Document 71Zg6w4y26zzwKRMV0JVZjL7e

Inspection Entry Date/Time Inspection Exit Date/Time Regulatory Program Type of Inspection EPA REGION 10 Enforcement Division INSPECTION REPORT 09/12/2023 08:48 AM (AKT) Announced: No 09/12/2023 02:00 PM (AKT) Access: Granted RCRA Compliance Evaluation Inspection (CEI) Company Name Facility or Site Name Facility/Site Identifier Facility/Site Physical Address City, State, Zip Code County/Borough Generator Status NAICS Type of Operation Geographic Coordinates Mailing Address/Secondary Address City, State, Zip Code Bartlett Regional Hospital Bartlett Regional Hospital AKR000210302 3260 Hospital Dr. Juneau, AK 99801 City and Borough of Juneau Very Small Quantity Generator (VSQG) 62211 - General Medical and Surgical Hospitals Hospital 58.32902777, -134.46644722 Mr. Nathan Overson, CHC Compliance noverson@bartletthospital.org 3260 Hospital Dr. Juneau, AK 99801 Juneau, AK 99801 Permit Number (If Applicable) Not Applicable Lead Inspector: Jon Jones EPA Region 10 Jones.Jon@epa.gov (907) 227-4316 Supervisor Review: Matt Quarterman EPA Region 10 Quarterman.matthew@epa.gov (206) 553-2146 SECTION I - INTRODUCTION Site Entry and Purpose of the Inspection Type of inspection: Compliance Evaluation Inspection (CEI) EPA Region 10 Lead Inspector, Jon Jones, arrived at the Bartlett Regional Hospital Facility (the "Site" or "Facility"), located at 3260 Hospital Dr., Juneau, AK 99801, at 08:48 AM (AKT) on 09/12/2023 for an unannounced inspection. EPA Region 10 Lead Inspector presented credentials to and informed Mr. Nathan Overson, CHC Compliance, that this was an EPA Region 10 inspection to determine compliance with Resource Conservation and Recovery Act (RCRA). The facility was inspected to ensure compliance with standards for hazardous waste generators and universal waste management (40 C.F.R. Part 262 through 273). The inspection 1 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 was conducted as part of a Core Program requirement for FY 2023. This report is based on information supplied by Bartlett Regional Hospital Facility representatives, observations made by the EPA Region 10 inspector, and records and reports maintained by the facility including, but not limited to: direct observations made by the EPA Region 10 Inspector(s), photographs taken by EPA Region 10 inspector(s), physical evidence collected by the EPA Region 10 inspector(s), measurements or samples taken by EPA Region 10 inspector(s), verbal or written statements made by information supplied by the facility representatives during or subsequent to the on-site Inspection, and materials, processes, data, photographs, or documents shown, demonstrated, or submitted to the EPA Region 10 inspector(s) by the facility representatives during or subsequent to the on-site Inspection. In addition, information gathered prior to or subsequent to the Inspection from a review of USEPA, State, and public records may be included in this report. Attendees Title/Organization Name Phone Lead Inspector/EPA Jon Jones REGION 10 (907) 2716329 CBJ Safety Officer/City and Borough of Juneau (CBJ) Daniel Blount CHC Nathan Compliance/Bartlett Overson Regional Hospital (907) 7968578 Grounds Keeper/Bartlett Regional Hospital Shawn Nolan Maintenance Kelvin Schubert Supervisor/Bartlett Regional Hospital Staff Safety Officer/Bartlett Regional Hospital Evan Price Acting CEO/Bartlett Nate Rumsey Regional Hospital Chief Operating Officer/Bartlett Regional Office Kim McDowell RCRA Inspector/ADEC Alan Pefley RCRA Inspector/ADEC Emily Vannortwick Lab Director/Bartlett Regional Hospital John Fortin Email Jones.Jon@epa.gov Opening Conf. Closing Conf. Yes Yes Yes Yes noverson@bartletthospital.org Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 2 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 Opening Conference After arriving at the hospital, we entered the Administration Building. I walked up to a customer service window, where I spoke to Admin personnel and explained the purpose of our visit. We were then directed to go upstairs and once there we were met by additional Admin staff as well as the CEO, and Safety personnel. We informed staff that we were there to perform a hazardous waste inspection. We were then escorted to a conference room where we met with the hospital staff listed above in the Attendees table, in Section I of this report. I presented my inspector credentials to and informed Mr. Nathan Overson, CHC Compliance, that this was an EPA Region 10 inspection to determine compliance with Resource Conservation and Recovery Act (RCRA). I provided business cards to the other hospital staff members at the opening conference. During the opening conference, we explained that the focus of the RCRA inspection was to identify types of wastes generated, points of waste generation, methods of waste management, and review relevant documents. Mr. Overson asserted that the facility was a very small quantity generator. I asked how the facility was managing their waste and we were told that it was being taken to the City and Borough of Juneau (CBJ) Household Hazardous Waste (HHW) facility. I asked if they maintained disposal records and Mr. Nolan, Grounds Keeper, told me they did. I asked to see the disposal records and Mr. Nolan left the conference room to retrieve the documents. Mr. Nolan returned a short time later with a binder that contained disposal records going back to 2017. I explained that I wanted to see the records of hazardous waste disposal to try and make an accurate determination of the hospital's generator status. During this preliminary review of the facility's hazardous waste disposal records, I saw that there were several times each year for multiple years, going back to 2017, when the hospital was an SQG, generating more than 220 pounds in a calendar month. I also saw that three pounds of Plisted waste had been disposed of through the HHW, indicating that the facility had accumulated more than 1 kg of P-listed waste at the facility making them a large quantity generator (LQG). Only those areas in which we observed areas of concern or noted other pertinent issues are discussed in this inspection report. Photo(s) 1. IMG_1680.jpg Facility/Site Information Bartlett Regional Hospital (BRH) is a hospital serving Juneau, Alaska, the capital city of Alaska and the largest city in Southeast Alaska, with a population of approximately 32,000. The hospital is owned by the CBJ. BRH is the only hospital in Juneau and provides the only emergency department in the city. In addition, BRH operates the adjacent Rainforest Recovery Center, an inpatient and outpatient drug and alcohol treatment center. BRH is licensed for a total of 57 inpatient beds, 16 residential substance-abuse treatment facility beds in the Rainforest Recovery Center, and 61 residential beds in Wildflower Court. The hospital serves a 15,000-squaremile region in the northern part of Southeast Alaska. Approximately 55,000 people reside in their service area, with most communities inaccessible by road. Length of Facility at Location Operating Hours Safety Training Provided to Inspector(s)? Since 1965 Hospital operates seven days a week, 24 hours a day. Administrative Staff, Monday through Friday from 8:00 a.m. to 5:00 p.m. No 3 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 What type of generator facility notified? What type of generator facility verified as? Weather Conditions Non-Notifier, operating as a Very Small Quantity Generator (VSQG) Verified as VSQG on the day of the inspection, however; based on facility records, the facility was a Small Quantity Generator (SQG) several times a year since 2017. Rainy and overcast Process Description During the opening conference, Mr. Shawn Nolan, Grounds Keeper, told us that wastes generated at the hospital included the following: Waste fluorescent lamps and batteries Waste paint related material Waste aerosols Pharmaceutical waste Various flammable/toxic wastes - Ethyl Alcohol waste and Paraffin Wax waste with traces of xylene Various P-listed wastes - Warfarin, and nicotine related products Waste diesel fuel Medical waste - Red bag waste and trace chemotherapy waste Mr. Nolan told us that he takes the waste to the local HHW facility on a monthly basis. According to Mr. Nolan, the HHW facility is located at the CBJ Landfill. We were accompanied throughout the inspection by Mr. Nolan and Mr. Overson and for a portion of the inspection by Mr. Fortin. During the inspection we looked at the facility's processes, in addition to hazardous waste management practices, generation points, and accumulation areas. We looked for wastes that facility representatives had not yet identified or designated as hazardous. We also observed the facility's universal waste and used oil management. Building(s) Building/Area/Sub-area Main Building Basement Shop Old Well Room Central Accumulation Area (CAA) Rm #1115 Medical Waste Storage Chemo Infusion Critical Care Unit (CCU) Room Rm #2809 Medicine Room Histology Lab Rm #2433A Chemical Storage Room Medical Surgery Process Description Accumulation of waste batteries Accumulation of waste lamps and batteries Accumulation of flammable/toxic waste Patient room with a wall mounted collection container for RCRA hazardous waste and non-toxic pharmaceutical waste SAA SAA 4 of 32 Area of Concern Yes No No Yes Yes No No No No No No Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 Nurses Station SAA No Rm #3360 Medication Room SAA No Mental Health Nurses Station No Rm #3126 Serenity Room SAA No OBGYN (Obstetrics and Gynecology) No Area Nurses Station adjacent to Rm #2752 SAA No Procedure Room Operating Room Area No SAA SAA in each operating room No Pharmacy (3rd floor) Rm #3483 No SAA No SECTION II - OBSERVATIONS Building: Main Building/Central Accumulation Area (CAA)/Rm #1115 Medical Waste Storage Observation #: JJ1-OB-001 Date: 09/12/2023 Contains AOC: Yes Contains CBI: No Person Interviewed: Shawn Nolan Title: Grounds Keeper While at the CAA, we observed containers of non-RCRA waste, including sharps, red bag waste, non-hazardous waste, and chemotherapy waste. We also observed three, 2.5 - gallon "Rx Destroyer" containers. There were two "Rx Destroyer" containers on a shelf that were not labeled with the words "Hazardous Waste" and were not dated. There was one "Rx Destroyer" container that was labeled with the words "Hazardous Waste," a hazard indicator, but not dated, and in an open blue, poly container that was adjacent to the shelf where the other two "Rx Destroyer's" were located. According to the "Rx Destroyer" website which I researched following the inspection, these containers are for pharmaceuticals that are controlled substances. The "Rx Destroyer" renders pharmaceuticals non-retrievable. At the time of the inspection, the facility was managing the "Rx Destroyer" containers as hazardous waste. I suggested to Mr. Nolan that he take a closer look at the "Rx Destroyer's" to make a waste determination, as this waste might not be hazardous. We also saw a one-gallon container that was labeled with the words "Ethyl Alcohol Waste," with trace amounts of xylene and a one-gallon container that was labeled with the words "Paraffin Wax Waste," with trace amounts of xylene on the same shelf. Both containers were marked with hazard indicators. According to Mr. Nolan, the ethyl alcohol and paraffin wax wastes were being managed by the facility as flammable/toxic waste. Photo(s) 1. IMG_1682.jpg 2. IMG_1683.jpg 3. IMG_1681.jpg Building: Main Building/Critical Care Unit (CCU) Room Observation #: JJ1-OB-002 Date: 09/12/2023 Person Interviewed: Shawn Nolan Contains AOC: No Title: Grounds Keeper Contains CBI: No While in the CCU, we went into a vacant patient room with facility personnel. While there we saw a wall mounted collection box that held a ~1.5-quart SAA container, at the top of the box, for the accumulation of 5 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 flammable/toxic waste, and a ~1.5-quart container, at the bottom of the box, for the collection of non-toxic pharmaceutical waste. At the time of the inspection, the SAA container was labeled with the words "Hazardous Waste" and a hazard indicator. The wall mounted collection box is just for waste generated in that room. At this point in the inspection, we met Mr. John Fortin, Lab Director, and he joined us for the remainder of the inspection. Photo(s) 1. IMG_1684.jpg Building: Main Building/Critical Care Unit (CCU) Room/Rm #2809 Medicine Room Observation #: JJ1-OB-003 Date: 09/12/2023 Contains AOC: No Person Interviewed: Shawn Nolan Title: Grounds Keeper Contains CBI: No While at the CCU, we inspected another SAA located in Medicine Room #2809. At this SAA, we saw one, black, five-gallon container being used to accumulate non-hazardous pharmaceutical waste, and a 2.5 gallon "Rx Destroyer." We also saw a five-gallon SAA container being used to accumulate flammable/toxic waste. At the time of the inspection, the SAA container was labeled with the words "Hazardous Waste" and marked with a hazard indicator. Photo(s) 1. IMG_1685.jpg Building: Main Building/OBGYN (Obstetrics and Gynecology) Area/Nurses Station adjacent to Rm #2752 Procedure Room Observation #: JJ1-OB-004 Date: 09/12/2023 Contains AOC: No Contains CBI: No Person Interviewed: Shawn Nolan Title: Grounds Keeper While at the Nurse's Station, we inspected another SAA. In this SAA, we saw a sharps container and another 2.5 gallon "RX Destroyer." We also saw a black, five-gallon container marked with the words "Highly Flammable." The container was not labeled with the words "Hazardous Waste." Photo(s) 1. IMG_1688.jpg 2. IMG_1687.jpg 3. IMG_1686.jpg 4. IMG_1689.jpg Building: Main Building/Histology Lab/Rm #2433A Chemical Storage Room Observation #: JJ1-OB-005 Date: 09/12/2023 Contains AOC: No Person Interviewed: Shawn Nolan Title: Grounds Keeper Contains CBI: No While at the lab, we inspected the SAA. Mr. Nolan took us to a yellow flammable storage cabinet that contained four, one-gallon containers that were labeled with the words "Ethyl Alcohol waste" (these were the same containers as seen in the CAA). We told Mr. Nolan that the containers should probably be moved to the 6 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 CAA. At the time of the inspection, all four containers were marked with hazard indicators, but none were labeled with the words "Hazardous Waste." Photo(s) 1. IMG_1692.jpg 2. IMG_1691.jpg 3. IMG_1690.jpg Building: Main Building/Histology Lab/Rm #2433A Chemical Storage Room Observation #: JJ1-OB-006 Date: 09/12/2023 Contains AOC: No Person Interviewed: Shawn Nolan Title: Grounds Keeper Contains CBI: No The information in Observation JJ1-OB-005 was inadvertently entered into Smart Tools a second time, creating Observation JJ1-OB-006 which is N/A. Building: Main Building/Operating Room Area/SAA Observation #: JJ1-OB-007 Date: 09/12/2023 Person Interviewed: Shawn Nolan Contains AOC: No Title: Grounds Keeper Contains CBI: No While in the Operating Room Area, we were told that each operating room has a SAA container for the accumulation of flammable/toxic waste as well as a 2.5 gallon "Rx Destroyer." We did not enter an operating room during the inspection in an effort to maintain the sterile environment, however; an on-duty nurse brought out a red, three-gallon container with a black strip for what the facility identifies as a SAA container for the accumulation of flammable/toxic waste which is handled as hazardous waste. At the time of the inspection, the SAA container was labeled with the words "Hazardous Waste" and marked with a hazard indicator. Building: Main Building/Pharmacy (3rd floor) Rm #3483/SAA Observation #: JJ1-OB-008 Date: 09/12/2023 Contains AOC: No Person Interviewed: Shawn Nolan Title: Grounds Keeper Contains CBI: No While inspecting this area, we met with and were accompanied by Mr. Carlo Rip, Pharmacy Purchaser. While in Room #3483, we saw the following SAA containers: Two full, black, five-gallon containers of flammable/toxic waste which, according to facility personnel, were ready to be transferred the CAA. These two containers were labeled with the words "Hazardous Waste" and hazard indicators, but no accumulation start date (ASD). Two, black, five-gallon containers labeled with the words "Non-Toxic Pharmaceutical Waste." One, black, five-gallon SAA container of flammable/toxic waste which waste was still be accumulated. The container was labeled with the words "Hazardous Waste" and marked with a hazard indicator. One, black, five-gallon container of waste aerosols (almost full and was estimated to be a 6-month accumulation). This container was labeled with the words "Aerosols: (Anything that is propelled)." The container was neither labeled with the words "Hazardous Waste" and marked with a hazard indicator nor was it being managed as universal waste and labeled with either the phrase, "Universal Waste Aerosols," "Waste Aerosols," or "Used Aerosols." 7 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 One, white, five-gallon container of waste nicotine products (2/3 full estimated to be a 1-year accumulation) and labeled with the words "P-List." The container was not labeled with the words "Hazardous Waste" or marked with a hazard indicator. Mr. Rip showed us a shelfing unit of potentially creditable pharmaceuticals for reverse distribution. According to Mr. Rip, the reverse distributor (Inmar) makes the determination as to what pharmaceuticals they will take for credit, and anything not taken gets wasted. The reverse distributor comes every three months and according to Mr. Rip, on average 2% of what the pharmacy deems as potentially creditable isn't taken by Inmar and ends up leaving the facility as hazardous waste. Photo(s) 1. IMG_1693.jpg 2. IMG_1697.jpg 3. IMG_1695.jpg 4. IMG_1696.jpg 5. IMG_1694.jpg 6. IMG_1698.jpg 7. IMG_1699.jpg 8. IMG_1703.jpg 9. IMG_1702.jpg 10. IMG_1701.jpg 11. IMG_1704.jpg 12. IMG_1700.jpg Building: Main Building/Medical Surgery /Rm #3360 Medication Room Observation #: JJ1-OB-009 Date: 09/12/2023 Contains AOC: No Person Interviewed: Shawn Nolan Title: Grounds Keeper Contains CBI: No While in the Medication Room #3360 SAA, we saw a five-gallon container that held non-toxic pharmaceutical waste and was labeled as such. We also saw a five-gallon SAA container that held flammable/toxic waste. The container was labeled with the words "Hazardous Waste" and marked with a hazard indicator. We also saw a three-gallon container of P-listed waste. At the time of the inspection, the three-gallon container was marked with the words "Hazardous Waste," but was not marked with a hazard indicator. Photo(s) 1. IMG_1706.jpg 2. IMG_1705.jpg Building: Main Building/Medical Surgery /Nurses Station Observation #: JJ1-OB-010 Date: 09/12/2023 Person Interviewed: Shawn Nolan Contains AOC: No Title: Grounds Keeper Contains CBI: No While still in Medical Surgery, we inspected the SAA at the Nurses Station. While there we saw a five-gallon container that was labeled with the words "Non-Toxic Pharmaceutical Waste" and a five-gallon SAA container 8 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 being used to accumulate flammable/toxic waste. At the time of the inspection, the container was labeled with the words "Hazardous Waste" and marked with a hazard indicator. Photo(s) 1. IMG_1707.jpg Building: Main Building/Mental Health Nurses Station/Rm #3126 Serenity Room Observation #: JJ1-OB-011 Date: 09/12/2023 Contains AOC: No Person Interviewed: Shawn Nolan Title: Grounds Keeper Contains CBI: No While at the Nurses Station, we saw another 2.5 gallon "Rx Destroyer" and a seven-gallon SAA container being used to accumulate flammable/toxic waste. At the time of the inspection, the SAA container was labeled with the words "Hazardous Waste," but was not marked with a hazard indicator. Photo(s) 1. IMG_1709.jpg 2. IMG_1708.jpg Building: Main Building/Chemo Infusion Observation #: JJ1-OB-012 Date: 09/12/2023 Person Interviewed: Shawn Nolan Contains AOC: No Title: Grounds Keeper Contains CBI: No While inspecting the SAA, we saw that there was no hazardous waste being accumulated. The only container we saw in this area was a five-gallon container that was labeled with the words "Non-Hazardous Pharmaceutical Waste." Building: Main Building/Basement Shop Observation #: JJ1-OB-013 Date: 09/12/2023 Person Interviewed: Shawn Nolan Contains AOC: No Title: Grounds Keeper Contains CBI: No While inspecting the Basement Shop, we saw a step-can style trash receptacle that was being used to accumulate waste Lithium batteries. At the time of the inspection, the container being used to accumulate the waste lithium batteries was labeled with the words "HAZ WASTE LITHIUM BATTS." We looked inside the container and saw that it held one, button style, waste lithium battery. While there, we took the time to discuss the management of waste lithium batteries as universal waste vs hazardous waste. The container was neither labeled as "Hazardous Waste" and marked with a hazard indicator nor was it being managed as universal waste and labeled with either the phrase "Universal Waste - Batteries," "Waste Batteries," or "Used Batteries." Photo(s) 1. IMG_1711.jpg 2. IMG_1710.jpg Building: Main Building/Basement Shop/Old Well Room 9 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 Observation #: JJ1-OB-014 Date: 09/12/2023 Person Interviewed: Shawn Nolan Contains AOC: No Title: Grounds Keeper Contains CBI: No While in the Old Well Room, we saw a small blue tray that held four waste compact fluorescent lamps (CFLs). Neither the waste CFLs nor the tray that held them was labeled. We also saw a gray tray that held some waste batteries, including at least one waste Ni-Cad battery. Neither the waste batteries nor the tray that held them was labeled. We also saw a large gray, open, wheeled trash receptacle that Mr. Nolan said the facility was using to accumulate waste fluorescent (linear type) lamps. At the time of the inspection, the container was not labeled in any way and held one small waste CFL. Photo(s) 1. IMG_1715.jpg 2. IMG_1713.jpg 3. IMG_1712.jpg 4. IMG_1716.jpg SECTION III - RECORDS REVIEW Record: Shipping Documents/Tolling agreements AOC: Yes Ref #: JJ1-RR-001 Reviewed By: Jon Jones Reviewed Date: 09/12/2023 At the time of the inspection, the facility believed they met the criteria of being a Very Small Quantity Generator (VSQG). As such, they have been managing their hazardous waste in accordance with the requirements of a VSQG and taking it to the CBJ HHW facility which is operated by Clean Harbors. Following the facility walk-through portion of the inspection, we returned to the conference room and inspected the disposal records for waste that the facility had taken to the HHW facility, for the period of 2017 through 2023, and identified the following months when the amount of hazardous waste generated at the facility exceeded 220 pounds: Date Waste Quantity 04/05/23 04/26/23 05/26/22 07/08/21 11/18/21 03/12/20 06/18/20 02/02/19 06/13/19 09/26/19 11/07/19 12/12/19 03/08/18 07/12/18 09/06/18 10/25/18 12/13/18 05/18/17 Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic P-listed Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic Flammable/Toxic 240 pounds 228 pounds 515 pounds 249 pounds 249 pounds 391 pounds 259 pounds 272 pounds 261 pounds 333 pounds 344 pounds 288 pounds 3 pounds 283 pounds 258 pounds 228 pounds 224 pounds 360 pounds 10 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 08/31/17 Flammable/Toxic 360 pounds 10/26/17 Flammable/Toxic 288 pounds Based on this information, the facility failed to notify EPA and obtain an EPA Identification Number (The EPA I.D.# AKR000210302 was issued internally as a result of the inspection). The facility also failed to ship the hazardous waste, listed above, to a permitted TSDF, using uniform hazardous waste manifests and land disposal restriction notices. Document(s) 1. Waste Log 2017.pdf 2. Waste Log 2018.pdf 3. Waste Log 2019.pdf 4. Waste Log 2020.pdf 5. Waste Log 2021.b.pdf 6. Waste Log 2021.pdf 7. Waste Log 2022.pdf 8. Waste Log 2023.pdf SECTION IV - AREA OF CONCERN The presentation of Area(s) of Concern does not constitute a formal compliance determination or violation. Building: Main Building JJ1-OB-001 Area: Central Accumulation Area (CAA) Sub-area: Rm #1115 Medical Waste Storage At the time of the inspection, the facility was managing the "Rx Destroyer" containers as hazardous waste. I suggested to Mr. Nolan that he take a closer look at the "Rx Destroyer's" to make a waste determination, as this waste might not be hazardous. Regulation: Sections: Record: Shipping Documents/Tolling agreements JJ1-RR-001 We inspected the disposal records for waste that the facility had taken to the HHW facility, for the period of 2017 through 2023, and identified the following months when the amount of hazardous waste generated at the facility exceeded 220 pounds: Regulation: 04/05/23 04/26/23 11 of 32 Sections: Bartlett Regional Hospital Inspection Date(s): 05/26/22 07/08/21 11/18/21 03/12/20 06/18/20 02/02/19 06/13/19 09/26/19 11/07/19 12/12/19 07/12/18 09/06/18 10/25/18 12/13/18 05/18/17 08/31/17 10/26/17 Based on this information, the facility failed to notify EPA and obtain an EPA Identification Number. The facility also failed to ship the hazardous waste, listed above, to a permitted TSDF, using uniform hazardous waste manifests and land disposal restriction notices. On 03/08/18, three pounds of Plisted waste was disposed of at the HHW facility after having accumulated greater than 1 kg of the acute hazardous waste which made the facility a Large Quantity Generator (LQG). 09/12/2023 - 09/12/2023 SECTION V - CLOSING CONFERENCE AND FOLLOW UP Closing Conference At the conclusion of the inspection, we conducted a closing conference that was attended by those listed in the Attendees table, in Section I of this report. We thanked everyone for their time and cooperation during the inspection and began a review of the areas of concern (listed in Section III - Areas of Concern) that we observed during my inspection of the facility. I told everyone, from what I saw while inspecting the facility, the wastes that are routinely managed by other facilities as universal waste, such as waste lamps, batteries, and aerosols, are not managed that way. I said that based on my findings, if what I observed in the way of waste lamps, batteries, and aerosols were added to the hazardous wastes I observed, their facility's hazardous waste generator status would be that of a VSQG. Based on that, the container labeling or lack of that we observed was not an area of concern as a VSQG. 12 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 I also told everyone present that it appeared as though the facility didn't really have a good understanding of the hazardous waste regulations, the management of hazardous waste, universal waste, or the waste determination process. I told them that our inspection of the disposal paperwork indicated that on more than one occasion, their facility generated more than 220 pounds of hazardous waste and their generator status was SQG. I explained that at that time, they should have notified EPA and obtained an EPA I.D. number. I also told them the disposal paperwork indicated that on one occasion, 3 pounds of P-Listed Waste was delivered to the HHW facility which indicated that greater than 1 kg of P-listed waste had been accumulated on-site and the facility should have complied with the requirements of an LQG. I told them they needed to manage their waste lamps, batteries, and aerosols as universal waste as this would reduce the amount of hazardous waste they generate. I also told them they needed to do better waste determinations because some of the hazardous wastes they think they're generating might turn out to be nonhazardous, like the "Rx Destroyer's." I explained that once that's done, if they were still a VSQG, counting both pharmaceutical and nonpharmaceutical waste, they would not have to opt into Subpart P for managing their hazardous waste pharmaceuticals. I explained that if they ended up being a SQG or LQG, they would also need to comply with the hazardous waste pharmaceuticals (HWPharms) regulations in Subpart P. During the closing conference there was discussion regarding 40 gallons of waste diesel fuel that was taken to the HHW collection site. There was discussion about this waste possibly being a hazardous waste, so we requested a copy of the Safety Data Sheet (SDS) for the diesel fuel. We also requested electronic copies of the waste disposal records for the waste delivered to the HHW collection site. I then explained the follow-up process that would take place once I finished the report. I explained they would receive a copy of the report as would a case officer. I told them the case officer would review the report to determine if any of my areas of concern resulted in determinations of violation. Following the Inspection The requested documents were provided following the inspection, in emails dated 9/13/23 and 9/21/23, and are included in the Document Log, in Section VII - List of Appendices. Mr. Overson emailed the SDS for the diesel fuel on 9/21/23. In that email he states that, "It looks like the flashpoint is ~125 ." I reviewed the SDS which indicated the waste diesel fuel was hazardous for ignitability (D001). SECTION VI - SAMPLING ACTIVITIES AND ANALYTICAL RESULTS - No sampling was conducted. SECTION VII - LIST OF APPENDICES 1. Photo Log 2. Document Log 13 of 32 Bartlett Regional Hospital Inspection Date(s): APPENDIX 1: PHOTO LOG 09/12/2023 - 09/12/2023 [Title] IMG_1680.jpg 09/12/2023 09:26 AM No CBI No PII Photographer: Jon Jones [Building/Area] 58.32902777, -134.46644722 View of documentation, seen during the opening conference, showing the amounts of Flammable/Toxic wastes that were managed through the local HHW facility in 2022. [Title] 09/12/2023 09:54 AM No CBI No PII Main Building/Central Accumulation Area (CAA) View of Rx Destroyer containers in the CAA. IMG_1681.jpg Photographer: Jon Jones 58.32894166, -134.46414166 14 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1682.jpg 09/12/2023 09:54 AM No CBI No PII Photographer: Jon Jones Main Building/Central Accumulation Area (CAA) 58.328975, -134.46412777 View of an Rx Destroyer container that has been labeled as "RCRA Hazardous Waste Flammable/Toxic." [Title] IMG_1683.jpg 09/12/2023 09:54 AM No CBI No PII Photographer: Jon Jones Main Building/Central Accumulation Area (CAA) 58.328925, -134.46414166 View of two, one-gallon containers of waste. One containing "Ethyl Alcohol Waste" and one containing "Paraffin Wax Waste" that contains traces of xylene. 15 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1684.jpg 09/12/2023 10:04 AM No CBI No PII Photographer: Jon Jones Main Building/Critical Care Unit (CCU) Room 58.32872777, -134.46539444 View of wall mounted waste collection container in a patient room within the facility's CCU. [Title] IMG_1685.jpg 09/12/2023 10:16 AM No CBI No PII Photographer: Jon Jones Main Building/Critical Care Unit (CCU) Room 58.32863333, -134.46565277 View of five-gallon container for non-hazardous waste, five-gallon container for flammable/toxic waste, and 2.5gallon Rx Destroyer. 16 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1686.jpg 09/12/2023 10:22 AM No CBI No PII Photographer: Jon Jones Main Building/OBGYN (Obstetrics and Gynecology) Area 58.32879166, -134.46562222 View of black, five-gallon container labeled "Highly Flammable," red sharps container, and 2.5-gallon RX Destroyer. [Title] IMG_1687.jpg 09/12/2023 10:22 AM No CBI No PII Photographer: Jon Jones Main Building/OBGYN (Obstetrics and Gynecology) Area 58.32877777, -134.46556111 Close-up view of black, five-gallon container in SAA that is labeled as "Highly Flammable." 17 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] 09/12/2023 10:22 AM No CBI No PII Main Building/OBGYN (Obstetrics and Gynecology) Area Close-up view of the Rx Destroyer in the SAA. IMG_1688.jpg Photographer: Jon Jones 58.32880277, -134.46562222 [Title] IMG_1689.jpg 09/12/2023 10:23 AM No CBI No PII Photographer: Jon Jones Main Building/OBGYN (Obstetrics and Gynecology) Area 58.32886944, -134.46560555 View of process/flow diagram chart for the disposal of waste, located on the inside of the SAA cabinet door. 18 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1690.jpg 09/12/2023 10:27 AM No CBI No PII Photographer: Jon Jones Main Building/Histology Lab 58.32880833, -134.46528611 View of four, one-gallon containers of Ethyl Alcohol waste (these were the same wastes seen in the CAA). [Title] IMG_1691.jpg 09/12/2023 10:27 AM No CBI No PII Photographer: Jon Jones Main Building/Histology Lab 58.32880833, -134.46528611 Close-up view of four, one-gallon containers of Ethyl Alcohol waste. 19 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1692.jpg 09/12/2023 10:28 AM No CBI No PII Photographer: Jon Jones Main Building/Histology Lab 58.32884166, -134.46531666 Another close-up view of four, one-gallon containers of Ethyl Alcohol waste. [Title] IMG_1693.jpg 09/12/2023 10:48 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32908888, -134.46430833 View of two, black, five-gallon containers of flammable/toxic waste which were ready to be transferred to the CAA. Two, black, five-gallon containers of non-toxic pharmaceutical waste, and one, black, five-gallon container of flammable/toxic waste which an active SAA container. 20 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1694.jpg 09/12/2023 10:48 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32908333, -134.464325 Another view of the containers seen in IMG_1693.jpg, and a black, five-gallon container of waste aerosols (almost full and estimated to be a 6-month accumulation) can be seen here on the right and on top of a white, five-gallon container of P-List nicotine products (2/3 full estimated to be a 1-year accumulation). [Title] IMG_1695.jpg 09/12/2023 10:49 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32905277, -134.46426388 Close-up view of the label on the waste aerosol container. 21 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1696.jpg 09/12/2023 10:51 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32908888, -134.46433888 View of the contents in the container labeled as "P-list waste." [Title] IMG_1697.jpg 09/12/2023 10:51 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.329075, -134.46435555 Close-up view of the label on the container of P-listed waste. 22 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1698.jpg 09/12/2023 10:51 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32910277, -134.464325 Another view of the white, five-gallon container, labeled as containing P-listed waste. [Title] IMG_1699.jpg 09/12/2023 10:54 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32904444, -134.46438611 View of signage posted on the wall, just outside of the Pharmacy SAA. 23 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] 09/12/2023 10:54 AM No CBI No PII Main Building/Pharmacy (3rd floor) Rm #3483 Close-up view of the signage seen in IMG_1699. IMG_1700.jpg Photographer: Jon Jones 58.32904444, -134.46438611 [Title] IMG_1701.jpg 09/12/2023 10:54 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32905833, -134.46438611 Another close-up view of the signage seen in IMG_1699. 24 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1702.jpg 09/12/2023 10:56 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32895, -134.46429444 View of the area where the potentially creditable HWPharms are accumulated prior to being picked up by the reverse distributer. [Title] IMG_1703.jpg 09/12/2023 10:56 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32896388, -134.46429444 Close-up view of the potentially creditable HWPharms in the red tote. 25 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1704.jpg 09/12/2023 10:56 AM No CBI No PII Photographer: Jon Jones Main Building/Pharmacy (3rd floor) Rm #3483 58.32896388, -134.46429444 Close-up view of the posted SOP regarding Medication Returns and Outdates. [Title] IMG_1705.jpg 09/12/2023 11:03 AM No CBI No PII Photographer: Jon Jones Main Building/Medical Surgery 58.32885833, -134.46482777 View of black, five-gallon container holding non-toxic pharmaceutical waste on the left, a three-gallon container of P-listed waste, and a black, five-gallon container of flammable/toxic waste. 26 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1706.jpg 09/12/2023 11:03 AM No CBI No PII Photographer: Jon Jones Main Building/Medical Surgery 58.32885833, -134.46482777 Close-up view of the three-gallon container of P-listed waste. [Title] IMG_1707.jpg 09/12/2023 11:07 AM No CBI No PII Photographer: Jon Jones Main Building/Medical Surgery 58.32909444, -134.464325 View of black, five-gallon container holding non-toxic pharmaceutical waste on the right, and a black, five-gallon container holding flammable/toxic waste on the left. 27 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1708.jpg 09/12/2023 11:18 AM No CBI No PII Photographer: Jon Jones Main Building/Mental Health Nurses Station 58.32859166, -134.46571388 View of 2.5-gallon Rx Destroyer on the left, and a black, seven-gallon container of flammable/toxic waste seen on the floor. [Title] IMG_1709.jpg 09/12/2023 11:18 AM No CBI No PII Photographer: Jon Jones Main Building/Mental Health Nurses Station 58.32859166, -134.46572777 Close-up view of black, seven-gallon container of flammable/toxic waste. 28 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] 09/12/2023 11:40 AM No CBI Main Building/Basement Shop View of the waste battery container. No PII IMG_1710.jpg Photographer: Jon Jones 58.32899444, -134.46647777 [Title] IMG_1711.jpg 09/12/2023 11:40 AM No CBI No PII Photographer: Jon Jones Main Building/Basement Shop 58.32899166, -134.46647777 View of waste lithium battery in the bottom of container. 29 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1712.jpg 09/12/2023 11:46 AM No CBI No PII Photographer: Jon Jones Main Building/Basement Shop 58.32881944, -134.46487499 View of fluorescent (compact type) bulbs in a blue unmarked tray, and NiCad batteries in a gray unmarked tray. [Title] IMG_1713.jpg 09/12/2023 11:47 AM No CBI No PII Photographer: Jon Jones Main Building/Basement Shop 58.32880277, -134.46464444 Another view of a trash receptacle being used to accumulate waste lamps. 30 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 [Title] IMG_1715.jpg 09/12/2023 11:48 AM No CBI No PII Photographer: Jon Jones Main Building/Basement Shop 58.32878888, -134.46516388 View of a trash receptacle being used to accumulate waste lamps. [Title] 09/12/2023 11:48 AM No CBI No PII Main Building/Basement Shop View of waste CFL bulb in the bottom of the container. IMG_1716.jpg Photographer: Jon Jones 58.32875555, -134.46496666 31 of 32 Bartlett Regional Hospital Inspection Date(s): 09/12/2023 - 09/12/2023 APPENDIX 2: DOCUMENT LOG Document Type Document Name Contains Contains Uploaded By CBI PII Date Received Records Review Waste Log 2017.pdf No No Jon Jones Records Review Waste Log 2018.pdf No No Jon Jones Records Review Waste Log 2019.pdf No No Jon Jones Records Review Waste Log 2020.pdf No No Jon Jones Records Review Waste Log 2021.b.pdf No No Jon Jones Records Review Waste Log 2021.pdf No No Jon Jones Records Review Waste Log 2022.pdf No No Jon Jones Records Review Waste Log 2023.pdf No No Jon Jones Facility Map BRH Map.pdf No No Jon Jones Other - Safety Data Sheet ULSD (AK)-sds.pdf No No Jon Jones Communications email9.21.23RE BRH Waste No No Jon Jones Logs.msg Process Description/Flow Diagram img20230912_12221279.pdf No No Jon Jones Other - Drug Disposal Waste Poster 3-22.pdf No No Jon Jones Guide 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 12/05/2023 32 of 32