Document Oz4B9JwwEYmznmRoDb5a9VKmX

REPORT OF INDUSTRIAL STORMWATER COMPLIANCE EVALUATION INSPECTION AT Emmert Welding and Manufacturing Co., Inc. 23500 MO-78 Hwy E Independence, MO 64056 NPDES NO: MOR203509 June 23, 2023 by U. S. ENVIRONMENTAL PROTECTION AGENCY (EPA) Region 7: Enforcement and Compliance Assurance Division INTRODUCTION I performed a Compliance Evaluation Inspection at the Emmert Welding and Manufacturing Co., Inc. in Independence, Missouri on June 23, 2023. The inspection was authorized by Section 308(a) of the Federal Water Pollution Control Act, as amended. I conducted this inspection following the procedures described here and followed applicable EPA Region 7 Standard Operating Procedures. This narrative report presents the findings of the inspection. PARTICIPANTS Emmert Welding and Manufacturing Co, Inc. Lawrence Andrew Whittaker, Business Manager (816) 796-4000 Email: andrew@emmertwelding.com U.S. Environmental Protection Agency: Caitlin Dix, Physical Scientist (Lead Inspector) (913) 551-7109 Email: Dix.Caitlin@epa.gov Naji Ahmad, Environmental Engineer (913) 551-7190 Email: Ahmad.Naji@epa.gov Missouri Department of Natural Resources: Gabrella Elliott, Environmental Specialist - Water Pollution Unit (816) 251-0746 Email: Gabrella.Elliott@dnr.mo.gov Grant Bicker, Environmental Specialist (816) 251-0708 Email: Grant.Bicker@dnr.mo.gov INSPECTION PROCEDURES I, Caitlin Dix, EPA Region 7 Lead Inspector arrived at the Emmert Welding and Manufacturing Co. Inc. (the "site" or "facility"), located at 23500 MO-78 Hwy E, Independence, MO 64056, at 09:00 a.m. (CT) on June 23, 2023, for an unannounced inspection. I presented credentials to Lawrence Andrew Whittaker and informed him that this was an EPA Region 7 inspection to evaluate the facility's compliance status with the requirements of the Clean Water Act and with the National Pollution Discharge Elimination System (NPDES) permit as authorized by Clean Water Act Section 308 and implementing regulations. This report is based on information supplied by the facility representatives, direct observations made by the EPA Region 7 inspector, records and reports maintained by the permittee, and other information including: photographs taken by EPA Region 7 inspector, physical evidence collected by the EPA Region 7 inspector, measurements taken by EPA Region 7 inspector, verbal or written statements, and information supplied by the facility representatives during or after the on-site inspection, and materials, processes, data, photographs, or documents shown, demonstrated, or submitted to the EPA Region 7 inspector(s) by the facility representatives during or after the on-site inspection. In addition, information gathered before or after the inspection from a review of EPA, State, and/or public records may be included in this report. Before the inspection, I reviewed facility background information including existing permits, information on the receiving stream, compliance and enforcement history, facility website, maps, and aerial images. Before entering the site on June 23, 2023, I looked for areas of concern observable from the public road such as discharges, drainage patterns, flow directions, distance and direction of nearest perennial waters, and facility location and layout. I explained to Whittaker that the inspection would be a review of required records, the facility's Stormwater Pollution Prevention Plan, and a visual inspection of the facility. Whittaker is the business manager and said that the Stormwater Pollution Prevention Plan lead was not available to join the inspection. Whittaker asked if we could reschedule the inspection until Monday since he did not know much about the NPDES permit and their Stormwater Pollution Prevention Plan. I declined Whittaker's request to reschedule the inspection but told him that if he did not know where to locate that Stormwater Pollution Prevention Plan or supporting documents that they could email them the next business day. I asked if there were any other members of the stormwater pollution prevention team available and Whittaker said that he was not a member of the stormwater pollution prevention team and there was not any stormwater pollution prevention team members available. Whittaker said that the owner, Mark McLelland was the primary and maybe sole member of the stormwater pollution prevention team. Whittaker did his best to speak on industrial activities and stormwater management, but said he was not the best person at the facility to answer our questions or find records for the Stormwater Pollution Prevention Plan. Whittaker did have access to some inspection reports and printed off a copy of the May 2023 inspection report completed by McLelland for us to view as an example during our site tour. I was not able to review the Stormwater Pollution Prevention Plan as part of the onsite inspection. During the opening conference, I described the confidential business information notice and small business resources information sheet to Whittaker. I emailed the Confidential Business Information (CBI) Notice for Information Collected During EPA Inspections of Other Compliance Monitoring and the EPA Small Business Resources Information Sheet to Whittaker and McLelland on June 23, 2023. I completed the visual inspection on June 23, 2023. I documented my findings and observations by taking photographs and taking notes. Page 2 of 10 I summarized the findings of the visual inspection with Whittaker during the closing conference of the inspection. I issued a Notice of Potential Findings on June 28, 2023 (attachment #2) after receiving and reviewing the Stormwater Pollution Prevention Plan on June 26, 2023 (attachment #3). I reviewed the findings in the Notice of Potential Findings with McLelland over the phone on June 30, 2023, at 10:30 a.m.. Findings have not yet been evaluated for a formal compliance determination. FACILITY DESCRIPTION Facility Location Emmert Welding and Manufacturing is located on Missouri 78 Highway west of the Little Blue River (Assessment Unit ID MO_422.00) in Independence, Missouri. The facility is approximately 11,000 square feet on a 2.3-acre parcel. There are two outfalls identified by the facility. Outfall 001 is located near the northeast corner of the facility and discharge flows east approximately 200 feet to the Little Blue River. Outfall 002 is to the southwest of the main facility. Discharge from Outfall 002 flows about 135 feet along the facility driveway into a ditch next to MO Highway 78. The ditch flows about 400 feet and discharges to the Little Blue River. U.S. Geologic Survey designates the Little Blue River as a perennial river/stream. This 35-mile section of Little Blue River begins at the Longview Dam and discharges to the Missouri River. The Missouri Department of Natural Resources has assessed the Little Blue River and determined the river is impaired for boating and canoeing and whole-body contact recreation due to pathogens. Facility Operations Emmert Welding and Manufacturing, Co., Inc. is a manufacturing company who serves customers through the fabrication of metal and plastic parts. The facility provides thermal spray coatings, machining and grinding, welding and assembly fabrication. Emmert Welding & Manufacturing, Co., Inc. is a privately owned company which has been in business for over 60 years. The facility operates 6 a.m. to 3:30 p.m. Monday through Thursday and 6 a.m. to 10 a.m. on Fridays. Emmert Welding and Manufacturing Co., Inc. employs approximately 14 people. Enforcement Compliance History Online shows the facility's Standard Industrial Classification (SIC) code as Fabricated Structural Metal (3441) and Industrial Machinery (3599). The facility's Stormwater Pollution Prevention Plan lists Industrial Machinery (3599), Fabricated Structural Metal (3441), Fabricated Plate Work (3443), Sheet Metal Work (3444), Coating, Engraving, and Allied Services, Not Elsewhere Classified (3479), and Welding Repair (7692). Industrial activities exposed to stormwater include: outdoor storage of fuels, raw materials, byproducts, intermediate products, and process residuals; loading and unloading operations; outdoor process activities; dust and particulate generating processes; and waste management. Regulatory History The Missouri Department of Natural Resources authorized the discharge of industrial stormwater from the site on September 6, 2019 under NPDES general permit ID #MOR203509. Emmert Page 3 of 10 Welding and Manufacturing, Co., Inc. is permitted under MoDNR's General Permit for Fabricating Metal, Light Industrial (MO-R203000) effective September 1, 2019 and expiring August 31, 2023 for stormwater discharges from ferrous and nonferrous foundries, casting, extrusion, rolling, galvanizing and finishing, structural steel production, light metal fabrication and electrical equipment manufacturing. Neither the Missouri Department of Natural Resources nor EPA has inspected the facility previously. FINDINGS AND OBSERVATIONS I noted the following observations during the visual inspection and record review. The weather conditions at the time of the inspection were sunny (78-82F). The most recent rain event was approximately 0.55 inches on Monday, June 19, 2023 and 0.50 inches on Sunday, June 18, 2023, using the High Plains Regional Climate Center's CLIMOD website. Emmert Welding and Manufacturing currently operates in one building considered the main facility. Emmert Welding & Manufacturing is constructing a new building for their machine shop and there was active construction with land disturbance less than one acre when we arrived. The main facility is where all welding and manufacturing occurs. Fabrication and welding activities will remain at the main facility when construction of the new building is finished. Whittaker said they broke ground around two months ago and the project is scheduled for completion in approximately two weeks. Whittaker said that the project may not be complete till August 2023. The ground around the new building is bare and looks recently disturbed and tamped (Photo #3). Vegetation has not started re-establishing in the area (Photo #34). There were no structural controls for erosion and sediment control as part of the new construction visible anywhere on the site during the inspection. A storage yard is located to the north of the main facility. The storage yard is approximately 0.25 to 0.3 of an acre and is partially surrounded by a chain-link fence. I saw outdoor storage of fuels, raw materials, by-products, and intermediate products. Raw materials organized and stored on racks outside include carbon steel, aluminum, and stainless steel. I saw areas used for loading and unloading operations, outdoor process activities, dust and particulate generating processes, and waste management. I saw concrete dust accumulated on the ground on the west side of the storage yard (Photo #6 & Photo #7). Whittaker said the construction contractors cut the concrete earlier that day. I saw an area of oil stains and free flowing oil on the ground on the west side of the storage yard along the fence next to a pole (Photo #4). I estimate the area of oil on the ground was less than, but up to five feet long and four feet wide. The spill area includes a small section of a concrete pad and the adjacent ground (Photo #5). I asked Whittaker the source of the oil and he said that he did not know the source. I asked Whittaker if there was anyone on site that knew what was stored in this area. Whittaker found and asked Charles Michael Chaffee, Operations Manager, to briefly join the inspection. Chaffee said he was not aware of where the oil came from. Chaffee and Whittaker said there was a portable toilet at that spot the day before the inspection. Chaffee Page 4 of 10 and Whittaker said they had spill kits available. Chaffee said he would clean up the oil or delegate cleanup of the oil spill or leak. I saw an uncovered dumpster containing metals fines and other metal scrap (Photo #8). The dumpster did not have a cover. There was no pooling stormwater in the dumpster suggesting that the dumpster drains stormwater. Whittaker said the dumpster was emptied two or three times per year. Whittaker said the recycling dumpster is hauled off by a contractor and then returned. Ahmad saw staining around the dumpster indicative of runoff from the dumpster. I saw seven 55-gallons drums stored on pallets on the west side of the storage yard (Photo #9). The 55-gallon metal drums were green, and all appeared to be the same style of drum. At least four of the seven drums were rusted on the top and at least one of the drums had a bulging top (Photo #12). Two of the drums had pooling liquids on top. One of the drums with pooling liquids had a white and opaque liquid pooling (Photo #10). One of the drums with pooling liquids was black and I thought the pooling liquid looked like oil (Photo #11). I did not see labeling on most of the drums, but at least one of the drums had a label for "KOOLRite 2290 HW" (Photo #13). All the drums appeared and felt full. I asked Whittaker what was inside the drums. Whittaker said that the green drums were originally coolant used during the manufacturing process, and used coolant and used oil were stored in the drums for recycling. Whittaker confirmed that the milky liquid pooling on top of the drum was the coolant and that the black liquid pooling on top of the other drum was oil. Whittaker said used oils--the milky-colored coolant and black oil-- were stored in the same drums and recycled together. I asked how often the oils were recycled and Whittaker said that when the containers are full they contact their waste contractor for pickup and recycling of their used oil. I advised Whittaker that used oil containers should be labeled. Ahmad provided more guidance on the labeling requirements and other requirements under Spill Prevention, Control, and Countermeasure (SPCC) regulations if the facility stores more than 1,320 gallons of aggregated oils aboveground. Whittaker said that drums used to be under an awning but were moved to the storage yard not protected by the awning due to space constraints. Gabrella Elliott asked when the facility moved the barrels and Whittaker said about six months ago. There was another 55-gallon green drum stored on a pallet in the storage yard (Photo #20). The drum felt full. The top of the drum had accumulated oil and oily residue. There was a smaller red bucket with a lid. The lid had a spout/bung. The red bucket was labeled as Mobil Oil. The label indicates a Mobil Vactra oil in the numbered series. The bucket is about the size of a 5-gallon bucket and appears to be labeled as Mobil Vactra No. 2, Way Oil. Whittaker said he did not know what was stored in the fifty-five gallon drum, but that it was maybe coolant or maybe used oil for recycling. The barrel was not labeled to identify the contents. There was accumulated oil residues on the top of the barrel. I saw a cardboard bulk bin wrapped in plastic film on a pallet stored outside in the storage yard and exposed to stormwater (Photo #14). I estimate the size of the box to be in the range of a 46 x 38 x 36" bulk storage bin. The cardboard box appeared full of a heavy material causing the sides of the box to bulge outwards from the weight of the stored material. The box and stored materials were wrapped in several layers of plastic wrap. The cardboard box was visible under the plastic and appeared deteriorated. Whittaker said the box stored "machine chips" from the manufacturing process ready for recycling. The plastic wrap did not appear fully storm resistant Page 5 of 10 as weathering was visible in between the layers of plastic film with some dirt and moisture accumulated between the layers, but did seem fairly well wrapped to exclude full exposure to stormwater. I saw scrap metal and metal fines on the ground outside throughout the storage yard (Photo #15 and #16). I asked Whittaker about the small pieces of metal on the ground throughout the area and Whittaker identified the materials as "metal chips" and the same material was stored in a nearby plastic-wrapped cardboard box. Whittaker said a broom and dustpan were used to clean up the metal chips once a week on Fridays. There was a fine gray material covering the east side of the storage yard (Photo #20, #21, #22, #23, #24, #26, #29, #31 and #32). Whittaker said the fine gray material all over the ground was abrasion blasting material and they abrasion blast stainless steel outside. There was a sheltered area, like a shed, where they store the abrasion blasting equipment (Photo #27 and #28). Whittaker said they can use this partially sheltered area to conduct abrasion blasting, but often blasting occurs outside in the storage yard, especially for bigger objects. Whittaker said the blasting material was a glass bead material and that they exclusively blast stainless steel. I saw limited controls to contain abrasion blasting fines. The limited controls for abrasive blasting outdoors include blasting on the asphalt pad, a weedy vegetative buffer to the north and east of the asphalt pad, and facility staff sweep up the storage yard once a week on Fridays. I saw an aboveground storage tank labeled as kerosene (Photo #25). Whittaker said the tank was functional and currently used by the facility to store kerosene. The 300-gallon tank was elevated on a metal stand and approximately 10 feet above the ground. There was secondary containment below the kerosene storage tank. The secondary containment was exposed to stormwater; there was not standing liquids in the bottom of the secondary containment. I saw no evidence of sheen or oil staining. The secondary containment had a closed bung at the base (Photo #26). Whittaker said he did not know the procedures to drain accumulated stormwater from the secondary containment. The secondary containment was full of dried leaves, debris, and equipment (Photo #25 and #26). Ahmad advised that the secondary containment is designed to hold the capacity of the kerosene tank and the leaves/debris and equipment reduce the capacity of the secondary containment. Ahmad advised that the leaves, debris, and equipment be removed from secondary containment to restore the design capacity. There were indicators of poor housekeeping in the storage yard. Indicators of poor housekeeping included a discarded glove on the ground covered in abrasion blasting waste (Photo #32), overturned deteriorated buckets amongst piles of scrap materials (Photo #31), accumulation of metal fines in random containers, accumulation of leaves in containers including secondary containment structure (Photo #15 and #30), metal chips on the ground throughout the east side of the storage yard, and blasting material covering approximately one-third of the storage yard ground. I saw scrap metal fines in a metal bin on the east side of the storage yard (Photo #30). Metal fines recycling is not consolidated to any particular area. I saw metal fines in containers throughout the storage yard including a rusted metal bin with leaves and metal fines. An indicator of poor housekeeping is the lack of organization and defined procedures concerning where and how to dispose of metal fines. Some metal fines are stored in the scrap metal dumpster, some are on the ground, some are in a wrapped cardboard bin for recycling, and some are in open containers amongst other scrap and waste materials. Page 6 of 10 No erosion and sediment controls were on site related to the construction of the new building to minimize loss of sediment off property. The construction project was less than one acre of disturbance. Whittaker said the City of Independence inspected the construction project several times and had no findings or concerns therefore the facility did not take any action to add erosion or sediment control. Recent construction activities disturbed the soil around the new building. Vegetation was not growing in the areas around the new building (Photo #3). Whittaker identified pieces of rebar and flagging that identified the property boundary. The area of disturbance and bare soil around the new building extends beyond the boundary based on the position of the rebar stakes (Photo #33). Soil is migrating onto the neighboring agricultural land and outside the property boundaries. An area of bare soil and sediment deposits extends the length of the north edge of the property from the new building to near the same area as Outfall 001, but primarily flows north of the vegetated swale and on the neighboring property to the north. At the eastern edge of the facility property stormwater would then flow downhill through a publicly-owned riparian buffer of the Little Blue River. I saw sediment deposits near the vegetated buffers on the north side of the facility. Flow patterns in the sediment deposits show the sediment flowed from the construction site. Sediment from the new construction areas flows on the neighbor's property to the north before reaching the edge of the public land buffering the Little Blue River. Stormwater from the storage yard flows in a vegetated swale on the north edge of the Emmert Welding storage yard. Stormwater from the new construction appears to be bypassing the conveyance and flowing north onto the agricultural land then flowing east towards the Little Blue River. Outfall 001 was not visible or accessible for inspection. The conveyance on the north side of the facility is overgrown by trees, shrubs, and herbaceous plants like poison ivy. We walked as close as we could to observe Outfall 001 in the northeast corner of the facility and storage yard. There was no evidence or indicators of runoff that I could see in the general area of the outfall. Outfall 002 is at the corner of the parking lot and driveway near the southwest corner and front of the main facility. The area was currently under construction and the outfall 002 sign was set aside for construction. Whittaker held the Outfall 002 sign in the approximate location of Outfall 002 to show where the outfall sign was normally located (Photo #34). Outfall 002 receives flows from parts of the materials storage yard on the west side, the scrap metal recycling dumpster, employee parking, loading and unloading areas, and the newly constructed manufacturing building. Stormwater Pollution Prevention Plan The NPDES permit requires the facility to develop and implement a Stormwater Pollution Prevention Plan. A copy of the Stormwater Pollution Prevention Plan was not available during the on-site inspection. A copy of the Stormwater Pollution Prevention Plan was promptly sent when the stormwater pollution prevention team returned to the office the following business day. McLelland submitted the Stormwater Pollution Prevention Plan using a shared OneDrive folder on June 26, 2023 (Attachment #3). I reviewed the Stormwater Pollution Prevention Plan for Page 7 of 10 completeness after the inspection and noted that the Stormwater Pollution Prevention Plan was incomplete. The title of the Stormwater Pollution Prevention Plan says "First Revision." The Stormwater Pollution Prevention Plan was prepared March 15, 2019, with a first revision on July 18, 2019. The current permit became effective September 1, 2019, and expires August 31, 2024. No revisions since 2019 suggests that the Plan may not be regularly updated. The facility is undergoing expansion and the facility must update their Stormwater Pollution Prevention Plan and select new best management practices (BMPs) as part of the facility expansion. The Responsible Party and Stormwater Team do not appear to be up to date since McLelland is identified as the secondary contact and team member, but Whittaker indicated McLelland is the primary contact for the Stormwater Pollution Prevention Plan. The Stormwater Pollution Prevention Plan does not include x An Alternative Analysis of the BMPs used on site to determine which BMPs are reasonable and cost effective. x A map of the location of all outfalls and structural BMPs. x A complete list of potential contaminants and an annual estimate of amounts used or produced for the described activities. x All outdoor industrial activities exposed to stormwater, such as abrasion blasting of stainless steel conducted outside and metal fines seen on the ground throughout the outdoor storage yard. x Corrective action reports x Inspection records that identify any deficiencies. x Records of employee training. x A provision for evaluating benchmarks established in the permit. The facility's Stormwater Pollution Prevention Plan does not meet the minimum requirements in the Missouri General Permit. McLelland submitted monthly inspection reports for May 2022 to June 2023 using a shared OneDrive folder on June 26, 2023. Inspections from September 2019 to April 2022 were either not conducted or inspection reports were not available to review. Inspection reports do not identify any deficiencies over the past year. No corrective actions were documented. Structural controls at the facility include an asphalted fenced area and a vegetated buffer on the northeast corner. Nonstructural controls identified in the Stormwater Pollution Prevention Plan include: using oil dry to clean up oil spills immediately; shipping metals to be recycled as containers are filled; making sure company vehicles are checked for leaks to prevent any oil from leaking on to the ground; recycling used oil with a licensed vendor; keeping lids on solid waste dumpsters; making sure equipment brought to the facility for repair is checked for leaks and taking corrective action when leaks are identified; using drip pans; no onsite washing of company truck & forklifts; sweeping up and disposing abrasive/grinding media/ thermal spray powders; placing spent machining fluids in sealed drums for proper recycling; keeping valved drums/tanks within secondary containment of sufficient size; loading and unloading liquid containers inside the fenced area; maintaining labels on all drums; replacing all bulging drums; protecting drum tops from weather; placing sealed drums on pallets; maintaining trees, brush, shrubs, undergrowth, grasses, and in-bedded rock surrounding the facility to prevent discharge of Page 8 of 10 sediment; promoting sheeting action of runoff; employee training plan; monthly inspections and inspection checklist. Other Observations Aerial images of the facility show a rusted patch around a vent on the roof. I saw and documented 740 gallons of oils stored outside--eight 55-gallon drums and the 300gallon kerosene tank. Ahmad observed two 300-gallon oil or fuel tanks under a canopy during the inspection that I did not document. SUMMARY During the closing conference on June 23, 2023, I summarized findings of the visual inspection with Whittaker. I issued a Notice of Potential Findings on June 28, 2023 (attachment #2) after receiving and reviewing the Stormwater Pollution Prevention Plan on June 26, 2023 (attachment #3). I reviewed the findings with McLelland over the phone on June 30, 2023, at 10:30 a.m. EPA inspector identified the following potential findings during the inspection and are included on the Notice of Potential Findings: 1) The Stormwater Pollution Prevention Plan does not include an Alternative Analysis of the best management practices as required by permit 10 2) Stormwater Pollution Prevention Plan is incomplete and does not meet the minimum requirements 13 3) Stormwater Pollution Prevention Plan does not include a map of the location of all outfalls and structural BMPs 13(c) 4) Stormwater Pollution Prevention Plan does not include a complete list of potential contaminants 13(a) 5) Stormwater Pollution Prevention Plan does not identify all outdoor industrial activities 13(a) 6) Stormwater pollution prevention team not up-to-date 13(d) 7) Inspection reports from September 2019 to April 2022 were either not conducted or not available to review 13(e) 8) Recent inspection reports do not identify any deficiencies 13(e) 9) Stormwater Pollution Prevention Plan does not include a provision for evaluating benchmarks established in the permit 13(g) 10) No records of employee training 13(f) 11) Stormwater Pollution Prevention Plan does not describe all BMPs currently used at the facility, including procedures for releasing water from petroleum secondary containment 13(b) and 8 12) Minimum BMPs required by the permit not effectively implemented 14 13) Some BMPs identified in Stormwater Pollution Prevention Plan not implemented 10 14) Oil stains and free flowing oil seen on the ground 14(a) 15) Stormwater contact with scrap metal and metal fines not minimized; dumpster receiving oil metal waste is not covered or other BMP not provided 14(g) 16) Oils pooling on top of drums and not protected from stormwater 14(c) Page 9 of 10 17) Metal chips and metal fines not properly managed and contained 14(g) 18) Abrasion blasting waste materials not contained 14(g) 19) Secondary containment for 300-gallon tank storing kerosene not in good working order 14(c) 20) Poor housekeeping in storage yard 14(e) 21) Lack of erosion and sediment control to prevent sediment loss off property from an active construction project 14(c) McLelland provided responses to the Notice of Potential Findings on July 7, 2023 (attachment #5). The facility responded to each finding, described both completed corrective actions and planned corrective actions with scheduled implementation dates, and sent photo documentation of completed work. Digitally signed by CAITLIN DIX Date: 2023.09.01 10:52:46 CAITLIN DIX ______________-_05_'0_0'_____ Caitlin Dix Physical Scientist NICOLE Digitally signed by NICOLE MORAN M__O_R_A__N_____1_0_:41_:3_0 -_05_'0_0'___ Date: 2023.09.05 Nicole Moran Section Chief ATTACHMENTS: 1. Photo Log (19 pages) 2. Notice of Potential Findings (3 pages) 3. Stormwater Pollution Prevention Plan (4 pages) 4. MoDNR NPDES General Permit (18 pages) 5. Facility Response to Notice of Potential Findings (45 pages) 6. CBI Form and Waiver Response (5 pages) Page 10 of 10