status by the agency. ------- Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 13 Timeliness of HPV Identification [GOAL] 100% 89.5% 0 0 0 | 8c Accuracy of HPV determinations [GOAL] 100% | 1 1 100% ! LRAPA Response: LRAPA accepts EPA finding. CAA Element 4 - Enforcement Finding 4-1 Area for Improvement Summary: 1 out of 2 formal enforcement responses did not include the required corrective action to return the facility to compliance. Explanation: 2 FCEs resulted in a formal enforcement response. 1 out of 2 files did not include the required corrective action. The violation was an unidentified High Priority Violation (HPV) of a MACT subpart. A penalty was not assessed and therefore the facility file did not include the required corrective action as per the HPV policy. Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % 9a Formal enforcement responses that include required corrective action that will return the facility to compliance in a specified time frame or the facility fixed the problem without a compliance schedule [GOAL] 100% 50% ------- LRAPA Response: LRAPA accepts EPA finding and agrees to include in the formal enforcement responses, the corrective action required or taken to return the facility to compliance. Recommendation: Ucc # Due Dale Recommendation By March 27, 2020, LRAPA will organize and provide HPV training to staff. EPA will provide HPV training already developed by EPA HQ. CAA Element 4 - Enforcement Finding 4-2 Area for Improvement Summary: An HPV was not addressed in a timely manner or alternatively did not have a Case Development Resolution Timeline (CDRT) in accordance with the HPV policy. Explanation: 1 facility file contained a High Priority Violation (HPV) that was identified by the agency. However, the HPV was not addressed in a timely manner or alternatively did not have a CDRT in accordance with the HPV policy. Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % 10a Timeliness of addressing HPVs or alternatively having a case development and resolution timeline in place 100% 0% LRAPA Response: LRAPA accepts EPA finding and agrees to address HPVs in a timely manner or alternatively have a Case Development Resolution Timeline (CDRT). and agrees ------- to improve efforts in consultation with EPA in determination of accurate HPV reporting and to develop the HPV timeline as recommended. Recommendation: Ucc # Due Dale Recommendation By September 30, 2020, LRAPA will develop and use a system to track the progression of an HPV (discovery, notify EPA, address, resolution). This system should include the actual dates, the listed timelines in the HPV policy, and a CDRT if the HPV is not resolved in a timely manner. This system can be developed in Excel, Word, a database, etc., but should be designed so that it can be printed and included in the facility file. CAA Element 5 - Penalties Finding 5-1 Meets or Exceeds Expectations Summary: Penalties were collected and documented. Explanation: 1 out of 1 facility file had documentation of check transmittal for a collected penalty. Relevant metrics: Metric ID Number and Description Natl Natl State State State Goal Avg N D % 1 la Penalty calculations reviewed that document gravity and economic benefit [GOAL] 100% 100% LRAPA Response: LRAPA accepts EPA finding and will continue to document violations and collect penalties properly. ------- CAA Element 5 - Penalties Finding 5-2 Meets or Exceeds Expectations Summary: The initial penalty value and final penalty value did not differ. Explanation: 1 facility file contained an assessed penalty. The initial penalty value and final penalty did not differ, so documentation of rationale for difference is not required. Relevant metrics: Metric ID Number and Description Natl Goal Natl Avg State N State D State % 12a Documentation of rationale for difference between initial penalty calculation and final penalty [GOAL] 100% ' ' 100% | LRAPA Response: LRAPA accepts EPA finding. CAA Element 5 - Penalties Finding 5-3 Meets or Exceeds Expectations Summary: Penalties were collected and documented. Explanation: 1 out of 1 facility file had documentation of check transmittal for a collected penalty. ------- Relevant metrics: , . Irk.. , , .. . . Natl Natl State State State Metric ID Number and Description „ , ; . .. ... 1 Goal Avg N D % 12b Penalties collected [GOAL] 100% 1 1 100% LRAPA Response: LRAPA accepts EPA finding. ------- |