Document XVMq5jqegnxd87Z91Bed0E2G

Region 6 - Enforcement & Compliance Assurance Division INSPECTION REPORT Inspection Date(s): Media Program: Regulatory Program(s) August 27 - 29, 2024 Air Clean Air Act (CAA) 112(r) and 40 Code of Federal Regulations (C.F.R.) Part 68 Chemical Accident Risk Management Plan (RMP) Company Name: Facility Name: Facility Physical Location: (city, state, zip code) Mailing address: (city, state, zip code) County/Parish: Facility Phone Number: Facility Contact: Schwan's Company SFC Global Supply Chain, Inc. 612 Georgia Ave Deer Park, Texas 77536 115 West College Drive Marshall, Minnesota 56258 Harris County (713) 740-7536 Vern Sanderson Senior Manager: PSM Vern.Sanderson@schwans.com FRS Number: 110000505043 Identification/Permit Number: Media Identifier Number: RMP 100000123797 NAICS: 31141 Frozen Food Manufacturing SIC: Personnel participating in inspection: Aimee Boss EPA Region 6 ECDAC Vern M. Sanderson Schwan's Jason Daniell APSM Natalie Reed Schwan's Waker Chavez Schwan's Kevin Mapps Schwan's Dan Connelly Schwan's Physical Scientist Senior Manager: PSM VP, Operations Senior EHS Manager Senior EHS Specialist Plant Manager Refrigeration Manager EPA Lead Inspector Signature/Date Supervisor Signature/Date AIMEE BOSS Digitally signed by AIMEE BOSS Date: 2024.10.29 10:04:34 -05'00' Aimee Boss Date SAMUEL TATES Date: 2024.10.29 10:36:11 -05'00' Digitally signed by SAMUEL TATES Samuel Tates Date 6ENFORM-019-R8.2 (02/12/2020) 1 Section I - INTRODUCTION SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 PURPOSE OF THE INSPECTION United States Environmental Protection Agency (EPA) Region 6 Inspector Aimee Boss ("I") arrived at the SFC Global Supply Chain, Inc. ("SFC" or the "Facility"), located in Deer Park, Texas at 9:00 AM on August 27, 2024, for an announced inspection. I met with Vern Sanderson (Schwan's Senior Manager: PSM) and Natalie Reed (Schwan's Senior EHS Manager) at security gate. I presented my credentials to security, Vern Sanderson, and Natalie Reed. Once inside the facility for the opening conference, I informed Vern Sanderson, Natalie Reed, Jason Daniell (APSM, VP, Operations), Waker Chavez (Schwan's Senior EHS Specialist), Kevin Mapps (Schwan's Plant Manager), and Dan Connelly (Schwan's Refrigeration Manager) that this was an EPA inspection to evaluate compliance with the requirements of the Chemical Accident Prevention Provisions of Title 40 of the Code of Federal Regulations (C.F.R.) Part 68 under CAA 112(r). Employee representatives were invited to participate in the inspection. The Facility does not have union representation. The inspection was prompted by the Facility's anhydrous ammonia release on July 4, 2021. The Texas Commission on Environmental Quality (TCEQ) Air Emission Event Report, dated September 24, 2021, estimated 64 lbs. of anhydrous ammonia for a duration of 1 hour and 30 minutes, according to TCEQ. The release was caused by a pump seal failure in the compressor room. FACILITY DESCRIPTION SFC is a frozen food manufacturing facility located at 612 Georgia Ave, Deer Park, Texas 77536. The Facility is in operation 24 hours a day, seven days a week, with approximately 371 employees. Anhydrous Ammonia is the only regulated substance used at this facility with a quantity of 42,000 lbs, over the 10,000 lbs threshold quantity for regulated substances and is a Program 3 process. The Ammonia is utilized as the primary cooling media in the closed-loop refrigeration systems. The system's purpose is to provide refrigeration and cold storage capabilities for SFC operations. An owner or operator of a stationary source that has more than a threshold quantity of a regulated substance in a process, as determined under 68.115, shall comply with the requirements of the Part 68 - Chemical Accident Prevention Provision. Section II - OBSERVATIONS The documentation review began onsite with SFC personnel as listed on page 1 of this inspection report. 2 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 40 C.F.R. Part 68 - CHEMICAL ACCIDENT PREVENTION PROVISION Subpart A - General 40 C.F.R. 68.10 Applicability - SFC is a stationary source that has more than a threshold quantity of regulated substances in their process. The most recent Risk Management Plan ("RMP") re-submittal was on April 30, 2024. SFC is a RMP Program 3 facility. The Facility is subject to the Occupational Safety and Health Administration's (OSHA) Process Safety Management (PSM) Standard (29 C.F.R. 1910.119). 40 C.F.R. 68.12 General requirements - SFC submitted their most recent RMP submission on April 30, 2024. The regulated substance (anhydrous ammonia) is a listed toxic substance over the threshold quantity for the RMP Program Level 3 process. 40 C.F.R. 68.15 Management - SFC uses a web-based software called APSM to hold most documentation for PSM/RMP program. SFC provided documentation that outlined the positions for implementation of the individual elements of the RMP, as required by this subpart, at the time of this inspection. The document provided requires signatures from the facility director, refrigeration leader, PSM leader, and EHS leader to complete the agreement of understanding and is effective per the last date of signature. There were no signatures on the documentation provided during the inspection [AOC 1]. On October 24, 2024, SFC provided EPA with the document signatures with the last date of signature on October 22, 2024. Subpart B - Hazard Assessment 40 C.F.R. 68.20 Applicability - SFC operates an RMP Program Level 3 process, which is subject to this subpart and is required to prepare a worst-case release scenario analysis. SFC provided the worst-case release scenario analysis and a five-year accident history in the RMP. I identified no areas of concern with this subpart. 40 C.F.R. 68.22 Offsite consequence analysis parameters - SFC provided the parameters in the RMP as required by this subpart. I identified no areas of concern with this subpart. 40 C.F.R. 68.25 Worse-case release scenario analysis - SFC analyzed and reported a worstcase release scenario in the RMP as required by this subpart. I identified no areas of concern with this subpart. 40 C.F.R. 68.28 Alternative release scenario analysis - SFC identified an alternative release scenario in its Program 3 process as required by this subpart. I identified no areas of concern with this subpart. 40 C.F.R. 68.30 Defining offsite impacts-population - SFC used the most current Census Bureau population data. I identified no areas of concern with this subpart. 3 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 40 C.F.R. 68.33 Defining offsite impacts-environment -SFC used a data source containing U.S.G.S. data to identify environmental receptors. I identified no areas of concern with this subpart. 40 C.F.R. 68.36 Review and update - SFC provided Marplot maps of the worst-case and alternative-case scenarios. The worst-case scenarios should be updated and reviewed at least every five years. I identified no areas of concern with this subpart. 40 C.F.R. 68.39 Documentation - SFC operates a RMP Program Level 3 process, which is subject to this subpart and is required to prepare a worst-case release scenario analysis and complete the five-year accident history. I reviewed the worst-case and alternative-case scenarios provided. I identified no areas of concern with this subpart. 40 C.F.R. 68.42 Five-year accident history - SFC reported the July 4, 2021, accidental release in their RMP that resulted in an injury and $399,00 in on-site property damage. In the accident history provided during the inspection, an injury occurred on January 1, 2021, as a result of liquid trapped in a valve bonnet to prepare to run a compressor. This injury was not reported in the 5-year accident history on the RMP as required by this subpart [AOC 2]. Subpart D - Program 3 Prevention Program 40 C.F.R. 68.65 Process safety information (PSI) - I reviewed various sections of the PSI for the RMP covered process at SFC. I was provided the original process and instrumentation diagram (P&ID) associated with the process, block flow diagram, safety data sheet, maximum indented inventory, and upper and lower limits. I reviewed documentation that outlines the design codes and standards, including the International Institute of Ammonia Refrigeration ("IIAR"). SFC's pressure relief valve information provided identifies four (4) pressure relief valves on site are missing tags and do not have information regarding the last installation and cannot confirm that the installation date is less than 5 years' old as required by IIAR 6 2020. On October 24, 2024, SFC provided EPA with an excerpt from a 2024 third party inspection, that was available during the EPA inspection, included the month and year a relief valve was installed and is within the 5-year replacement timeline [AOC 3]. During the facility tour on August 28, 2024, I observed several pipes did not have proper labels as required by IIAR 9 2020 Chapter 7. It was explained that SFC had recently painted the equipment. The documentation provided during the inspection state the painting was completed on August 19, 2024. Some labels were returned to the piping while on the tour and I was informed SFC would be adding all other labels shortly. On October 24, 2024, SFC notified EPA that all the labels have been reinstalled. 40 C.F.R. 68.67 Process hazard analysis (PHA) - I reviewed the two most recent PHA's from 2014 and 2019. The 2024 PHA is schedule to be completed in October 2024. There were several 4 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 findings and recommendations from the 2014 PHA that did not have a date they were addressed by SFC. On October 24, 2024, SFC noted that all the 2014 PHA items have been addressed and the current process at SFC requires that a date of closure be recorded. No findings and recommendations actions were provided to EPA for the 2019 PHA at the time of this inspection [AOC 4]. Several Consequences/Hazards in the 2019 PHA have "N/A" written in, when should be more descriptive by addressing the checklist questions. Additionally, the 2019 PHA was missing information required by the policy such as PHA meeting minutes, documentation did include the day the meetings took place with attendance, and the hazard analysis in 2019 PHA attachment A [AOC 5]. 40 C.F.R. 68.69 Operating procedures - I reviewed several operating procedures such as: Lock out/Tag out, Confined Space Policy, Schwans Ammonia Refrigeration Standard, and the Transfer Pump V1134 #3 System G Pumps. The Lock out/ Tag out Policy has conflicting timelines for recordkeeping, in one section the retention for Lock out/tag out records are to be keep for one (1) year while another section it is three (3) years. On October 24, 2024, SFC had notified EPA that the conflicting timelines in the policy have been resolved. The Certification Policy for operating procedures reflects that certification tracking in online compliance software is available but is currently not used. Additionally, the copies of operating procedures were missing the annual certification signature as required by this subpart and SFC's certification procedures [AOC 6]. 40 C.F.R. 68.71 Training - I requested the training records, including competency evaluations such as exams, for three (3) randomly selected employees. I received the training record of the most recent ammonia awareness December 12, 2023, for several employees, including the three (3) I requested. The remaining training records I received were for only two (2) of the three (3) employees I selected. Many of these trainings are PSM Participation Records for varying subjects. The March 27, 2020, "PSM Participation Record" was missing the presenter signature and a circle around the participation type: Informative, Consultation, or Training. Some PSM Participation Records have a signature line and a presenter signature. However, several of the PSM Participation Records provided are missing a line to accommodate the presenter signature. All PSM Participation Records provided during the inspection are missing a circle around the participation type, as instructed by the form. Additionally, the PSM Participation Records and two (2) Level I (Entry) trainings provided do not describe or present a means used to verify that the employee understood the training as required by the subpart [AOC 7]. 40 C.F.R. 68.73 Mechanical integrity (MI) - I reviewed records for the RMP covered process equipment and SFC's Mechanical Integrity Standard. Preventative maintenance is based on the IIAR standard, day to day observations are tracked in a master maintenance log (MML), and each shift has an ammonia daily round sheet to document shift daily duties. The MML is reviewed once a month by management to ensure items are addressed accurately. The 2024 IIAR 6 Annual Ammonia Inspection reports for both system G and system H had identified several deficiencies. The reports both state, "a follow-up log has been provided 5 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 tracking progress as each recommendation is addressed" and are in Tab 5 of the report. I did not receive the follow up log or Tab 5 Findings: Deficiency Log in the reports at the time of inspection [AOC 8]. On October 24, 2024, SFC notified EPA the inspection reports had recently been issues to the facility and believes that Tab 5 of the report was still compiling it at the time of the EPA inspection, therefore the action log is blank as follow-up had not yet occurred at the time of EPA's inspection. While on the facility tour on August 28, 2024, I encountered ammonia in engine room G. The ammonia was coming from two separate pieces of equipments, the sight glass located on the high-pressure receiver and an auto purger located near the low-pressure receiver. The sight glass leak was measured by the facility at zero (0) and dissipated shortly after measuring. In the PSM/RMP team meeting notes from August 20, 2024 (noted as delayed until September 3, 2024), sight glasses were identified to be leaking on July 15, 2024, noted as not repaired on August 5, 2024, and describes that the sight glass will need to be pumped out. The MML from August 27, 2024, 6:00 entry noted multiple leaks on sight glass column. The auto purger ammonia emission was not measured, and I evacuated the area. I was informed that the auto purger had a cap loose on the bubbler. There is no mention in the MML about the ammonia odor. On the August 27, 2024, ammonia daily round sheet at 6:30PM checks off that both purgers have NH3 detected. The daily round sheet from the previous shift for that day left the purger section blank and for August 28, 2024, the machinery purger boxes are crossed out for both the G and H machinery room for several shifts. The daily round sheet states that any abnormal conditions shall be noted in the MML. The August 27, 2024, MML does not reflect ammonia odor at the purgers, nor did it note the odor I observed during the facility tour on the following day [AOC 9]. On October 24, 2024, SFC notified EPA that the bubbler was readily repaired and is not considered an abnormal condition but a minor maintenance adjustment. 40 C.F.R. 68.75 Management of change (MOC) - I reviewed SFC's MOC standard, MOC Task Flow Diagram, and reviewed a list of issued MOC's for the past three years at the time of this inspection. Four MOC's were open at the time of this inspection. MOC's are divided in major and minor changes and described in SFC's PSM Standard. A major change would require a PHA. There were no major MOC's for the past three years. The minor MOC's do require a process safety questionnaire. I identified no areas of concern with this subpart. 40 C.F.R. 68.77 Pre-startup safety review (PSSR) - I reviewed the SFC PSSR standard and the provided most recent PSSR's MC-230209 and MC-227836. I identified no areas of concern with this subpart. 40 C.F.R. 68.79 Compliance audits - I reviewed the compliance audits conducted in 2020 and 2023. There were 40 recommendations identified in the 2020 compliance audit, only 10 recommendations with status and notes were provided at the time of this inspection. There were 12 compliance recommendations in the 2023 compliance audit. The documentation 6 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 provided at the time of inspection does not document that deficiencies have been corrected in response to the recommendation [AOC 10]. 40 C.F.R. 68.81 Incident investigation - I reviewed SFC's Incident Investigation Standard. The incident investigation standard is states that "fugitive emissions are generally not considered eligible for incident investigation" however, fugitive emissions are not defined in this standard. I reviewed the Incident Reporting and Investigation Form for the July 4, 2021, incident and the tracking for the 2021 pump incident investigation follow up. In the incident investigation findings tracking sheet, several of the items were closed after the projected due date and there was no description of the action taken documented in the tracking sheet provided. [AOC 11]. On October 24, 2024, SFC informed EPA that the tracking sheets are intended to be self-evident as to the actions performed. I requested the investigation report for the January 1, 2021, incident with an injury and received a salesforce document about the incident. I was unable to review an incident investigation report for this incident with injury at the time of this inspection [AOC 12]. 40 C.F.R. 68.83 Employee participation - I reviewed SFC's Employee Participation Standard which did not have a signature on the final page's line of approval, as required by this subpart. [AOC 13]. 40 C.F.R. 68.85 Hot work permit - I reviewed SFC's hot work standard and one year worth of hot work permits. The hot work standard has conflicting timelines for recordkeeping. In one section the retention for hot work permits to be kept is for one (1) year while another section it is three (3) years. The retention should be updated to reflect the current requirement. Additionally, several hot work permits reviewed from 2023 were not filled out in line with the standard [AOC 14]. On October 24, 2024, SFC notified the conflicting timelines for retention has been resolved. 40 C.F.R. 68.87 Contractors - SFC does general maintenance with in-house employees and relies on contractors to do larger projects. SFC uses Avetta, a 3rd party website that enables and verifies ongoing safety of contractors that come on site. When a new contractor is to come on site, a MOC is generated to track the hiring process. I reviewed the SFC contractor policy and general contractor orientation and training video. I identified no areas of concern with this subpart. Subpart E - Emergency Response 40 C.F.R. 68.90 Applicability - SFC is not a responding stationary source in case of an accidental release of a regulated substance and is applicable to this subpart need not comply with 68.95 of this part. I reviewed the Ammonia Mitigation Plan - Appendix K and the Emergency Planning and Response Standard. Emergency Action Plan. I identified no areas of concern with this subpart. 7 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 40 C.F.R. 68.93 Emergency response coordination activities - SFC sent the notification for annual coordination on February 1, 2024, as required by this subpart and reflected in 68.96(c)(2). I identified no areas of concern with this subpart. 40 C.F.R 68.96 Emergency response exercises - The February 1, 2024, notification for annual coordination and exercise was completed, as required by this subpart. I identified no areas of concern with this subpart. Subpart G - Risk Management Plan 40 C.F.R. 68.195 Required Corrections - SFC's RMP submittal was on April 30, 2024. I called the facility's Emergency Number after the inspection, and it went straight to voicemail. I also called the Emergency Contact 24-Hour Phone, and the call rang but went unanswered and to voicemail. The person's name in the voicemail of the Emergency Contact 24-Hour Phone is not the current person listed as the Emergency Contact Name [AOC 15]. On October 24, 2024, SFC notified EPA that there has been a corporate personnel chance and is within the 30 days to make the change. Section III - AREAS OF CONCERN (AOC) AOC 1 - 40 C.F.R. 68.15 Management (c) When responsibility for implementing individual requirements of this part is assigned to persons other than the person identified under paragraph (b) of this section, the names or positions of these people shall be documented and the lines of authority defined through an organization chart or similar document. SFC failed to capture signatures on the documentation provided during the inspection, that outlines the positions for implementation of the individual elements of the RMP. The document requires signatures from the facility director, refrigeration leader, PSM leader, and EHS leader to complete the agreement of understanding and is effective per the last date of signature. On October 24, 2024, SFC provided EPA with the document signatures with the last date of signature on October 22, 2024. AOC 2 - 40 C.F.R. 68.42(a) Five-year accident history (a) The owner or operator shall include in the five-year accident history all accidental releases from covered processes that resulted in deaths, injuries, or significant property damage on site, or known offsite deaths, injuries, evacuations, sheltering in place, property damage, or environmental damage. SFC failed to report an injury in the 5-year accident history in the RMP. An injury occurred on January 1, 2021, because of liquid trapped in a valve bonnet to prepare to run a compressor. This injury was reported in the OSHA 300 Work-Related Injury & Illness log. AOC 3 - 40 C.F.R. 68.65(d)(2) Process safety information (PSI) 8 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 (d) Information pertaining to the equipment in the process. (2) The owner or operator shall ensure and document that the process is designed and maintained in compliance with recognized and generally accepted good engineering practices. SFC failed to maintain the schedule of 5-year replacement as required by IIAR 6. SFC's pressure relief valve information provided identifies four (4) pressure relief valves on site are missing tags and do not have information regarding the last installation and cannot confirm that the installation date is less than 5 years' old as required by IIAR 6 at the time of inspection. On October 24, 2024, SFC provided EPA with an excerpt from a 2024 third party inspection that included the month and year a relief valve was installed and is within the 5-year replacement timeline. AOC 4 - 40 C.F.R. 68.67(e) Process hazard analysis (PHA) (e) The owner or operator shall establish a system to promptly address the team's findings and recommendations; assure that the recommendations are resolved in a timely manner and that the resolution is documented; document what actions are to be taken; complete actions as soon as possible; develop a written schedule of when these actions are to be completed; communicate the actions to operating, maintenance and other employees whose work assignments are in the process and who may be affected by the recommendations or actions. SFC failed to assure recommendation are resolved in a timely manner and document the resolutions. No findings and recommendations actions were provided to EPA for the 2019 PHA at the time of this inspection. Several findings and recommendations from the 2014 PHA that did not have a date they were addressed by SFC. On October 24, 2024, SFC noted that all the 2014 PHA items have been addressed and the current process at SFC requires that a date of closure be recorded. AOC 5 - 40 C.F.R. 68.67(a) and (c) Process hazard analysis (PHA) (a) ...The owner or operator shall determine and document the priority order for conducting process hazard analyses based on a rationale which includes such considerations as extent of the process hazards, number of potentially affected employees, age of the process, and operating history of the process. (c) The process hazard analysis shall address:(1) The hazards of the process; SFC failed to address some of the hazards of the process and could not locate the hazard analysis for the 2019 PHA. Several Consequences/Hazards in the 2019 PHA have "N/A" written in, when should be more descriptive by addressing the checklist questions. Additionally, the 2019 PHA was missing the hazard analysis located in 2019 PHA attachment A. AOC 6 - 40 C.F.R. 68.69(a) and (c) Operating procedures (a) The owner or operator shall develop and implement written operating procedures that provide clear instructions for safely conducting activities involved in each 9 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 covered process consistent with the process safety information and shall address at least the following elements. (c) The operating procedures shall be reviewed as often as necessary to assure that they reflect current operating practice, including changes that result from changes in process chemicals, technology, and equipment, and changes to stationary sources. The owner or operator shall certify annually that these operating procedures are current and accurate. SFC failed to annual certify several operating procedures and maintain timelines in the Lock Out/ Tag Out Policy. Varying operating procedures were missing the annual certification signatures from the certification pages. On October 24, 2024, SFC responded stating that the list showing the recertification of every SOP is distributed to every operator monthly, as part of the PSM/RMP meeting minutes. The Certification Policy for operating procedures reflects that certification tracking in online compliance software is available but the software is not currently in use. The Lock out/ Tag out Policy has conflicting timelines for recordkeeping, in one section the retention for Lock out/tag out records are to be keep for one (1) year while another section it is three (3) years. On October 24, 2024, SFC had notified EPA that the conflicting timelines in the policy have been resolved. AOC 7 - 40 C.F.R. 68.71(b) and (c) Training (b) Refresher training. Refresher training shall be provided at least every three years, and more often if necessary, to each employee involved in operating a process to assure that the employee understands and adheres to the current operating procedures of the process. The owner or operator, in consultation with the employees involved in operating the process, shall determine the appropriate frequency of refresher training. (c) Training documentation. The owner or operator shall ascertain that each employee involved in operating a process has received and understood the training required by this paragraph. The owner or operator shall prepare a record which contains the identity of the employee, the date of training, and the means used to verify that the employee understood the training. SFC failed to describe or present a means used to verify that the employee understands and adheres to the current operating procedures of the process. The March 27, 2020 "PSM Participation Record" was missing the presenter signature and a circle around the participation type: Informative, Consultation, or Training. Some of the PSM Participation Record's provided don't have a line for a presenter signature. However, all PSM Participation Record's provided are missing a circle around the participation type, as instructed by the form. Additionally, the PSM Participation records and two (2) Level I (Entry) trainings provided do not describe or present a means used to verify that the employee understood the training. 10 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 AOC 8 - 40 C.F.R. 68.73(e) Mechanical integrity (MI) (e) Equipment deficiencies. The owner or operator shall correct deficiencies in equipment that are outside acceptable limits (defined by the process safety information in 68.65) before further use or in a safe and timely manner when necessary means are taken to assure safe operation. SFC failed to document that deficiencies have been corrected. The 2024 IIAR 6 Annual Ammonia Inspection reports for both system G and system H had identified several deficiencies. The reports both state, "a follow-up log has been provided tracking progress as each recommendation is addressed" and are in Tab 5 of the report. I did not receive the follow up log or Tab 5 Findings: Deficiency Log in the reports at the time of inspection. On October 24, 2024, SFC notified EPA the inspection reports had recently been issues to the facility and believes that Tab 5 of the report was still compiling it at the time of the EPA inspection, therefore the action log is blank as follow-up had not yet occurred at the time of EPA's inspection. AOC 9 - 40 C.F.R. 68.73(d) and (f) Mechanical integrity (MI) (d) Inspection and testing. (1) Inspections and tests shall be performed on process equipment. (f) Quality assurance. (2) Appropriate checks and inspections shall be performed to assure that equipment is installed properly and consistent with design specifications and the manufacturer's instructions. SFC failed to ensure the daily inspections on process equipment documented equipment deficiencies identified during the facility tour. During the facility tour on August 28, 2024, I observed an ammonia scent in Engine Room G at the auto purger located near the low-pressure receiver. I was informed that the auto purger had a cap loose on the bubbler. Additionally, the daily round sheet for August 27, 2024, ammonia daily round sheet at 6:30PM checks off that both purgers have NH3 detected. The daily round sheet from the previous shift for that day left the purger section blank. The August 28, 2024, the daily round sheet machinery purger boxes are crossed out for both the G and H machinery room for several shifts. The daily round sheet states that any abnormal conditions shall be noted in the MML. The August 27, 2024, MML does not reflect ammonia odor at the purgers nor did the MML note the odor I observed during the facility tour on the following day. On October 24, 2024, SFC notified EPA that the bubbler was readily repaired and is not considered an abnormal condition but a minor maintenance adjustment. AOC 10 - 40 C.F.R. 68.79(d) Compliance audits (d) The owner or operator shall promptly determine and document an appropriate response to each of the findings of the compliance audit, and document that deficiencies have been corrected. 11 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 SFC failed to document deficiencies have been corrected for the 2020 and 2023 compliance audit findings. Forty (40) recommendations were identified in the 2020 compliance audit, only 10 recommendations with status and notes were provided at the time of this inspection. Twelve (12) compliance recommendations in the 2023 compliance audit were identified. The documentation provided notes that the items are completed however, it does not explain the actions taken in response to the 2023 compliance audit recommendations. AOC 11 - 40 C.F.R. 68.81(e) Incident investigation (e) The owner or operator shall establish a system to promptly address and resolve the incident report findings and recommendations. Resolutions and corrective actions shall be documented. SFC failed to document resolutions and corrective actions for the July 2, 2021, incident recommendations. I reviewed the Incident Reporting and Investigation Form for the July 4, 2021, incident and the tracking for the 2021 pump incident investigation follow up. In the incident investigation findings tracking sheet, several of the items were closed after the projected due date and no description of the action taken documented in the tracking sheet provided. On October 24, 2024, SFC informed EPA that the tracking sheets are intended to be self-evident as to the actions performed. AOC 12 - 40 C.F.R. 68.81(a) and (b) Incident investigation (a) The owner or operator shall investigate each incident which resulted in, or could reasonably have resulted in a catastrophic release. (b) An incident investigation shall be initiated as promptly as possible, but not later than 48 hours following the incident. SFC failed to provide an incident investigation report for the January 1, 2021 incident. During the inspection I received a salesforce document about the incident geared with information about a worker's comp claim which did include information about the incident. SFC failed to define fugitive emissions in the incident investigation standard. SFC's Incident Investigation Standard states that "fugitive emissions are generally not considered eligible for incident investigation" however, fugitive emissions are not defined in this standard. AOC 13 - 40 C.F.R. 68.83(a) and (e) Employee participation (a) The owner or operator shall develop a written plan of action regarding the implementation of the employee participation requirements required by this section. SFC failed to ensure the employee participation plan was signed. SFC's Employee Participation Standard requires a signature on the final page line of approval. This signature was missing from the documentation reviewed during this inspection. 12 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 AOC 14 - 40 C.F.R. 68.85(b) and (c) Hot work permit (b) The permit shall document that the fire prevention and protection requirements in 29 CFR 1910.252(a) have been implemented prior to beginning the hot work operations; it shall indicate the date(s) authorized for hot work; and identify the object on which hot work is to be performed. SFC failed to ensure hot work permits are filled out in accordance with the hot work standard. Several hot work permits reviewed from 2023 and August 2024 were not filled out in line with the facility's hot work standard in a variation of the following: no LEL readings recorded when marked "yes", fire monitor and post work fire monitoring sections are not filled out when the permit indicates a fire watch is an additional require precaution, and expiration date and time of the permit is not filled out. (c) The permit shall be retained for three years after the completion of the hot work operations. SFC failed to maintain timelines for the hot work standard. SFC's hot work standard has conflicting timelines for recordkeeping, in one section the retention for hot work permits to be kept for one (1) year while another section it is three (3) years. The retention should be updated to reflect the current requirement. On October 24, 2024, SFC notified the conflicting timelines for retention has been resolved. AOC 15 - 40 C.F.R. 68.195(b) Required corrections. (b) Emergency contact information--Beginning June 21, 2004, within one month of any change in the emergency contact information required under 68.160(b)(6), the owner or operator shall submit a correction of that information. SFC failed to update emergency contact information in the RMP. SFC's last RMP submittal was on April 30, 2024, and does not represent the most accurate contact information. I called the Emergency Contact 24-Hour Phone listed in the RMP, and it went to voicemail after a few rings. The person's name in the voicemail of the Emergency Contact 24-Hour Phone is not the current person listed as the Emergency Contact Name. On October 24, 2024, SFC notified EPA that there has been a corporate personnel chance and is within the 30 days to make the change. I conducted a closing conference at SFC at 3:30 pm on August 29, 2024, for the inspection. During the closing conference, we explained the EPA inspection report process. At the time of this closing conference, I identified thirteen (13) areas of concern. However, some have been condensed into a single AOC. Additionally, AOCs 1, 2, 7-9, 13, and 15 were determined after the conclusion of the inspection and were not included in the closing conference. Section IV - FOLLOW UP 13 SFC Global Supply Chain, Inc. Inspection Dates: August 27 - 29, 2024 EPA received documentation on from SFC on September 17, 20, and 23, 2024 in response to the inspection records request on August 27, 28, and 29, 2024. On October 18, 2024, EPA sent SFC the draft inspection report and on October 24, 2024, SFC responded with updates and clarifications to the draft inspection report. Section V - LIST OF APPENDICES No Appendices. 14