Document embpjgYqMEmm21wGbQYm4VY6q

Clean Air Act Compliance Inspection Report United States Environmental Protection Agency Region 10 - Seattle, WA Clean Air Act Asbestos NESHAP Compliance Inspection Report Saint Alphonsus Regional Medical Center 1055 North Curtis Road Boise, Idaho Inspection Date: November 10, 2021 JOHN PAVITT Report Author Signature Digitally signed by JOHN PAVITT Date: 2022.01.07 14:14:48 -09'00' Date John Pavitt Asbestos NESHAP Inspector EPA Region 10 ALYSON SKEENS Peer Review Signature Digitally signed by ALYSON SKEENS Date: 2022.01.10 06:26:39 -08'00' Date Alyson Skeens Asbestos NESHAP Inspector EPA Region 10 KATHERINE MCCLINTOCK Date: 2022.01.10 15:49:32 -08'00' Digitally signed by KATHERINE MCCLINTOCK Section Chief Signature Date Katie McClintock ATES Section Chief EPA Region 10 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID Table of Contents Contents Contents .......................................................................................................................................... 2 1. Facility and Inspection Information ........................................................................................ 3 2. Introduction ............................................................................................................................. 4 3. Compliance History ................................................................................................................. 5 4. Records Review ....................................................................................................................... 5 5. Inspection Elements/Order ...................................................................................................... 9 Attachments Attachment 1 ........................................................................ EPA Region 10 Digital Image Log Attachment 2 ................................................ Notifications of Asbestos Demolition/Renovation Attachment 3 ........................................................................................................................ Map Attachment 4 ......................................................................................... Email, Records Request Attachment 5.........................................................................Email Response, Records Request Attachment 6 ................................................................................................... Asbestos Surveys Attachment 7 ...................................................................................... Waste Shipment Records Page 2 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID 1. Facility and Inspection Information Facility Owner: Saint Alphonsus Regional Medical Center 1055 North Curtis Road Boise, Idaho 83706 AFS/FRS Number: Saint Alphonsus Regional Medical Center No. ID0000001600100027 Abatement Contractor: Northwest Technologies, Inc. 11911 West Franklin Road Boise, Idaho 83709 David Holman, President (208) 323-0757 James Morledge, Project Manager (208) 323-0757 Other Operator: Andersen Construction Company, General Contractor 12552 West Executive Drive Boise, Idaho 83713 Chris Jackson (208) 275-8905 NAICS: Property Owner Contractor 622110 General Medical and Surgical Hospitals 562910 Remediation Services U.S. EPA Inspectors: John Pavitt Air and Toxics Enforcement Section (ATES) Enforcement and Compliance Assurance Division (ECAD) U.S. EPA Region 10 (R10) Alaska Operations Office 222 W 7th Ave., M/S 19 Anchorage, AK 99513-7588 (907) 271-5083 pavitt.john@epa.gov Alyson Skeens ATES/ECAD U.S EPA R10 (206) 553-5139 skeens.alyson@epa.gov State/Local Inspectors: None Page 3 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID Date of Inspection: 11/10/2021 Date of Report: 1/7/2022 Inspection Start/End Times: 1:11 pm - 3:46 pm Inspection Notice: This inspection was announced. Scheduled dates asbestos removal1: 11/8/2021 Scheduled dates demolition/renovation: 9/20/2021 - 1/31/2022 Were samples collected for this inspection? No Were any sample results positive for asbestos? N/A 2. Introduction The purpose of this inspection was to determine compliance with the Clean Air Act (CAA), National Emission Standards for Hazardous Air Pollutants for asbestos ("asbestos NESHAP") (40 CFR Part 61, Subpart M), which applies to renovation and demolition activities which may disturb asbestos at a "facility" as defined in the asbestos NESHAP.2 The inspection was led by John Pavitt, EPA R10. Also participating for on-the-job training was EPA R10 inspector Alyson Skeens. The facility is a 30+-year-old, 10-story hospital serving the Boise, Idaho area. Asbestos contractor Northwest Technologies (NWT) submitted a series of renovation notifications to EPA R10 throughout 2021 describing asbestos abatement from the hospital's South Tower, 2nd Floor (above ceilings), and 3rd Floor mechanical air shafts. At the time of the inspection, the most recent revised notification had been submitted on 10/20/21. (See Records Review below for details.) The inspectors confirmed during the on-site inspection that the facility was undergoing a series of asbestos abatement projects as notified. Work was temporarily paused on the day of the inspection which is typical for the project. The scope of work overall is to remove thermal system insulation (TSI) from pipes while the hospital renovates work space for new uses. The hospital remains open 24/7, and abatement workers have to work around hospital staff and patients for brief periods as schedules allow. 1 Most current project dates at the time of the inspection. Multiple notices have been submitted to EPA R10 as the work is performed in phases. 2 See 40 CFR 61.141. Facility means any institutional, commercial, public, industrial, or residential structure, installation, or building (including any structure, installation, or building containing condominiums or individual dwelling units operated as a residential cooperative, but excluding residential buildings having four or fewer dwelling units); any ship; and any active or inactive waste disposal site. Page 4 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID Disclaimer This report is a summary of observations and information gathered from the facility at the time of the inspection and from records review. The information provided does not constitute a final decision on compliance with CAA regulations or applicable permits, nor is it meant to be a comprehensive summary of all activities and processes conducted at the facility. 3. Compliance History A review of EPA's Enforcement and Compliance History Online (ECHO) database3 shows the Saint Alphonsus Regional Medical Center (St. Alphonsus) facility operates under a State of Idaho minor source air permit, has no history of CAA violations in the last three years and no enforcement actions in the last five years. Contractor NWT has no history in EPA's ECHO database other than this inspection. Environmental Justice Information The ECHO database shows the area of Boise, Idaho where the St. Alphonsus facility is located has an Environmental Justice (EJ) Screen Index rating above the 80th percentile for seven indices. 4. Records Review I reviewed the following records for this asbestos NESHAP compliance inspection. a. Asbestos Notifications (Attachment 2) Notice Type Asbestos Renovation Notice Revision #3 Revision #4 Submittal Submitted by Date 10/20/2021 NWT 10/21/2021 NWT Work Description Removal of 700 linear feet of asbestoscontaining thermal system insulation (TSI) Work Schedule Start: 10/22/2021 End: 10/22/2021 Continuation, removal of 700 linear feet of TSI. Comment The 700 linear feet of TSI is identified as Regulated Asbestos Containing Material (RACM). NWT is also the Waste Transporter for this project. Work Schedule 3 See https://echo.epa.gov/. For more information on EPA's EJ Screen Indexes, see EJSCREEN home page. Page 5 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID Revision #5 10/27/2021 NWT Start: 10/28/2021 End: 10/28/2021 Continuation, removal of 700 linear feet of TSI. Revision #6 11/1/2021 NWT Work Schedule Start: 11/2/2021 End: 11/2/2021 Continuation, removal of 700 linear feet of TSI. Work Schedule Start: 11/8/2021 End: 11/8/2021 b. Asbestos Survey and Waste Shipment Records On 11/16/2021, I sent an email to NWT representatives requesting records related to asbestos removal at the St Alphonsus facility (Attachment 4): 1. Asbestos sampling results for areas EPA viewed in the hospital during the tour. 2. Waste Shipment Records (WSR) for all asbestos-containing-waste materials removed from the facility from January 1, 2021 until the date of the request. NWT responded the next day (Attachment 5) and provided the following records. Asbestos Surveys (Attachment 6) The asbestos NESHAP requires the owner or operator of a demolition or renovation activity to conduct a thorough survey for the presence of asbestos prior to commencing the activity (61.145(a)). Records provided from 2020 and 2021 show NWT and in some cases a 3rd-party lab, collected extensive samples in 10 different sampling events and analyzed them for asbestos. According to the test results provided, the most common type of asbestos found in the hospital was Chrysotile. Samples with positive asbestos results ranged in content from 2% up to 60%. Full results are shown in Attachment 6. As a brief summary, the samples testing positive with more than 1% asbestos were the following. Lab Received Date/ Area Sampled 1/16/2020 20NW33A / St. Alphonsus: Mechanical Room 2nd Floor 2/19/2020 SARMC South Tower, 3rd Floor Sample Description Mechanical Room, Air Handling Unit No. 3 TSI, Hot Water Lines, White Layer 2 - 12" vinyl floor tile-beige compact hard granular Layer 3 - mastic-black pliable Result 30% Chrysotile 4% Chrysotile and 5% Chrysotile Page 6 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID Lab Received Date/ Area Sampled 3/5/2020 SARMC - South Tower, 3rd Floor ICU Step Down Remodel 3/23/2020 St. Alphonsus: Mechanical Room 2nd Floor 20NW33A 7/28/2020 20NW33A - St. Alphonsus Mechanical Room 2nd Floor 4/8/2021 SARMC 3rd Floor ICU Stepdown 21NW33B Sample Description Layer 1 - 12" vinyl floor tile-3CA-tan mottled compact hard granular Layer 2 - mastic-black pliable Layer 2 - vinyl floor tile-beige compact hard Granular Layer 3 - mastic-black pliable Layer 1 - 12" vinyl floor tileequipment room entry-brown mottled compact hard granular Layer 2 - mastic-black pliable Layer 3 - mastic-black pliable 12" beige floor tile with black mastic 12" tan mottled vinyl floor tile with black mastic Beige vinyl floor tile with black mastic 12" brown mottled vinyl floor tile with black mastic Remnant black mastic under carpet Mechanical Room Air Handling Unit No 4 HVAC Ducting Sealant, Silver Mechanical Room Air Handling Unit No 3 HVAC Ducting Sealant, Silver HVAC ducting sealant-mechanical room air handling unit no. 3 ceiling grey pliable with fibers HVAC ducting sealant-mechanical room air handling unit no. 3 wall-grey pliable with fibers Layer 2 - HVAC ducting sealant mechanical room air handling unit no. 3 floor-grey pliable with fibers Thermal System Insulation Fire Door Insulation Result 3% Chrysotile 4% Chrysotile and 5% Chrysotile 2% Chrysotile 3% Chrysotile 4% in tile, 5% in Mastic 3% in tile, 3% in Mastic 4% in tile, 5% in mastic 2% in tile, 2% in mastic 3% 2% Chrysotile 2% Chrysotile 4% Chrysotile 4% Chrysotile 2% Chrysotile 15% Chrysotile 15% Amosite 4% Chrysotile 5/13/2021 SARMC 3rd Floor ICU Stepdown 6/16/2021 21NW33B - SARMC 3rd Floor ICU Stepdown Hydronic Pipe Wrap (White) - Room 3436-white pliable fibrous Layer 1 - vinyl floor tile-conference room-tan and brown compact granular Layer 2 - mastic-black pliable Sheet Vinyl 35% Chrysotile 4% Chrysotile 8% Chrysotile 60% Chrysotile Page 7 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID Lab Received Date/ Area Sampled 6/18/2021 21NW33B SARMC 3rd Floor ICU Stepdown 6/22/2021 21NW33B SARM 3rd Floor ICU Stepdown Sample Description Layer 2 - backing-grey fibrous Sheet Vinyl Layer 2 - backing-tan fibrous Vinyl floor tile-beige compact granular with fibers Result 60% Chrysotile 4% Chrysotile Vapor barrier mastic-patient room No. 3445 shower-black bituminous resilient with fibers Counter top mastic puck-patient room No. 3448 exterior window-brown brittle with fibers 4% Chrysotile 2% Chrysotile Asbestos Waste Shipment Records (Attachment 7) The asbestos NESHAP requires the owner or operator of a project subject to the NESHAP to maintain Waste Shipment Records (WSR) for each load of waste transported from the job site. The WSR form must include details including the contents of the load, quantity of waste, the job site where it was generated, contact information for the generator and transporter and the landfill destination. (40 CFR 61.150(d)) The WSR forms provided by NWT included all details required by the NESHAP. No discrepancies were noted by the landfill when they received the waste. The records provided show that abatement contractor NTW transported eight loads of asbestos waste from the St. Alphonsus facility to the Idaho Regional Waste Services Landfill in Boise on the following occasions: Date Transported/ Delivered 4/22/2021 5/27/2021 5/27/2021 Waste Description/Amount Fireproof Doors, Carpet, Floor Tile, Mastic Friable ACM - 27 Bags - 9 Boxes - 3 Wraps (wrapping materials) Sheet Metal and Caulking Non-Friable ACM - 1 Wrap. HVAC Duct w/ Fireproofing Friable ACM - 1 Box - 22 Bags 18 Cubic Yards (CY) Discrepancies Noted by Landfill? No 10 CY No 2 CY No Page 8 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID 5/27/2021 6/1/2021 6/15/2021 7/22/2021 9/2/2021 Total Sheet Metal and Caulking 10 CY No Non-Friable ACM - 1 Wrap. Sheet Metal and Caulking 10 CY No Non-Friable ACM - 1 Wrap. TSI, Carpet, Floor Tile and 3.75 CY No Mastic Friable ACM - 2 Boxes - 13 Bags TSI, Carpet, Floor Tile and 4.0 CY No Mastic Friable ACM - 34 Bags - 1 Box - 7 Wraps TSI, Sheet Vinyl, Floor Tile and 6 CY No Mastic Friable ACM - 53 Bags - 1 Box 63.75 CY 5. Inspection Elements/Order Pre-Inspection Observations This was an announced inspection. EPA inspectors John Pavitt and Alyson Skeens arrived at the facility at about 1:00 p.m. and parked in the hospital parking lot. We entered the hospital at about 1:10 pm and signed a visitor's log with hospital staff who also took our temperatures and asked us health questions as part of their Covid-19 pandemic screening process. We work face masks as required by the hospital during our visit. We were met by NWT representatives David Holman and James Morledge. Entry and Opening Conference with Facility Representatives EPA inspector Skeens and I introduced ourselves to the Mr. Holman and Mr. Morledge and I showed them my inspector credentials. I explained we were there to check on compliance with the asbestos NESHAP at this job site. I pulled out a copy of the most recent asbestos renovation notification EPA received for the project (Attachment 2). The notification states that 700 linear feet of asbestos-containing thermal system insulation (TSI) was being removed for this project. The NWT representatives described the scope of work. Mr. Morledge said that originally the quantity was going to be 300 linear feet but they revised the notice to reflect the larger amount as Page 9 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID the project grew in scope. He said the TSI was mostly pipe elbows and fittings. He said they are not demolishing anything for this project, just renovating. He said they have to work around hospital staff and go through service areas and hallways, so they plan ahead to avoid disturbing hospital operations. He said the waste material is double-bagged and moved through the hospital in carts. Waste material is brought to their company office location in Boise and temporarily stored in a locked shed, then brought to the landfill when they have a full load, he said. If they have a full load at the hospital they will go directly to the landfill, he said. I asked the NWT representatives to let me know if they believed any information I was gathering was Confidential Business Information (CBI). They did not make a CBI claim during the inspection. Facility Walk-Through We toured the hospital facility with the NWT representatives. Work was temporarily paused that day, as described in their most recent notification to EPA. The NWT representatives showed us where they had been abating asbestos in 2019, 2020 and 2021. They described how they were doing the work. Our tour included the South Tower, 2nd Floor (areas above ceilings) and the 3rd Floor, Mechanical Air Shafts. Other trads workers (electrician, carpenters, etc.) were working throughout the areas we viewed. They showed us the 2nd Floor Cafeteria where they will be removing asbestos from above the ceiling. The Cafeteria was being used by the public during our inspection. They said they use glove bags when working on pipes to prevent visible emissions. They sometimes have to use a crane to remove bagged asbestos waste from the work area and set it outside, they said. They also described constructing a portable work space for workers in some locations, with plastic walls and keeping it under negative air to prevent visible emissions. The NWT representatives said their work sometimes includes hot surfaces (hot pipes) which cannot be turned off. I said the asbestos NESHAP allows contractors to request permission to do dry removal in situations where it's not safe or would cause equipment damage, for example around hot pipes. Additional controls need to be used in those situations and written permission is required. (61.145 (c)(i)(A)) I did not see suspect asbestos debris, waste material or dust from any of the areas we toured at the St Alphonsus facility. We asked to see a waste storage area on site. The NWT representatives said no waste was currently stored on site, but offered to show us the storage area at their company office location, at 11911 West Franklin Road. NWT Office and Storage Area, 11911 W Franklin Road At about 2:40 pm left the St Alphonsus facility and drove to the NWT office to inspect their waste storage area, arriving at about 3:10 pm. Mr. Holman and Mr. Morledge met us there. They showed us a storage shed which was locked when we arrived. They opened the shed and we saw three bags of waste stored inside. The bags were intact, seal tightly and were labeled as coming Page 10 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID from the St Alphonsus facility. Mr. Holman and Mr. Morledge said the bags were filled with glove bags which had asbestos in them from the abatement. I examined the bags and saw small water droplets in two of the bags. I did not see dry dust in the bags. I said the asbestos NESHAP requires all waste to be "adequately wet" and emphasized that they have to ensure the materials are wet enough to prevent any visible emissions. Sampling I did not collect samples for this inspection. Asbestos sampling results were provided by the facility representatives and are included as Attachment 6 to this report. Closing Conference At about 3:20 pm we had a closing conference with the NWT representatives at their office, outdoors by the storage shed. I said that this inspection allowed us to learn about the past, present and future work at the St Alphonsus facility. I said the work spaces we viewed that day were clean, with no suspect asbestos residue visible. I said I believed the debris we saw at the work site was from other workers (electricians, carpenters, etc.) who came into the work spaces after the abatement. I said my understanding from our inspection that day was they were routinely using glovebags to remove TSI on pipes. We viewed the mechanical shafts there had been abating. The waste bags we saw in the storage shed were labeled appropriately. I said I would send them an email asking for the following additional records:4 - Waste Shipment Records for asbestos removed from the project. I said my recommendation for improvement was to use more water in their waste bags because water should be easy to see in the bags. I had to really search them to find signs of water droplets and it shouldn't be that hard. I said I would check on the labeling requirements for waste containers under the asbestos NESHAP and let them know if they needed additional details on their labels. (61.150(a)(v))5 We asked the facility representatives if they had any questions for the EPA inspectors. Mr. Holman asked whether or not they need to submit notifications for projects at residences (homes). I said notification is not required for those projects. I said he can always call us if he has questions on specific projects. He also asked about flooring material projects. I said a renovation that involves nonfriable flooring material does not require notification to EPA. I said that if they think it's possible that it could become friable, then go ahead and submit a notice just in case because a notice would be required at that time and they would have to wait the normal 10-working-day waiting period. 4 I send an email requesting records on 11/16/21. 5 61.150(a)(v) requires waste containers to be labeled with the name of the waste generator and the location at which it was generated. The bags viewed during this inspection included those details. Page 11 of 12 Asbestos NESHAP Inspection, St. Alphonsus Regional Medical Center, Boise, ID We left the facility at about 3:45 pm. Page 12 of 12