SOP #: EMP 1 Revision #: Current Version Implementation Date: Page #: Page 1 of 8 Last Reviewed/Update Date: Expiration

Transcription

1 Implementation Page #: Page 1 of 8 Last Reviewed/Update 1. Purpose and Scope The purpose of this document is to describe the Management program at Boston University (BU) and the Boston Medical Center (BMC), and to define the interactions, roles, and responsibilities of the Management Division with respect to other BU and BMC departments. The Management program at BU and BMC is the sum of the personnel, policies, and activities which promote compliance with environmental regulations and environmental stewardship. The Management program is a division of Health and Safety (EHS). 2. References The Management program is responsible for ensuring BU and BMC compliance with a number of regulations, standards, and best practices, including but not limited to those listed below Regulations Federal Regulations Oil Spill Prevention, 40 CFR 112 Hazardous Chemical Waste, 40 CFR 260 Air Emissions, 40 CFR 60,70 Water Emissions, 40 CFR 403 PCBs, 40 CFR State Regulations Underground Storage Tanks, 527 CMR 9 Massachusetts Contingency Plan, 310 CMR 40 Hazardous Chemical Waste, 310 CMR 30 Medical/Biological Waste, 105 CMR 480 Air Emissions, 310 CMR 7 Water Emissions, 360 CMR 10, 314 CMR 7&12, 257 CMR Other SOPs Boston Medical Center Management System Boston University Health and Safety Policy Manual 2.3. Supplementary Documents Boston Medical Center Integrated Contingency Plan Boston University Medical Campus Integrated Contingency Plan

2 Implementation Page #: Page 2 of 8 Last Reviewed/Update Boston University Charles River Campus Integrated Contingency Plan Boston Medical Center Sewer Use Discharge Permit Boston University Medical Campus Sewer Use Discharge Permit Boston University Charles River Campus Sewer Use Discharge Permit Boston Medical Center Air Plan Approvals Boston University Charles River Campus Title V Operating Permit 3. Definitions Stormwater: rainwater as well as water from washing cars, overwatering lawns, and other sources. Stormwater is of concern as it flows either directly or via discharge piping into surface waters such as rivers, lakes, and streams. Industrial Wastewater: water from industrial activities including laboratory and facility operations. Industrial wastewater generally undergoes pretreatment and is discharged to the sanitary sewer. At BU and BMC industrial wastewater discharges are managed under the provisions of an institution-specific Sewer Use Discharge Permit. Massachusetts Water Resources Authority (MWRA): the local Publicly Owned Treatment Works responsible for managing the sewer effluents for greater Boston. MWRA regulates industrial wastewater discharges and issues Sewer Use Discharge Permits. Protection Agency (EPA): the branch of the federal government tasked with protection of the environment. EPA promulgates and enforces environmental regulations on a national level. Massachusetts Department of Protection (DEP): the branch of the state government tasked with protection of the environment. DEP promulgates and enforces environmental regulations on a state level. DEP regulations must be at least as strict as the national EPA regulations. In many circumstances (including hazardous waste, water emissions, air emissions, and underground storage tanks), DEP regulations overlap with and even exceed EPA regulations. Massachusetts Department of Public Health: the branch of the state government which promulgates and enforces biological waste regulations.

3 Implementation Page #: Page 3 of 8 Last Reviewed/Update Hazardous Waste: refers to chemical wastes which are governed under federal or state regulations due to their hazardous characteristics. In Massachusetts, waste oil is considered a hazardous waste. Underground storage tank: a storage tank which is partially or completely buried in the earth. At BU and BMC underground storage tanks are used to store fuel oil. Medical/biological waste: human and animal tissues and fluids, infectious organisms, contaminated items, and sharp medical/research implements. Universal waste: a subset of federal and state hazardous waste for which the regulatory burden is slightly less onerous. They are called universal because they are generated universally across industrial sectors, and include things like fluorescent bulbs (due to mercury content), mercury-containing devices such as switches, pesticides, and certain batteries. 4. Roles and Responsibilities Management Division is responsible for: Serving as the liaison between governmental environmental authorities and BU/BMC; Developing policies and procedures for BU/BMC which ensure compliance with environmental regulation and responsible environmental stewardship; Managing the disposal of regulated wastes, including chemical, biological, and radiological wastes at BU/BMC; Serving as environmental subject matter experts for other departments, such as Facilities Management, affected by environmental regulations and considerations; Providing training in environmental management to relevant staff at BU/BMC; Inspecting and tracking compliance with environmental programs at BU/BMC; Preparing most regulatory-driven environmental plans, permits, reports, and submittals for BU/BMC; Responding to environmental incidents at BU/BMC, including site management, internal and external notification, and remediation; Working with the BMC Green Committee and the BU Sustainability Department to promote sustainable operations and practices; and Tracking changing and emerging environmental rules and regulations.

4 Implementation Page #: Page 4 of 8 Last Reviewed/Update BU Facilities Management and Planning (FMP) / BMC Facilities and Energy Management (FEM)is responsible for: Overseeing the daily operation, maintenance, testing, and general management of environmentally significant installations including: o Fuel storage tanks o Fuel burning equipment including boilers and emergency generators o Equipment which contains refrigerant gases o Industrial Wastewater pretreatment systems o Stormwater management infrastructure o Building heating and cooling systems o Building plumbing and ventilation systems Issuing internal notification prior to the addition or significant alteration of any environmentally-significant installation; Tracking the quantities and types of fuel used at BU/BMC; Tracking the consumption of water and energy at BU/BMC; Providing adequate space and facilities to manage regulated wastes including chemical, biological, and radioactive wastes; Carrying out operations in conformance with existing BU/BMC policies, including maintenance schedules, disposal practices, incident notification, and record keeping; and Managing the disposal of recyclable materials including paper, cardboard, and surplus furniture. Office of General Counsel is responsible for: Providing advice and counsel in the event of an environmental incident; and Negotiating with environmental regulators in the event of an enforcement action taken against BU/BMC in response to an environmental incident. Research and Clinical Departments are responsible for: Generating and accumulating wastes according to BU/BMC policies and procedures; Providing internal notification in the event of an environmental incident; and Attending all required environmental training sessions. 5. Special Requirements 5.1. Equipment and Supplies Required Chemical spill kits and materials

5 Implementation Page #: Page 5 of 8 Last Reviewed/Update Oil spill kits and materials Emergency response equipment including PAPRs, containment drums and berms, and personnel protective equipment (PPE) Dedicated storage rooms for chemical, biological, and radioactive waste Drums, containers, and labels for managing chemical, biological, and radioactive waste Radiation detectors Industrial wastewater pretreatment and monitoring systems Stormwater collection and treatment systems Emission stacks for fuel burning equipment Run-time meters for emergency generators Secondary containment structures for fuel storage installations Overfill, corrosion protection, and leak detection equipment for underground storage tanks Recycling equipment including cardboard bailers, solvent distillation equipment, and silver-recovery equipment Amalgam separators at dental facilities 5.2. Safety Requirements Management operations require compliance with all applicable BU/BMC safety policies and procedures implemented through the Health and Safety Training The Management Division of EHS provides training to the BU/BMC community, including: Oil and Waste Management/SPCC for Facilities Management staff Universal Waste training for Facilities Management staff Hazardous Waste training to BU/BMC departments who do not receive Laboratory Safety Training Department of Transportation (DOT) training to custodial leads and others who sign biological waste shipping papers Staff members in the Management Division receive OSHA training and Resource Conservation and Recovery Act (RCRA)/DOT training from a third party vendor each year, which allows them to be first responders to environmental incidents and to sign and manage dangerous goods shipping papers Monitoring Requirements

6 Implementation Page #: Page 6 of 8 Last Reviewed/Update Sewer Use Discharge Permits for industrial wastewater require sampling of industrial wastewater systems multiple times each year. Some operating permits for fuel burning equipment require air monitoring. Contaminated site cleanup typically requires a monitoring schedule for soil and ground water to document cleanup activities. Sampling is often necessary to characterize a waste product prior to disposal Personnel Protective Equipment (PPE) Management operations require compliance with all applicable BU/BMC safety policies and procedures implemented through the Health and Safety Medical Surveillance Staff members in the Management Division receive Hazardous Materials physical examinations annually through Occupational Health Center or the Research Occupational Health Program Other Prerequisites None. 6. Applicable Locations All BU/BMC locations. 7. Procedures and Instructions In general, the Management Division provides guidance, oversight, and training to help departments such as Facilities Management carry out their operations. The Management program can be administered only through cooperation between the Management Division and the various other departments at BU/BMC which conduct environmentally sensitive operations. Building operation and maintenance, solid waste management, research and clinical laboratory work, and many other campus activities require input and direction from the Management Division in order to ensure compliance with a variety of environmental regulations.

7 Implementation Page #: Page 7 of 8 Last Reviewed/Update Procedures for specific environmental programs are described in detail in the BU Health and Safety Policy Manual and the BMC Management System policies. 8. Forms Forms and signage exist for a variety of Management processes. The attached Management functional chart further illustrates the disciplines within the division. Forms also exist for environmental management processes including but not limited to inspections, equipment testing and maintenance, tracking environmental samples, and transporting dangerous goods and wastes. 9. Records Management Management records are maintained either by the Management Division of EHS, or by a department which operates or maintains environmentally significant equipment. 10. SOP Revision History Version Section / Paragraph Changed Changes Made Effective Date V.1 N/A None, Original Version V.2 See Track Changes

8 Management AGENCY LIAISON COMMITTEES CONSULTATION/ INVESTIGATION INSPECTIONS/ AUTHORIZATIONS MONITORING PERMITS TECHNICAL OPERATIONS TRAINING EMERGENCY RESPONSE EPA BMC Green Committee Haz, Bio, or Rad Waste Disposal Hazardous Waste SAA / MAA Wastewater Discharges MWRA Wastewater Permits Management System (EMS) Hazardous Waste Integrated Contingency Plan MA DEP Sustainability Committee Spill, Release, or Improper Disposal of Oil or Haz Mat Rad Waste Storage Areas Waste Volumes And Data Air Permits/ Approvals Integrated Contingency Planning Oil SPCC Wastewater Staffing Plan MWRA IBC MWRA Permit Discharge Violation Oil Installations Air Emissions Recycling Permits Permit Applications Universal waste On Call Program DOT C2E2 Regulatory Enforcement Action/Audits Wastewater Treatment New Installations And Construction Storm water Permits Spill / Release Remediation DOT Emergency Response Plans MA DPH H2E Construction Projects Universal Waste Areas Emerging Regulations Fuel Storage Tanks Incident Notification Pharmaceutical Waste NRC AIM BUMC Biological Waste Storage Areas Consent Order Hazardous Waste Determinations BPHC CRC Biological Waste Storage Areas Hazardous Waste Collection, Management Internal Programs (Air, Water, Oil, Etc) Reporting Sampling Research Radiation Campus Clinical Emergency Mgmt Facilities Management Lab Animal Services Public Safety Research Occ. Health Department / Division Responsible