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Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho Clean Air Act Asbestos NESHAP Compliance Inspection Report Veterans Affairs Hospital - Boise 500 West Fort Street Boise, Idaho Inspection Date: November 9, 2022 Report Author Signature: ALYSON SKEENS Date: 2023.01.04 12:14:11 -08'00' Digitally signed by ALYSON SKEENS _________________________________________________ Alyson Skeens, Environmental Engineer, Region 10 Peer Review Signature: _J__O__H___N____P__A___V__I_T__T___D_a_t_e:_2_0_2_3_.0_1_.0_4_1_3_:0_2_:1_3_-_0_9_'0_0_' _ Digitally signed by JOHN PAVITT John Pavitt, Air Compliance Inspector, Region 10 Section Chief Signature: DERRICK TERADA Date: 2023.01.04 14:10:49 -08'00' Digitally signed by DERRICK TERADA _________________________________________________ Derrick Terada, Acting ATES Section Chief, Region 10 Page 1 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho Table of Contents 1. Facility and Inspection Information ........................................................................................ 3 2. Introduction ............................................................................................................................. 4 3. Compliance History ................................................................................................................. 5 4. Environmental Justice Information ......................................................................................... 5 5. Records Review ....................................................................................................................... 5 6. Inspection Elements/Order ...................................................................................................... 6 7. Post Inspection......................................................................................................................... 9 Attachments Attachment 1 ........................................................................ EPA Region 10 Digital Image Log Attachment 2...................................................Notification of Asbestos Renovation, Original 1 Page 2 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho 1. Facility and Inspection Information Facility Owner: Department of Veterans Affairs (VA) 500 West Fort Street Boise, Idaho 83701 Facility Representative: Austin Gatz Industrial Hygienist - VA 208-422-1000 - extension:7829 Austin.gatz@va.gov Jessie Roberts Health and Safety Personnel - VA Facility Personnel: Ron Poyner Volunteer Jake Faulkner Voluntary Service Coordinator AFS/FRS Number: 110071356560 Abatement Contractor: Asbestos Abatement, Inc. (AAI) P.O. Box 2593 Boise, Idaho 83701 106 West 30th Street Boise, ID 83714 https://buildingdemo.biz/ Korry Holden President of AAI 208-345-3574 korry@buildingdemo.biz Ezequiel Iniguez On-Site Supervisor NAICS: 562910 - Remediation Services U.S. EPA Inspectors: John Pavitt Enforcement and Compliance Assurance Division (ECAD) Air and Toxics Enforcement Section (ATES) U.S. EPA Region 10 (R10) (907) 271-5083 Pavitt.john@epa.gov Page 3 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho Alyson Skeens ECAD/ATES U.S. EPA R10 (206) 553-5139 Skeens.alyson@epa.gov Date of Inspection: November 9, 2022 Date of Report: January 3, 2023 Inspection Start Time: 2:55 PM Inspection End Time: 4:15 PM Inspection Notice: Unannounced Scheduled dates asbestos removal1: October 31, 2022 - November 25, 2022 Scheduled dates demolition/renovation: Blank 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 with Alyson Skeens, EPA R10 participating. The facility is a 65-year-old plus hospital with various new construction added on to the original structure. The hospital is approximately 60,000 square feet with the main hospital area as building 67. The facility hired AAI to remove approximately 4,600 square feet of asbestos containing tile and mastic as well as two linear feet of asbestos containing material (ACM). The asbestos NESHAP notice of demolition or renovation submitted by AAI (40 C.F.R. 61.145 (b)(3)(i)) stated that the renovation was occuring in building 67, on the 3rd floor. The inspectors 1 Dates provided in notifications to EPA R10. 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 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho confirmed during the on-site inspection that renovation was occuring on the third floor in a section of the medical/surgical stepdown unit (2-M/S). 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 showed the abatement contractor AAI has not had informal or formal enforcement actions in the last five years. ECHO shows the one-site inspection that this report covers is the only compliance monitoring activity in the last five years. 4. Environmental Justice Information EPA's Environmental Justice Screening and Mapping Tool (EJScreen)4 showed the VA Hospital in Boise, Idaho is not in an area with an index over the 80th percentile for one or more EJ indices. 5. Records Review Asbestos Notifications The asbestos NESHAP requires each owner or operator of a demolition or renovation activity to which this section applies to provide the Administrator with written notice of intention to demolish or renovate. The owner or operator must postmark or deliver the notice at least 10 working days before asbestos stripping or removal work or any other activity begins (such as site preparation that would break up, dislodge, or similarly disturb asbestos material). (40 C.F.R. 61.145 (b)(3)(i)) Approximately on October 19, 2022, the EPA Region 10 Office received an original asbestos NESHAP notice of demolition or renovation, attachment 2. The notice stated that regulated asbestos containing materials (RACM) and Category I non-friable asbestos were to be removed. Summarized Notice Information: Certification Signature Date: October 19, 2022 Asbestos Removal Start Date: October 31, 2022 Asbestos Removal End Date: November 25, 2022 Work hours: M-F 7:00 AM - 4:00 PM Facility Point of Contact: Shawn Alexander Testing Methods: Polarized light microscopy with dispersion staining RACM to be removed: 2 linear feet 3 See https://echo.epa.gov/. 4 See EJSCREEN: Environmental Justice Screening and Mapping Tool | US EPA Page 5 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho Category I non-friable: 4,600 square feet Waste Disposal Site: Idaho Waste Systems Based on the certification signature date and the asbestos removal start date, the notice was submitted 8 working days in advanced. As noted, in section 7 during the on-site inspection the abatement contractor stated that work actually started on the day of the inspection, November 9, 2022. Asbestos Survey The asbestos NESHAP requires that the owner or operator of a demolition or renovation activity, prior to the commencement of the demolition or renovation, thoroughly inspect the affected facility or part of the facility where the demolition or renovation operation will occur for the presence of asbestos, including Category I and Category II nonfriable ACM. (40 C.F.R. 61.145 (a)) Inspectors were told during the on-site inspection by Mr. Gatz that the VA Hospital Boise had previously conducted asbestos testing. Mr. Gatz offered to send the testing results to the inspectors. The inspectors ultimately did not request this document. Waste Shipment Record For all asbestos-containing waste materials being transported off the facility the owner or operator are required to maintain waste shipments records (WSR). This record must be certified and include the name, address and telephone number of the generator, the name and address of the EPA regional office, the approximate quantity or waste, the name and physical location of the disposal site, the name and phone number of the disposal site, the date or transport and the transport's name, address and phone number. (40 C.F.R 61.150(d)(1)) Inspector Pavitt asked Mr. Iniguez for a copy of any WSRs for waste generated from this current project. Mr. Iniguez stated that waste material had not yet been taken from the work zone for disposal. Because the waste had not left the facility, the requirement for a WSR had not yet been triggered at that time. 6. Inspection Elements/Order Pre-Inspection Observations The inspectors did not make any pre-inspection observations, as the asbestos work zone was in an interior space of the hospital and not visible from public spaces. Entry and Opening Conference with Facility Representatives Inspector Pavitt and Skeens entered the hospital at approximately 2:55 PM. Upon entry both inspectors went to the front desk where Inspector Skeens asked Mr. Poyner, a hospital volunteer, if he was aware of an asbestos renovation and how to get to the worksite. Inspector Pavitt Page 6 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho explained the purpose of the inspection, said that we were with the Environmental Protection Agency then presented his credentials. Inspector Skeens showed her credentials shortly after. My. Poyner introduced the inspectors to Mr. Faulkner, volunteer services coordinator. Inspector Pavitt again explain the purpose of the visit, who we were looking for and the potential work site location. Inspector Pavitt called the phone number listed in the notification for Mr. Alexander with the VA and left a voicemail. During this, Mr. Faulkner looked up Mr. Alexander in the internal VA system and discovered Mr. Alexander was not associated with the VA hospital but was located on the east coast. Mr. Poyner then led the inspectors to 2-M/S area of the hospital believing this to be the location of the renovation. Inspector Pavitt asked the medical staff at 2-M/S about asbestos removal taking place in the ward. A nurse showed the inspectors a cordoned off doorway where an "Asbestos Warning" sign was posted but stated she had not seen contractors working there. Both inspectors observed that the inside of the door it was covered with plastic, in addition to the asbestos warning sign. Both inspectors then returned to Mr. Faulkner's office with Mr. Poyner to inquire about a point of contact with the health & safety office. Mr. Faulkner contacted Ms. Roberts about the inspection, who met them shortly thereafter with Mr. Gatz at the front lobby. Both inspectors introduced themselves and presented their credentials. Inspector Pavitt explained the purpose of the inspection to the VA representatives Ms. Roberts and Mr. Gatz. Mr. Gatz and Ms. Roberts escorted the EPA inspectors to the asbestos work site entrance located at a third-floor stairwells. Shortly upon arrival to the work site Ms. Roberts left placing Mr. Gatz as the representative for VA Hospital Boise. At approximately 3:30 PM Inspector Pavitt opened the stairwell door leading directly into the work site but left the plastic protective barriers in place and called out for the on-site supervisor. While waiting for the on-site supervisor Mr. Gatz stated that the renovation work started today, as the containment set up was completed that morning. Mr. Iniguez stepped out and introduced himself as the on-stie supervisor for AAI during this project. Both inspectors introduced themselves and presented their credentials. Inspector Pavitt explained the purpose of visit. Inspector Pavitt asked what the scope of work was and what type of removal methods were being utilized. Mr. Gatz stated that the 2-M/S section of the hospital was receiving an equipment upgrade with renovations taking place before the installation. Mr. Iniguez stated that AAI was hired to remove floor tile and mastic. He said AAI was provided testing results that showed that floor tile was negative and the mastic positive for asbestos. Mr. Iniguez continued that there were two types of mastic and the black mastic along the edge was the positive layer. Mr. Iniguez stated AAI would also be removing portions of interior walls in order to remove the tile and mastic. For work practices, Mr. Iniguez stated the workers were using a "black bar" (pry bar), to remove the tiles then would be using a chemical mastic remover which he called "747" with rags to remove the mastic. Inspector Pavitt asked what the manufacture and name of the mastic remover Page 7 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho was. Mr. Iniguez retrieved a container of chemical mastic remover to show inspectors. The container label listed the manufacture as Sentinel and the name of the chemical as formula 747 fresh scent mastic remover, (See attachment 1, photos 90095-90099. Mr. Iniguez stated that AAI uses 747 in federal buildings, schools and hospitals and they have not experienced problems with it. Inspector Pavitt asked for more detail about the removal process of both the tile and mastic. Mr. Iniguez stated AAI workers were applying water to the tile with an airless sprayer then using black bars to remove tiles. Mr. Iniguez explained AAI frequently uses the work practice of applying water during tile removal as the material can easily become friable. For the removal of the mastic 747 is applied with a hudson sprayer then left to sit for several minutes after which workers use rags to wipe and squeegee up the solution. Saturated rags are placed in a disposal bag. Filled disposal bags are placed in a waste drum and later removed from the work site. Mr. Iniguez reiterated to inspectors that the chemical mastic removal method does not produce dust. Inspector Pavitt asked if any power tools would be used during the removal process. Mr. Iniguez stated AAI would be using a buffer to removal the large swatches of mastic. A worker would apply 747 to the mastic then another would use the buffer with a low abrasive pad. An additional worker would follow behind the buffer using rags to squeegee the solution left behind. Mr. Iniguez stated that he was mainly seeing the mastic just on the edge, so he had the worker apply 747 then wipe the solution up with rags. Inspector Pavitt asked if hand grinders were being used. Mr. Iniguez stated that grinders were not being used and typically AAI does not use them on asbestos work sites. Inspector Pavitt asked if the amount of material to be remove listed on the notice was still accurate and if there were any additional floor layers were found. Mr. Iniguez stated that the 4,600 square feet was still an accurate scope and that no other floor layers we found. The floor layers were tile, mastic then cement slab, he said. Inspector Pavitt asked how many rooms were being renovated. Mr. Gatz stated that he could not remember but layout of the work area was an L-shaped hallway with patient rooms coming off of it. Inspector Pavitt asked if testing was conducted before the project began. Mr. Gatz stated a baseline survey was conducted approximately in 1985, followed later with a comprehensive AHERA inspection in 2019. He said the AHERA inspection was conducted before the bidding process was initiated for a different, previous renovation project. Mr. Gatz stated due to this being an active hospital projects required a lot of advanced planning. The samples taken during the AHERA inspection showed the tile and base cove was negative for asbestos but the mastic under the tile was positive. Inspector Pavitt asked if the testing results were currently available. Mr. Gatz stated he could provide the test results once he was back at his office. Inspector Pavitt asked what work was being conducted currently and how AAI ensured fugitive emissions were not leaving the work site. Mr. Iniguez stated that workers had so far removed all of tile and had just begun removing mastic. AAI was still early into the project and were not slated to end until next week. In order to prevent fugitive emissions, he said, plastic tarp was covering doorways and most other surfaces. In addition, three negative air machines were being used to filter air from the activity. and currently did not have air build up in work area. Page 8 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho Facility Walk-Through From approximately 4:00 PM - 4:05 PM Inspector Pavitt stepped into the work area where Mr. Iniguez provided a quick tour. Inspector Pavitt observed workers using rags, mastic remover chemical and the buffer Additionally, he did not see visible dust and saw barriers in place at doorway. Inspector Skeens and Mr. Gatz stayed in the stairwell outside of the work zone during the work site tour. Mr. Gatz stated that he preferred more strict safety protocols than less due to his experience as an industrial hygienist in Oregon. Mr. Gatz stated that if the tile was positive for mastic he would have placed air monitoring at the entrance to stairwell and the entrance to 2 M/S that inspectors previously observed. Sampling The inspectors did not collect samples for this inspection. Inspectors ultimately did not request the VA's sampling results from Mr. Gatz after leaving the facility. Closing Conference The closing conference began after Inspector Pavitt and Mr. Iniguez came out of the work area. Inspector Pavitt stated that he did not see visible dust and the materials being removed did not appear friable. Inspector Pavitt said that under the asbestos NESHAP regulations, a renovation project that disturbs only non-friable materials, like the flooring mastic, is not subject to the regulation. ( 61.145(a)(4). Inspector Pavitt said EPA would be writing an inspection report and would send the facility a copy and verified that Mr. Gatz would be the point of contact (POC) for the inspection. Inspector Pavitt stated that the asbestos NESHAP notice listed Mr. Alexander as the POC under the facility description. Mr. Alexander was unable to be reached and during the on-site inspection and was discovered to not be associated with the VA Hospital Boise. Mr. Gatz provided another VA contact: Joel Holtrop 208-941-0977 Joel.holtrop@va.gov Mr. Gatz stated the Mr. Holtrop is the POC for contractors and Mr. Gatz is brought in when there are hazardous materials present. 7. Post Inspection The EPA inspectors did not request additional records or other follow-up from the facility representatives. The inspection confirmed that the renovation project involved the use of solvent and a mechanical buffer with an abrasive pad to remove asbestos-containing mastic. After the Page 9 of 10 Asbestos NESHAP Inspection, Veteran's Affairs Hospital, Boise, Idaho on-site inspection, the EPA inspectors reviewed EPA guidance which shows that EPA has previously determined that this work practice causes nonfriable floor mastic to become friable and is considered RACM under the asbestos NESHAP.5 The notification provided by the contractor stated work would start on October 31st, however, the inspection documented that work actually started on the day of the inspection, November 9th (9 days later). The asbestos NESHAP requires that notification be revised if the start day changes. The notice must be revised as soon as possible before the original start date, and no later than the original start date which was not done as required. (61.145(b)(3)(iv)(A)) 5 See EPA's Applicability Determination Index (http://cfpub.epa.gov/adi/). Control No. A060002, Removal of Floor Mastic Using a Mechanical Buffer, 12/05/2005. Page 10 of 10