Document RJoNRQpqymnY4bapeyGyxrvQE

June 4, 2024 ELECTRONIC MAIL DELIVERY RECEIPT REQUESTED Ms. Kayla Rosenberg Patient Safety and Regulatory Compliance Manager Protestant Memorial Medical Center Inc. 4500 Memorial Drive Belleville, Illinois 62223 kayla.rosenberg@bjc.org Re: Notice of Potential Violation and Opportunity to Confer Compliance Evaluation Inspection Report and Description of Areas of Concern Protestant Memorial Medical Center Inc. Facility ID: ILD079886479 Belleville, Illinois Dear Ms. Rosenberg: On May 16, 2023, the U.S. Environmental Protection Agency conducted a RCRA compliance evaluation inspection of Protestant Memorial Medical Center Inc. ("Memorial Hospital - Belleville," "facility" or "you") located in Belleville, Illinois. The purpose of the inspection was to evaluate Memorial Hospital Belleville's compliance with certain provisions of RCRA and its implementing regulations related to the generation, treatment and storage of hazardous waste. We have enclosed a copy of the inspection report for your convenience. Information currently available to EPA suggests that Memorial Hospital - Belleville, a large quantity generator of hazardous waste and small quantity handler of universal waste, may be in violation of RCRA. By this letter, EPA is extending to you an opportunity to advise the Agency, in person or in writing, of any further information EPA should consider with respect to the areas of concern. During the inspection, EPA observed several areas of concern, described below. The description of the areas of concern is not a final determination regarding the facility's compliance with RCRA. EPA requests that you voluntarily submit a response in writing to us no later than 30 calendar days after receipt of this letter documenting the actions, if any, which you have taken since the inspection to address the areas of concern described below or demonstrating why the areas should not be of concern. After 30 calendar days from your receipt of this letter and, if applicable, review of your response, EPA will notify you of any further action. Areas of Concern During the inspection, EPA observed the following areas of concern: 1. Date When Each Period of Accumulation Begins Under Ill. Admin. Code tit. 35 722.134(a)(2),1 a large quantity generator must clearly mark each container holding hazardous waste with the date upon which each period of accumulation begins. At the time of the inspection, one 55-gallon drum of hazardous waste, two large boxes of hazardous waste (waste lamps),2 and three medium boxes of hazardous waste (waste lamps) were missing the required date. Please see photos DSCN0025.JPG, DSCN006.JPG, and DSCN007.JPG in the enclosed inspection report. Following the inspection, Memorial Hospital - Belleville marked the required date on the 55gallon drum, two large boxes, and three medium boxes, which addressed the items described above. EPA is not requesting any further information for this area of concern. 2. Hazardous Waste Container Labeling Under Ill. Admin. Code tit. 35 722.134(a)(3),1 a large quantity generator must label or clearly mark each container holding hazardous waste with the words "Hazardous Waste." At the time of the inspection, two 1-gallon containers of hazardous waste and two large boxes of hazardous waste (waste lamps)2 were missing the required label. Please see photos DSCN0012.JPG and DSCN0006.JPG in the enclosed inspection report. Following the inspection, Memorial Hospital - Belleville labeled the two 1-gallon containers and two large boxes, which addressed the items described above. EPA is not requesting any further information for this area of concern. 3. Use and Management of Containers Under Ill. Admin. Code tit. 35 722.134(a)(1)(A)1 and 725.273(a), a large quantity generator must always keep a container holding hazardous waste closed during storage, except when it is necessary to add or remove waste. At the time of the inspection, one 30-gallon drum of hazardous waste, three 1-gallon containers of hazardous waste, one hanging container of hazardous waste, one container of hazardous waste (biohazard waste) and two large boxes of hazardous waste (waste lamps)2 were left open when waste was not being added or removed. 1 We note that on November 19, 2018, the State of Illinois promulgated revised regulations which have not yet been authorized by EPA. EPA authorized an earlier edition of the Illinois hazardous waste regulations which contained a provision at Ill. Admin. Code tit. 35 722.134 that remains the RCRA authorized Large Quantity Generator provision in Illinois. 2 We note that the State of Illinois' universal waste lamp regulations, which are contained in Ill. Admin. Code tit 35 Part 733, have not been authorized by EPA. Thus, for purposes of RCRA, hazardous waste lamps continue to be regulated under Ill. Admin. Code tit. 35 722.134. 2 Please see photos DSCN0019.JPG, DSCN0020.JPG, DSCN0022.JPG, DSCN0026.JPG DSCN003 and DSCN0004 in the enclosed inspection report. Following the inspection, Memorial Hospital - Belleville closed the one 30-gallon drum, five containers and two boxes, which addressed the items described above. EPA is not requesting any further information for this area of concern. 4. Hazardous Waste Determination Under Ill. Admin. Code tit. 35 722.111, a generator must determine whether its waste is hazardous. At the time of the inspection, Memorial Hospital - Belleville had not made a determination whether the waste generated as spilled materials in the secondary containment from four 55-gallon containers of flammable waste medicine was hazardous. Please see photo DSCN0024.JPG in the enclosed inspection report. Following the inspection, Memorial Hospital - Belleville made a hazardous waste determination for the spilled materials, which addressed the item described above. EPA is not requesting any further information for this area of concern. 5. Inadequate Aisle Spacing of Hazardous Waste Under Ill. Admin. Code tit. 35 722.134(a)(4)1 and 725.135 a large quantity generator must maintain aisle space to allow the unobstructed movement of personnel, fire protection equipment, spill control equipment, and decontamination equipment to any area of facility operation in an emergency, unless aisle space is not needed for any of these purposes. At the time of the inspection, Memorial Hospital - Belleville's 90-day hazardous waste storage area did not have adequate aisle spacing between the container accumulation area (CAA), the storage shelf, and corner of building for emergency response access. Please see page 7 of the enclosed inspection report. 6. Weekly Inspections Under Ill. Admin. Code tit. 35 722.134(a)(1)(A)1and 725.274, a large quantity generator must inspect areas where containers are stored at least weekly, looking for leaks and for deterioration caused by corrosion or other factors. At the time of the inspection, Memorial Hospital - Belleville did not provide proof that weekly inspections were performed in the hazardous waste storage area between May 2022 and the date of the inspection. Please see page 12 of the enclosed inspection report. 7. Contingency Plan Under Ill. Admin. Code tit. 35 722.134(a)(4)1 and 725.152(c), a large quantity generator must have a contingency plan that, among other things, describes arrangements agreed to by local police department, fire departments, hospitals, contractors, and State and local emergency response teams to coordinate emergency services, pursuant to Section 725.137. 3 Under Ill. Admin. Code tit. 35 722.134(a)(4)1 and 725.152(d), a large quantity generator must have a contingency plan that, among other things, lists names, addresses, and phone numbers (office and home) of all persons qualified to act as emergency coordinator (see Section 725.155), and this list must be kept up to date. Where more than one person is listed one must be named as primary emergency coordinator and others must be listed in the order in which they will assume responsibility as alternates. Under Ill. Admin. Code tit. 35 722.134(a)(4)1 and 725.152(e), a large quantity generator must have a contingency plan that, among other things, includes a list of all emergency equipment at the facility (such as fire extinguishing systems, spill control equipment, communications and alarm systems (internal and external), and decontamination equipment) where this equipment is required. This list must be kept up to date. In addition, the plan must include the location and a physical description of each item on the list and a brief outline of its capabilities. At the time of the inspection: Memorial Hospital - Belleville did not have a description of arrangements made and agreed to by local police department, fire departments, hospitals, contractors, and State and local emergency response teams to coordinate emergency services in its contingency plan. Memorial Hospital - Belleville did not have current emergency coordinator information in its contingency plan. Memorial Hospital - Belleville did not have a list of emergency equipment in its contingency plan. Please see page 10 of the enclosed inspection report. 8. Exception Reporting Under Ill. Admin. Code tit. 35 722.142(a)(2),1 a large quantity generator must submit an Exception Report to the Agency if the generator has not received a copy of the manifest with the handwritten signature of the owner or operator of the designated facility within 45 days of the date the waste was accepted by the initial transporter. At the time of the inspection, Memorial Hospital - Belleville had not submitted an Exception Report to the Agency for the following six manifests for which it had not received a copy of the manifest with the handwritten signature of the owner or operator of the designated facility more than 45 days after the date the waste was accepted by the initial transporter: 013173209FLE, 016717449FLE, 016717780FLE, 016723664FLE, 016715555FLE, and 016718397FLE. Please see page 9 of the enclosed inspection report. 9. Universal Waste Requirement Under Ill. Admin. Code tit. 35 733.114(a),1 a small quantity handler of universal waste batteries must clearly label or mark universal waste batteries (i.e., each battery) or a container 4 in which the batteries are contained with any one of the following phrases: "Universal WasteBatteries," "Waste Batteries," or "Used Batteries." Under Ill. Admin. Code tit. 35 733.115(c), a small quantity handler of universal waste that accumulates universal waste must be able to demonstrate the length of time that the universal waste has been accumulated from the date it becomes a waste or is received. At the time of the inspection: Three small boxes of Nicad batteries were not labeled or marked and were missing accumulation start dates. Multiple ballast waste batteries were not labeled or marked and were missing an accumulation start date. One small box of universal waste batteries was incorrectly labeled as Non-Hazardous Waste and was missing an accumulation start date. Please see photos DSCN0009.JPG, DSCN0010.JPG, and DSCN0011.JPG in the enclosed inspection report. Following the inspection, Memorial Hospital - Belleville addressed the items described above. EPA is not requesting any further information for this area of concern. 10. Fire Extinguisher Under Ill. Admin. Code tit 35 722.134(a)(4)1 and 725.133, all generator communications or alarm systems, fire protection equipment, spill control equipment, and decontamination equipment, where required, must be tested and maintained as necessary to assure its proper operation in time of emergency. At the time of inspection, Memorial Hospital - Belleville's fire extinguisher in the Bio-Room was observed to be blocked from easy access. Please see page 11 of the enclosed inspection report. Actions Requested By no later than 30 calendar days after receipt of this letter, please provide information documenting the actions, if any, which you have taken since the inspection to address the identified areas of concern, as well as any additional information requested. You do not need to provide documentation regarding areas of concern that are noted above as having been addressed following the inspection. Please send all information requested by this letter by electronic mail to: r5lecab@epa.gov and garvin.melissa@epa.gov The subject line of all email correspondence must include ILD079886479. All electronically submitted materials must be in final and searchable format, such as Portable Document Format (PDF) with 5 Optical Character Recognition (OCR) applied. If you are unable to send a response to these email addresses due to email size restrictions or other problems, contact Melissa Garvin to make additional arrangements for transmission of the response. This letter is not subject to the Paperwork Reduction Act, 44 U.S.C. 3501 et seq., because it seeks information from specific individuals or entities as part of an administrative investigation. You may assert a claim of business confidentiality under 40 C.F.R. Part 2, Subpart B for any part of the information you submit to EPA in response to this letter. Information subject to a business confidentiality claim is available to the public only to the extent, and by means of the procedures, set forth at 40 C.F.R. Part 2, Subpart B. If you do not assert a business confidentiality claim when you submit the information, EPA may make this information available to the public without further notice. The EPA contact in this matter is Melissa Garvin. You may call her at (312) 886-1462 or email her at garvin.melissa@epa.gov if you have additional questions. Thank you for your prompt attention to these concerns and your efforts to protect human health and the environment. Sincerely, MICHAEL HARRIS Digitally signed by MICHAEL HARRIS Date: 2024.06.04 10:40:14 -05'00' Michael D. Harris Division Director Enforcement and Compliance Assurance Division Enclosure cc: Paul Eisenbrandt, Illinois Environmental Protection Agency, paul.eisenbrandt@illinois.gov 6