Document N2w7g5eZOG0K8akxV66XR4NDy

REPORT OF RCRA COMPLIANCE EVALUATION INSPECTION At ST. LUKES METHODIST HOSPITAL 1026 A Avenue NE Cedar Rapids, Iowa 52402 319-369-8225 EPA ID Number: IAD065223166 On October 23, 2023 By TOEROEK ASSOCIATES, INC. For U.S. ENVIRONMENTAL PROTECTION AGENCY Region 7 Enforcement and Compliance Assurance Division INTRODUCTION At the request of the Enforcement and Compliance Assurance Division/Chemical Branch/RCRA Section (ECAD/CB/RCRA) of the U.S. Environmental Protection Agency (EPA) Region 7, Toeroek Associates, Inc., and its subcontractor CLAENE Group (Toeroek team) conducted a hazardous waste compliance evaluation inspection (CEI) at St. Lukes Methodist Hospital (St. Lukes) at 1026 A Avenue NE in Cedar Rapids, Iowa. The CEI was conducted under the authority of Section 3007 of the Resource Conservation and Recovery Act (RCRA), as amended. The CEI covered hazardous waste generator requirements, used oil management, and universal waste requirements, as applicable. This report and its attachments present the results of the CEI. PARTICIPANTS St. Lukes: Clifton White, Safety Officer Brandie Dolter, Environmental Service Adam Burns, Supervisor Plant Operations Scott Kallemeyn, Director Facility Planning & Operations Robert Schreckengast, Manager Plant Operations/Maintenance Toeroek Team: Clifford Nelles, Inspector, 816-213-5192 INSPECTION PROCEDURES Prior to the CEI at St. Lukes on October 23, 2023, I conducted a drive-by visual inspection. I did not observe any areas of concern during the drive-by. At approximately 8:00 a.m., I entered the facility through the SurgiCare entrance and explained to the receptionist that I was there to conduct a CEI at the facility. I asked to speak with Mr. White, who was listed as the RCRA site contact on the Notification Acknowledgment/Verification Report (Verification Report) provided by EPA prior to the inspection (Attachment 1). The receptionist contacted Mr. White by telephone. Mr. White arrived at the reception area after approximately 10 minutes. I introduced myself to Mr. White and explained the purpose and scope of the CEI. Mr. White escorted me to a conference room where we were met by Ms. Dolter and Messrs. Burns and Kallemeyn. After introductions, I proceeded to conduct an entry briefing with them. During the entry briefing, I presented my business card and EPA credentials to Messrs. White, Burns, Kallemeyn and Ms. Dolter. I explained the scope and procedures for the CEI. I explained the facility's right to make confidentiality claims for any or all the information obtained and provided a Notice Regarding Proprietary/Confidential Business Information. I stated that at the conclusion of the CEI, Mr. White would be presented with a Confidentiality Notice (Notice) with which he could make or not make a claim of confidentiality for the facility. I also provided to Messrs. White, Burns, Kallemeyn and Ms. Dolter a copy of U.S. Federal Codes 1001 and 1002, concerning communication of false statements and documents to federal inspectors, and RCRA Section 3007, explaining EPA's inspection authority, both of which they read. A copy of each of the following documents was left with Mr. White during the inspection: x RCRA Facility Access Information Sheet x RCRA Section 3007 x U.S. Federal Codes 1001 and 1002 x Instructions for Responding to a Notice of Preliminary Findings x Notice Regarding Proprietary/Confidential Business Information An electronic copy of each of the following documents was also left with Mr. White during the inspection: x E-Manifest Fact Sheet: Generators x Managing your Hazardous Waste: A Guide for Small Businesses x U.S. EPA Small Business Resources Information Sheet x Solvent-Contaminated Wipes Final Rule Summary Chart x IDNR Excluded Solvent-Contaminated Wipes Rule: Management Practices for Wipes, Rags, and Shop Towels x Recycling Electronics: A Guide for Businesses x Lead-Based Paint Activities: Handling and Disposal x Battery Recycling/Disposal x Management of Fluorescent Lamps for Businesses x Incompatible Chemicals x Universal Wastes - Including Aerosol Cans 2 x TCLP - Toxicity Characteristic Leaching Procedure x Part 279 Requirements: Used Oil Management Standards x EPA Region 7 Emergency Response Program x Chemical Facility Anti-Terrorism Standards x Iowa Environmental Guide for Businesses I reviewed the Verification Report with Mr. White (Attachment 1). Based on this review, I changed the generator status from large quantity generator (LQG) to small quantity generator (SQG). I made no other changes to the Verification Report. I conducted a visual inspection of the facility. Messrs. White, Burns, Kallemeyn and Ms. Dolter accompanied me during the visual inspection. After the visual inspection, I reviewed facility records including uniform hazardous waste manifests with land disposal restriction (LDR) notifications, safety data sheets (SDS), inspection records, and training documentation. I prepared and completed a site-specific inspection checklist to document my observations. At the conclusion of the CEI, I conducted an exit briefing with Messrs. White, Burns, Kallemeyn and Ms. Dolter. During the exit briefing, I provided a Receipt for Documents and Samples, which Mr. White signed, acknowledging receipt (Attachment 2). I provided Mr. White the Notice, which he signed indicating no confidential business information had been provided (Attachment 3). I also provided Mr. White a Notice of Preliminary Findings (NOPF) which he signed to acknowledge receipt (Attachment 4). Maps of the facility obtained during the CEI are included in Attachment 5, and a Google Earth aerial photograph of the facility is included as Attachment 6. All 15 photographs taken during the CEI are included in Attachment 7, of which 14 are described in this report. FINDINGS AND OBSERVATIONS 1. Facility Description and General Information St. Lukes is a full-service hospital, including a histology and pathology laboratory, pharmacy, oncology ward, and physical plant. Raw materials used by St. Lukes include solvents, pharmaceuticals, and other chemicals related to the operations of the laboratory and the pharmacy. The facility began operations at this location in 1884. St. Lukes currently employs approximately 3,200 full-time personnel, who work a variety of shifts covering the hospital's 24 hours per day, 7 days per week, operating schedule. The facility consists of a primary building that encompasses approximately 900,000 square feet, a parking structure (ramp) that includes a maintenance shop and a stand-alone maintenance building (the Rapids Building). The Rapids Building is also on Avenue A, approximately 1 block southwest of the primary building on the opposite side of the street, and appeared to be contiguous property. Tissue samples are analyzed in the laboratory. Analytical procedures generate laboratory waste, which the facility considers to be hazardous waste. Laboratory waste is accumulated in a satellite 3 accumulation area (SAA) in the laboratory. Two automated analytical units generate waste solvent consisting of waste xylene and waste ethanol. When the receptacles attached to the equipment are full, they are removed and the waste solvent is reclaimed in one of two distillation units (stills). The stills reclaim xylene and waste ethanol for reuse. Reclamation generates waste ethanol and xylene condensate and still bottoms. Waste ethanol condensate and still bottomV that are considered to be pourable liquid aUH discharged WRthe laboratory drain with copious amounts of water. The facility considers these wastes exempt from the definition of solid waste when mixed with sanitary sewage in the drain, per Title 40 Code of Federal Regulations (40 CFR) 261.4(a)(1)(ii). If the still bottoms are too viscous to be put down the drain, they are accumulated in a container in the laboratory SAA. Activities at the pharmacy and on the treatment wards generate pharmaceutical waste. Pharmaceutical waste includes formulation waste, solid debris (such as empty intravenous delivery bags or empty containers), and spill cleanup waste. The facility has a labeling system to distinguish hazardous from nonhazardous pharmaceutical waste, and acutely toxic hazardous (Plisted) from other hazardous pharmaceutical waste. Acutely toxic pharmaceutical waste is accumulated in 1-liter SAA containers; all other pharmaceutical waste is accumulated in 4- and 8-gallon SAA containers. The pharmacy also generates unadministered, expired, or other off-specification pharmaceuticals. St. Lukes has notified EPA that it is a healthcare facility subject to the standards of management for hazardous waste pharmaceuticals in 40 CFR 266 Subpart P. A reverse distribution company determines which expired or off-specification pharmaceuticals are hazardous or nonhazardous wastes, and which can be returned for credit or partial credit. The reverse distribution company sorts and packages creditable and non-creditable hazardous waste pharmaceuticals for offsite shipment. Hazardous waste pharmaceuticals managed under 40 CFR 266 Subpart P are not counted toward the facility's hazardous waste generator status. Activities throughout the hospital generate medical waste. The facility keeps all pharmaceuticals out of the medical waste stream, so the facility considers medical waste nonhazardous based on product and process knowledge. Radiology generates waste lead aprons when protective aprons are deemed unfit for continued use. The facility considers waste lead aprons to be D008 hazardous waste based on product and process knowledge. Building maintenance activities at the facility generate waste fluorescent lamps and waste leadacid batteries. The facility manages waste lamps and waste batteries as universal waste according to provisions of 40 CFR Part 273. Facility maintenance, including painting and maintenance of equipment, generates spent solvent (used thinner), which is considered hazardous waste. Maintenance of hydraulic and grounds-keeping equipment generates used oil, which the facility manages according to provisions of 40 CFR Part 279. Building and facility maintenance activities also generate used ballasts, waste electronics, and general trash. The facility considers used ballasts, waste electronics, and general trash to be nonhazardous wastes based on product and process knowledge. 4 St. Lukes was last inspected by an EPA contractor on March 6-7, 2012, as a LQG of hazardous waste, generating more than 1,000 kilograms (kg) or 2,200 pounds of hazardous waste per month or accumulating more than 1 kg (2.2 pounds) of acute hazardous waste at any time. The inspector made the following preliminary findings: x Failure to label containers of universal waste lamps as "Used Lamps," "Waste Lamps," or "Universal Waste Lamps" x Failure to store universal waste lamps in closed containers x Failure label a container of universal waste batteries as "Used Batteries," "Waste Batteries," or "Universal Waste Batteries" x Failure to date or otherwise document accumulation time for universal waste lamps x Failure to train employees in management of universal waste x Failure to label a used oil storage container as "used oil" x Failure to keep a SAA container closed x Failure to submit a Hazardous Waste Biennial Report x Failure to include the evacuation route in the contingency plan x Failure to include the location and description of emergency response equipment in the contingency plan x Failure to identify an emergency coordinator (EC) and provide EC contact information in the contingency plan x Failure to provide annual training to all personnel responsible for management of hazardous waste x Failure to conduct weekly inspection of the two hazardous waste container accumulation areas (HWCAAs) x Failure to maintain spill response equipment for the flammable hazardous waste HWCAA Of these, failure to adequately label and close universal waste lamps accumulation containers, failure to date or otherwise track universal waste lamp accumulation times, failure to adequately train employees in management of universal waste, and failure to keep a SAA container closed were repeated during this inspection. 2. RCRA Status The Verification Report (Attachment 1) indicates that St. Lukes is registered with EPA, under EPA ID IAD0465223166, as a LQG of hazardous waste (various D, F P, U waste codes). I reviewed the 2021 Biennial Report summary provided by EPA before the inspection (Attachment 8). The 2021 Biennial Report summary indicated a total of 6,771 pounds of hazardous waste generated in 2021. Of this, 3,355 pounds of hazardous waste was lab-packed pharmaceutical waste with numerous EPA hazardous waste codes (including P-listed acute hazardous waste codes P001, P075, and P188). The facility generates two primary hazardous waste streams--laboratory waste for offsite disposal or reclamation in two onsite distillation units, and pharmaceutical waste. I reviewed an E-manifest report provided by EPA before the inspection (Attachment 9). The table below 5 summarizes quantities of hazardous wastes shipped in calendar year 2023 to date, based on the E-manifest report and my review of facility uniform hazardous waste manifests during the CEI. Date 01/05/23 01/17/23 02/08/23 03/02/23 03/23/23 04/13/23 05/03/23 05/25/23 06/14/23 07/05/23 07/27/23 08/17/23 09/07/23 09/28/23 10/19/23 Total Lab Waste (Pounds) 199 231 278 329 266 148 160 169 169 134 246 2,329 Pharm. Waste (Pounds) 90 240 195 219 126 156 206 214 148 267 315 819 149 3,144 Total (Pounds) 199 90 471 195 497 126 485 206 480 296 427 484 169 953 395 5,473 Based on reviews of the E-manifest report, facility manifest copies, and interviews, it appears that St. Lukes generates between 148 to 329 pounds (67 to 150 kg) of laboratory waste per month and 90 to 819 pounds (41 to 372 kg) of pharmaceutical waste per month in 2023. I did not determine how much of the dual pharmaceutical waste was excluded from counting toward the facility's hazardous waste generator status, but the E-manifest report indicated that none of the pharmaceutical waste generated in 2023 was acute hazardous waste. The facility did not appear to meet the LQG thresholds of more than 2,200 pounds of hazardous waste or 2.2 pounds of acute hazardous waste per calendar month. Therefore, I inspected St. Lukes as a SQG of hazardous waste (generating between 100 kg [220 pounds] and 1,000 kg [2,200 pounds] of hazardous waste per calendar month). Based on the quantities of universal waste batteries and lamps accumulated onsite between shipments, I inspected St. Lukes as a small quantity handler (SQH) of universal waste (accumulating less than 5,000 kg [11,000 pounds] of universal waste onsite at any time). I also inspected the facility as a generator of used oil. 3. Waste Streams This section of the CEI report describes the waste streams generated by the facility, including the facility's waste determination and waste codes, generation process and rate, management at the facility, and ultimate disposition. The following discussion of waste streams is based on conversations with facility representatives, the visual inspection, and my review of waste shipping documents. Messrs. White, Burns, Kallemeyn and Ms. Dolter accompanied me during the visual inspection. The visual inspection included the pharmacy, the laboratory, the behavioral health area, the maintenance shop in the main building, the maintenance shop in the parking ramp, the Rapids Building, and the two HWCAAs. Mr. Schreckengast joined the visual 6 inspection at the maintenance shop. All inspection participants were provided a copy of U.S. Federal Codes 1001 and 1002, which they read. Laboratory waste is generated in the laboratory from a variety of analytical processes. The facility makes hazardous waste determinations on laboratory waste based on product and process knowledge (D001, D002, D011, F003). Laboratory waste is accumulated in satellite accumulation containers (SACs) in the laboratory, and full SACs are transferred to the laboratory HWCAA. The facility has generated and shipped approximately 2,195 pounds of laboratory waste for offsite treatment or disposal in 2023 to date. The waste is collected by Clean Earth Specialty Solutions and transported to Solvent Recovery in Kansas City, Missouri, for bulking and offsite transfer. The bulk of the waste generated in the laboratory is spent xylene and ethanol solvent from two automated analytical units. The facility considers spent xylene and ethanol laboratory waste to be hazardous waste (D001 and F003) based on process and product knowledge. Copies of the SDS for xylene and ethanol are included as Attachments 10 and 11. All spent xylene and ethanol solvents are transferred to two onsite stills for xylene and ethanol recovery. The facility generates approximately 1 gallon of spent xylene and ethanol solvent per day for distillation. During the CEI, I observed one SAC of waste lithium carbonate in the laboratory (Attachment 7, Photograph 1). The SAC was under control of the operator, near the point of generation, closed, and labeled with the words "Hazardous Waste." However, the SAC was not labeled with an indication of the nature of the hazard, as required by 40 CFR 262.15(a)(5)(ii) (NOPF No. 2). I provided compliance assistance regarding management of SACs. I also observed two 1-liter SACs for narcotics in the laboratory (Attachment 7, Photographs 4 and 5). The SACs were under control of the operator, near the point of generation, closed, labeled with the words "Hazardous Waste," and labeled with an indication of the nature of the hazard. Waste alcohol is generated as a waste condensate when spent xylene and ethanol solvents are reclaimed in one of the two stills in the laboratory. The facility considers the waste alcohol to be hazardous (D001 and F003) based on process and product knowledge; the F003 code is applied because the waste derives from the reclamation of F-listed spent solvent (xylene). Ms. Dolter estimated that the distillation process generates approximately 1 gallon of waste alcohol per month. She said that when the 1-gallon receptacle attached to the still is full, the waste alcohol is poured down the drain with copious amounts of water. Because this hazardous waste mixes with sanitary sewage at the drain, the facility considers it exempt from the definition of solid waste at this point, as described by 40 CFR 261.4(a)(1)(ii). The facility has a land disposal restriction (LDR) on file for waste alcohol. During the CEI, I observed the receptacle attached to one of the stills. The receptacle held less than 0.25 gallons of waste alcohol. The other still was not operating. Still bottoms are generated during distillation of spent xylene and ethanol solvents in the laboratory. The facility considers still bottoms to be hazardous waste (D001 and F003) based on process and product knowledge. Ms. Dolter estimated that the distillation process generates approximately 2 gallons of still bottoms per month. She said that when the 1-gallon receptacle 7 attached to the still is full, the still bottoms are typically poured down the drain with copious amounts of water. Because this waste mixes with sanitary sewage at the drain, the facility considers it exempt from the definition of solid waste at this point, as described by 40 CFR 261.4(a)(1)(ii). Infrequently, the still bottoms are too viscous to be discarded by this method, and they are decanted into a designated 1-gallon SAC to be ultimately sent for offsite disposal with other F003 waste generated by the facilLty. During the CEI, I did not observe any still bottoms being generated or accumulated onsite. The facility has an LDR on file for still bottoms. Hazardous waste pharmaceuticals are generated in the pharmacy when materials are found to have aged past their expiration dates, are unused, or have other condition issues such as being stored at the wrong temperature. The waste is managed according to provisions of 40 CFR 266 Subpart P. A reverse distribution company (PharmaLogistics in Mudelein, Illinois) determines which expired or off-specification pharmaceuticals are hazardous or nonhazardous wastes, and which can be returned for credit or partial credit. The reverse distribution company sorts and packages creditable and non-creditable hazardous waste pharmaceuticals for offsite shipment. Hazardous waste pharmaceuticals managed under 40 CFR 266 Subpart P are not counted toward the facility's hazardous waste generator status. During the CEI, I did not observe any hazardous waste pharmaceuticals being generated or accumulated onsite. Pharmaceutical waste, including pharmaceutical waste mixed with medical waste (dual waste), is generated in treatment areas and in the pharmacy. Activities at the pharmacy and on the treatment wards generate pharmaceutical waste. Pharmaceutical waste includes formulation waste, solid debris (such as empty intravenous delivery bags or empty containers), and spill cleanup waste. The facility has instituted special labeling and management procedures to keep pharmaceutical waste out of the medical waste stream and to segregate acutely toxic hazardous waste from other pharmaceutical waste. The facility makes waste determinations on pharmaceutical waste using product and process knowledge. Based on the 2021 Biennial Report summary (Attachment 8, Page 7), the facility generates approximately 3,355 pounds of pharmaceutical waste (D001, D005, D007, D009, D010, D013, D018, D022, D024, D026, U002, U035, U058, U059, U089, U129, U132, U150, U188, U200, U201, U204, U205, U206, and U248) per year. Pharmaceutical waste is collected by Clean Earth Specialty Solutions and transported to Solvent Recovery in Kansas City, Missouri, for bulking and offsite transfer. Acutely toxic pharmaceutical waste is accumulated in 1-liter SAA containers, and all other pharmaceutical waste is accumulated in 4- and 8-gallon SAA containers. During the CEI, I observed approximately 30 SACs for pharmaceutical waste in the pharmacy (Attachment 7, Photographs 6 and 7). Each of these containers was closed, labeled, and empty. During the CEI, I did not observe any pharmaceutical waste being generated or accumulated onsite. Medical waste is generated throughout the facility in all the treatment areas, in the laboratory and in the morgue. Because the facility keeps the pharmaceutical waste out of this waste stream, the facility considers it to be nonhazardous based on product and process knowledge. The facility generated approximately 175,000 pounds of medical waste in 2022 (based on interview with Mr. White). It is collected in small containers throughout the facility and then consolidated into larger containers in the medical waste storage room. It is collected for incineration at a Stericycle 8 facility. According to Ms. Dolter, the destination facility varies depending upon Stericycle's capacity. I noted no deficiencies with accumulation of medical waste during the CEI. Waste lead aprons are generated when protective aprons can no longer be used in the radiology department. The facility considers waste aprons to be hazardous waste (D008) based on product knowledge. The facility generated 128 pounds of waste lead aprons in 2021 (Attachment 8, Page 6). The waste is collected by Clean Earth Specialty Solutions and transported to Solvent Recovery in Kansas City, Missouri, for bulking and offsite transfer. During the CEI, I did not observe any waste lead aprons being generated or accumulated onsite. Used oil is generated during maintenance of facility equipment (primarily compressors and hydraulic equipment). The facility manages used oil according to requirements of 40 CFR Part 279. Mr. White said that used oil is collected approximately once a year, and estimated the facility generates approximately 55 gallons per year. It is collected by Hydrite Chemical and transported to WRR Environmental Services in Eau Claire, Wisconsin for recycling. During the CEI, I observed one 55-gallon used oil storage container in the maintenance shop (Attachment 7, Photograph 14). The container was in good condition with no apparent leaks or damage, held approximately 10 gallons of used oil, and was labeled with the words "Used Oil." I noted no deficiencies regarding management of used oil during the CEI. Waste thinner is generated during cleaning of painting equipment and other facility maintenance. The facility considers waste thinner to be hazardous waste (D001, D018 and F003) based on product knowledge. Mr. Schreckengast said that the facility uses a variety of solvents to clean and maintain equipment. The facility generates approximately 10 gallons of used thinner per year. It is collected by Hydrite Chemical and taken to Tradebe Treatment in East Chicago, Indiana for fuel blending. During the CEI, I observed one 55-gallon SAC of waste thinner in the maintenance shop (Attachment 7, Photographs 11 through 13). The SAC was under the control of the operator and near the point of generation. However, the SAC was not closed, as required by 40 CFR 262.15(a)(4) (NOPF No. 7), labeled with the words "Hazardous Waste," as required by 40 CFR 262.15(a)(5)(i) (NOPF No. 3), or labeled with an indication of the nature of the hazard, as required by 40 CFR 262.15(a)(5)(ii) (NOPF No.2). I provided compliance assistance on the management of SAC. During the CEI, employees of St. Lukes closed the SAC of waste thinner (Attachment 7, Photograph 15). Waste batteries are generated by maintenance personnel replacing spent batteries in equipment. Waste batteries are primarily alkaline and lithium-ion batteries; however, other batteries such as nickel-cadmium batteries are occasionally generated. The facility manages all waste batteries as universal waste batteries according to requirements of 40 CFR Part 273. Waste batteries are accumulated in a two gallon universal waste accumulation container in a HWCAA. St. Lukes generates less than one gallon of waste batteries per month. Waste batteries are collected by Retrofit Recycling in Owatonna, Minnesota, for recycling. 9 During the CEI, I observed one 2-gallon container of universal waste batteries in a HWCAA (Attachment 7, Photographs 2 and 3). The container was labeled with the words "universal waste batteries," dated July 24, 2023, and held five waste batteries. I noted no deficiencies with management of waste batteries during the CEI. Waste lamps are generated by maintenance personnel replacing spent fluorescent lamps. The facility manages waste lamps as universal waste lamps according to requirements of 40 CFR Part 273. Waste lamps are accumulated in fiberboard containers in the maintenance shop. St. Lukes generates approximately 3,000 pounds of waste lamps per year. Waste lamps are collected by Midwest Lamp Recycling of Madison, Wisconsin, for recycling During the CEI, I observed one container for 4-foot waste lamps in the maintenance shop (Attachment 7, Photographs 9 and 10). The container held approximately 100 universal waste lamps. The universal waste container was not closed, as required by 40 CFR 273.13(d)(1) (NOPF No. 5), or labeled with the words "Universal Waste-Lamps," or "Waste Lamps," or "Used Lamps," as required by 40 CFR 273.14 (NOPF No. 6). The waste lamps were not dated or otherwise tracked to demonstrate accumulation time, as required by 40 CFR 273.15(c) (NOPF No. 4). I asked Mr. Schreckengast how long the waste lamps had been accumulating. He stated that the lamps had been accumulating for approximately 6 months. I provided compliance assistance regarding management of universal waste lamps during the CEI. I asked Mr. Schreckengst if UW training had been provided to employees he stated that it had been provided. Due to the number of preliminary findings related to management of universal waste, it appears that St. Lukes has not adequately trained their personnel on the management of universal waste, as required by 40 CFR 273.16 (NOPF No. 8). NOPF #8 was not initially left with the facility during the CEI, but was added on October 30, 2023. Mr. White was notified of its addition by email on October 30, 2023. General trash is generated during facility maintenance and manufacturing. The facility has determined that general trash is nonhazardous waste based on product and process knowledge. General trash includes, but is not limited to, floor sweepings, paper, and cardboard packaging. Allied Waste of Marion, Iowa, collects the general trash and transports it to the Cedar Rapids/Linn County Solid Waste Agency landfill in Marion, Iowa, for disposal. During the CEI, I observed accumulation of general trash and noted no deficiencies. 4. Required Response Equipment and Hazard Management Per 40 CFR 262.15(a)(8) and 262.16(b), a SQG must operate to minimize the possibility of a fire, explosion, or spill, and must maintain emergency response equipment. During the visual inspection, I observed spill response equipment comprised of mats, absorbent materials, shovels, and brooms, as well as the presence and availability of fire extinguishers. I determined that the spill and fire response equipment was adequate for the hazardous wastes generated and accumulated at the facility. 10 5. Container Accumulation Areas St. Lukes maintains two HWCAAs--laboratory and pharmaceutical. At the time of the CEI, there were no hazardous waste accumulation containers (HWAC) in the HWCAAs. I asked Mr. White if the HWCAAs were inspected. He stated that weekly inspections of all HWCAAs are conducted by Ms. Dolter. I asked Ms. Dolter if she maintains an inspection log. She stated that an inspection log is maintained. During the records review, I viewed the inspection log for the last three years and noted no missed inspections. A copy of the inspection log from May 17, 2023, through October 18, 2023, is included as Attachment 12. I asked Ms. Dolter how someone would summon emergency assistance. She stated that each person who handles hazardous waste carries a facility-provided cell phone. I noted no deficiencies with management of the facility's HWCAAs. 6. Manifests St. Lukes generated 68 uniform hazardous waste manifests from October 23, 2020, to October 23, 2023. During the CEI, I reviewed five uniform hazardous waste manifests and LDR notifications from 2020, six from 2021, six from 2022, and six from 2023. I noted no deficiencies during my review of uniform hazardous waste manifests and LDR notifications. Copies of the uniform hazardous waste manifests for the last two off-site shipments of hazardous waste, dated September 28, 2023, and October 19, 2023, are included in Attachment 13. 7. Preparedness and Prevention SQG facilities are required by 40 CFR 262.16(b) to meet the emergency preparedness, prevention, and procedures requirements including documented arrangements with response agencies. According to Mr. White, St. Lukes is the subject of a regular inspection by the Cedar Rapids Fire Department. He explained the fire department is shown the layout of the facility, the location of the hazardous waste HWCAAs, and other facility features during inspections. I asked Mr. White if the facility had a contingency plan DQGhe stated that since they were a SQG they did not have a contingency plan. I asked Mr. White to identify the facility's emergency coordinator. Mr. White stated that he is the primary emergency coordinator and Ms. Dolter is the first alternate. During the CEI, I did not observe a posting of the emergency coordinator's name and phone number, fire department's phone, and locations of fire extinguishers and spill control equipment near a phone, as required by 40 CFR 262.16(b)(9)(ii) (NOPF No. 1). During the CEI, I provided compliance assistance regarding required information posting for SQG facilities. 8. Personnel Training Requirements Personnel training is required by SQG regulations specified in 40 CFR 262.16(b)(9)(iii) to ensure that employees are thoroughly familiar with proper waste handling procedures relevant to their responsibilities. Copies of the 2023 training certificates for Ronda Silver, Dawn Spencer, and Marie Schrock, who are the operators in the HWCAAs, are included in Attachment 14. 11 9. Summary of Preliminary Findings In summary, as part of the CEI, I made the following preliminary findings: x Failure to post emergency coordinators name and phone number, fire departments number and locations of fire extinguishers, as required by 40 CFR 262.16(b)(9)(ii) (NOPF No. 1) x Failure to label three satellite accumulation containers with an indication of the nature of the hazard, as required by CFR 262.15(a)(5)(ii) (NOPF No. 2) x Failure to label a satellite accumulation container with the words "Hazardous Waste," as required by 40 CFR 262.15(a)(5)(i) (NOPF No. 3) x Failure to date or track accumulation times for universal waste lamps, as required by 40 CFR 273.15(c) (NOPF No. 4) x Failure to keep a universal waste lamps container closed, as required by 40 CFR 273.13(d)(1) (NOPF No. 5) x Failure to label a universal waste lamps container with the words "Universal WasteLamps," or "Waste Lamps," or "Used Lamps," as required by 40 CFR 273.14(e) (NOPF No. 6) x Failure to keep a satellite accumulation container closed 40 CFR 262.15(a)(4) (NOPF No. 7) x Failure to adequately train employees in the management of universal waste, as required by 40 CFR 273.16 (NOPF No. 8) NOPF #8 was not initially left with the facility, but was added on October 30, 2023. Other than items specifically noted in the narrative, I observed no additional issues. However, further review by EPA may change or add to my findings. Clifford A. Digitally signed by Clifford A. Nelles _N_e_l_le_s________0_9_:20_:0_6_-0_6'0_0_' ________________________ Date:___________________ Date: 2023.12.06 Clifford A. Nelles, Inspector CLAENE Group Mike Martin - signing Digitally signed by Mike Martin - signing for Amber Whisnant for Amber Whisnant Date: 2024.02.09 14:49:33 -06'00' _____________________________________________ Date: ___________________ Amber Whisnant, Section Chief ECAD/CB/RCRA, EPA Region 7 12 Attachments: 1. Notification/Acknowledgement Verification Report (2 pages) 2. Receipt for Documents and Samples (1 page) 3. Confidentiality Notice (1 page) 4. Notice of Preliminary Findings (2 pages) 5. Site Maps (2 pages) 6. Google Earth Aerial Photograph (1 page) 7. Photographic Documentation (Photolog and 15 Photographs) (11 pages) 8. Copy of 2021 Biennial Report Summary (7 pages) 9. Copy of E-manifest Report (30 pages) 10. Copy of SDS for Xylene (13 pages) 11. Copy of SDS for Ethanol (9 pages) 12. Copy of Inspection Log (1 page) 13. Copies of Manifests and LDRs for shipments on September 28, 2023, and October 19, 2023 (6 pages) 14. Copies of Training Records for Ronda Silver, Dawn Spencer and Marie Schrock (3 pages) 13