HomeMy WebLinkAboutRISK MANAGEMENT (2)BUSINESS/DEAPRTMENT NAME:
ADDRESS: ?.0.~o~ cQ(3 (3
PROJECT DESCRIPTION: '~m??
PROJECT NUMBER: ~-5'2-- ·
.... TIME
DATE: NAME: " CHGD: coMMENTS:
PROJECT COMPLETION: DATE:
"WE CARE" . .,..
April 7, 1993
TO: Esther Duran
FROM: Barbara Brenner
SUBJECT: RMPP Billing
Please generate bills for time spent reviewing RMPP documents or conducting RMPP
implementation inspections at the following locations.
1. Gist-brocades 9 hr x 47.25/hr = $425.25
2. Crystfil Geyser 2.5 hr x 47.25 = $118.13
3. Pacific Bell (#896) 1 hr x 47.25 = $47.25
4. Pacific Bell (#895) 1 hr x 47.25 -- $47.25
5. Pacific Bell (#653) 1.25 hr x 47.25 -- $59.06
6. Valley Propeller 3.5 hr x 47.25 = $165.38
7. Nestle (#1407) 3.0 hr x 47.25 = $141.75
8. San doaquin Community Hospital 3.5 x 47.25 = $165.38 /~Z~)~,_~7
9. Argo Chemical 5.25 x 47.25 = $248.06
Total RMPP Billings 1st quarter of 1993 = $1,417.51
cc: Ralph Huey
SELF-CERTIFICATION
(~ originally eliminating, substituting, or else reducing the type and quantity of acutely
The
RMPP
consisted
of
either
hazardous materials below the threshold planning quantities, and this is still in effect. (If yes, please check this box
and sign the Certification Statement below and retum, this form).
Please submit updates and changes for any of the following elements:
Check as Reviewed
[ ] The RMPP shall identify, by title, all personnel at the business who are responsible for carrying out the specific elements
of the RMPP, and their respective responsibilities.
[ ] A detailed training program to ensure that those persons specified in the RMPP are able to implement the RMPP.
[ ] A description of each accident involving acutely hazardous materials since the RMPP was prepared, together with a
description of the underlying causes of the accident and the measures taken, if any, to avoid a recurrence of a similar
accident.
[ ] A report specifying the nature, age, and condition of the equipment used to handle acutely hazardous materials at the
facility and any schedules for testing and maintenance.
[ ] Design, operating, and maintenance controls which minimize the risk of an accident involving acutely hazardous
materials.
[ ] Detection, monitoring, or automatic control systems to minimize potential acutely hazardous materials accident risks.
[ ] The implementation of additional steps to be taken to reduce the risk of an accident involving acutely hazardous
materials. These actions may include any of the following:
· Installation of alarm, detection, monitoring, or automatic control devices.
· Equipment modifications, repairs, or additions.
· Changes in the operations, procedures, maintenance schedules, or facility design.
[ ] Auditing and inspection programs designed to confirm that the RMPP is effectively carried out.
[ ] Recordkeeping procedures for the RMPP.
[ ] A clearly prepared map noting the location of the facility which shows schools, residential areas, hospitals, health care
facilities and child day care facilities and the zones of vulnerability, including the levels of expected exposure in each
zone. If no such map,was prepared originally, one is now required. ,-Please call 326-3979 for more details. .
CERTIFICATION STATEMENT
I, ~ ~---'~-~;) ~ /'~, ~ [~/J'~ hereby certify that I have reviewed the existing' Risk Management
(Name of Facility Operator)
and Prevention Plan (RMPP) for S ~ ~ ~ ~ ~. v / ~ ~,,,,~=,,,~--f .'~. ~,~? ,~ / and that it, along with any
(Name of Facility)
corrections or additions submitted herewith, constitutes a current and complete RMPP according to
Please mail this "Self-Certification" form along with any corrections and additional RMPP information to;
Bakersfield Fire Department, Office of Environmental Services 1715 Chester Av. 3rd Floor Bakersfield, CA 93301
FIRE SAFETY SERVICES & OFFICE OF ENVIRONMENTAL SERVICES
1715 CHESTER AVE. * BAKERSFIELD, CA · 93301
April 4, 1996
R.E. HUEY R.B. TOBIAS,
· t-{AZ-MAT COORDINATOR FIRE MARSHAL
(805) 326-3979 (805) 326-3951
Dennis Gardner, Plant Operations Director
San Joaquin Commmunity Hospital
P.O. Box 2615
Bakersfield, CA 93303-2615 Certified Mail
NOTICE OF RECERTIFICATION REQUIREMENT
for the
- RISK MANAGEMENT and PREVENTION PLAN
"Self-Certification Process"
Dear Mr. Gardner:
Approximately three to five years ago, you or someone under direction from your facility
submitted a Risk Management and Prevention Plan (RMPP) document to this office.
State law requires that your business review the RMPP every three to five years and make
necessary revisions. Our records indicate that it is now time for your business to conduct a review
of the RMPP document, make any necessary revisions, and submit the "Self-Certification" checklist
along with any necessary RMPP changes to this office no later than 30 days after receipt of this
letter.
To assist you in the review process, the following guidance documents are enclosed:
· A brief summary of the current RMPP strategies for your facility. This is only for your
convenience, a thorough review of the entire RMPP document is also required.
· "Self-Certification" checklist to' be signed and returned along with any RMPP revisions.
If you have any questions regarding the RMPP review process,' preparation guidelines, or
required elements, please call Howard Wines at 326-3979.
Sincerely,
Howard H. Wines, III
Hazardous Materials Technician
HHW/dlm
enclosures
RMPP FIVE YEAR REVIEW
BUSINESS NAME; San Joaquin Community Hospital
LOCATION: 2615 Eye Street
PRIMARY RMPP CONTACT: Dennis' Gardner
P. HONE NUMBER:: (805) 395-3000 *'
RMPP MATERIAL & QUANTITY: Ethylene Oxide, 6-140' lb cylinders
RMPP IMPLEMENTATION STRATEGIES:
Toxic gas cabinet.
Cylinders checked for proper composition, 12% ethylene oxide.
Employees trained in Self-Contained Breathing Apparatus.
Ethylene oxide lines protected from steam line heat.
Exhaust system in storage room.
Containers and lines clearly labeled.
SENDER: I=~s?~o receive the..~_.
· Complete items 1 and/or 2 for additional services.
· Complete items 3, and 4a & b. followi~r~kJe~ ,~for;. ~- c"~ an extra.,~.~._
· Print your name and address on the reverse of this form so that we can fee~:
return this card tO you. ~'-~
· Attach this form to the front of the mailpiece, or on the back if space ~:: [] Addresse~'$ Address
does not permit. ~/t
· Write "Return Receipt Requested" on the mailpiece below the article number. 2k~D 'Re~t~; ~ted/b elivery '"~
· The Return Receipt will show to whom the article was delivered and the date '0~.~..~. ~ ~t~.r~
delivered. C os for fee.
3. Article Addressed to: 4a. Article Number
P-390-214-539
])~T_S GA_RJ)NF.R '4b, Service Type
[] Registered [] Insured
SAN JOAQUIN COI~flJ-NIT~ HOSPIIAL ~ Certified [] COD
i/ P.O. BOX 26157.[] Express Mail []Date of Return Receipt for
BAK~RSFI~-~; CA 93303-2615 Merchandise
Delivery_ _
'" and fee is paid)
6: Si~l~ture (Agent~' /
~'~ PS Form 3811,1 p ;~=J13 E3,4 5q'=J tETURN RECEIPT
R~c~ipt ~or ~
C~rtifi~d Mail
No Insurance Coverage Provided
u~osr~s Do not use for International Mail
(See Reverse)
sent to
DENNIS GARDNER
Street and No.
P.O. BOX 2615 .~
P.O., State and ZIP Code
BAKERSFIELD, CA 93303'-261
Postega $ .32
Certified Fee
1.10
Special Defivery Fee
Restricted Delivery Fee
~,3 Return Receipt Shewing
O'3 , to Whom & Date Delivered I. 10
~) Return Receipt Showing to Whom,
c- Date. and Addressee's Address
~ TOTAL Postage
~ &Fees $ 2,52
(~ Postmark or Date
Official Business PENALTY FOR PRIVATE
USE TO AVOID PAYMENT
OF POSTAGE, $300
Print your name, address and ZIP Code here
· CIl~ OF BAKERSFIEIJ) FIKE DEPT. ·
CE OF SEI~VICES
300
~~~~~RSFIE~C~ v
~z ~
CITY of BAKERSFIELD FIRE DEPARTMENT
FIRE SAFETY SERVICES & OFFICE OF ENVIRONMENTAL SERVICES
1715 CHESTER AVE, · BAKERSFIELD, CA · 93301
April 4, 1996
R.E. HUE¥ R.B, TOBIAS,
HAZ-MAT COORDINATOR FIRE MARSHAL
(B05) 326-3979 (805) 326-3951
Dennis Gardner, Plant Operations Director
San doaquin Commmunity Hospital
P.O. Box 2615
Bakersfield, CA 93303-2615 Certified Mail
NOTICE OF RECERTIFICATION REQUIREMENT
for the
RISK MANAGEMENT and PREVENTION PLAN
"Self-Certification Process"
Dear Mr. Gardner:
Approximately three to five years ago, you or someone under direction from your facility
submitted a Risk Management and Prevention Plan (RMPP) document to this office.
State law requires that your business review the RMPP every three to five years and make
necessary revisions. Our records indicate that it is now time for your business to conduct a review
of the RMPP document, make any necessary revisions, and submit the "Self-Certification" checki~st
along with any necessary RMPP changes to this office no later than 30 days after receipt of t~s
letter.
To assist you in the review process, the following guidance documents are enclosed:
· A brief summary of the current RMPP strategies for your facility. This is only for your
convenience, a thorough review of the entire RMPP document is also required.
· "Self-Certification" checklist to be signed and returned along with any RMPP revisions.
If you have any questions regarding the RMPP review process, preparation guidelines, or
required elements, please call Howard Wines at 326-3979.
Sincerely,
Howard H. Wines, III
Hazardous Materials Technician
HHW/dlm
enclosures
RMPP FIVE YEAR REVIEW
BUSINESS NAME: San Joaquin Community Hospital
LOCATION: 2615 Eye Street
PRIMARY RMPP CONTACT: Dennis Gardner
PHONE NUMBER: (805) 395-3000
RMPP MATERIAL & QUANTITY: Ethylene Oxide, 6-140 lb cylinders
RMPP IMPLEMENTATION STRATEGIES:
Toxic gas cabinet.
Cylinders checked for proper composition, 12% ethylene oxide.
Employees trained in Self-Contained Breathing Apparatus.
Ethylene oxide lines protected from steam line heat.
Exhaust system in storage room.
Containers and lines clearly labeled.
SELF-CERTIFICATION
[ ] The RMPP originally consisted of either eliminating, substituting, or else reducing the type and quantity of acutely
hazardous materials below the threshold planning quantities, and this is still in effect. (If yes, please check this box
and sign the Certification Statement below and return this form).
Please submit updats8 and changse for any of the following elements:
Check as Reviewed
[ ] The RMPP shall identify, by title, all personnel at the business who are responsible for carrying out the specific elements
of the RMPP, and their respective responsibilities.
[ ] A detailed training program to ensure that those persons specified in the RMPP are able to implement the RMPP.
[ ] A description of each accident involving acutely hazardous materials since the RMPP was prepared, together with a
description of the underlying causes of the accident and the measures taken, if any, to avoid a recurrence of a similar
accident.
[ ] A report specifying the nature, age, and condition of the equipment used to handle acutely hazardous materials at the
facility and any schedules for testing and maintenance.
[ ] Design, operating, and maintenance controls which minimize the risk of an accident involving acutely hazardous
materials.
[ ] Detection, monitoring, or automatic control systems to minimize potential acutely hazardous materials accident risks.
[ ] The implementation of additional steps to be taken to reduce the risk of an accident involving acutely hazardous
materials. These actions may include any of the following:
· Installation of alarm, detection, monitoring, or automatic control devices.
· Equipment modifications, repairs, or additions.
· Changes in the operations, procedures, maintenance schedules, or facility design.
[ ]. Auditing and inspection programs designed to confirm that the RMPP is effectively carried out.
[ ] Recordkeeping procedures for the RMPP.
[ ] A clearly prepared map noting the location of the facility which shows schools, residential areas, hospitals, health care
facilities and child day care facilities and the zones of vulnerability, including the levels of expected exposure in each
zone. If no such map was prepared originally, one is now required. Please call 326-3979 for more details.
CERTIFICATION STATEMENT
I, hereby certify that I have reviewed the existing Risk Management
(Name of Facility Operator)
and Prevention Plan (RMPP) for and that it, along with any
(Name of Facility)
corrections or additions submitted herewith, constitutes a current and complete RMPP according to
the checklist above.
(Signature) (Date)
Please mail this "Self-Certification" form along with any corrections and additional RMPP information to:
Bakersfield Fire Department, Office of Environmental Services 1715 Chester Av. 3rd Floor Bakersfield, CA 93301
CITY of BAKERSFIELD
"WE CARE"
2101 HSTREET
S. D. JOHNSON November 25, 1992 BAKERSFIELD, 93301
FIRE CHIEF 326-3911
Mr. Dennis Gardner
Director, Plant Operations
San Joaquin Community Hospital
P.O. BoX 2615
Bakersfield, CA 93303-2615
Dennis:
During the risk management and prevention program (RMPP) implementation
inspection today, several items on the inspection checklist were identified as requiring
follow up action or documentation. I have listed these below.
.1 .~--"~The RMPP (pg. 1) states that there are a maximum of 4 full ethylene oxide/freon
(EtO) cylinders on site at any one time. If the actual quantity will be 6 full
cylinders as discussed during the inspection, the hazardous materials inventory
will need to be revised. Please verify the maximum quantity of EtO and submit
an inventory revision if necessary using the enclosed form.
~. The gas storage cabinet needs to be labeled with either the names of the
materials stored within or with a National Fire Protection Association hazard
identification placard.
3.~/ The EtO cylinder storage area has not been relocated as discussed in the RMPP.
If no more desirable location exists and historically there have been no problems
with this location, you may want to amend the RMPP to indicate that no change
will be made. However, EtO cylinders must be transferred to a secure location
and properly restrained immediately upon receipt. Make certain that they are.not
left in an area of public access such as on the loading dock. Empty cylinders
must also be secure, restrained and not allowed to accumulate.
4. NIOSH recommends that a sign be posted in the EtO receiving and storage area
stating "Check tank label for proper EtO/freon composition". This type of reminder
should help to insure that only 12% EtO/88 % freon deliveries are accepted by
hospital staff.
.~ Please submit a copy of records verifying the dates'of sterilizer service by AMSCO
and leak checks by Gas Monitoring, Inc.
.6~ NIOSH recommends that EtO supply lines be labeled and that they be protected
from heat released by adjacent steam lines.
~7: Employees who are expected to use the SCBA must be fit tested and certified in
proper use of the equipment. Please submit documentation of this training once
it has been delivered. ~//..//¢¢:~ "~;~ ,w/ ~FP (.pc. '~,'C~,~$.,k,4'r_5
8.r/-/'' Please supply documentation that the ventilation system has been balanced and
verified as maintaining a negative pressure in the equipment room. ·
Please respond to each of the items above by outlining a plan of action, providing
the necessary documentation or justifying why the item should not be addressed. This
information should be submitted to Bakersfield Fire, Hazardous Materials Division by
December 31, 1992. Following is the information which I'promised to pass along to you.
1. The chemical "List of Lists" can be obtained from CAL/EPA P.O. Box 942732,
Sacramento, CA 94234-7320. I think it can be ordered by phone by calling (916)
327-1848. For your immediate information, glutaraldehyde is listed only as being
on the AB 2588 - Air Toxic Hot Spots list. It is not listed on the CAL-OSHA
carcinogen. Our list is dated 1/90 and may still be the latest version. Check with
CAL-EPA for the most recent information.
2. The CAL-OSHA ConsUltation Service in Fresno serves the Bakersfield area. They
can be contacted at (209) 454-1295.
3. Bill Martin requested a printout of the hospital's business plan. It is enclosed.
Call me at 326-3979 if you have any questions regarding the RMPP
implementation follow up points outlined above.
Sincerely,
Barbara Brenner
Hazardous MateriaJs Planning Technician
cc: Ralph Huey
San Joaquin Hospital
RMPP Implementation Inspection Checklist
November..1~, 1992
INVENTORY AND STORAGE:
1. How many ethylene oxide/freon cylinders are on site? (pg. 1) ~ Fu~
2. Verify percent composition using labeling information? (pg. 1) ~'* 'Z__~.
3. Are cylinders adeq,uately restrained? (pg,
~. Where are the spare cylinders stored? (pg.
5. Are the cylinders of the recessed valve type? (pg. 1)
,,-~, Has sign been posted in the storage area stating "Check tank label for proper
EtO/freon composition"? (NIO~I~t Haz OP Table 2)
SYSTEM MAINTENANCE:
.~.~. Have records been maintained regal'ding the bimonthly service of the sterilizer by
2. H.._ave the quarter.l,y le_c_SJ~cbecks_b.y_G~,s..Mo.r:dtor, ir~,gH, r~,c,_been__conlinued_.or have
these been replaced using the inhouse gas monitor9 (pg 2)
What is the detector set point fei leak surveys/~?
SAFETY EQUIPMENT & PRECAUTIONS:
1. Does the sterilizer include an alarm relay system to alert personnel that the
sterilizer cannot be operated if the exhaust system in not operating? (pg.3) ~(¢2
2. Is the gas detector system equipped with 4 sensors in the Central Supply area?
What is the set point on these detectors? (pg.3) 2° ~?¢f'~ (~*~
3. Does the sterilizer include an interlock so that the EtO inlet valve will not operate
unless the sterilizer door is Iocke6t-? (NIOSH Haz OP Table 3)
· .~.; L/~ ~'' ~.. ~
4. Are air temperatures in the equipment room and gas storage' areas less than 100
degrees fahrenheit? (pg; 6 of letter 10-18-90 & NIOSH Table 9)
Has an automatically closing door been installed between Central Supply & the
adfjacent corridor? (pg. 6 of letter 10-18-90) ~n ~6r. ~o.~ /)¢.~ q-0 -~4& /,q-fO
6. Does the delivery route to the sterilizer room avoid patient areas? (NIOSH Haz Op
Table 1) LiE,~
7. Has the delivery ramp into the equipment room been installed to eliminate trip
hazard of piping? (Punchlist item #3) ~6,5'/ ,~O¢%-,-
8. Are incompatible cleaning supplies stored outside Central Supply? (pg.7 of letter
dated 10-18-90) i~ f._G.~;~,.,-k-~
9. Is piping containing EtO labeled? (NIOSH Table,2)
10. Is EtO piping directly adjacent to steam lines? (NIOSH Table 2) .
11. Has air sampling been continued to monitor for routine exposures in the Central
Supply area? (Punchlist item 7)
EMPLOYEE TRA N NG: . ' r', ~ ,
.... .:.
1. Have initial employee training and annual refresher training been' conducted and
documented? (pg.3) ~ ~. k 9¢¢A5 , % ·
What is the content of this employee training? ~"~ ~.9,'c~ ¢ ~c~/ .
Have employees who may be expected to use the SCBA been fit tested and
ce~ified in its proper use? (pg. 4) ~o
3. Have emergency contingency plans been established and reviewed with
employees? (pg. 2 of letter dated 10-18-90, NIOSH Haz Op Table 2) ~
VENTILATION:
---~. Where does the air inlet for the sterilizer chamber pick up? From the room or
from the exhaust shaft? (NIOSH Haz Op Table 4)
2. Is the exhaust release point on the side of the building away from the roof area?
(pg. 6)~)~ ~,~j.. ~ ~ti0,0',~. CL'~(h'¢,~ ~r','~ ~'~'C~'
Have the windows ne~ to the exhaust outlet been sealed to prevent opening?
(leAer 10-18-90) ~ %
~. Has the ventilation system been balanced and verified as maintaining negative
pressure in the equipment room? The exhaust air rate should exceed central
supply (ate by 110 cfm? (LeAers dated 10-18-90, 1-28-91 and NIOSH H~ OP)
CITY of BAKERSFIELD
'~' ~"' -':" "WE CARE" ~ .~,~
FIRE [DEPARTMENT ',. 2101 H STREET
D. S. NEEDHAM .' BAKERSFIELD, 93301
FIRE_ CH~E~ ....... . ............ 32E-3~1A _
March 5, 1991
Mr. Kenneth Gibb
Chief Financial Officer
San Joaquin Community Hospital
P.O. Box 2615
Bakersfield, CA 93303-2615
Dear Mr. Gibb,
I have reviewed the Risk.Management and Prevention Program (RMPP)
submitted by The FPE Group regarding the use of ethylene oxide in the
equipment sterilization process· at San Joaquin Hospital's 2615 Eye
Street facility. This RMPP satisfies the requirements of Chapter 6.95,
Sections 25531 et sec, of the California Health and Safety Code and has
been accepted by the Bakersfield Fire Department..
The RMPP must be fully implemented within one year of acceptance by
this Administering Agency. Bakersfield Fire will·inspect your facility
at least once every three years to Verify compliance with the. program
proposed in your RMPP.
Thank you for your cooperation during the development of San
Joaquin's Risk Management and Prevention Program. I appreciate all of
the effort that Mr. Martin and Mr. Gardner have put into the completion
of this document. Please call me if I can be of any further assistance
in hazardous materials planning. '~'
cerely, ,
Barbara Brenner
Hazardous Materials Planning Technician
cc: Ralph Huey
SAN JOAOUlN
COMMUNITY HOSPITAL
1-30-1991
Ms. Barbara Brenner
Hazardous Materials Planning Technician
City of Bakersfield
Ms. Brenner:
As you know Barbara, San Jaoquin Community Hospital received
yOur approval of the proposed schedule for addition review of the
city's concerns in the revised RMPP. Working with Dan Cox and the
hospitals department directors we have made the recommended changes
to our policies and researched addressed problem areas of the eto
system. The hospital appreciates the extension of the 60 day
limit of RMPP revisions. This is a cover letter to explain contents
of what we have completed in the way of RMPP revisions, policies
changes and the corrective action taken.
References are to the original RMPP:
Item #2,Page #2: A draft for the engineering departments handling
of the eto cylinders.
Item #3,Page #3: The installation of the ramp over the pipe that
was a tripping hazard in the sterilizer equipment room is
complete.
Item #4,Page #3: Included in the revised Hazard Material Management
Policy is an evacuation plan that includes the boiler room
occupants.
Item #6a,Page #4: Included in the revised Hazard Material
Management Policy is a plan which incorporates a calculated
concentration versus time into the reoccupancy after a worse-case
release in central supply and the boiler room.
Item #6B, Page #4: Included is a copy of the certified air balance
report conducted on the 4th day of June 1990.
Item #7, Page #4: Included is documentation that the hospital is
conducting both short-term and full-shift air sampling for ethylene
oxide routine exposures of the central service and engineering
staff.
A Member of Adventist Health System/West
26]5 Eye Street
Post Office Box 26i5
Bakersfield, California 93303-2615
8051395-3000
SAN JOAOUlN
COMMUNITY HOSPITAL
Page 2
Item #1, Page #6: This item is addressed in a recommendation and
RMPP revision that was completed by Dan Cox of FPE Group on 1-28-
1991.
Item #7, Page #7: Included in the revised hospitals Hazard Material
Management Policy is a section which mandates that all cleaning
products storage be moved outside the central service area.
From the hospital's prospective, we have addressed all of the
recommended issues that the city of Bakersfield has been concerned
with. We thank you for your patience with us and are pleased to be
waiting your response. ~r ~ ~.
Dennis W. Gardner
Director of Plant Operations
A Membe~ of ,*~dver~tist Health System/West
2615 Eye Street
Post Office Box 2615
Bakersfield, California 93303-2615
805/395-3000
SAN JOAQUIN COMMUNITY HOSPITAL
RMPP FINDINGS
PREPARED BY: BARBARA BRENNER
FEBRUARY 11, 1991
The following information was reported by the FPE Group in the RMPP
· submitted for San Joaquin Hospital's ethylene oxide sterilization
system.
1. One of the Ethylene oxide cylinders in Central is "on-line" and
connected to the gas sterilizer.
2. The severity of consequences due to the worst-case AHM release is
rated high, although it would not be expected that large numbers of
people would be affected. The probability of a worst-case release
is low to medium.
3. The worst case release rate for a one-cylinder release is 550 cubic
feet of the gas mixture released over five minutes. Thus, an
excess of exhaust versus supply air of at least 110 cfm is required
for Central Supply. The 300~ cfm net exhaust appears adequate to
exhaust the entire release of mixed gases, with an excess exhaust
of 190 cfm. The addition of' a self closing door will reduce the
opening between the exhausted enclosure .and Central Supply to
approximately 1 square foot. The sterilizer room will be isolated
form the rest of Central Supply, if a minimum control velocity of
50-100 fpm is maintained at the opening of the sterilizer room to
Central Supply.
CONCLUSIONS:
The risk reduction measures proposed by FPE in this RMPP have been
accepted by San Joaquin, Community Hospital for implementation.. These
measures appear to be adequate controls for reduction of the risks posed
by the Hospital's handling of ethylene oxide.
~~ SAN JOAOUlN
COMMUNITY HOSPITAL
1-30-1991
Ms. Barbara Brenner
Hazardous Materials Planning Technician RECE~VEO
city of Bakersfield
MAZ. MAT, DIV.
Ms, Brenner:
This is the copy of the R~P Punch list that you had
reqUested. I was glad to hear that you had received the
certification that you had needed for our report. If there is
anything else that I can help you with please let me know.
Director of Plant Operations
RE(~£1VED
M&R 0 t 1991
HAZ. MAT. DIV.
A Member of Adventist Health System/West
2615 Eye Street
Post Office Box 2615
Bakersfield, California 93303-2615
805/395-3000
CITY of BAKERSFIELD
"WE CARE"
FIRE DEPARTMENT .2;01 H STREET
D. S. NEEDHAM December 19, 1990 BAKERSFIELD. 9330~
FIRE CHIEF 3'26-39.11
Mr. Kenneth Gibb
Chief Financial Officer
San Joaquin Hospital
P.O. Box 2615
Bakersfield, CA 93303-2615
Mr. Gibb:
I have reviewed the Risk Management and Prevention Program
implementation schedule submitted by Mr. Dennis Gardner. 'The proposed
schedule is acceptable and can easily be added to the RMPP. Although
the RMPP is very nearly complete, one item of concern persists and.must
be addressed before the Bakersfield Fire Department will accept San
Joaquin Hospital's Risk Management and Prevention Program.
FPE's calculations, summarized on page 4 of the RMPP, indicate that
the exhausted enclosure will not protect employees in the Central Supply
work area from rapidly occurring high concentrations of ethylene oxide
in the event of an emergency release. In order for San Joaquin
Hospital's Risk Management and Prevention Program to be accepted by this
Administering Agency, an engineering solution must be proposed which
will effectively reduce the consequences to life in the event of a worst
case emergency release of ethylene oxide in Central Supply. Otherwise,
the Hospital will need to submit engineering data which verify that life
and health will not be endangered in the'event of a rapid release of
ethylene oxide in the exhausted enclosure. '.
There are a variety of viable possibilities which could provide
added protection for the Central Supply staff. The law provides a 60
.day time limit for the revision of RMPPs which are not accepted upon
submission. I responded regarding San Joaquin's RMPP on November 2,
1990. Therefore Jan. 2, 1991 is the date by which this additional
information is due. Because I did not formally state this deadline in
my Nov. 2 letter, I will extend the due date for this additional
planning to January 31, 1991. Please'call me at 326-3979 if you. have
questions or if I can be of assistance.
Sincerely,
Barbara Brenner
Hazardous Materials Planning Technician
cc: Mr. Dennis Gardner
.i'CITY BAKERSFIELD
FIRE DEPARTMENT 2101 H STREET
D. S. NEEDHAM BAKERSFIELD. 93301
FIRE CHIEF 326-3911
November 2, 1990
Mr. Dan Cox
Senior Vice President
The FPE Group
3687 Mt. Diablo Blvd., Suite 200
Lafayette, CA 94549
Mr.
Enclosed is a copy of Bakersfield Fire's response to San Joaquln
Hospital regarding the Risk Management and Prevention Progrmm for the
.ethylene oxide sterilization system. Thank you for resolving the
concerns expressed'in my letter of August 6.
Sincerely,
Barbara Brenner
Hazardous Materials Planning Technician
FIRE DEPARTMENT 210~ H STREET
D. S, NEEDHAM BAKERSFIELD, 93301
FIRE CHIEF 326-3911
November 2, 1990
Mr. Kenneth Gibb
Chief Financial Officer
San Joaquin Hospital
P.O. Box 2615
Bakersfield, CA 93303-2615
Dear Mr. Gibb,
I have reviewed the revised RMPP submitted by The FPE Group
regarding San Joaquin Hospital's ethylene oxide sterilization system.
The materials submitted contain satisfactory responses to the questions
that I asked on August 6, 1990. Two areas of concern still exist and
may require some further'Planning on the part of. the hospital..
FPE's calculations indicate that, despite the addition of the
exhausted equipment enclosure, concentrations of ethylene oxide can
build up rapidly and persist for an extended period of time in the
Central Supply area if a cylinder's contents are. released. I continue
to have great concern for the individuals who work in the Central SuPply
area in the event of an earthquake. If their ability to escape is
impeded, it appears that the consequences would be grave. Will the
balancing of the ventilation system, recommended by FPE to ensure
maximum efficiency of the system, improve this situation .? What other
measures can be taken to reduce the flow of ethylene oxide vapors from
the exhausted enclosure into Central Supply during a release?
PAGE 2
The location of the spare EtO cylinder storage also needs further
consideration. The concern of FPE regarding temperatures exceeding 100
degrees Fahrenheit is valid. However, the exhausted enclosure appears
to be very crowded presently.. The location of additional cylinders in
this area could increase the potential for human error during cylinder
changes due to the limited space. The potential for high concentration
exposure of Central Supply employees during a disaster increases as the
quantity of ethylene oxide in the area increases. Are there other
alternatives for the storage of the spare cylinders
San Joaquin Staff now'need to develop an implementation schedule
for the recommendations proposed by FPE and consider these final
planning items. Once. these last issues of concern have been addressed
by the hospital, Bakersfield Fire will be able to accept this Risk
Management and Prevention Program. At that time, I would like to
receive a copy of the RMPP document and associated reports which do not
contain .facsimiles. The reduced blueprints of the system, which were
referred to in page 2 of the RMPP, are also missing from the materials
which I currently have.
Please call me at 326-3979 so that we may agree upon a reasonable
time frame for the Hospital to address the planning issues outlined
above and to provide a final copy of the RMPP which contains an
implementation schedule. Thank you for all of your cooperation in this
matter.
Sincerely,
Barbara Brenner
Hazardous Materials Planning
Technician
cc: Mr. Dan Cox, FPE
FINDINGS: S~n Joaquin Community Hospital RMRR
Based on the RMPP, Hazard and Risk 8nalyses completed by
The FPE Group
Prepared by Barbara Brenner
10-24-90
One ethylene oxide (EtO) cylinder, 12Z 5t0 and 88% freon, is
on line connected to the sterilizer. The worst
credible release in the Central Supply exhausted enclosure is
defined by FPE as the full release of the contents of one
cylinder of EtO. (Pg, 1, RMPP)
2. 8 worst credible case release of EtO, over S Minutes, in the
exhausted enclosure would result in an EtO concentration in
Central Supply of t,455 ppm after one minute. 8fret
minute~, the concentration is predicted to be 6550 ppm.
would take about 80 minutes for the EtO concentration in the
Central Supply area to decrease to 800 ppm, the IOLH.
(Pg. 4, RHPP)
The worst case release from the EtO storage area on ~he
loading dock is also defined as a release of the contents of
one full cylinder, This storage area J.s of concern due to
the potential for ambient temperatures to exceed 100 degree~
Fahrenheit. (Pg 8,, RMPP Questions)
"Regardless of the cause, the release of the entire contents
of a cylinder could cause seriou~ injury or death to a person
or persons near and at some distance from the release point.
Therefore, the severity of consequences due to worst case 8HM
release is rated high, although it would not be expected that
large numbers of people would be affected." (Pgs, t-2, RMPP)
1'he probability of an EtO release is either low or medium.
(Pg, 2, RMPP)
P~GE 2
"It is suggested to have separate containment rooms (one for
the equipment room, and a second for the loading/unloading
room>. Where separate loading and unloading rooms are
provided, these should both be maintained at a lower pressure
'than surrounding areas." (Table ?, NZOSH Haz-Op) There
should be a negative pressure in the equipment room relative
to loading room, amd a negative pressure in loading room
relative to all other areas, if for example, a tank hose were
to rupture. ('Table 2, NIOSH Haz-Op)
7. "The loading room should not be occupied during operation."
(Table B, NIOSH Haz-Op)
8. The possibility of EtO, in concentrations equal 'to or' greater
~han the IDLH~ ~ntering the hospital air supply ~rom the
roof air intake for' a brief period during a worst case
release is re~ote, 61though the roof air in~ake is within
t60 feet of the EtO vent, it is not on a direct down~ind line
from the vent. The release point is on the side of the
building and the air intake is located on the recessed roof
area around the building's corner from (he EtO vent.
Worst Case Releases)
The FPE Group
3687 Mt. Diablo Blvd., Ste. 200, Lafayette, CA 94549 (415) 283-8860 Fax: (415) 283-5727
October 18, 1990
Ms. Barbara Brenner
Hazardous Materials
Planning Technician
City of Bakersfield
Fire Department 2101 "H" Street
Bakersfield, CA 93301
Dear Barbara,
Below is The FPE Group's response to the areas you found incomplete or
deficient in our risk analysis of the use of ethylene oxide/freon as a
sterilant at San Joaquin Community Hospital.
First, we are submitting to you and the hospital a slightly modified version
of a general hazard and operability study for ethylene oxide use in hospitals
published recently by NIOSH. We are recommending that the hospital follow
all the NIOSH recommendations that are feasible. We are providing the
hospital with a copy of the NIOSH document (Control Technology for Ethylene
Oxide Sterilization in Hospitals).
Next are our replies to the points made in your letter of August 6, 1990.
1. We have been unable to find a specific prediction of the likelihood of
an 8.3 or similar scale earthquake in Bakersfield. We have been told by
Dr. Robert Uhrhammer of the University of California Seismographic
Station a quake of this magnitude is very unlikelyf because the active
fault in the area is relatively short. You have confirmed that the
Bakersfield Fire Department also does not know the probability of an
earthquake of this magnitude. The October 27, 1987, issue of The
Bakersfield Californian listed the probability of a 6.0 or larger quake
occurring in Kern County as 80-100 percent in the next 50 years. If the
hospital were near the epicenter of a quake gKeater than 6.0,
significant damage to the hospital could occur. The probability of a
quake that causes damage in Kern County in the next 50 years appears
high. The probability of the hospital being the target of the
significant damage is lower, and the probability of the damage actually
being a full-cylinder release of ethylene oxide is even lower. The
probability of a worst-case release due to an earthquake is low to
medium.
Whether the cause of a worst-case release is operating error, equipment
failure, or external event (e.g., earthquake), the largest release will
likely be the entire contents of a full cylinder of ethylene oxide.
Regardless of the cause, the release of the entire contents of a
The FPE Group
Ms. Barbara Brenner
October 18, 1990
Page 2
cylinder could cause serious injury or death to a person or persons near
and at some distance from the release point. Therefore, the severity of
consequences due to the worst-case AHM release is rated high, although
it would not be expected that large numbers of people would be affected.
The probability of the worst-case release is certainly not high; worst-
case release is simply not a frequent occurrence. The State suggests
that records of releases for the past three years be used to identify
probable releases. A major release has not occurred in three years and
a release approaching worst-case has never occurred at the hospital that
any of the staff can remember.
Regardless of the cause of the worst-case release, the probability of
release is either low or medium. If low, the EPA guideline is that the
worst-case release is a concern which may require planning for credible
events. If medium,, the EPA guideline is that the worst-case release is
a situation of major concern.
The hospital is treating the worst-case release as a situation of major
concern that requires planning for credible'events. Through a
combination of engineering controls {such as ventilation}, required work
practices, training, alarm systems, personal protection {respirators and
protective clothing), and emergency response andevacuation procedures,
the hospital is working both to decrease the likelihood of the worst-
case release occurring, as well as to mitigate the severity of the
consequences of the worst-case release. ---
It is our hope that the Bakersfield Fire Department will recognize that
the hospital is treating the worst-case release {and less significant
potential releases} with the proper level of concern.
2. The possible consequences of leaks in lines, fittings, and regulators
range from low level exposures to one person {engineering staff changing
cylinders or repairing lines, fittings, and regulators) to the
consequences of the worst-case release.
The hospital has alarm systems to detect low-level but significant leaks
{>5 ppm), quarterly leak checks by.Gas Monitoring, Inc., and a
continuously operated, dedicated exhaust system connected to emergency
power to mitigate all releases.
Recommendation: We recommend that the engineering staff obtain a
portable ethylene oxide monitor to be used for leak detection every time
a cylinder is changed.. The portable monitor should be used to check
cylinder valves, lines, fittings, and regulators for leaks too low to
trigger the alarm system.
3. There exists a risk of a cylinder falling, due to a floor-level pipe in
the sterilizer equipment room in the path of cylinder delivery. The
The FPE Group
Ms. Barbara Brenner
October 18, 1990
Page 3
cylinders are protected by a welded-ring protecting collar, so that
leakage from the fallen tank is not likely to occur. However, the
falling cylinder could damage lines or fittings, even without visible
damage, so that they could subsequently leak.
Recommendation: We recommend that the hospital cover the pipe with a
smooth ramp to prevent accidents during delivery.
4. We inspected the exhaust duct path and found it to be isolated from the
general air return system. It is designed to be a dedicated exhaust
system, and the design has been approved as such by OSHPOD.
However, the duct traverses the boiler room at ceiling level. If both
an ethylene oxide release in Central Supply and a duct rupture in the
boiler room occurred, the ethylene oxide/freon mixture would spread to
the boiler room. This scenario is possible in a major earthquake.
Recommendation: We recommend that the hospital assume, in a major
earthquake, that both an ethylene oxide release and a duct rupture has
occurred. In this case, the boiler room occupants should be included in
the emergency response and evacuation plan.
5. Unless the cylinder itself is punctured, which is an extremely unlikely
event, the ethylene oxide/freon mixture will be released as a gas in the
proportions of 12 percent ethylene oxide and 88 percent freon.
Different gases diffuse at the same rate, regardless of molecular
weight; so in the absence of gravity, the proportions of the gaseous
mixture will remain the same regardless of the dilution, as the mixture
diffuses into the air.
Gravity does have an effect on gases, so that a column of gas is more
dense at lower than at higher elevation. We have calculated the effect
of gravity on a gaseous mixture of ethylene oxide/freon and found that
the effect of gravity would be that at a height of 500 meters, the
proportions would be 14 percent ethylene oxide and 86 percent freon by
weight, rather than the~12 percent and 88 percent at ground level. We
contend that this minor change in proportions will have no significant
effect on the properties of the mixture. Specifically, the mixture
would remain nonflammable even if it were to diffuse upward through the
entire height of the hospital.
(As we discussed previously, the normal atmospheric reactions of
ethylene oxide are not sufficiently rapid to significantly reduce the
proportion of ethylene oxide in the mixture.)
6. The exhaust system dedicated to the sterilizer loading area and the
sterilizer equipment room is 1850 cfm by design.
The FPE Group
Ms. Barbara Brenner
October 18, 1990
Page 4
'The concentration of ethylene oxide versus time has been calculated for
a full-cylinder release in Central Supply, assuming release over five
minutes of 148 cubic feet of EtO (16.8 lbs) and an exhaust rate of 1850
cfm in a 21,000 cubic foot space (Central Supply). The calculations
show that the ethylene oxide will be exhausted so that the average
concentration will drop below the IDLH level (800 ppm) in 78 minutes and
drop to 1 ppm in 308 minutes.
The actual exhaust rate will likely actually be somewhat greater than
that, since the exhaust is located near the release rather than being
general dilution ventilation, but this calculation represents a
conservative estimate.
Recommendation: We recommend the hospital incorporate this calculated
concentration versus time into its plan for reoccupancy after worst-case
release in Central Supply.
Recommendation: We recommend that the hospital proceed with balancing
and verification of the performance of the dedicated exhaust system and
the ventilation system in Central Supply. The performance check must
confirm that Central Supply is at negative pressure rel.ative to the rest
of the hospital. The exhaust air rate in Central Supply should exceed
the supply air rate by at least the worst-case release rate. The worst-
case release rate is 550 cubic feet of the gas mixture released over
five minutes. Thus, an excess of exhaust versus supply air of at least
110 cfm is required for Central Supply. --
7. Monitoring to compare with the PEL is done to measure the eight-hour
time-weighted average exposure. Short-term exposures may exceed the PEL
but should not exceed the STEL. A person may have a short-term exposure
above the PEL without having an eight-hour time-weighted average
exposure above the PEL. The nature of ethylene oxide exposure in
hospitals is such that comparison to both standards is appropriate.
Recommendation: We recommend that the hospital proceed with both short-
term and full-shift air sampling for ethylene oxide to determine routine
exposures of the Central Supply and engineering staff.
8. The risks associated with fire have been considered. The designs for
the construction of the sterilizer area of Central Supply and for the
ventilation system have been approved by OSHPOD and by the State Fire
Marshal. The hospital assures us that the construction materials and
sprinkler system were installed to meet code and that no source of
ignition exists in Central Supply.
Our most experienced fire protection engineer, Ed Vining, assures me
that the nonflammable mixture of 12/88 percent ethylene oxide ~freon
will be nonflammable at any dilution with air. The manufacturer,
Penngas, on its material safety data sheet claims that the mixture will
The FPE Group
Ms. Barbara Brenner
October 18, 1990
Page 5
help to extinguish a fire rather than add to the fire. We have no
reason to dispute their experience with the mixture. Both Richard
Nusbaum of Penngas and Ed Vining of FPE are willing to discuss this
issue with you if you wish. Mr. Nusbaum's phone number is on the MSDS
already submitted and Mr. Vining's number is {415) 283-8860.
OFF-SITE CONSEQUENCE ANALYSIS
1. The documentation for EPI Code has been provided and accepted.
2. Our vapor dispersion calculations have been modified to use a five-
minute release period for modeling the worst-case scenario.
There have been discussions as to the actual release period for a full-
cylinder release. Richard Nusbaum of Penngas, the manufacturer of the
gas used by the hospital explained to me that the cylinder has a dip
tube delivery system that limits the release rate of the contents. The
contents of the cylinder are liquid not. gaseous. His experience, gained
over 25 years, is that full release from an open valve or line takes 30
to 45 minutes. This is why we used 30 minutes in our initial modeling.
The NIOSH document referred to a release rate of 5.4 lbs per second,
which is a period of 25 seconds for full release. This may have-been an
error and may have been calculated for a compressed gas rather than for
a compressed liquid delivered through a dip tube. Certainly this rapid
release rate is strongly denied by the manufacturer.
We have chosen to rely on the experience of the manufacturer, but have
used five minutes in our calculations as a conservative estimate and to
be more in line with EPA and apparently Bakersfield Fire Department
guidelines. Richard Nusbaum has offered to talk to you about his
experience with release periods as well.
3. Our attached air dispersion modeling has been modified to take into
account the possibility of receptors at the height of the elevated
exhaust vent {30 feet).
4. See 3.
5. The modeling has been modified to assume a "point" source for the worst-
case release.
6. The deposition velocity was documented in the EPI Code-documentation and
accepted.
The FPE Group
Ms. Barbara Brenner
October 18, 1990
Page 6
EXISTING OR PROPOSED MEASURES TO MITIGATE POINTS OF CONCERN
1. The ethylene oxide storage area has been moved away from close proximity
to the child care facility. The two cylinders not in Central Supply are
now stored on the loading dock in a cylinder storage cabinet. We are
concerned 'that this storage area may allow the cylinders to reach
temperatures greater than 100 degrees F.
£e¢ommendation: Store all four ethylene oxide cylinders in the
sterilizer equipment room. This room is temperature controlled and
served by the dedicated exhaust system. The worst-case release in the
sterilizer equipment room would continue to be the release of one full
cylinder.
Cylinders would be transported directly to and from the delivery truck
to the sterilizer equipment room.
2. The roof exhaust outlet has been placed to be as far as Possible from
openings or air intakes into the building, and its placement was
recommended by a Cal-OSHA safety engineer. We have recommended that the
windows nearest to the exhaust be sealed from opening. Further
discussions of possible consequences are included with our dispersion
modeling.
3. The dedicated exhaust system is-attached to the emergency power supply
for the hospital, so that a failure of normal power is not sufficient to
disable the exhaust. The hospital has revised emergency response and
evacuation procedures based on the possibility of high levels of
ethylene oxide existing in Central Supply as a result of worst-case
release.
The alarm panel for ethylene oxide is also attached to the emergency
power supply.
4. The hospital has agreed to build a ramp over the pipe.
5. The hospital has sent a letter to Penngas requiring only welded-ring
protecting collar (recessed valve type) cylinders be delivered. Penngas
assures us that this is their only product today, lhe hospital will
refuse delivery of any non-protected cylinders.
6. There is a self-closing door between Central Supply and the corridor.
Central Supply ventilation is designed to remain under negative pressure
relative to the corridor due to the dedicated exhaust system. The
recommendation for balancing and performance checking of the ventilation'
system applies.
The FPE Group
Ms. Barbara Brenner
October 18, 1990
· Page 7
7. The hospital does use a variety of cleaning supplies and disinfectants
in Central Supply.
Recommendation: We recommend the hospital store these items outside
Central Supply and that quantities within Central Supply be limited to
the amount needed for each task. Containers should be capped
immediately after each use.
8. We are providing the hospital with a comprehensive training manual for
ethylene oxide developed and tested in hospitals in Massachusetts. A
description of the training manual is attached.
9. The hospital has revised their plan and will likely make some additional
revisions based on this report.
Si~ely,
Dan Cox, PhD, CIH
Sr. Vice President
Industrial Hygiene & Environmental Health
ddc/docs/9051441tr
The FPE Group
EARTHQUAKE INFORMATION
In our search for earthquake information we contacted the
following agencies:
San Francisco Public Library
San Francisco Public Library Business & Sciences Dept.
Bakersfield Public Library
Earthquake Engineering Research Institute
US Geological Survey
Earth Scan ~
Office of Emergency Services
Office of Emergency Services Natural Disasters
Cal Tech
UC Berkeley Seismographic Station
Table 1..(NIOSH B-2). HAZOP Analysis of EtO/Freon Supply Cylinders
GUIOEWORO/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOMMENDATION
SAFETY High ten~erature. High pressure. Store tanks in well ventilated area below
IO0°F. Follow storage regulations of
pressurized ethylene oxide gas (use of
caps, etc.).
Faulty or damaged cylinder. Ethylene oxide release. Continue to use a transportation route to
avoid patient areas, and transport one tank
at a time using a cart with a holding
strap.
Check for Leaks from tanks using a halogen
Leak detector, or other appropriate Leak
detector, before ,transporting to equipment
room, after transporting, and after
connecting to piping. If ethylene oxide ..
tank is dropped, assume Leaking. If an
audible or visible Leakage, assume a severe
Leak and Leave area tma~diateLy.
Table 2. (NIOSH B-3). 'HAZOP Analysis of Piping and Valves for EtO Transport from the Storage Cylinders to the Sterilizer Unit {Refer to Figure B-4)
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/gUESTION/RECOHMENDATION
NO FLO~ Ctosed valve in tine or No hazard. No safety issue.
ethylene oxide tank is empty.
REVERSE FLOI4 Ethylene oxide tank is not FLow of trapped material into Written procedures should be placed near
present and valves A and B equipment room. valve B indicating that the valve should
are open, and check valve not be open while changing ethylene oxide
faits, tanks.
HIGH FLO~J Broken line or hose due to an Oamage to piping or other Instruction to operator must be to leave
(CONTINUOUS accidental break, equipment. Chemical burns, the room and initiate eflergency procedures.
RELEASE) Pool of ethylene oxide forms.
Respirator equipment should be close by
equipment room (room where ethytene oxide
sterilizer, tanks, and piping are located).
Equipment room should have two exits.
Att ethylene oxide tanks ~hould be tocated
in one general area.
Piping design should fottow the code for
madical gases and NFPA ~ codes (fire
codes). NFPA code recommnds that copper
containing at[oys are not suitable for
ethylene oxide. This is the case if the
ethylene oxide contains acetytene as a con-
taminant. Since all U.S. manufactured
t\ethy[ene oxide now contains no acetylene,
copper piping is considered here to be
acceptable. This should specify hard COl~oer
ttYotng, silver sotder joints, and adequate
supporting. The piping diameter (1/4" min.)
and routing should be chosen to minimize'
the liquid inventory. Piping shoutd be
labeled to identify it as carrying ethylene
oxide. The ethylene oxide piping should not
be adjacent to steam lines.
Table 2. (continued)
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/GUESTION/RECOMMENDATION
Oparmtors and matntenmnce staff should be
trained in the hazards of ethylene oxide
and Freon 12 according to OSHA regulations.
The atmosphere in the equipment room should
be monitored to provide a gross leak alarm
in the case of an accidental release. A
suitable atam concentration would be to a
maximum of 100 ppm. The monitor should be
tested periodicaLLy mt the manufacturer's
recommended frequency or every three
months, whichever comes first. An organic
vapor detector would be suitable. A
sampling point should be located in the
approximate breathing zone in the Loading
area, near potential Leak sources.
The equipment room ventilation, Loading
room (room in which the sterilizer
Loading/unLoading takes place),
ventilation, and machine exhaust should be
routed to a dedicated ventilation system,
separate from other systems. It should be
sized to maintain a negative pressure in
equipment room relative to loading room,
and a negative pressure in Loading room
relative to aLL other areas, if for
example, a tank hose were to rupture.
LESS FLOW No hazard. No safety issue.
MORE PRESSURE Equipment rooel ten)3erature EthyLene oxide Leakage around Vent shoutd be sized to ensure that
increase warms tank. tank valve. Polymerization in temperature in equipment room should be
tank. Less than 100°F as specified by ethylene
oxide gas distributor.
LOW PRESSURE No safety issue..
Table 2. (continued)
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOMMENDATION
HIGH TEMP. High room tempereture. High pressure. Same as for more pressure.
(NONAMBIENT)
Steam Leak onto tank. Possible fusing of fusible When working on pressurized ethylene oxide
plug. system, (e.g., when changing cylinders,
protective equipment should be worn,
including face shield and
facilities should be provided to aL[ow
rapid washing off of any spiLLage or
splashing to the skin (e.g., a safety
shower).
COMPOSITION Composition in tank has pure ExpLosion or fire. Inspection for correct LabeLing (usuaLLy by
ethylene oxide (no Freon 12). color and sticker) of newly arrived
ethylene oxide and Freon tanks should be
done. Tanks should be stored in an isolated
area. Operator should ensure that the
proper ethylene oxide and Freon tank is
hooked up to sterilizer.
A sign saying "Check tank Label for proper
ethylene oxide and Freon composition"
should be posted in the storage room.
CONTAMINATION Dirt contaminates process FiLter should remove. No safety issue.
stream while making
couplings.
RELIEF BLocked needle valve in vent No depressurization of hose A system of two isolation valves should be
(VENTING) Line. and Line between valves A and present on ethylene oxide inlet Lines.
B (see Figure 2). Addition of a bleed between the two valves
would reduce the consequence of Leakage.
ALternativeLy, addition of a pressure
indicator between the valves would aLLow
: Leak detection. Move or add the pressure
indicator to position upstream of valve B.
This configuration is shown in Figure B-/+.
The recommended configuration is shown in
Table 2. (continued)
GUIDEWORO/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/gUESTION/RECOMMENDATION
MAINTENANCE Leak from valve stems, Low concentrations of ethylene Carry out regular check for teaks around
joints, etc. oxide in atmosphere, fittings using an appropriate teak detector
(i.e., a halogen or hydrocarbon leak
detector).
SAFETY Major leaks. High concentration of ethylene Develop a contingency plan for use when
oxide in area. major leak occurs. See Operational
Procedure 9 in NIOSH document.
(SECURITY) Unauthorized entrance into Equipment misuse. Exposure to Equipment room should be marked, and a
equipment room or access ethylene oxide, locked door should be used if po. ssib[e.
area.
(HAZARDS OF See recommendations for high flow.
PROCESS
MATERIAL)
(EMERGENCY See recommendations for high flow.
EQUIPMENT)
Table 3. (NIOSH B-4). HAZOP Analysis of EtO Introduction into the Sterilizer
(Refer to F~gure B-2.)
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOMMENDATION
NO FLOW No hazard. No safety issue.
REVERSE FLOW Not possible. No safety issue.
MORE FLOW SoLenoid valve opens when EthyLene oxide transport An interlock ts required to ensure that the
chanYoer door is open. through piping, ethylene oxide inlet valve (or valves)
cannot open unless the chanter door is
Locked.
ReguLar wear on solenoid Leakage of solenoid valves. A system of two isolation valves should be
valves, present on ethylene oxide inlet Lines.
Aokiition of a bleed petween the two valves
would reduce the consequence of Leakage. In
addition, the addition of a pressure
indicator between the valves would aLLow
Leak detection. Hove or add the pressure
im~icator to position upstream of valve B
in Figure B-3.
MORE FLOg Pressure switch fails. - ReLief valve on chamber Chanber relief valve should be routed to
Lifts. the dedicated ethylene oxide ventilation
system.
- FaiLed door gasket. Door gasket should be inspected before each
use; replace when necessary.
LESS FLOW General use. - Longer time to pressurize. No safety issue.
FaiLs after time Limit. '
LESS PRESSURE Steam vent Line from heat Higher: temperature in ethylene No safety issue.
exchanger is blocked, oxide and polymer forms.
Table 3. (continued)
GUIDENORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOMMENDATION
LO~ TEMP. IN Not chamber contains liquid - No safety hazard if relief Relief valve should be sized for maximum
ETHYLENE ethylene oxide and Freon. valve is adequately sized. Liquid feed rate to hot chamber, assuming
OXIDE LINE all Liquid will evaporate.
- Rapid evaporation of
ethylene oxide and Freon.
- Overpressure in chamber.
SERVICE Power failure during - Sequence stops. Manual venting arrangement for power
FAILURE sterilization steps, failure should not be used as thfs could
- Valves close. Lead to ethylene oxide~ exposure to
operator. It is recommended that either the
manual vent valve be disabled, or only used
under careful management control.
Table 4. (NIOSH B-5). HAZOP Analysis of Routine Sterilizer Operation.
GUIDEWORD/ ACTIONS/QUESTION/
STEP DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES RECO~I~ENDATION
WARMUP SAFETY Setting temperature higher than Contact Burns - alarm sounds at No safety issue.
HAZARDS 130'F. 160°F.
Misreading of temperature (hish Out of limits - won't start. No safety issue.
or iow).
Misreading of pressure (high or Out of limits - won't start. No safety issue.
low).
PREHEAT SAFETY Timer malfunctions. No hazard. No safety issue.
HAZARDS
EVACUATION SAFETY Air or steam leakage into Causes higher pressure or pumps No safety issue.
AND STEAM HAZARDS chamber, work harder. No hazard.
PULSING
Vacuum switch faulty. - Pressure not achieved. No
hazard.
- Overpressurize chamber
possible, but no hazard.
Air in chan~er during No hazard.
evacuation.
Faulty reading of pressure Too long in cycle - alarm sounds.
during evacuation. No hazard.
CHARGING WITH NO FLOW Alarm from watchdog timer. No unresolved safety issue.
itC
MORE FLOW Leakage in heat exchanger Steam carries ethylene oxide gas No unresolved safety issue.
(tubes). to drain.
Reverse flow into air line via Ethylene oxide leak to equipment Air inlet to chamber should not
leaking valve, room. pick %p air from equipment room,
but from exhaust duct to reduce
risk from reverse leakage of
ethylene oxide.
Table 4. (continued)
GUIDEWORD! ACTIONS/QUESTION/
STEP DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES RECO~4ENDATION
CHARGING WITH SAFETY Prior evacuation of air was not No hazard to operators - not sure See Operational Procedure 2b in
EtO (cont.) HAZARD achieved; begins to charge with of sterility of load. NIOSH document.
ethylene oxide and Freon.
STERILIZING SAFETY Leakage of ethylene oxide and Notification by computer No unresolved safety issue.
PROCESS HAZARD Freon. printouts and alame if leakage
is severe.
EVACUATION SAFETY Rapid depressurization of Overloadins of vent (exhaust) Maximum exhaust rate of gas from
HAZAitD cha~er, system at the pluming gap. cha~e= must not exceed ventila-
tion system capacity.
EVACUATION LEAKAGE OF Faulty pressure switch allows Open door when not actually safe See Operating Procedures 2h and
AND AIR WASH ETHYLENE cycle to step on without proper to do so. 2c in NIOSH document. Also, an
OXIDE evacuation, interlock is ~equized to ensure
that the ethylene oxide inlet
valve (or valves) cannot open
unless the chamber door is
locked.
Add a 20-min. air wash procedure
if not already on system.
Table 5. (NIOSH B-7). HAZOP Analysis of the Air Supply for Vacuum Relief
in the EtO Sterilizer
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES 'ACTIONS/gUESTION/RECOHMENDATION
NO FLOW - Valve closed. - Machine hangs up. No hazard. No safety issue.
- Filter plugged. - Machine hangs up. No hazard.
Takes too long, alarm goes
off.
- Too much vacuum. - Deep vacuum, cantt open
door. No hazard.
REVERSE FLOW Air line should be connected Air Inlet to chanber should not pick up air
to vent. from equipment room, but from exhaust duct
to reduce risk from reverse leakage of
ethylene oxide.
No safety issue.
HIGH FLOW
LESS FLOW Partial blockage. Takes longer - No hazard. No safety issue.
HIGH PRESSURE No hazard. No safety issue.
LESS PRESSURE No hazard. No safety issue.
HIGH TEHP. No hazard. No safety issue.
LOW TEMP. No hazard. No safety issue.
VISCOSITY No hazard. No safety issue.
COMPOSITION Draw in contaminated air Concentration is too tow to No safety issue.
(exhaust from other cause hazard.
equipment) from vent.
Table 5. (continued)
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOMMENDATION
CONTAMINATION Bfo[ogica[ contamination. Filter takes care of problem. No safety issue,
INSTRUMEN- Leaking vatve - air leaks fn. Chamber doesntt reach required No safety issue,
TATION vacut~ for function steps.
Notified by watchdog alarm -
No hazard.
Loose water supply to water Cantt open valve - system No safety issue.
SERVICE actuated valve, hangs.
FAILURE
Table 6. (NIOSH B-8). HAZOP Analysis for the Steam Supply to the EtO Sterilizer
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOMMENDATION
NO FLOW - Valve doesn't open. - Cycle won,t proceed since it No safety Issue.
looks to see a pressure
- No steam, change.
- Plugged steam tine (due to - If it gets through cycle,
crud), proper sterilization is not
achieved. No hazard to
employees.
HIGH FL(7,/ Vatve sticks open. High pressure in chan~oer. No safety issue. UnLikely to go above
atmospheric pressure bocause running vacuum
High te~oerature, p~znp st the sa~ time.
- Machine aborts cycle.
LESS FLOW Steam tine blockage. Cycle takes [onger. No safety issue.
HIGH PRESSURE Steam valve stays open. No hazard for tine. No safety issue.
LOW PRESSURE No hazard; designed for No safety issue.
vacuum.
HIGH TEMP. steam valve doesn't close System designed to handle No safety issue.
when supposed to. it.
- Damage of toad, printout
saying load is damaged.
- If pressure too high, relief
vakve .opens.
- Can't open 'door if this is
the case.
COMPOSITION No problem. No safety issue.
Table 6. (continued)
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEGUENCES ACTIONS/GUESTION/RECOMMENDATION
CONTAMINANTS Boiler fautt. - System should be abte to No safety issue.
IN STEAM handte it.
- Corrodes at high levers.
- Maintenance probtem.
RELIEF Piping can withstand max. No safety issue.
steam pressure - No hazard.
SERVICE No steam. Pressure not achieved; hangs No safety issue.
FAILURE Up,
Table 7. (NIOSH B-9). HAZOP Analysis for the Drain Line from the Sterilizer
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOMMENDATION
NO FLO~4 - No water flow. - No vacuum level achieved for No safety issue.
additional steps (stops
- CLosed valve in tine. cycle).
-P~np not running. - Ethylene oxide goes to vent.
REVERSE FLOW Exhaust valve fails, other Water into chamber. No hazard. No safety issue.
valves fait.
MORE FLOW The Loading room ventilation should
maintain s pressure lower, than that in
surrounding areas not containing ethylene
oxide. The equipment room ventilation
should maintain a pressure below that of
the Loading room. It is suggested to have
separate containment rooms (one for the
equipment room, and a second for the
Loading/unloading room). Where separate
Loading and unloading rooms are provided,
these should beth be maintained at a lower
pressure than surrounding areas. Efficient
ventilation would require a high [eve[
exhaust outlet and a tow [eve[ supply inlet
because of thermal stratification (exhaust
above sul~o[y).
The minimum velocity at the vents
connecting the Loading room and operating
room should be 100 ft./min, to overcome
normal air movements. Louvers to the
exhaust duct should be Located above 'each
door into each area. A stol hood should be
Locatod above the Loading /unloading door
of the sterilizer. The area ventilation
should be to a dedicated exhaust system.
Table 7. (continued)
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUES?ION/RECONMENDATION
Drain plugs. Water with ethylene oxide on Hospital should have an emergency procedure
floor; creates emergency for this case. Avoid continuing cycle if
situation, drain is known to be plugged (do this by
cutting power to sterilizer).
High concentration sensed in
equipment room.
If interlock is on: Where pract'ics[, a dedicated drain section
should be used connecting to a main drain
- Goes into exhaust cycle. Line, to reduce risk of blockage.
- CLoses ethylene oxide
charging valve.
- CLoses valve S3 to avoid
dump.
- Alarm sounds.
If splashes away from funnel,
ethylene oxide is picked up by
venti [ation. No hazard.
LESS FLOW Cycle takes Longer. No safety issue.
HIGH PRESSURE Can handle high pressure. No safety issue.
LESS PRESSURE Designed for Low pressure. No safety issue.
HIGH TEMP. - Less efficient on cycle. No safety issue.
- Pun~o is dry. Damage to pump.
No hazard.
CONTAHINANTS Line contains contaminants. Strainer removes any (if not - Strainer in chamber should be inspected
no flow), before each use.
INSTRUHENTA- - PLugged restrfcter (needle - Hangs up. No safety issue.
TION valve), i
Cycte takes longer.
- VaLve doesn't open,
- Hange up, watchdog alarm.
- VaLve doesn't open.
Table 8. (NIOSH B-lO). HAZOP Analysi~ for the Pressure Relief and
Temperature Recorder/Indicator on the Sterilizer
GUIDEWORD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECO~4MENDATION
MORE PRESSURE Overloaded relief valve. Gasket failure - venting into Loading room should not be occupied during
room. operation. The door to Loading room ~hould
contain a wir~low for observation.
LOW PRESSURE Designed for vacuum. No No safety issue.
hazard. (Can't open door.)
HIGH TEMP. Maximum steam ten~nerature No concern.. No safety issue.
reached,
LOW TEMP No concern. No safety issue.
CONTAMINANTS Polymerization of ethylene Polymer deposits that could See Operating Procedure 4b in NIOSH
oxide in chamber and reaction retain ethylene oxide, document.
of this with water.
RELIEF Relief valve sticks, or inlet Regular testing of valve Relief valve should be tested periedicaLly.
plugged with [int. should solve the problem. (Procedure for test should be carried out
according to manufacturerfs recommenda-
tions).
INSTRUMEN- Leakage arour~ tenl~erature Picked up by Leak checks. Carry out regular check for Leaks around
TATION probe, fittings using an appropriate Leak detector
(i.e., a halogen or hydrocarbon Leak
detector).
Leakage of relief valve. Ventilation system removes Chamber relief valve should be routed to
No hazard, the dedicated ethylene, oxide ventilation
system. '
CORROSION No safety issue due to. materials of
construction.
SERVICE Steam failure. No warm-up, canft get into No safety issue.
FAILURE cycle.
SAFETY Manual valve. Manual venting arrangement for power
failure should not be used as this could
Lead to ethylene oxide exposure to
operator, It is recommended that either the
manual vent valve be disabled, or only used
under careful management control.
Table 9. (NIOSH B-11). Reliability of the Dilution Ventilation System.
GUIDE~RD/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEQUENCES ACTIONS/QUESTION/RECOHMENDATION
NO FLOW Fan at point A stops, (see Beck flow from sterilizer Monitoring .of pressure with a positive
/REVERSE FLO~4 Figure 4). exhaust into other ventilated indication of failure should be used.
areas during exhaust cycle. Pressure should be monitored by a
differentia[ pressure switch that is faiL-
safe, such that a Lack of negative pressure
in the exhaust duct sounds an alarm and
inhibits the exhaust cycle of the
sterilizer.
VentiLation system should be sized to keep
temperature in area below 100°F.
HIGH FLOW No hazard. No safety issue.
LOW FLOW Picked up by a differential No safety issue.
pressure switch. PossibLe
failure to clear ethylene
oxide from area.
MORE PRESSURE Fan at point A stops, (see See LOW FLOW. The equipment room ventilation, Loading
Figure 4). room (room in which the sterilizer
Loading/unLoading takes place),
ventilation, end machine exhaust should be
routed to e dedicated ventilation system,
separate from other systems. It. should be
sized to maintain a negative pressure in
equipment room relative to Loading room,
and a negative pressure in Loading room
relative to aLL other areas, if for
example, a tank hose were to rupture.
HIGH TEMP. No hazard. No safety issue.
LOW TEMP. No hazard - should be No safety issue.
controLLed for comfort.
COMPOSITION No hazard. No safety issue.
SERVICE FaiLure of ventilation No ventilation. InstaLL Low fLow switch and aLarm (aLarm
FAILURE system, should be faiL-safe) as noted above.
Table 9. (continued)
GUIDEWORO/
DEVIATION POSSIBLE CAUSES POSSIBLE CONSEgUENCES ACTIONS/gUESTION/RECOflMENDATION
DISCHARGE Check local codes for location of discharge
POINT to prevent reentering of gases into
building. Also, Locate for minima[ exposure
to passers-by.
EQUIPMENT Drain must be sealed. This ~iLL not violate
ROOM pLunt~ing codes as the drain piping within
the sterilizer provides a plumbing gap
which is not sea[ed. Local ventilation
should be provided to the p[unt~ing gap. The
drain system to which the stertkizer is
connected should be fitted with drain
traps, to prevent gas flow. If the drain is
not likely to be used, it should be capped.
The drains local to the sterilizer should
be [abe[ed,'to indicate that they may
contain ethylene oxide.
AVAILABILITY. OF NEW' TR~ININ~ & REFERENCE MANUAL . ON ETHYLENE OXIDE HEALTH ~ S~FETY
Ethylene ·oxide (EtO) is a colorless, odorless gas used·
extensively by hospitals' and in the medical products industry as
a sterilizing agent. EtO overe~,xposure. :i,n humans has been clearly
linked to genetic ~ damage, "~eur0~'=0~'ic 'effects, and tissue
' '. .irritatio~.~:. Other...human studies.· suggest that EtO overexposure
........ suppor~edi~i..by'[..~'~Clear'._ animalL. 'evide'nc"~ Of~"!EtO ¥ca~cifibgenicity
· ' regulated bY the ocCUPationaI Heai~h and :Safet¥:-~.Adm~nistration..
(OSHA) in..1971... In..response to .grow. ing evidence .of po~ial long-.
·" 1984 --and -'. :1988 ;' each revision, provided inCreasin %y ':.str~icter
· . . ............ ~ ~. ~ .'.'! -. .. . .... : . . . .. ,
The Massachusetis''' 'Department~ bf industriaZ--~ Accidents funded -
the Occupational Health Service at .Mass. Respiratory Hospital to
develop and deliver'EthYlene Oxide (EtO).. Training Programs in 1989
and -1-9.90~- ..... Training-participants-hav~---tncluded-hospital_p~rs_ollD~_!.
(central sterile and maintenance · workers, '.-health &_ safety
committees, employee/occupational ' health, security, and
administrative . personnel,- and · others), .. fire-fighters (as · first'
.responders to EtO leaks or spills),, and museum and library(
conservators (where EtO 'is used to-fumigate various artifacts) .
A central goal of the '-Department of Industrial Accidents
..... Training...Grant~?rogram is to provide for continuation of the
benefits, of. the trainin~·'b&Yond 'th~':' te~i'nat-~n=·'of '~rafit?' fundihg
to ~ihdividual grantees... .To this end,. the' Mass. ' Respiratory
Safety.:._Manual_~in :_June o f ::11989 ~ ..' ~' This·. Manual.haS.'. ~ been revI~ed[':and.'2h
e_x]~anded _for publica_tion._a_n_d_ the Second Edition is now available.
· . Because its development .was -.funded by~6~'b~partmen~c~u-s~c~al--."~
· Accidents, it 'is available : to "' interested' persons at its cost of
production ($20.00). .An Order.· Fo.rm 'is attached. -.
Safety including Health· Effects .Of. overexposure, Reco~m~hdati-o-n-s-
for--EtO Use Reduction, .Medical, sUrveillance, Emergency Treatment,
Emergency 2planning.',.' ;and~:' two new FactsheetS:.~:~ one.. ~fOr" 'Firefighters
contained and -.hence Can .be ..used ·either- individually :0r :' as.:-.part.- of
....... and their Answers, designed to serve as a-':~e~effCe for~workers'and.
a resource for trainers~ and 3) a Section of Notes for Trainers
who would like to use the Manual to run their own EtO training
.... : ..... programs; ...... This section-includes participatory-training exercises,
...... ::-:: ..... :-"~:- suggeste_d:lw_ork .pract_i_c_~..:.d~m0nstrati'ons~---and other: .ideas _-for-: making
training 'as participatory - and hence ~ff~fi~ve_- as
-'ETHYT'.RNE :' OXIDE .~AT,TU' "~. ,bAF~T'Y ' ~AL: -'.':Tra~igZ~q-<& Re~eregce ~ '~-.
.... M.S.W., ClS;S. First..p~lished by.the Occupat~onaliHea~h
copy ' thanks :. to funding .-ProVided.-'"for~evelop~eh~'::~
Co~onwe'al~ 'of MasSachusetts Dop~n~' of ~ndust~i~:!~'~=~dents.':~ ~ · --
A bulk order discount ~s 'availablef~for "orders'-~'of -:'10 or~ :more'c:.~.
copies, the.price is-reduced to, $15.00 .per copy.
.. ..... .,.
· . .
ADD, SS: · ..
:' .. 'We are pr'esent~Y, aP~lhg~:for,'' funding to tra~'late.'this Manua'l'~:~ ·
· .. ' ' 'potentially interested "and:'.~6'~.'name."wiii~be .put-:'on::a :,.mailing .~'
~.-- ' .... ~ist~ for~-n°tif-ication-~if'~,and~hen~ed~-?e~ns~ecom~:~
The FPE Group
3687 Mt. Diablo Blvd., Ste. 200, Lafayette, CA 94549 (415) 283-8860 Fax: (415) 283-5727
SAN JOAQUIN COMMUNITY HOSPITAL'
Ethylene Oxide Risk Management and Prevention Program
Job Number 905144
San Joaquin Community Hospital was identified by the Bakersfield Fire
Department as a handler of ethylene oxide, which is an acutely hazardous
material (AHM). The City of Bakersfield~s Fire Department determined that
SJCH~s operations could pose an acutely hazardous materials accident risk;
therefore, it would be required to submit a Risk Management and Prevention
Program {RMPP) pursuant to section 25534 of the Health and Safety Code.
The purpose of a RMPP is to establish and maintain a comprehensive management
program to assess and prevent, to the greatest degree possible, the risk of a
release of acutely hazardous materials, in a manner which might cause harm to
the safety and health of the community and the environment.
San Joaquin Community Hospital is a 162-bed facility and employs
approximately 500 employees. The main hospital is 133,289 square feet. The
Central Service Department is located in the basement of the main hospital
and is 2,160 square feet in area.
A. Storage and Quantities Used
Currently, SJCH uses Penngas, a 12 percent ethylene oxide (EtO) 88
percent dichlorodifluoromethane gas (CFC-12) for sterilization purposes.
CFC-12 is used as a dilutent to render the 12/88 mixture non-flammable
and non-explosive. The gas mixture is supplied by Pennsylvania
Engineering Company and is shipped in 140-pound, 12" by 38" high
cylinders as a liquid under 70 psig.
The hospital uses approximately one 140-1b., 12:88 EtO cylinder every
three weeks, or approximately 17 cylinders a year. This amounts to
approximately 1.4 pounds of EtO used daily and for our purposes
discharged daily. Annual use of EtO is calculated to be approximately
500 pounds.
At any one time there is a maximum of four full cylinders (67.2 pounds
of EtO) on hospital property: two behind the sterilizer in the basement
in Central Supply and two currrently outside the main hospital in a gas
cylinder storage cabinet on the loading dock. The cylinders are chained
to prevent accidental falls and the valves are recessed within a ring-
protecting collar to prevent accidental release during a fall.
One of the EtO cylinders in Central is "on-line" and connected to the
gas sterilizer. About every three weeks, Central Supply notifies
engineering the tanks need to be changed; an engineer picks up a reserve
tank from the outside storage area with a dolly, transports it to
Central and exchanges the tanks in the area behind the sterilizer unit.
San Juaquin Community Hospital -1- October 18, 1990
The FPE Group
B. Sterilization Process and Emission Releases
The sterilization process involves EtO gas, relative humidity
(moisture}, proper exposure time, and temperature. The relationship of
these four elements depends on the sterilizer and materials to be
sterilized. After the materials are humidified and gasified, excess
gases and moisture are eliminated by vacuum, exhaust, and purge cycles.
SJCH has one AMSCO sterilizer, Model No. 2045, which has a 24 cubic foot
capacity and an AMSCO Aerator. The AItSCO sterilizer is six years old
and it and the aerator are serviced every other month by an AMSCO
service technician. In addition to this service, the hospital has Gas
Monitoring, Inc. come out quarterly and check the AMSCO sterilizer and
AMSCO Aerator for leaks with a Miran lA Spectrophotometer during
operation.
The hospital currently runs one sterilization load a day for a total
cycle period of four hours (actual sterilization time is 1.75 hrs.),
cracks the sterilizer door for 15 mins., moves the load into the aerator
for 12 hours and then prepares it for redistribution. Emissions of EtO
occur primarily during the latter part of the 1.75-hour sterilization
cycle and during transfer of the load to the aerator.
Construction workers working in the vicinity of the sterilizer were
recently monitored for EtO exposures. All results were Well below the
current Cal/OSHA permissible exposure limit (PEL) of 1.0 part per
million {ppm). Central Supply employees' short-term exposure levels
(SlEL} to EtO have been measured in the past and are in the range of
0.49 to 0.75 ppm, which is well below the Cal/OSHA 15 min. STEL of 5
ppm. Estimates of their eight-hour, time-weighted average.exposures are
well below the PEL of 1 ppm.
C. EtO and General Ventilation
lhe hospital is now in the process of modifyingthe exhaust ventilation
system which services the sterilizer area. For your reference, addended
to this report you will find the reduced blueprints of the modifications
to the mechanical system servicing Central Supply. Basically, the
exhaust is a dedicated system with a canopy hood installed along the
sterilizer and aerator bank, with a exhausted closet for the gas
cylinders. The design is to have the sterilization area under negative
pressure relative to the rest of Central Supply and the rest of the
hospital at all times.
The dedicated exhaust duct passes into the adjacent mechanical room and
traverses it at ceiling level before penetrating the roof and entering a
rooftop blower. The blower output is ducted at rooftop level through a
14" square duct to a point thirty feet above street level and as far
away as feasible from any outside intake, operable windows, or routine
personnel passage.
San Juaquin Community Hospital -2- October 18, 19g0
The FPE Group
The ventilation design is for the blower to provide a total of 1850 cfm
of local exhaust ventilation in sterilizer loading and mechanical areas.
· When completed the central supply room will have 13 air changes per hour
(ach/hr) and the sterilizer equipment room will have 22 ach/hr.
An alarm relay system has been installed which alerts personnel in
Central to the fact that the sterilizer equipment cannot be operated if
the non-recirculating mechanical exhaust system is not operating.
D. Accidental Releases
SJCH has an EtO Gastech Alarm with four sensors, which alarms at levels
greater than 5 ppm. SJCH has had no accidents within the last three
years with EtO. However, on 2/26/g0, Sensors #1 & #3 alarmed. The
AMSCO technician was called and found no leaks. The Gastech alarm is
not specific for EtO or Freon, but also reacts to alcohols, perfume, and
auto exhaust and that is what apparently happened on this day.
The EtO cylinders are designed to resist breakage and leakage. The
cylinders are supplied with a welded-ring protecting collar so that the
valve is effectively recessed and protected from damage.
The sterilizer and aerator cannot operate if the mechanical exhaust
system fails. A Gastech Alarm system with four remote sensors is
activated if leaks of EtO are detected.
Employees who may be potentially exposed to ethylene oxide are trained
at the time of initial assignment and at least annually on the proper
use of the sterilizer, handling techniques and precautions, emergency
procedures, and the right to medical surveillance. Attached to .this
report is a copy of San Joaquin Community Hospital's "Ethylene Oxide:
Employee Training and Coemunications Program," which is a part of their
ongoing HAZARDOUS MATERIALS MANAGEMENT PROGRAM.
Although ethylene oxide is widely used, serious systemic poisonings from
EtO are rare in the literature. Neither Richard Nusbaum of Penngas, who
has 25 years experience, nor Tony LaMontagne, who performed literature
searches and interviews during the preparation of a comprehensive
training manual for Massachusetts hospitals, knew of any fatalities due
to ethylene oxide use in hospitals.
The Immediately Dangerous to Life and Health (IDLH) level for humans for
EtO is listed as 800 ppm, and the odor threshold is listed as 700 ppm,
so odor is not a good warning for potentially harmful exposures. High
concentrations of EtO gas are both irritating to the mucous membranes
and depressing to the central nervous system.
Guinea pigs exposed 'to 51,000 to 64,000 ppm of EtO for ]0 minutes died
within 24 hours of lung edema. Ethylene oxide is carcinogenic in animal
studies and is a suspect human carcinogen. Ethylene oxide is also a
suspect reproductive toxin.
San Juaquin Community Hospital -3- October 18, 1990
The FPE'Group
If a rupture of tubin9 or valve occurred so that one fuji cylinder was
released in the sterilizer equipment room, essentially all EtO would be
confined to the Central Supply and exhausted to the outside air. See
attached air dispersion modeling. A release of one full cylinder is a
release of 16.8 pounds of EtO or 148 cubic feet at standard temperature
and pressure.
Using standard industrial hygiene equations for dilution ventilation
{see for example page 76 of the NIOSH text}, a full release of an EtO
tank in five minutes, confined to Central Supply {volume of area is
21,000 ft3} would produce an average concentration in Central Supply
increasing to approximately 7,000 ppm at five minutes, which would
produce a hazardous condition for all in Central Supply. Thus immediate
evacuation and isolation of Central Supply would be imperative. No one
would be able to enter the area without the use of a self-contained
breathing apparatus (SCBA) and impervious protective clothing {such as
polychlorinated ethylene} as EtO is quite irritating to the skin. The
dedicated exhaust of 1850 cfm would dilute the EtO in time. The half-
life can be calculated to be about 23 minutes. The average
concentration would be 800 ppm at about 80 minutes and 1 ppm at about
310 minutes..
In an actual release, concentrations of EtO near the point of release
would exceed the average, but the exhaust would also function more as a
local exhaust rather than simply as dilution ventilation. The actual
half-life for clearance would likely be less than calculated.
SJCH has a standby Survivair SCBA outside the immediate Central Supply
Area. In order to assure that this emergency equipment is used properly
during an EtO spill or rupture, personnel on all three shifts will need
to be trained to respond to acutely hazardous materials emergencies by
learning how to don protective equipment an operate an SCBA. This
first-responder hazardous materials training should be at least 24 hours
and be repeated annually.
San Juaquin Community Hospital -4- October 18, 1990
AVAILABILITY OF NEW TRAINING & REFERENCE MANUAL
ON ETHYLENE OXIDE HEALTH & SAFETY
Ethylene oxide (EtO) is a colorless, odorless gas used
extensively by. hospitals' and in the medical products industry as
a sterilizing agent. EtO overexposure in humans has been clearly
linked to genetic damage, neurologic 'effects, and tissue
irritation. Other human studies suggest that EtO overexposure
-lead's to increas~driskSofleUkemia andOther cancers,~spontaneous
abortions,, and other reproductive problems; these studies are
supported~ by clear animaI evidence, of EtO carcinogenicity and-
reproductiwe~toxicit~ ..... - ~.~
'~to 'Was included i5 the' first~ g~oup ~-of . chemicals to be
regulated by the Occupational Heaith'~and Safety~Adm~istration
(OSHA) in 1971. ~ In response to growing evidence of po~al long-
~term~heal~h~e~ects~0f EtO~,~OSHA~s_EtO~Standards_~ere. ~gvised in
1984 and 1988; each' revision p~oVi~ed increasingly stricter
protection ~or potentially exposed workers..'
The Massachusetts' Department'bf Industrial'.Accidents funded
the. Occupational Health Service at .Mass. Respiratory Hospital to
develop and deliVer'Ethylene Oxide (EtO) Training Programs in 1989
and-l-9~.0~. .... T_raining~participants_ha~e_included~hospit~al p_er~onne_!
(central sterile and maintenance workers, -health &_ safety
committees, employee/occupational health, security, and
administrative ~personnel, and others), fire-fighters (as first
responders to EtO leaks or spills), and museum ~nd library
conservators (where EtO is used to fumigate various artifacts).
A central goal of the Department of Industrial Accidents
Training ~_rant Prog~am~S~o _~rovide for continuation of the
benefits of_the training beyond.~the ter~i~ation-6f-~fit~ funding
to ih-dividual grantees. .To~-this end, the Mass."tResPiratory
Hospital!s.O_ccupational~__Hea!th_S~r~i~e published an EtO Health-&-7'
Safety_Manual_in_June of1989~ __This_Manual[~a~_bee~_~iS'e__d_~nd
expanded for .publication and the Second Edition is now available.
Because [tsdevelopmentw~-~u~-by the
Accidents, it is available, to interested persons at it~.c~st._o~_
production ($20.00). An Order Form is attached.
-- '~The Second Edition inOludes-~he~f~llbWing~-~'~i-1-)
2 p~ge-F~ctshe%ts~°h-~a~h~b-f--l~or'-asp~t~-~°f=Et~O~H~a~-t~&-
Safety including HealthEf'f~cts -of.overexposure, Recomi~hdat~%nB
for EtO Use Reduction, Medical Surveillance, Emergency Treatment,
Emergency .Planning,..~and two new Factsheets:.'one for'Firefighters
an-d~a-~Gl~o-s-s-ary--of--Heal-th--&--Safety~.Terms. E-ach--s-heet~s~se-l-f
contained and hence Can be.used either individually or as Part of
a com~-~h~nsYve-t~i-ffi~-)--a--Se-cti~h=o~-C_0~._.on~ly~asked~Q.uesti'~n~
and their Answers, designed to serve as a reference for'worKers an~.
a resource for trainers; and 3) a Section of Notes for Trainers
who would like to use the Manual to run their own EtO training
programs J--This section-includes participatory-training exercises,
sugg~sted~work-practice demonstratiOns¥-and other, ideas-for:-making--<~.
training as participatory - and hence ~f~t~Ve_- as pose-iSle.
.... . :'ETHYLENE OXIDE HEALTH & 'SAFETY MANUAL:. Traininq & Reference
. Materials on~ the' Safe Use of Ethylene' Oxide in -steriliZinq .............
Facilities.- A.D LaMontagne, M.A..,_ M_._Ed._}__K.T; "KelSey,, M.D., :'
M.O.H., D.C. Christiani, M.D., M.P.~H.,. M~-.', and'D. Plantamura,
M.S.W., C~.S.S. First. published by the Occupational Health Service', "
Massachusetts Respiratory Hospital in .~une. 1989~ R~Vised and
..' .... Expanded~. Second., Edition~./.published :in. July 199.0. (~2_P~ges) · ...
-This r~'source i,s~ availabte'.'.at its'~Preduction- cost .of $20.00 per
copy 'thanks. to funding provided for--i~s-~development -:bY the- '
Commonwealth of MaSsachusetts Department of:Industrial:. ACcidents.
A bulk order discount is available:' for orders of 10 or..more
copies, the price is reduced to $15.00.per copy. ~'~ ~
NAME:
TITLE; ....
ADDRESS:
........ Please 'enclose payment m~de out to OEMS (Occupational "and ..
Please:.s'end orders to:'' OccuPational Health-Service
MasS. Respiratory HOspital
..... 2001-Washington-S~. ---
.Braintree, MA 02184
***.POSTSCRIPT ***
Weare presently applying for funding to translate this Manual
i ....... -~-'~into Spanish-and-Haitian-Creole.'--~lease--writeus-if--¥ou~ar~e .... -~ ....
' .'. Potentially interested and your name'will be put on a'mailing
I ~. _'..~st__for_.noti_fiCation_if_and_when__~ran~ta~ed. versions~become
available. '-Thank you.--.--~
OCT 19 '90 14:47 FPE LAF.CA.
APPENDIX B:
NAZARD AND OPEPJ~ILITY ~TUDY
OF AN ETIiYLENE OXIDE STERILIZER
INTRODUCTION
The main body of the present =sport summarizes a 1984-$6 study by NIOSH
researchers on ~on=rols for continuous or routine emissions of ethylene oxide
from sterilizer ins=alia=ions in hospitals. The goals of this study were to
evaluate and documen= effective e~Sineering controls used by cbs hospitals
we~ ~tudied. This study involved conductin~ a aeries of walk-=h=oush surveys
~o ~2tlfy hospitals for further study, and week-long industrial hygiene]..
sampling at six facilities =ha2 were thought to represent stare-of-the-ar=
con==cl. This approach is effective in evaluatin§ the efficacy of con=role
currently in use, but is less useful for identlfy~n§ possible causes of
in£~equ~t ~ '?~tially cz=as=ropbic releases. Unless process or work
p~o~ ~ ,ere observed during the survey (which is ~nlikely), ~hey may
~ ~ h~v® ~n considered in chis ~ype of study.
As a follow~up to the field sCudy, a second s~udy was conducted to evaluate the
potential ffo~ a catastrophic or non~ouCine releases of Er0. A hazard and
operability study (HAZOP), a ~orm of process hazard analysis, was conducted on
an Et0 sterilize= supplied by compressed-Sas cylinders. This sterilize= is
simila~ =o most of =He sterilizers that are currently used in hospitals. Tbs
sterilizer ~nstalla=ien0 equipment, and operational p~ocedures were reviewed
and recommenda=ions were developed both specifically £or the studied
installaCton and for the generic ins=dilation o£ any Er0 s~erilizer.
The success o£ a HAZOP study depends upon the =he knowledge and experience of
the personnel involved and on the completeness of =he info=marion =hat is
available. A team is assembled drawing £=om all the areas o~ ~erest. In
case of =be ste~ilizer HAZOP, =he equlpmenc designs=s, a manu£, 'urers service
representative, ~be hospital engineering supervisor, and the
maintenance supervisor provided the ~eohnical expertise on ~he sterilizer
equipment, ins=dilation, and procedures. In addition, a ream leader and
recording secretary were provided on a consulting basis (Technics, Inc.,
Columbus, Ohio). The team leader was ~espons~ble for carrying out che HAZOP
a systematic manner.
The HAZ0P technique involves studying the operation as a series of
systems (called nodes). Using the se~ of guidewords listed in Table
team leader guides the group through each segment o~ the operation. ~uidewo~
f~om the £trst pa=c of the lis= relate ~o devia~ion~ in p~ocess parameters,
such as too much pressure or no Zlo~., Fo~ each Sui~ord~ the team atcemp~ed
=o tden=i£y a cause, or a s~rie~ of ~u~e~. i~ no cause could be identified,
the ream moved on =o =he next ~uid®~,~ ~f a eau~ wa~ found, ~he ceam
discussed the consequences and plaus£bility o£ ~he deviation. If there ~ere no
significant consequences, cbs team proceeded Co the next item. For items
both a plausible likelihood and a sisniftcanc consequence, recon~nendattons were
formulated co eliminate or reduce the likelihood of the process deviation. In
some cases, notes for additional study or later action were made. A similar
procedure was used for &uidewords from the second part of the list in Table
B-l, These guidewords are not related to process deviations, but rather co
Specific subject a~eas or conditions of operation.
PROCESS DESCRIPTION
The p~ocess under study is sterilization of hospital equipment using an
ethylene oxide sterilizer. The sterilizer consists of a jacketed chamber and
associated pumps, pipes, £11ters, valves, etc.
The actual equipment layout of the sterilizer at the facility of interest is
divided into ~wo containment areas: a loading/unloading area, which
incorporates ~he ~ronts o£ cwo aerators and two sterilizer/aerators; and an
equipment area, which contains the aerators, piping, ethylene oxide Csnks, and
the sterilizer/aerators~ The sterilizer chambers are fitted with a safety
valve which, depending on the machine design, relieves the chamber at 15 psi or
~0 psi; and a jacket safety valve (on steam-heated units) as shown in
Figure B-l. '
The sterilization process begins with a mixture of liquid ethylene oxide and
Freon 12 that passes ~hrou§h a steam-heated heac exchanger and is gasified.
The gaseous mixture is fed into a preheated chamber, which con,sins the
materials to be sterilized. The maCerials remain in the ~aseous enviror~ent
for the required amount o£ time for proper sterilization. Then, ~he e~hylene
ox~de/Freon mix,ute is removed from the chamber by a sequence of exhaust and
aeration cycles. A £1nal air wash of the chamber is done to complete the
process,
The vented gases leave the chamber ~hrough a venC~lation system where they mix
with air to give an acceptable concentration o£ ethylene oxide before they are
exhausted to aim°sphere.
Aqueous effluent from the sterilizer passes to a disengaging funnel, so that
any dissolved ethylene oxide which outgasses ~rom the water can be directed
~he ven~ilaClon system before the liquid effluent passes to the drain.
To aid in underacandtn~ the equipment layout, ~he followin~ definitions were
developed:
,(l) 'Equipment Room - Room where ethylene oxide sterilizer, tanks, and
piping are located.
(ii) Loadir~ Room . Contained room ~n which the sterilizer
loadini/unloadins takes place.
The layout of ~hs sterilizer is shown in Figure B-1. An overall piping
instrumentation diagram is ~iven ~n Figure B-2.
120
OCT 19 ~90 14:~9 FPE _AF.CA.
The EtO sterilizer system that was evaluated in the HAZOP study was divided
into the following components, or nodes, for purposes of the HAYOP:
e Layout o£ =he E=O sterilizer facility (Figure B-l)
Storage, transport, and changing o£ the EtO/Fzeon supply cylinder
(Table B-2, Figure B-S)
· EtO piping from the cylinders to the sterilizer
(Table B-3, Figure
· Introduction o£ EtO/Fzeon into the EtO sterilize~
(Table B-4, Figure ~-2)
Operation of =he EtO sterilizer
(Tables ~-§ and B-6, Figure
· Utilities and procees lines to and from the EtO sterilizer
(Tables B-7, B-S, and B-9, Figure
· Eeliability of ~he dilution ventilation system
(Table B-il, Figure ~-~)
Reliability' of the EtO area monitorir~ system
(Tables B-12 and B-l$, Figure B-6)
These nodes are discussed in the remainder of Appendix
LAYOUT OFT gE ETO STERILIZER FACILITY
The design intention is to assure a sa~a working area, and to minimize the
chances o~ EtO exposures, General ~ecommendations £or ~his a~e as £ollows:
· Ethylene oxide equipment should be isolated from other hospital
equipment and should be in a separately enclosed area (containment
room). Minimum size and layou~ should be such tha~ staff and
~aiy~enance pezsonnel should have adequate room for
especially for ~ransportation of ethylene oxide tanks. The
ethylene oxide sterilizer and equipment should not be installed in
or adjacent to pa=lent areas,
· If ~he machine control panel cannot be seen from outside tbs
loading room, a remote control pane~ should be used.
STORACE, T~SPORT, AND CHA~IN~ OF THE ETO/FREON SUPPLY
The design intent is to safely score, transport, and install the Z~O/Freon
cylinders. Figure B-~ depicts the recommended plpinS and rely(ns arrangements
for ~he supply cylinders. ~eneral recommendations for lnstallin~ new cylinders
are as follows:
121
· Supply valve, tank valve, vent valve, and needle valve to vent
should be labeled (see Figure B-~). The same labeling system
should be used in the written operating procedures,
· Ethylene oxide pipin~ ~rom tank to sterilizer should contain a line
tO ~be exhaust ventilation system.
The HAZOP analysis for cylinder s~orage is given in Table
ETO/FXEON PIPIN~ FROM THE CYLINDERS TO T~E ~TERIL~ZER
The design lnten~ of this system is ~o transfer liquid E~O/Freon from the
s~orage cylinders to the sterilizer unit. Figure B-~ shows the arrangement
perform ~his function. The IAAZOP analysis £o~ EtO ~ansport is shown in
Table
INTRODUCTION OF ETS INTO T~E STERILIZER
The design intent of this system is to introduce vaporized RiO/Fresh into the
sterilizer. This system is a continua=£on of the EtS/Fresh piping in ~he
previous section, The HAZOP &nalysts is shown in Table ~-$, which refers
Figure ~-2.
OPERATION OF THE ETS STERILIZER
The design in~en= of the EtS sterilizer is to provide appropriate sterilization
of the reusable hospital supplies without allowing the E=O to escape into the
workplace in unacceptable amounts. Table B-5 shows a HAZOP analysis ~or tbs
routine sterilizer ope~ation. Also, the writ=eh opera=lng procedures were
reviewed in conjunction with this analysis, and safe practices for these
procedures are siren.
UTILITIES AND PROCESS LINES TO AND FROM THE STERILIZER
In addition =o E=O, sterilizer operation also involves flows of air, steam, and
condensate, as shown in Flsure ~-2. Consequences of deviation in ~hese flows
are considered in this section. Air is used as a vacuum break in between the
vacuum cycles =hat are used to remove ~he EtS. Table B-? shows the results of
a I{AZOP analysis for this air.
Table B.$ shows the results of a HAZOP analysis for the steam supply to the
sterilizer. The design intent is to provide humidification and some heating
durin~ =he sterilization cycle.
Table ~-9 shows the results of a HA20P analysis for the drain line from the
sterilizer. The design Intent is to depressurize and evacuate the sterilizer.
Fo= later machines, an interlock prevents a high discharge rate through the use
of a flow restricter, l~hen the chamber pressure is below a~mospheric, a bypass
valve opens around the restricter.
A I~20P analysis of the steam supply ~o the heat exchanger and sterilizer
Jacket and off the condensate line from ~he heat exchanger and steril~zer jacket
()CT 19 '90 14:50 FPE LAF.CA. P.6
showed no lss~es'o~ concern, The coolinS water supply and drain also showed no
concerns.
The ~AZOF of the pressure relief valve on the sterilizer and of the gas
temperature recorder/indicator is shown in Table B-lO. The design intent of
these items is to maintain proper conditions of temperatures and pressure for
s=artliz&tion.
P~LIABILITY OF THE DILUTION UENTILATION
The dilution ventilation should be designed in conjunction with the sterilizer
equipment. The design intent is co remove E=O that has escaped into the work
area and to vent excess heat from the sterilizer. General recommendations are
as follows:
The equipment room ventilation, loading room (room in which the
sterilizer loading/unloading takes place), ventilation, and machine
exhaust should be routed to a dedicated ventilation system,
separate £rom other systems. It should be sized to maintain a
negative pressure in equipment Zoom relative to loadtn$ room, 'gnd a
negative pressure in loading room relative
for example, a tank hose were to rupture; (this corresponds to a
5.4 lb/s release). A reclrculation ventilation system is not safe
for ethylene oxide areas.
Final exhaust fan should be outdoors. Co keep a negative pressure in
the indoor ducts.
· The loadin~ room ventilation should maintain a pressure lower ~han
=hat in surrounding areas not containing ethylene oxide. The
equipment room ventilation should maintain a pressure below that of
the loading room. It is suggested to have separate containmen~
rooms (one for the equipment room, and a second for the
loading/unloading room). %~here separate loadin~ a~d unloadin~
rooms are provided, these should both be maintained at a lower
pressure =hen surrounding a~eas. Efficient ven~lation would
require a hiSh level supply inlet because o£ thermal stratification
(exhaust above supply).
Table B-11 gives the IiAZOP analysis for the dilution ventilation system.
ET0 AREA~0NITO~IN¢ SYSTE~
The facility that was evaluated used a ilxed-point gas chromatograph which
rote=ed between a series of lines tha~ drew air from various locations in the
A HAZOP analys~s'was done on the =ransport lines for potentially E=O-laden air
from ~be work areas to the ~¢. This is shown in Table ~-12.
123
· igure B-2. Piping and lns~rumenta~ion Diagram for
the ~tO Sterilizer ~valuate~ in the HAZOP.
X7
SUPPLY VALVE
"~~ TI2 VENT
VALVE ~
TANK NEEDLE
VALVE VALVE
· to VENT
ETHYLENE OXIDE TANK
(1BY. w/w E'thytene Oxide in Fr"eon)
Figure B-3. Labeling of Val,~ on she ECO Supply Line.
127
OCT 19 ~90 14:51FRE LAF.CA. P.9 ~
~ILT~R Vi~ALV~ , I V~LV£
'
V£NT VENT
Fisure B-4. Piping for Transport of E~O/Freon
from the Supply Cylinders to the Sterilizer.
138
OCT 19 ~90 14:52 FPE LAF.CA.
gxhausc flor the BoO S~ertltze~.
129
JCT 19 '90~ 14:52 FF'E LAF.CA.-- ..... ' '" ~
CALIBRATION ~
OAS (15 ppm CARRIER
to ~0 ppm
~Xlde In N~
SCHEMATIC I .~ 7
OF MULTIPORT
VALVg I SAMPLING PUMP
L ........... J
~0 VENT
Figure B-6. Schem&tic o£ A~ea Monito~inS System for EtO.
OCT 19 ~90 14:53 FPE LAF.CA.
Table B-1.' HAZOP Ouideword
Flow NO Flow
Reve=sa Flow
~o=e Flow
~ss Flow
~ss Level
Pressure ~ore Pre~u~e
Temperature More Temperature
~ss Temperature
,Viscosity ~ore Viscosi~y
~ss Viscosity
P~T II - O~he~ I~ems
Composition
Con~i~Cion
Pressure Relief
Ins tr~enta=ion
Corrosto~Erosion
Se~tce Failure
Abno~l Opera~ion
~in~e~nce
Static Electricity
Spare Equipment
Safety
131
OCT 19 '90 1~l:53 FPE LRF'.CR. ..... P.i~ "'"-'~
AERATOR A devLce for ~he removal of ethylene oxide £rom sterilized
materials by ~he exposure ~o ~he circulation of air; aeration
is no,ally accomplished at an elevated cemperaeure,
AIR ~USH ~a~ par~ off ~he stez~lizer cycle when the vacu~ p~p
operates continuously and a valve opens a~i~n~ filtered
air into ~he s~erilizer ch~ber.
~0~ A s~ll glass vial con~aintng e~hylene oxide.
~ISI~0N A device ~o preven~ back,low o~ con~ina~ed wa~e~ in~o ~he
AIR ~A~ potable wate~ system; the ai~ gap ~y be pa~tially enclosed
and co~ec~ed ~o a local e~auat system.
AUTOC~VE A p~easu~ize~, s~e~-hea~ed vessel used fo~ sterilization.
BI0~L A vial containing bacteztal epores used ~o~ ~te~ina~lon o~
iNDICATOR ate~llization.~
CL~ ~0~ ~e a~ea within ~he hospital where washed ma~e~iala are
d~ied, inspected, and packased.
DEC0~INATION ~at a~ea within the hospital where used materials are washed
RO0~ p~io~ to sterilization; also kno~ aa the isolation room.
DEDICATED ~ exhaust system $~ing only the aa~a~o~, stezilizer,
~UST and/or the i~ediate a~ea.
D~E~ P~IOD ~at pa~ ~ the stezilizer c2cle du~ing which ste~iltzatioa
Cakes place.
EVA~ATiON/ ~at pa~t o~ the sterilizer cycle when ~he vacu~ p~p ~uns
~UST ~o remove ~he bulk o~ the ethylene oxide ~om ~he ch~be~,
~ollowed by the opening of a valve Co a~ic ~ilteze~ ai~ in~o
the ate~ilizer ch~be~, re~u~nins it to atmospheric p~esaura.
GEN~ ~echanical vencila~ion applied ~o a room or an area flor the
VE~I~TION purpoees of climate control and dilution off hazardous~
chemical concentrations ~o safe levels.
HOOD ~e poin~ of entry into a local exhaus~ system.
iSO~TIO~ ROO~ A separate room containins the s~erilizer and the stezilizer
loading a~ea.
166
P. 14
OCT 19 '90 14:~4 FPE LRF.CR.
LOADiN~ AEEA The arsa ~n front of =he s=ertlize~ and aerator; in some
hospitals, =he loading area is a separate room with limited
LOCAL EXHAUST Hechanical ventilation applied a= o= close to the source of
VENTILATION an emission, for =he purpose of d=awtn~ clean, uncon=am£na=ed
at= pas= =he worker, cap~urlng the emission, collecting i= in
an exhaust hood, and removing ~t from =he building.
HECHANICAL A room into which the mechanical equipment of the sterilizer
~lu~h wl~h the wall; also known as the recess room.
NOR~M.L LOAD The materials sterilized by =he hospital.
PULSE-PURGE That ~art of the sterilizer cycle after evaoua=io~/exhaust
consisting of repeated cycles of operation of the vacuum pump
~ollowed by vacuum relief.
RECESS RO0~ The mechanical access room.
RELIEF VALVE A device to vent the sterili~er in the event the pressure
exceeds the chamber design pressure.
TEST LOAD A "standard~ load used in this study consistin~ of len~he of
latex tubing in a wrapper.
167
OCT 19 '90 14:54 FPE ~F.CA. P.15
E. ~orst-Case Releases
We have used the EPI Code ?ftware program to evaluate the atmospheric
release of EtO using air dtspersion ~odeling. Attached are modelings
based on the release of one full cylinder either on the loading dock or
in Central Supply,. The modelings are based on a release of 16,8 pounds
of EtO over five m~nutes, w~nd speed of 6.4 mph (average for
Bakersfield), worst-case stability class, deposition velocity of 0.1 cm/
sec, and worst-case terrain. The modeling for release in Central Supply
uses a release to atmosphere height of 30 feet, the height of the
outside exhaust duct o~tlet. The exposures to receptors at three
different heights are ~ncluded in the modeling. The modeling for
release to the atmosphere on the loading dock uses a release height of 8
feet and a receptor height of 8 feet,
I. Modeling I. is for a release at the outside exhaust duct outlet, at
a height of 30 feet, and predicts the exposure to a person at street
level (breathing zone height 5 feet).
There is a maximum predicted concentration of 12 ppm for a receptor 0,03
mile (160 feet) directly downwind from the release. There are no
maximum predicted concentrations above the IDLH level (800 ppm).
II. Modeling II. is for a release at 30 feet and predicts the exposure
to a person whose breathing zone would be at the same height, for
example a person working on the roof, or predicts the concentration that
could enter through a rooftop air intake.
There is a maximum predicted concentration of 13,000 ppm for a receptor
within 0.006 mile {32 feet) directly downwind from the release. Maximum
predicted concentrations fall below the IDLH level (800 ppm) at about
0.03 mile (160 feet).
T~e maximum predicted concentration falls off sharply for a receptor not
d~rectly downwind. For a receptor 0.005 mile (~6 feet) off the d~rect
downwind line, the maximu~ predicted concentration is 11 ppm, at a
distance of 0.05 mile (265 feet).
It is possible that a worker, on the roof could get a brief exposure
above the IDLH level during a worst-case release in Central Supply.
Since worst-case release in Central Supply is most likely to happen when
an engineer is working in the sterilizer equipment room, a good policy
would be to have no one on the roof during that time.
IIt is also possible in this worst-~ase release that a brief IDLH
?n~en~ration co~Id enter the hospital through an air intake within 160
feet of the ~uts~d~ exhaust outlet. This is a much less likely
occurrence since the air intake would have to be directl~ downwind from
the release. The release point is on the side of the bu~.lding, which
helps direct.the release away from t~e building: It.is much more l~kely
that an a~r ~ntake will be off the direct downwind line, and much lower
concentrations are predicted. Nevertheless, the hospital should be
prepared to treat persons exposed to a b~ief IDLH concentration in case
the unlikely were to occur, We are sending the hospital the ~nformation
San Joaquin Community Hospital ~6~ October 18, 19gO
OCT 19 ~90 14:55 FPE LAF.CA. F'.16
from a database for physicians concerning the treatment of persons
exposed to ethylene oxide.
III, Modeling III. is for a release at 30 feet and predicts the
exposure to a receptor at height one story above the release (40 feet),
for example a window.
There is a maximum predicted concentration of ~! ppm for a receptor 0,01
mile (53 feet) directly downwind from the release, which is well below
the IDLH level {800 ppm). Again, the maximum predicted concentration
falls off significantly for a receptor not directly downwind. For a
receptor 0.005 mile {26 feet) off the direct downwind line, the maximum
predicted concentration is 8,5 ppm, at a distance of 0.04 mile {21!
feet),
IV. Modeling IV. is for a release at 8 feet on the loading dock and
predicts the exposure to a person whose breathing zone would be at the
same height, for example a person working on the loading dock or a
window at 8 feet.
There is a max!mum predicted concentration of 27,000 ppm for a receptor
within 0.006 mle (3~ feet) directly downwind_from the release Maximum
predicted concentrations fall below the IDLH level (800 ppm) a~ about
0.04 mile (211 feet).
Here again, the maximum predicted concentration falls off sharply fgr a
receptor not directly downwind. For a receptor 0.005 mile (26 feet) off
the d~rect downwind line, the maximum predicted concentration is ~ p.pm,
at a distance of 0,2 mile (~0)6 feet).
Brief con'centrattone above the IBLH could occur a~ receptors that
happened to be within 211 feet of the release and directly downwind, and
brief concentrations above the STEL could occur within 0.7 mile
do~n~ind.
Recommendation: Work practices should be followed to minimize the
likelihood of a release on the loading dock, and moving the storage to
another area should be considered.
V, A very difficult release to model, is a worst-case release within
th? hospital in an area other than Central.Supply, which has dedicated
exhaust. Anyone near the release would quickly be exposed above the
IDLH, ethylene oxide ~ould spread from the point of release in a
difficult to predict path,
Recommendation~ Due to the possible consequences of a wors~-case
release inside the hospital put outside Central Supply, the hospital
should develop strict work practices concerning delivery of cylinders to
Central Supply, including checking the cylinders for leakage prior to
entry into the building and using a buddy system for delivery.
vi. Maximum predicted concentra~ion~ fall significantly if a 30-minute
release period is used in the ~odeling versus a E-minute release period.
We will continue to try to find additional corroboration of the release
period.
San Joaquin Community Hospital =7,- October 18, 1990
OCT 19 ~90 14:$6 FPE AF.CA. R.l?
CALCULATIONS
I. The effect of gravity on gasesl
The formula for the effect of gravity on the pressure of a gas
P/Po = e-gy/RT
where,
g = the gravitational constant = 9.8 m/sec2 (meters per
square second)
y - vertical distance in meters
R = the gas constant - 8.3 Joules/mole-degree
(a Joule is a new%on-meter or a kg-mZ/sec2)
T = degrees Kelvin (298 at 25 degrees C)
P = pressure at vertical distance y above reference height
PO ~ pressure at reference height
The molecular weight of dichlorodifluoromethane is 121 grams or
0.121 kg. The molecular weight of ethylene oxide is 44 grams or
0.044 kg.
-(0.004 X MW X y) where MW ~ molecular weight in kg.
P/PO = e
At 50 meters, p/pO for freon is 0.976.
At 50 meters, p/pO for ethylene oxide is 0.991.
The ratio of freon to ethylene oxide (by weight) at 50 meters is
calculated~
88/12 x 0.976/0.991 - 7.2 = 87.8/12.2
At 500 meters, p/pO for freon is 0.79.
At 500 meters, p/p0 for ethylene oxide is 0.92.
The ratio of freon to ethylene oxide (by weight) at 500 meters is
calculated:
88/12 X 0.79/0.92 = 6.3= 86/14
The ratio of freon to e%hylene oxide changes only slightly due to
gravity.
ddc/docs/905144calc
OCl 19 '90 14:57 FPE LAF.G'.A. F'.18
II. Concentration versus tame after full-cylinder release in
Central Supply:
During release of a gas, the average concentration in a room
versus time is determined by the equation:
Ct = (G/mQ)'(1 - e'(mQ/v)t
G - 148 cubic feet/5 minutes (rate of generation or release)
m = 0.33 (mixing factor; 0 = no mixing; i = perfect mixing)
Q = 1850 cubic feet per minute (exhaus~ rate)
v - 21,000 cubic feet (room volume of Central Supply).
At t = i minute, C = 1,455 ppm.
At t - $ minut~ C - ~ 550 ppm
After the release ends, the average concentration in a room versus
tame is determined by the equationl
Ct/CO e'(mQ/V)t
= (t0 - 5 minutes)
The tame required to reach a given concentration can be determined
by solving the above equation for t:
t = (-In(Ct/C0))/0'.029
The time for ~he concentration to reach the IDLH level (800 ppm)
is:
t - (-ln(800/6550))/0.029 - 72.5 minutes, plus § minutes, =
77.5 minutes
The time for the concentration to reach the PEL (1 ppm)
t = (-ln(1/6550))/0.029 = 303 minutes, plus 5 minutes,
308 minutes
ddc/docs/905144calc
EF'Icode 4.0 S/N 12153 "!"Pie FPE Group
SUBSTANCE I.D. : ETH'./L. ENE OXIDE (1990:LIBRARY)
Molecular Weight : 44~0 gram/mole
CAS Number: [75.-.2].-8]
'TWA : 1.0 ppm TWA : 1.8 mg/m'"'3
IDt._H : 80C, D~m
TERM : 1,, 7E+01 pounds Rel ease I}Ltr'a~i or'~ ~ 5. OE+O() MinLd:es
D.O.T. ,b 1040
HE I GHT-EF'F:'ECT I VE: 30 Feet
HEALTH : 2
SUF;;FACE N:f. ND SPEED :6.4 Mites/hour
DEPOSITION VELOCI]"Y: 0.:[00 cm/secc, nd
F LA MMA B ]: L. I ]" Y: 4
STABILITY CLASS : NORST CASE (A - F:)
'T'ERFt:A I I',f : S'T'ANDAFb:)
RECEPTOR HEIGHT (z) : 5 Feet:
REACT];VITY : 3
Lr_')CATIC)N OF MAX;:MLJM !"t:i'tC'6;'.Yt"RATI[)N L..t:}.']VEL_
D.i. stance: < ().()6MZ
Level ~: > 1. bE']+O 1 m~.;.~/'m'""3 8.9E::+0() F'PM
MA X I MLJH
D [] !.'4 N W I Iq D C J':i N C: E N T R A T I 0 Iq A R R t V A L T I M E S'L a t.~ .1. ]. i t v
X-.Mi Y-Mi mg / m'""5 ppf~ howrs: mi nutes
[;'DDD~}D DDD~)DD DDDDDDDD ~gZ)D L')~]DDD DDD~:~Z'.)DDDDDDDD DDDDD~}DDD
O. ()¢ { O. 000 1. '7E-05 9. :];E-06 0: 0 A
O. 0~ 0. 000 1.7E-05 9.3E...-06 0: 0 A
O. 0~ O. 000 1.7E-05 9. :::E-.06 0: 0 A
O. 0~¢ 0,, 000 1.7E-05 9.3E:-06 O: 0 A
O. ()0~ (). 000 1. '7E-()5 9.7;E-..06 O: 0 A
O. 0~ 0,000 1.7E-05 9. :5E-06 0: , 0 A
0.0 O~ O. ()()0 5.5E-'04 5.0E-04 (): 0 A
() ,, 0 ~ 0 ,, C:,0 () () ,, 011 0.0060 0: () A
0. ()¢ 0. 000 O. ()78 0. ()43 0: 0 A
0.0]. C,.OC, O ().31 0.17 0~: 0 A
0.02 0,,000 15 8,,2 O: 0 A
0 ,, 03 0. ,::::,C:,0 21 ~' (): 0 A
O. 04 O. 00() 18 10 O: () A
0,,05 0. 000 17 10 0: 0 B
().06 0.()()() 16 9.1 O: 0 B
(),,07 0.000 16 8.7 O: C, C
O. 08 O. 0()0 16 8 ,, 8 0: . 0 C
0.09 0.00() 15 8.4 0: 0 C
0. 1() 0.000 14 7.8 0: () C
EF:'Icooe 4,,0 S/N 1215:5 The F'PE Grc:,uo
SL)E.:S"i"AI'xICE:: il:. D. : E:'T'HYLENE OX I Z;,E ( 1990 ',: L I BFkARY)
Idolecular We:i.c;ht : 44.0 oram/mole
CAS l'./~L.tdflz, er: [75-21-.8]
TWA : 1. () ppm TWA : :[ ~ 8 m~/~r"":~;
J]DL.I,..I : 80() ppm
'T'ERM : 1.7E+()i Douncls Release Duration : 5.0E+()0 Mi~L.r~;.es
D.O.T,, $~ 1040
HE I GHT-E;F::FECT I VE: 30 Feet.
HEALTH : 2
SURF'ACE WIND SPEED : 6.4 fell ].es/hoLtr'
DEPOSITION VIEL. OCI. TY: 0,,1()0 cra/second
F'LAMMAB :[ L I TY: 4
STABIL. ITY CL.,ASS : WORST CASE (A - F)
"r'ERRAIN : S'T'AIxlDARD
RECEF::'TOF~ HEIGHT (z) : 5 Feet.
REACTIVITY : 3
I_OCATION OF:' MAX ii: MUM CONCENTRAT'ION L_EVEL
][).i.s.~tsn(:::e : < 0.06M:L.
Level : > 1.6E+O1 mo/re'""3 8.9E+()() F:'F'M
M A X i M U M
0 W N k~ ! F. ID C 0 N C E H'I" R ¢:~ T i 0 N A R R I V A L T I M IE S t a b i I i t v
s t. a n c e-'Id i m g / m"" 3 p p m i~ o u r' s: m i n u t e s
0.05 17 1 () 0: 0 B ~
0. 10 14 '7.8 O: 0 C ~
0.20 9.0 5.0 0: 1 D
. ~¢ .... :,. 3 (): 1 E '
.0.40 4.5 2.5 O: 2 E ~
0 '='"'~ .5 6 '" 0 O' 2
0 ,, 60 3.3 1 .8 0". .~.': F
(). 70 .~'"' ,, 9 1 ,, 6 O: 3 F:'
0.80 '"~ ,, ' .....
.,=.6 1 4 O: .~, F:
0 90 "' '') 4 F
,, z .... 1.2 ():
1,,00 ="~.0 ]..~ 0: 4 F
.~"~. 00 O. 8;~; O. 46 O.: 8 F:'
""..:,. 00 0.50 (). 28 0: ~ .:. ''~ F
4. O0 O. 36 O. 20 O~ 16 F
5. ,:)0 0 ,, 27 (). 15 (): 20 F
6.00 0.22 0.12 0:24 F
'7.00 0. 18 0. 10 0: 28 F"
8 00 0. 1 =' 0.085 0: :];~; F
9.00 O. 13 0.0'74 0: 3'7 F
10. 0 (). 12 (). (]65 0: 4 :L F
20.0 (). 049 0. ()2,7 l: 21 F
40.0 O. 016 O. 0090 1:;~: 43 F
60.0 0.()10 0.0057 4.: 4 F
80.0 0. 006:3 O. ()()'55 5: 2L5 F
100 0. 0041 (),, 002:5. ,.~ .' 47 F
EPIcode 4..0 S/N ].215:3 'The FPE Group
SUBSTANCE: I,D. : ETHYLENE OXIDE (199():LIBRARY)
Mc,]. ecul ar We:i. oht : 44. C) oram/mole
CAS Number: [75-.21.--.8]
, . ITl
TWA : 1.0 oom TWA : 1,,8 mo/ ..... ":~
!DL.H : 80() ppm
'FE~RM : 1.7E+01 pc)unds Relea~e Duration : 5.0E+0C) Minu~es
D.O.T. :~1:lC)40
HE I GHT-EF:F:'ECT I VE: :3() F'eet
HEALTH : 2
SURFACE WIND SPEED :6.4 Miles/hour
DEI:'.)OSITION VELOCITY: 0. 100 cra/second
FL. AMMAB]:L. ITY: 4
STABILITY CLASS : WORST []ABE (A - F)
'T'EF~F~'.AIN : STANDARD
RECEPTOR HEIGHT (z) : 30 Feet
REACTIVITY : 3
L. OCATION OF MAX IMUM CC')NCENTRATI[]N LEVEL
Distanc:e : < 0.06Mi
Level = > '~. 4F+C.~2 mo?re'""3 i ':~r...;.'+(:,,~ PPM
MAX I MUM
.i DOWI',IW ]] ND CONC)ENT RA.T I ON ARR ].' VAL. "t" I ME St ab i 1 i t. y
D i s t a n c: e -.- M i m ~..] / m'""3 !::' P m h o u r s: m i n u t. e s I
0,, 05 370 200 0: 0 F
0 ,, 10 94 52 0: 0
F
i~ 0,,20 25 14 0: 1 F
i 0.30 12 6.4 0: 1 F
0.40 6.8 3.8 r~: ~. F'
0.5(:) 4. '7 2.6 0: 2
0,,60 :3,5 1.9 0: 2 F
0,70 2.8 1,6 0: 3 F
0.80 2.3 1.:~: O: 5 F
0.90 2.0 1.1 0: 4 F
1.00 1.8 1.0 0: 4. F
') ("~0 0,75 0.42 0: 8 F
3,,00 0,46 0.26 0:12 F
4.00 0.34 0. 19 C): 16 F:'
5.00 O. 26 0,, 14 O: 20 F
6.00 0.21 0. 12 0:24 F'
7.00 0.17 0. 10 0;28 F
8.0() O. 15 O. 082 0:33 F
9.00 O. 13 O. 071 0:37 F
1 C). 0 O. 1 i O. (:)63 0: 4. ], F
20.0 O. 048 O. 026 1:21 F'
40.0 O. 016 0. 0089 2:43 F
60.0 0.010 ().0056 4: 4 F
80,, 0 (}~ 0062 0, 0035 5:25 F
1 C)C) 0. 0040 0. 0022 6: 4'7 F "'
EF'Icode 4.0 S/N 12].53 The FF:'E Group
SUBSTANCE I.D. : E:THYL. ENE OXIDE (1990:LIBRARY')
Molecular Weight. : 44.0 (~ram/mole
CAS Number: [75--2].-8]
'T'WA : ].. 0 ~:)pm TWA : 1.8 mg/m'""3
IDLH : 8()() ppm
TERM : 1.7E+0]. pounds Release Duration : 5.0E+00 Minut. es
D.O.T,, ~ 1040
HE I GHT--EF:'FECT ! VE: 30 F'eet.
HEAL.'T'H : 2
SURF'ACE WIND SF'EED :6.4 Miles/hour
DEPOSITION VELOCITY: 0. 100 c::m/second
FLAMMAB ]'. L I T'Y: 4
STABIL. IT'Y CL. ASS : WORST CASE', (A -F)
TE:RRAIN : STANDARD
RECEF']"OR HEIGH]" (z) : 30 Feet
REA[:YI" ]'. V I TY : 3
L 0 iS A T I 0 N 0 F' PlA X I M Li M C: 0 N C E N T R A T :[ 0 N L E V E L
Distance : < ().06Mi
Level : >.,~.~'.'. 4E-~-02. mci/re"'3,., 1 .3E+02 F'PM
MAX I
DOWI',iW I ND CONCEI'¥TRAT I ON ARR I VAL T I ME St ab i 1 i t y
X-M:i, Y-Mi mc~ / m'""3 ppm hc:)LIl'",~: mi nLI. t E,S
~';)i!:):OL?Dl.) ~)i~,~Z:;',~,:)PD ;2,'O[,~DD[)DD
0. OJS)l 0. 000 23000 13000 C): 0 F
0.0~ ~ 0.00C) 230()0 1:3000 0: 0 F'
0.0 ~ ~ 0. 000 2'~ C~00 1:3000 0: 0 F:'
0.0 ~'~ 0. 000 27~ OCx:) :[ 3000 C): 0 F
0.0 ~ ~ 0.0()0 2 ? 0(")0 :1. 3000 0: 0 F'
(),, 0~ ~ O. ()()0 2:3000 ].:];000 0: 0 F
0.0~ 0.00C) 18000 1()()00 0: 0 F
0.0~ 0.0()0 14000 7800 0: () F
C). ()~~ (). 000 11 OCx:) 620() 0: 0 I:::'
0.01 0 ,, 000 9000 5000 0: 0 F'
0,, ()2 0. 000 2300 1300 O: 0 F
0.03 0,, 000 :t000 560 O: 0 F
0.04 0. 000 570 320 0: 0 F:'
0.05 O. 000 :370 2Cx} 0: 0 F
O. 06 0.0C)0 260 140 (): 0 F
0.0'7 0.000 190 :L10 0: 0 F
0.()8 0.()00 150 81 0: 0 F
0.09 0.000 120 64 O: 0 I:::
0. 10 0.000 94 52 0: 0 I::'
SLJBS'T'ANCE I.D. : E'T'HYLENE OX :[Dill!: ( 19:.20: L.I]:.31::;.'.AR'f)
Molecular Weigh't: : 44.() gram/mole
CAS Numi:.~er: ['75-21-8]
'T'WA : ~. 0 F)pm TWA : ~. 8 mg/m'""3
IDLH : 800 ppm
TERi'") : 1.7E+01 pounds Release Duratic)n : ',:.5~ OE+OC, Vlinute~
D.O.T. ~ ~.040
-.~E I GH't'.--EFFECT I VE: 30 Feet
HEAL,'T'H : 2
SLJF'.~ACIF2 W~ND ~F'EED ~ 6.4 M:i.l~s/hour
........ ' .......... . ..... 0 100 cra/second
DI :.1- Oc~ ~ I Z ON MI:::' tic I "I-V ~ . .
FI_.AMPIR~ I L, I TV: 4
,t~BILI'T'V CLASS : WOi~,~t CASE (A .... F)
]"EF~Fb:~ I N ~ ~'T'~NDARD
RECEF'TOR I.~IEZGHT (z) ..~,t.. F~et
REACT'IVITY : 3
L.,OE:A'T' iii ON OF MA X ]'. r:ILJM CI]NCE:.N"FF(A'T I ON L. EVEI_
D:i. stance: < 0.06Mi
Level : > 2.4E..H)2 mg/m'"'3 1.3E+02 PPM
MAX I MUM
DCn:,,!]',.!W I ND COt',tCEN TRAT I ON ARR I VAI... T I ME St ab i 1 :i. t y
X-Mi Y-M:i. mcj/m'""3 [.)pm hour-s: mi nut. es
L:~DDDDL) L)DDDDD DDD't:)DDDD L)DDDL'n,')D,D DDD/.)DL)DDDDDDD L)DDDDDDDD
0.0 ~ ~ (). (') C) 5 6.4 E-(') 5 .3.6 E-... 05 0: 0 A
0.01)~ 0. 005 6.4E-05 3.6E-05 0: 0 A
("). C!i~ ~ 0. 005 c':). 0() 16 (). 0()Cl88 0: 0 A
0.0~) ~ c:). 005 0.0:24 0.013 0: c) A
C). c:l~ 0. 005 0. 15 O. 082 O: 0 A
0.01 0.c)05 0.52 0.29 0: 0 A
0.02 (). 005 14. 7. [3 0: 0 A
0. ():3 0.0c)5 .t 8 10 0: 0 B
0.04 0.c"105 18 10 0: 0 B
0,,c)5 0.005 19 11 0: 0 C
0 ,, 06 0. ('z05 18 10 /il: 0 C
0,,()'7 0,005 18 10 0: 0 D
O, 08 0. 005 19 :1.0 0: 0 E
0.09 0,005 19 ll 0: 0 E
0. :1. 0 O. 005 ]. 9 1.1. 0: 0 E
,:"l. 50 Ci, ,005 4.3 2.4 0: 2 F'
1.00 0.005 1.7 1.() (): 4 I:::'
EPicode 4.0 S/N 121~..=, The FPE Grou~:~
SUBSTANE:E I D. : ETHYL_ENE OXI,.E (] 990:I....IFF¥.)~R'V)
Piolec:ular Weight : 44.0 E~ram/mole
E.,Ac) Number: [ 7,.~"-z.l'"-E~J
TWA : 1.0 ppm TWA : 1.8 mg/m'""3
IDLFI ~ 800 ppm
D.O.T. ~: 104C:,
HE I GHT-EFF::ECT t VE: 30 Feet
HEALTH : 2
SURFACE WIND SF:'EED :6.4 Mi ]. es/i~eur
D[:i-[..:::~.I.] ION VELOCITY: () 10() em/second
FfLAMMABILITY: 4
STABILITY CLASS : WORST CASE (A ..... F)
TE..r,[~¢4I.N : STANDARD
RtE C E F'T OR i'-lE ]: Gt'-IT ( z ) : 40 F'ee t
REACTIVITY : 3
L.C)CAT I ON OF' ?'tAX .~ NUM COl' ICI:N ~ R qT I .]lq LEVEL
Distance : ~' 0.06M:i.
L e. v e 1 : > /-I., 3 E + 01 m g / m'"" 3 2.4 [2: + 01 P P M
MA X I MUM
DOWNWIND COI'qCENTRATION ARR];VAL TIME Stability
D i s t a n c e- M i mc] / m'"'3 c, o m h o u r s: m i n u t e s
I)DD~)DDD,C)Z;'DEt~:OZ2D DDDDDDDD DZ)DDD~)Z)D DDZ)I)~OZ2.DDZ)/.;~L)Z)D I)DiODDDZ')/2Z)
0,,05 54, 30 O: 0 D
() ~ 10 27 15 0: 0 E
0.20 15 8.3 0: I F
0,30 9.0 5.0 0: 1 F
0,40 5.9 :3.3 0: 2 F
0.50 4. 1 2.3 0: 2 F
0.60 3.1 1,,7 0: 2 F
0.70 2.5 1.4 O: 3 F'
0.80 2.]. 1.2 O: 3 F
0.90 1.8 1.0 0: 4 F
1.00 1.6 ().87 0~ 4 F
2.00 ().69 0.38 0: 8 F::'
3.00 0,.44 0.24. 0:12 F
4.00 0. ;:};2 O. :t 8 0: ]. 6 F
5 ,. 00 0.25 0. 14. 0: 20 F
6.00 0.20 0.11 0:24 F'
'7.00 0. 1 '7 (). 093 0: 28 F'
8.00 O, 14 0. 079 0:33 F
9.00 0.12 0.069 0::37 F
10.0 0. 11 0. ()61 0: 41 F
20.0 O. 047 0. 026 1: 2~ F
40, 0 O. 016 0. 0088 2:43 F=
60,0 0.010 0. 0056 4:: 4 F
80.0 0. 0062 0. 0034 5:25 F
!00 O. 0040 0. 0022 6:47 F
EPIcode 4.0 S/N 12:L53 The FPIi!:' Grou~
SLiBSTANCE:' I,,D. : E]THYLENE OXIDE (1990:LiI]BRARY)
Molecular Weight. : 44~0 gram/mole
CAS Number: [75-21-8]
TWA : 1.0 ppm TWA : 1.8
IDLH : 800 ppm
TERM : 1.7E+();~ [;)ounds Release Duration : 5.0E+00 Minu~;:es~.
D.O.T,, :~ 1040
HE I GHT-E:FFE:CT I VE: 30 F'eet
H E A L TH : 2
SURFACE WIND SPEED :6.4 M:i. les/hc)ur
DEPOSITION VELOCITY: O. lC)() em/second
FL..AMMAB ]: L ! TY: 4
STABILITY CLASS : WORST CASE (A ..... F)
TERRAIN : STANDARD
F~EC:EPTOR HEIGHT (z) : 40 Feet
REACTIVITY :
MAX I MUM
DC)~.4NW I ND CONCENTRAT I ON ARR '.[ VAL T l ME St. ab i 1 i t y
X-....P'I i Y-M .~. m~_ / m'""::!; p p m h our s: m i n u~: es
0.0 ~ 0. ()()() 42 2:].": 0: () A
0.0~ 0. 000 42 2:3 O: () A
0.0~ ~ 0. 000 42 2~ O: 0 A
0.0 D ~ 0 . ()00 42 .,~.")'~'.., 0 ,,' 0 A
0. O~b O. 000 42 23 0: 0 A
0.0~ ~ () . ()('~0. 42 ~.")=.~ 0: 0 A
0.0D~ 0.000 60 :]:3 0: 0 A
0.0~ 0.000 78 43 (): 0 A
O.0D ~ 0.000 87 49 0: 0 A
0.01 0.000 91 51 O: 0 A
0.02 0.000 73 40 0: 0 B
0.03 0. 000 67 37 0: 0 C
0.04 0.()00 63 35 O: 0 D
0.05 0. 000 54 30 0: 0 D
0.06 0.000 45 25 0: 0 D
0.07 0.000 36 20 0: 0 D
0.08 C).000 51 17 0: c) E
0.09 0.000 29 16 0: 0 E
0. :~.0 0.000 27 15 0: 0 E
SUbSTAhlL::E.'] i.D. : ETHYL. ENE OXIDE (1990~L. IBRARY)
Mo].ecuiar Weioht : z~.4,.O c~ram/mole
CAS I',tumber: 1175-21-8]
TWA : 1[,0 ppm 'T'MA : 1.8
IDLH = 800 ppm
TERM = 1.7E5+.01 pounds Release Duration = 5.0E+00 Mi[nitres
HE I GH'T'.,...EF'FE:CT I VE: :150 Feet
HEAL'T'H ~ 2
SUF~',F:ACE WIND SPEED :6.4 Miles/hour
DEF'OS ]; T I ON VIELOC ]: TY: O. :[ OD c:m/second
F'L. APIHAB ]; L I TY: 4
S'TABILITY CLASS : WORST CASE (A- F)
'T'EIRF:;4A t N : S]'AIqDAFIi;)
RECEPTOR I'-IEIGHT (z) : 4() Feet
R E A C T i V t 1" Y
LOt']ATION OF= MAX IMUM CONCEiiN'I'RA'T'ION LIEVEL
Distance : < 0.06Mi
Level : > 4.3',E.+O.t mg/m"'3 2. Zt, E+C)I PF'id
MAX ]: IVlUM
D{3WNN :i: ND C;ONCENTRAT I ON ARR :[ Vf:.ll_ "1' ]: FIE
X-M:i. Y-Mi mg/m'""3 ppm hoL.tr S .'. rfli nLttes
D P,!l.:'P P D D12DDDD DDDDf;'DD'/.) ?.,Z)Z.~DDDDD DP/.?Di?r,..L?;'~,(;~DE,'D[)D
(). 0 ID ~" 0. () 05 .'3.9tiE.-.. 08 2. 1 E- 0 a 0: 0 A
0.0 ilIDG 0. 005 3.9E.-06 12. ]. E'""06 0 ',', 0 A
O. ()0~ 0,, ()()5 O. 0044 0. 0025 0: 0 A
O. 00~ O. 005 O. 03?9 0,, ()22 O: 0 A
0,,01 ().005 0. 18 0,,10 0: 0 A
0.02 0.005 1/. 6.0 O: 0 A
0 ,, O::L"; () ,, 005 ]. 3 7 ,, 4 0: 0 A
0.04 0.005 15 8.5 O: 0 B
0,,05 0.005 1~ 8.0 0: 0 C
0.06 0.()06 11 6.0 O: 0 C
C,.06 0.005 15 8.2 O: 0 C
0.07 0.()05 14 7.'? O: 0 C
0.08 0.0,:)5 14 7.9 O: 0 D
0.09 0. 005 :54 7.7 O: 0 D
0.10 0.005 13 7.2 C:,: 0 D
0,,20 0.005 9.2 5. 1 0: 1 r='
0. :'-'.;0 0. 005 7. :3 4.0 (): 1 F
0.40 0.005 5.2 2.9 '0~ 2 F'
0.50 0,,()05 3.8 2. 1 0: 2 l::'
0.60 0.005 3.0 :l..6 0,: 2 F
0.70 0.005 2.4 1.3 0: 3 F
0.80 0.005 2.0 1.1 O: Z; F'
0,,90 0.005 :[.7 ~.0 0: 4 F
EPIcoc~e 4.0 SIN 12153~ The F'PE Grour~
SLiBSTANCV I.D. : E:'~"HYLE~NE OXIDE (1990:LIBRARY)
Molecular Weiq:~ht : 44.0 ~ram/mole
CAS Number: [75-21-8]
TWA : 1.0 ppm TWA : ].. 8 m~/m""3
IDL. H : 800 pr~m
TERM : 1.7E+01 pour~ds .l:~e:[ ease Durati c)n : 5. OE-PC)O P'linLltE~:
D.O,,T. ~ 104C)
HE I GHT-'EF'FECT :[. VE: 8 F:'eet
HEALTFI : 2
SURF'ACE WIND SPEED :6.4 Mil. es/hour
DEPC)StTIC)N VEL..OCITY: 0. 100 cra/second
F'I_AMMABIL!TY: 4
STABIL. ITY CLASS : UORST CASE (A - F)
TERF~A:[N : S'T'AN[}ARD
RECEPTOR PiE]]GHT (z) : 8 Feet
REACY'[' I V i TY : 3
LOCY:~T I (::)lq OF P'IA X :[ !"tLIM C:()NCEI"¥TRAT I ON LE:'VEI_
Distance : < 0.061q:i.
L. eve]. : > 4.9E+02. mg/m'"':3 2.7E+02 PPM
0. (}5 '?6(} 420 0: 0 F:
0.].0 190 110 0: 1 F
0.20 64 36 0: 2 F
0. ~;0 36 20 0: :3 F'
0.40 23 13; 0: :3 F
0.50 ].6 9.1 (): 4 F
0.60 ~2 6.8 O: 5 F
0.70 lC) 5.:]; 0: 6 F
0.80 7.7 4. :3 0: 7 F'
0.90 6.4 3.5 0: 8 F
1.00 5.4 :3.0 (): 8 F
2.00 1.9 1.1 0:17 F'.'
3. O0 ].. 0 0.58 O: 25 F
4.00 0.69 0.58 0:34 I::'
5.00 0.50 (). 28 0:42 F
6.0() 0.39 (). 22 0:50 F
7.00 0.:31 0.17 0:59 F
8.00 0.26 0. 14 1: 7 F
9. OC) 0.22 O. 12 1: 16 F
10.0 0. 19 0. 10 ~: 24 I:::'
20.0 0. 056 0.0:3 ]. 2 :: 48 F
40.0 0. 014 0. 0075 5:36 F
60.0 0. 0072 0. 0040 8:25 F
80.0 0.0043; 0.0()24 11:13 F
~C)O 0.0028 0.0016 14: 1 F
EPtcode 4.0 S/N 12153 The FFii:.:] Grou.~)
SUBSTANCF:'. I.D. : ETHYLENE OXIDE (1990:LIBRARY)
Molecular Weight : 44.0 gram/mc, le
CAS Number: [75-21-8]
TWA : 1.0 ppm ]"WA : 1.8 mg/m'""3
i.OLJ...I : 800 ppm
TIERM : 1.7E-!-()1 oounds Release Our~ltion : 5.()E+00 Minut. es
D.O.T. ~. :~040
HI.E I GHT-EF:'F:ECT I VIE: 8 Feet
HIEAL..TH : 2
:~:%JRF"ACE Wti'qD SPEED : 6.4. M:i. :l. es/hour
DIEPOSI'TION VEL. OC::ITY: 0. 100 em/second
F::'LAMHAB I L. I TY: 4
STABILITY CLASS : WORST CASE (A -F')
TERRAIN : STANDARD
RECEPTOR HEIGHT (z) : 8 Feet
REACTIVITY : 3
t r'~r:ATION OF HAXiHUM ",'r ..........
.......... o ~I_,E ,~] ...,.A 110N I...EVEL
Distance : < O.()6Mi
l .... w:.l : > 4.9F+02 mo/re'""3 '")
.......... 7E+02 PPM
MA X I MUtd
c,'cab 11 i ty
:i:;,t'..'!t/,~NW I ND CONCENTF;h'::Ft- ! ON ARR I VAL T ;1'. ME ~"' i ·
X -Id i Y-M :i. in f:j / m'"' 3 p p m h c:) L.t r s: f~l i n Lt ~] e s
D[..:',,:)DDD DS'.DD~,}D 5'5':r,.:'.DDDDD DDDD:.ODDD D,~?'/.'..,~f)L;'.r)igi2DDDDD
0. O~DI O. 0()0 48000 27000 0: 0 F
0.0~ 0.()0C) 48000 27000 0: 0 F
(). 0~ ] 0.00C) 48000 27()00 0: 0 F'
0.0¢~ 0.000 48000 27000 0: 0 I::
O. 0¢ ~ 0. 000 48()00 27000 0: 0 F
O. 0~ (),, 000 48000 2'7000 0:0 F
0,, 0~ ~ 0. 000 38000 21()00 O: 0 F
0.0 D ~ 0.000 :79 () 00 ], 6000 0: 0 F
0.0 ~ 0. 000 2:];000 :1. 3000 0: 0 F
0.01 0.000 :L9000 10000 O: 0 F
0,, 02 0. OCx} 470() 2600 0: 0 F
0.03 0. 000 2100 1200 0: 0 F
O. 04 O. 000 1200 650 O: 0 F
0.05 0. 000 '760 420 (): 0 F
0.06 0. 000 530 290 0: 1 F
C,. 07 0. ()00 39() 220 0: I F
0.08 0.00() :300 1 '70 0: 1 F'
0.09 0..000 240 130 O: 1 F
0. 10 0.000 J. 90 110 0: 1 F
E:F'tcode 4~0 S/N J. 2.1.5::!~ The FPE G~oup
SUB:B-f'ANCIE I.D. ". EfHYL.:.qE OXIDE.,: (1990~LIBR~RY)
Molecular Weic]ht ~. 44.0 (~ram/'mc, le
CAS Number: E75-21-8]
TWA : 1.0 ppm TWA : 1.8 mcj/m"':3
IDLH : f300 ppm
'T'ERM : 1.7E+C):1. pounds Release Durat.:i, on : 5.0E+00 Minut. e:s
D.O.T. ~ 1040
HE i GHT-IE]::'FECT :[ VE: 8 Veer
HE:ALTH : 2
c.L.l~[-~L[:. W'J'lq'F) SF:'EED : 6.4 Mi 1E~S~/'I'IOLtF
DEPOSi'T'IC)N VELOCITY: 0,, 100 cra/second
I::LAMMAB I L. I TY ~ 4
S'TABILITY CLASS : WORST CASE (A -' F')
TERRAIN ~ STAixH}AFRD
F,'SJ"SJ:EPTCiF~ HIE I GHT ( z ) : 8 F:~et
RIEACT .I, ~ t TY "
C.a I .ION OF" MAXI:MUM CONC;EN-t'RRTION LEVEL
Distanc:e.~ ~ < 0.06M.i
Level ~ > 4.. 9E:.+.rr::'. ... ~ mo/re'"":3 .~.,'~.. '7F'..-O2_ . PF'M
MA X I MUM
D C) W N W i N D C 0 hl C E iq TR A T ! 0 N A R R I V A L. "[' I I'fi E S t: a b i 1 i t. y
X -M i Y -M i m 9. / m'"' 3 p p m h o u r' s: m i n u t e is
DDDDDD DDDDDD DDDDDDDD DDDDDDDD DDD,ODDDDDDDDD DDDDDDDDD
() ,, 0 I~ ~ 0.0C)5 '7. C)E-,()5 .3.9E-05 C): C) A
0. <:.~t3~ 0,, 005 ;7.0E-0.5 :3.9E-,-0~ 0~ () A
0,0~ 0,005 0.0017 0,0010 0~ 0 ~
0=0~ ().()05 0,027 0,015 0~ 0 A
0. C)~ 0.0()5 0. :1.7 0. ()9:3 C)~ 0 A
O,,Ot 0. 005 0.60 0. :33 O~ 0 A
0,, ():Z C). 005 2:3 1 :~ 0 ~ C) A
0.0:]; 0.C)05 29 16 O: 0 B
(), 04 0, C)05 :]};:L~ 18 0: 0 B
0~ 05 0. 005 :32 1~ 0~ () C
(). 06 (), 0()5 3:!~ 18 0 ~ :t. C
0,07 ().0()5 33 1.~ 0~ 1 D
0. C)8 0.0()5 34 17 0~ 1 D
O. 09 0. 005 :3'7 20 0~ 1 E
(). lC) 0.005 38 21 OD 1' E
0~ 2 () f.) ,, () 0 5 40 22 0: 2 F
(). :]',0 0. 005 29 16 0: 3 F
O. 40 0. ()05 20 1 ]. 0: :3 F'
0.50 0.0C, 5 15 8.3 0: 4 F
0.60 0.C, 05 12 6.4, 0: 5 F
0.70 0.005 9.1 5,,0 0: 6 F
0,,80 0.005 7.4 4. I 0: 7 F
0.90 0.()05 6.2 3.4 0: E~ F'
1.00 0. 005 5.:3 2.9 0: 8 F
2.()0 0.005 1.9 1. 1 0:17 F
3.00 0. 005 1.0 O. 58 (): 25 t~'
~ .......................... 0CT-19-"90 10:45 JO~QUIN HOSPITAL TEL N0:805~i62 ~?17 P01 ....
SAN JOAQUIN COMMUNITY HOSPITAL
2615 Eye Street
P.O. Box 2615
Bakersfield, CA 93303-2615
Telephone: (805) 395-3000 ,,
Telecopier: (805) 324-5162 ~
Barbara Brenner
city of Bakersfield
TELECOPIER: (805) 395-1349
FROM: Billy Martin
Director, Safety/Security
DATE: October 16, 1990
The following documents are being transmitted to you and consist
of ? pages, including this cover page:
If you have any problems with the clarity or in receiving these
documents through your telecopier, please call us at (805) 395-
3000~ X2221.
Th~nk you. .
Tammy s~i~h
Administrative Secretary
1
POLICY
M~ Safe~y/Se~u~i~y 18.0
August, ~988
$~ Ethylene Oxide Handling
~: To ensure safe use o~ Ethylene Oxide, eo protec~
patients and visitors, and to comply ~lth Cal Title 8, Section
5220.
1. AIl gTC equipment shall be installed to meet applicable local, ~tate and
iedera[ e~anda~ds and shall be inspected prior ~o use.
2. ETO ~xhaust shall be located a~ a safe distance ~rom air intake~
occupied areas,
3, ~t will be ~he ~esponsibili~y of Central Processing to ~rain its
employees about the hazards and safe use of ETO and associated equipment
annually, Training shall be doc~ented in the employee's record and at
the Personnel and Safety Offices.
A training of employees shall be conduc~e~ accordf~g to Safety Policy
and Procedure ~46.5 - attached.
4. Employea knowledge of the emergency shall be teated and
throuih drills conducted by Central Processing ManaEemen~ periodically.
5. The ETO ~terilfze~ shall be inspected Bi-monthly and the results
doc~ented by the operator.
6, Required moni=orin~ shall be the responsibility of ~he Central
Procesaii8 ~anaEer. Records and results of required ~est shall be
maint~ined in Central Processing. Monitoring reports shall be posted in
the work area, within 15 days of receipt and shall describe corrective
action bein~ taken, if such actions are required.
7. Routine ~intenance, equipment inspections will be the responsibility
A. Routine changin~ of the cylinders will be =he responsibility of
maintenance.
8, ~ergenc~es related =o ETO, (leaks, ventilation failure alarm):
A. AIl Central P~ocessing Personnel will leave department
i~adia=ely, secure all exterior doors and con,act maintenance via
0CT-19-'90 18:46 JO~OUIN HOSPITAL TEL biO: 52 ~717
POLICY
safety/$ecvrity 18.0
~~~N Ethylene Oxide Handling _
I, ~hen a n~w ~ylfnder ~s required cantraZ Processing will eon~ac~
A. Deliver replacemen= cylinder ~o Central Processtn~ via
sleva~or. (DO NOT USE OENT~L SERVICE
B. Uss appropriate safe~y apparel and equipmsn~,( Sco==s Air Pac and
gloves),
C. ~i name, ac=~on and dace tn lo~ book.
D. Return emp=y cylinder ~o cylindsr s~orate area.
2. Routine ~aintsnance:
A. ~ork co b~ performed only by main~enance and desi~na~ed
co~Cractor.
B. Ii we~d by ETO, ~horou~hly wash area and affected clothing.
3. Rou~tn~ ~aincenanc~ of the ETO ~xhaus~ sys~e~:
A. Before shu=-do~ of exhaus= system, arrange an agTetabLe ~tm~
Central Processin~.
B. Central ~rocessin~, do not use ETO Sterilizer un~il no=ified by
maintenance or outside contractor that the system ts opera~in~.
0CT-19-'90 18:47 JOAQUIN HOSPITAL TEL NO:8053~lE,2 ~717 P04
POLICY
Safety/Security 18.0
~/]~~N E~hylene Oxide Bandlin~
EMERGENCY DUE TO ~AD/ET0 A~ ACTIVATION/VENTI~TION FAIL~ A~
1, Notify all employe~s in ohs area of the emergency.
2. Evacuate personnel from area,
3, Oonfins any possible release by closin8 all doors leading =o Central
Processins,
4, Report the emersency from s safe locacio~.
A. Call Enginee~in~ (Dial 700)
B, 'Call ~afety-Security (Dial 2287)
~. Advise =he /ollowtnt of a possible ETO incident:
a, Adm~nis=racor On Call
b. Nursin~ Supervisor
~. i~curity, respond =o basemen=, assist with eval~tion and securin~ area,
6. Engineering, turn off air condl=ionin8 to Central Processing A~ea.
7. D~aontaminat~ personnel and material(s) as necessary,
8, Dispose of contaminated ~aterial(s),
9. No:ify Central Brocessin~ and Safety-Securi~y ~hen area is ~eady for
~ 0CT-19-'90 10:47 I JOAQUIN HOSPITAL TEL N0:8053~162 ~?17 P05
?OLIC¥
Safety/Security 15.0
Au~u~, 1988
~ ~hylono Oxide
.....
1. Train~n8 shall Be done annually.
~e training o~ employees who handle ETO shall ~nclude:
A, M~thodg used to de~ect ET0 in the work area,
B, Physicai and health hazards el ETO,
C. P~otective measures CO include safe work p~actices, personal
prot~ctive clothin~ ii ~squi~ed. and equipment.
D. Hanufacturer's reco~sndstions for workinE ~he equipment in use.
E. Emergency plan.
F. ~e hazard co~unication plan (Includi~s "~terial Safety Da=a
Sheets).
~. Tra[nin~ of employees who work in an area where ET0 is used,
· do not handle ETO, shall include i~ems E and F.
2. ~ou~ine daily inspec~fons and ~hecks.
A. Daily checks, opera,or shall visually inspec~ doo~ gaskets
cracks, debris and other foreign objects,
B, I~ debris or foreign objects a~e observed, clean and star~
opera~ions,
C, If cracks ate obse~ed, call ~inCenance for semite.
~. Record observa~ions i~ ~g Book,
3, Bi-Weekly checks,
A. ~e ventilation alarm aye=em.
B. ~o following using a Fluorocarbon Leak Detector:
a, ETO entrance port to Sterilizer while tank valve is on, door
~s open and solenoid valves are closed,
b, Entire system with Chamber ~der p~essur~; areas co check
include: Door Gaske~ Cylinder and Vacu~ Piping, Hoses,
Fil~ers, Valves and Solenoid Valves,
~ 0CT-i9-'98 18:48 JOAQUIN HOSPITAL TEL NO:B053~162 ~717 P06
POLICY
~a~y/Security 18,0
............. AuBus~,
~~~J ~chylene Oxide Handl~n~ .,
~EOTECTIVE ~TEIN~ ~D E~UI~NT
1. Dur~n8 work w~th ETO Equipment. Personnel mus~ wear:
A. .Hea~ du~y neoprene ~loves ~ S~ore in aerator.
'~ 0CT-19-'90 10:~8 JOAL.]UIN HOSPITAL TEL NO:805~=~J162 ~?17 PO?
POLICY
~a Sa~azy/S,cur~y I8.0 .
$~ E~hylene Oxide Handlin~
PXR~ONa~L ~O~ITORIN~
sho~ ~arm exposure lever valves when equipment ~s ins~alled and/o~
~here are changes in equipment and/or operations,
~aiannual moni~orin~ is required if personnel exposure is
2ha ac2ion level. (I.P.P.H.) bu= less than the p~rmi~sible
~apoaura l~vel (I.P,P,H,)
~y ~vent when permissible exposure level a~/-'?
aapo~u~e level is exceeded.
CITY of BAKERSFIELD
"WE CARE"
FIRE DEPARTMENT 2101 H STREET
D. S, NEEDHAM BAKERSFIELD, 93301
FIRE CHIEF 526-3911
~eDtember 19, 1990
Mr. Kenneth Gibb
Chief Financial Officer
San Joaquin Community Hospital
P.O. Box 2615
Bakersfield, CA 93303-2615
Dear Mr. Gibb,
I wish to reiterate the contents of the meeting today between
San Joaquin representatives, Mr. Cox of FPE , Ralph Huey and
myself. Through our point by point discussion of my letter dated
August 6, 1990, we attempted to clarify the reasons that the Hazard
and Operability study was found to be incomplete and the RMPP as
presented on July 25 was rejected. The RMPP must be based upon an
adequate hazard analysis which systematically evaluates failure
scenarios for the system's components and for failure scenarios
caused by external events such as an earthquake. FPE can accomplish
this by describing and the risks (probability vs. consequence)
posed by each of the appropriate scenarios and by documenting their
conclusions. Thoughtful responses to the questions I have Dosed
should satisfy this requirement. If any confusion still remains,
I encourage any of the parties involved· to call me ss soon as
possible.
The FPE response to the questions outlined my August 6 letter
will be 'due on October 19, 1990. I am willing to review it
earlier, in pert or in full, if that will be helpful. Based upon
the completed Haz-Op Study, I will outline any amendments which
need to be made to the RMPP. We will then set a date for submittal
of the RMPP.
Thank you for all YOUr cooperation.
Sincerely,
Barbara Brenner
Hazardous Materials Planning Technician
cc: Mr. Dan CoX, FPE
Mr. Bill Ma,"tin
Oire~or of Safety & Security
San $oa~ui~ Com~t~nity Hospital
P. O. Box 2~15
Bakersfield, Ch g3J~B-2815
Beat~ Mr. Martin,
The following i~ a lis~ of consulting firm5 ~ho have had
Ri~k Management and F)r'e'v'en~ion Program,5 accepted by' ~hi's
book con(ains a lon~ tiBt of environmental consui, tant~ and
o¢ project.
- WZt Inc.
480~ Eaaton Dr., Suite 1t4
Caker~fie].d, C~ B3~88
14~5 18th St., Suite 681
324-85~1
-- L. uCt Environmental Consulting
Bakersfield, C~ 9~3~8
-. Groundwater T~chnology, thc.
izpo~tan~ that we have a ~eeti. nQ of all {he app~opr~.ate
par'ii, es .~o thai we can es[abti,~h a plan of acfion fo~ard the
compl~io~ of San J'oa'quin~ RMPP.
Hazardou~ Material,a Planning Technician
" CITY of BAKERSFIELD
"WE CARE"
FIRE DEPARTMENT 2101 H STREET
D.S. NEEDHAM BAKERSFIELD, 93301
FIRE CHIEF 326-3911
Mr. Kenneth Sibb
Vice President of Finance
San Joaquin Community Hospital
P.0. Box 2BtS
Bear Mr. 6ibb,
The following information is in regard to the risk
analysis and draft Risk Management and Prevention Plan
<RMPP> submitted by the FPE 6roup on behalf of San Joaquin
Community Hospital. Ms. Anne Harrington, Senior Consul%ant
for FFE, has requeeted that all communication regarding this
project be directed to you as she lacks the authority
0roceed ant further.
California law requires that a RMPP shall be based upon
the results of a Nazard and Ooerabi!ity Study and shall
¢cosider the hazards a~sociated with the handling
aculely hazardou~ meterlai due to operating error,
fallure and external events whlch may present an accident
r:sk. The information submitted by FPE on July 27, 1990 doe~
not fulfill the~e r~quirement~ and has been rej~c~md
8dmlnistering Agency. The risk analysis submitt~d is
¼~comp!ete and deficient in the following areas:
I. The study did not rate ~he risk <probability of
occurrence vs. consequences of occurrence) for the event
of an earthquake or other credible wors~ case scenario.
2. hi%hough the ~robability of l~a~:~ in lines, fittings and
regulators were addressed generically, ~he ~ossib!e
consequences of such lea~s wer~ omitted. The summary
provided no in?ormation re~arclng safe~>' de,,'~ca5 which
3. The risk, of human arror due to the location of the ~e'tal
pipe in the path of cylinder delivery was omitted,
'The probability of hospital air supply contamination due
to a rupture in 'the exhaust duct was mated Iow.
it remains unclear whether the duct shaft is actually
isolated from the general air return systeM. This
conclusion is unsubstantiated.
5. The conclusions regarding the potential for the
separation of freon and ethylene oxide must be clarified.
Elaborate on the reactions which occur diminishing the
concentration of ethylene oxide in the atmosphere.
5. Define the capacity of the exhaust systez. What is
the rate of the air flow and how long would it take to
evacuate the contents of one cylinder ? ~S-~ 1'-,~;~4~
C~ac~fy ~he d~scu~on ~ PEL and STEL ~on~oc~ng,
appear5 tha~ Cen~ca~ ~uppJy e~p~oyees ex~o~uc~ exceed
8. The risks associated uiih a fire have not been ~rAq','6
State law alao~equir~ %ha% offsite consequence, be
considered fop %he most likely hazards. ~n eap%hquake which
could mosul% in %he melease of %he con%er%5 of pp~ssupized
cylinden i5 a credible risk which must be planned fop
utilizing appropriate vapor dispersion Modeling. The offsite
consequence analysis submitted by FPE is unacc~p%abl~ for
'following reasons:
Documentation must be provided to verify that %he EPI
Code soft,are is appropriate for ~he modeling of '
accidental chemical releases. -- ~0~ ¢
Fedemal Ememgency Managemen% hgency vapom di5persion
models do no~ substantiate %he use o¢ a 30 minute
pemiod rom %he modeling.of a woms% case scenario.
The modeling resul~$ do no% consider %he possibi!i~y of
-- ~ecep~ors or building air intakes at (he height of a
__ release from the elevated exhaust vent.
Since ~he relocation of ~he e~h~u~ vent., ~he ~se of a
foot release height is in question.
The source radii of 1.0 and 152 feet are in question.
She most credible point o.f release for ~he conten~$ of a
pressurized cylinder is at the valve stem which generally
is less 'than one inch in diameter,
Oocument the basis for using a deposition velocity of
.I om/second, and verify that %his corresponds to the
rate of the exhaust system draft.
The RMPP must be based on a hazard analysis and offsite
consequence analysis which resolve the issues listed above.
after reviewing all of the information submitted by FPE, I
recommend that a RMPP based upon a revision of these
observations address either existing or proposed measures
which mitigate the following points of concern.
The location of the ethylene oxide storage area in close
proximity to the child care facility.
The adequacy of separation between the exhaust vent and
ope~lqgs or air intakes into the building.
The consequences of a power failure which would disable
the ventilation system. 'FPE predicts that ethylene oxide
concentrations could exceed ]3,000 ppm in Central Supply
if a cylinder evacuated during a power outage.
The pipe that crosses the path of cylinder delivery in
%he exhausted enclosure presents a hazard during delivery
and set up of cylinders.
Some of the cylinders in use at the time of inspection
were not of the recessed valve type. FPE based some of
their'conclusions regarding probability of release on the
use of this style of cylinder,
The need to impede the progress of vapor dispersion
throughout the entire basement during an evacuation from
Central Supply.
The need to segregate cleaning supplies which may react
Identify ~¢aining pmocedune's ~hich pro%er% against ~n
ennon amd will increase %he probability o¢ an adequate
Outline an evacuation and response plan for ~he even( of
a ethylene oxide release.
Upon completion of your rev±ew of ~his analysis of ~he
materials submitted by FPE, i~ ~ill be necessary to have a
meeiing of al! ihe appropriate par!irs. ~ RMPP %hai~ after
meview, is found to be deficient shall be corrected and '
resubmit%ed with in 8~ days of ~he no%ice from the
6dminis%ering ~gency,(Ohpt 8.85 Section 25535 Ch Heai~h and
Safety Code) The corrected RMPP wlll be due on Frlday
October 5, 1890. Please call me at J28-~978 so %ha% we may
schedule a convenient time ~o discuss the completion of this
RMRP.
Sincerely,
Ralph E. Huey
Hazardous Mat'erials O0ordina%or
Barbara Brenner
Hazardous Materials Planning Technician
cc: B. Martin
H~ZARDOUS MATERIAL =EtO
AODRESS\ LOO~TION ~ San Joaquin
DATE OF ASSESSMENT = 8-1-80
NAME OF DiSK FILE =
*** SCENARIO DESCRIPTION
EtO release~ 17 lb
******* TOXIC U6POR DISPERSION ~NAL. YSIS RESULTS
Downwind distance to corlce~tration of 800 ppm
-- at groundlevel = Not obsecved
-- at dischacge height = ~B feet
Note: Minimum computable answer is 3~ fee{:!
Actual hazard distance may be ].ess,
Peak concentration on ground is
at a downwind distance o~ ~ feet for
elevated emission source specified by user,
See attached table(s) for further details,
TOXIO VAPOR OISPERSION '~N~L¥SIS RESULTS
Downwind Oistanoe 6r'oundlevel Source Height Initial Evacuation
...................... Concentra{ion Concentr'ation Zone Wid{h*
(feet) (miles) (ppm) (ppm) ('feet)
32 .01 ,88 75t8 24
37 ,01 8.5 5881 27
4,2 ,01 35,7 44.16 30
SI ,0t 172 2903 57
SS ,02 285 2424. 40
60 .02 357 2055 44
64 .02 441 1785 47
89 .02 Sir 1553 50
73 ,02 563 t348 S4
78 ,02 802 1193 57
8~ .02 827 t068 80
87 .02 840 88t 84
92 .02 845 873 59
96 .~2 84.2 800 t
*Usually safe for < 1 hour release. Longer releases or' sudden wind shifts
may require a larger width or different direction for the evacuation zone.
See Chapters S and t2 of %he guide for details. Source haight specified
by %he user for ~his scenario was 3 feet.
TOXIC VAPOR DISPERSION ANhL, YSIS RESULTS
Downwind Distance Contaminanf, ~r'r'ival Time Contaminant Depar'%ure Time
................................ at Downwind Location at Downwind Location
(feet) (miles) (mi. nu~es) (minLlte5)
32 81 . i G .2
57 e~ t 6
42 et .1 6.2
46 01 .1 6.2
S 1 ~ 1 . I G. 2
SS 82 .1 G. 2
60 02 .2 8.3
84 02 .2 G ,3
69 02 ,2
73 02 .2 G, 3
78 ~2 ,2
83 82 .2 G. 3
87 ~2 .2 8.4.
92 02 ,2 G ,4
C~UTION: See guide for assumptions used in estimating these times.
INPUT P~R~METER SUMM~RY
PHYSIOCHEMIC~L PROPERTIES OF M~TERI~L
MOLECULAR WEIGHT = 44.05
TOXIC V~PDR LIMIT = 80¢ pp~
CONTAINER CHRR~CTERISTICS
TEMP OF CONTAINER CONTENTS = ?0 degr*ees F
ENVIRONMENT~L/LOC~TION CH~RBCTERISTICS
&MBIENT ]"EMPER~TURE = ?0 degr'eas F
WIND VELOCITY = 6.4 ~ph
~TMOSPHERIC STABILITY CLASS = F
U~POR/G~S [)ISCH~RGE HEIGHT = ~ feet
KEY RESULTS PROVIDEB BY USER INSTEAD OF BY EVaLUaTION METHODS
V~POR EVOL. UTION R~TE = 2.87 lb/~in
V~POR EVOLUTION DURATION = B minutes
KEY RESULTS OVERRIDDEN BY USER ~T SOME POINT ~F'TER COMPUTATION
NONE OBSERVED
INPUT PBREMETER SUMMARY
PHYSIOCHEMICAL PROPERTIES OF MATERIAL
NORMAL BOILING POINT = -21 d~gr~ees F'
MOLECULAR WEIGHT = 120.91
VAPOR PRES AT CONTAINER TEMP = 73.49
= 3883 mM Hg
VAPOR PRES AT AMBIENT TEMP = ?3.S1
= 3883 ~ HQ
SPECIFIC HEAT RATIO FOR GAS =
CONTAINER CHARACTERISTICS
TOTAL WEIGHT OF CONTENTS = 148 lbs
DISCHARGE HOLE DIAMETER = .S inch(es)
DISCHARGE' COEFFICIENT OF HOLE = .62
TEMP OF CONTAINER CONTENTS = 70 degrees F
ENVIRONMENTAL/LOCATION CHARACTERISTICS
AMBIENT TEMPERATURE = 70 degrees F
WINO VELOCITY = 6.4 ~ph
KEY RESULTS PROVIDED BY USER INSTEAO OF' BY EVALUATION METHODS
NONE OBSERVED
KEY RESULTS OVERRIDDEN BY USER BT SOME POINT AFTER COMPUTATION
NONE OBSERVED
HAZARDOUS FIATERZAL =
ADDRESS \ LOCBTION = San Joaquin Hospi~l
DBTE OF ~SSESSHENT =
N~HE OF DZSK FZLE = S3,BSF
*** SCENRRZO DESCRZPTZON
**~***~ DISCHARGE R¢~TE/OUR~T~ON ESTIMATES
Compressed ga5 discharge ¢ro~ container
Peak discharge rate = 24.'7 lbs/~i~
~ration of discharge " 5.6B minute,~
~ount di ~charg~d = 14.~ lbs
S~a~e o¢ ~aterial = Gas
H~Z~ROOUS M~TERI~L = E~O
8OORESS \ LOC~TION = San Joaquin
D~TE OF ~SSESSMENT =
N~ME OF OISK FILE = SJ2.~SF
*** SCENARIO OESCRiP~ION
t'7 lb ~elease in 6 mirl
******* TOXIC ~POR BISPERSION ~N~LYSIS RESULTS
Down~ir~d distance to concentmation of 80¢ ppm
a~ discharge height : 95 fee~
No're: Mir~imum computable answer is 33
8cruel hazand distance may be tess,
Peak concer~tcation on gcound ts ~.84 pp~l
at m dowr~wind distance of 2e4,e feet fop
elevated emission soucce specified by
See attached ~able(s) fcc fucthec
TOXIC VAPOR DISPERSION ANALYSIS RESULTS
Downwind Distance Gr'oundlev~l Source Height Initial Evacuation
.................... Concentration Concentr'at lon Zone Width*
(feet) (miles) (ppm) (ppm) (feet)
32 01 0 7518 24
57 01 0 5898 27
4,1 01 0 4.46? 30
46 01 0 359B ~3
50 01 0 2958 37
55 02 0 24,76 40
58 02 0 2184 43
54 02 0 1810 4B
68 02 0 1574 S0
72 82 0 1382 53
77 02 0 1225 56
81 02 0 t091 59
8G 02 0 ~78 85
90 .OZ 0 884. 58
95 .02 0 800 1
*Usually safe for' ,( 1 hour release. Longer releases or sudden wind shifts
~ay require a larger width or different direction ~or the evacuation zone,
See Chapters ~ ~nd 12 o? the guide for details. Source height ~pecified
by the user for thi~ ~cenario was S0 feet,
TOXIC VAPOR DISPERSIO~ ANALYSIS RESULTS
Downwind Distance Contaminant Arrival Time Contaminant Bepartur'e Time
............................. at Downwind Location at Downwind L. ocation
(feet) (Miles) (minutes) (minutes)
32 .O1 .l
~? .01 t
41 .01 1
46 .01 1 G.'~
50 ,0~ t
SS ,02 1 6,2
59 ,02 1 8,3
64 ,02 2 6.3
68 .02 2 6.3
72 .02 ,2
77 .02 .2 8,3
8t ,02 ,2
86 ,02 .2 8.4
90 .02 .2' 8.4.
95 .02 .2 6.4
CAUTION: See guide for assumptions used in estimating these 'times,
INPUT PARAMETER SUMMARY
PHYSIOCHEMICAL PROPERTIES OF MATERIAL
MOLECULAR WEIGHT = 4,4,05
'TOXIC VAPOR LIMIT = 800
CONTAINER CH~RGCTERISTICS
TEMP OF CONTAINER CONTENT'S = 70 degrees F
ENVIRONMENTaL/LOCATION CHARACTERISTICS
AMBIENT TEMPERATURE = 70 degrees F
WIND VELOCITY = 6.4 ~ph
~TMOSPHERIC STABILITY (]LASS = F
VAPOR/G~S OISCHGRGE HEIGHT = 50 feet
KEY RESULTS PROVIDED BY USER INSTEAD OF BY EVALUATION METHODS
VAPOR EVOLUTION RATE = 2.83 Ib/min
k)APOR EVOLUTION OURATtON = ~ minutes
KEY RESULTS OVERRIDDEN 8Y USER 6T SOME POINT AFTER COMPUTATION
NONE OBSERVEO
H6Z~ROOUS MF4TERI~L = ethylene oxide
~BDRESS \ LOOSTION = SanJoaquin Hospital
DATE OF 6SSESSMENT
N~ME OF DISK FILE = ~,,~SF
*** SCENARIO DESCRIPTION
******* TOXIC V6POR DISPERSION ~N~[.YSIS RESULTS
Oownwind distance to concentration of 800 ppr,~
-- at groundlevel
-- at discharge heigh'[ = 339 feet
Peak concentration on ground .ts ~0882,7 ppF~
at a downwind distance of 35 feet for
elevated emission sour'ce specified by u~er,
See attached table(s) for further details,
TOXZC UhPOR DISPERSION hN6LYSlS RESULTS
Downwind Distance 6noundlevel Sour'ce Height Initial Evacua~ien
.................... C)oncen~pat ion Concentr'a~ ion Zone Width*
(feet) (miles;' (pp~) (ppm>
188 ¢2 78e8 7254 73
118 85 58,58 5518
155 ~; 4528 4.;31 t98
t52 ~3 3615 3489
169 ~4 2~5B 28"7 ~
188 ~4 2485 24~5 t 40
22t 85 1794 1762
238 ~S 1568 1555 t
25S 8S 1 ~'78 15S 1 1
272 .86 12t ~ 1 t g8 28e
289 .8G 1883 leT1 228
387 .CB ~74 '~G4 238
~.4 .¢7 880 872 220
~41 .87 88~ 88~
*Usually ~afo fon < 1 hour r'eleaso, Longer ~elease¢ or audden wind 5hif~s
may requir-e a ].anger' wldth or diffenent dir"oc%ion for the evacuation zone.
See Chap(ers ~ and t2 of the guide fon details. Sour'ce heigh% ~pecified
by the user' for' this scenar',io wa~ 1 feet.
TOXIC UhPOR DISPERSION ~NhLYSIS RESULTS
Downwind Distance (]on~;arqinant ~lrnival Time Con%aml. nan~ Depan~ur'e T.i, me
............................ at Downwind Location a'f, Downwind Location
(fee%) (mile~,) ( ~ninu%es ) (~inute~)
lee .e2 .2 t .4
118 .83 .3 1 S
13S .85 ,3 1 S
152
t89 .04 .4 I 7
18G .84 .4 'l ?
284 .04 .4 I 8
221 .8S .4 1 8
238
2S5 .0S .5 2
2?2 .OG .S 2
289 ,8G . G 2.1
~87
324 .07 .G 2.2
541 ,07 .7 2.~
CAUTION: See guide Con assump(ion5 used in estimating these times.
INPUT P~RNMETER SUMMB, RY
PHYSIOCHEMIC~L PROPERTIES OF M6TERI~L
MOLECULhR WEIGHT = 4.4. ~5
TOXIC V~POR LIMIT = 8~ ppm
CONTAINER CH~R~CTERISTICS
TEMP OF CONTAINER CON]tNT= = 7¢ degrees F
ENVIRONMENTAL/LOCATION CHAR~OTERISTIOS
hMBIENT TEMPERhTURE = '7e degrees F
WIND 'VELOCITY = 8.4 ~ph
6TMOSPHERIC SThSILITY CL6SS = F
V6POR/S¢~S DISCHhR6E HEI6HT = 1 feet.
KEY RESULTS PROVIDED BY USER INSTEAD OF BY EVhLUhTION METHODS
V~POR EVOLUTION RhTE = 17 lb/~,in
VhPOR EVOLUTION DURATION = 1 minu~es
KEY RESULTS OVERRIDDEN BY USER ~T SOME POINT ~FTER COMPUThTtON
NONE OBSERVED
HAZARDOUS M~TERI~L = ethylene oxide
ADDRESS \ LOCATION = SanJoaquin Hospi~;al
DATE (}F ASSESSMENT = 7-.50-~0
NAME OF OISK FILE =
*** SCENARIO OESCRIPTION
1 minute r'elea~e
******* TOXIC USPOR DISPERSION ANALYSIS RESULTS
-- at Qroundlovel = 5iS feet
.... at discharge height = Z~3 feet
Peak concentration on ground is 2214.2 ppm
at a downwind distance
elevated emission sour'ce specified by user'.
See attached table(s) for further detc~ils.
TOXIC V~POR DISPERSION ANALYSIS RESULTS
Downwind Distance Ground].evel Source Height Initial Evacuation
....................... Concentration Concentrat ior~ Zone Width*
(feet) (mites) (ppm) (ppm) (feet)
100 02 20;8 4284
14'7 03 2077 2t51 110
1G2 84 192G 184~ 120
19~ 04 I509 1458 140
208 04 145S 1293 150
~ 0S t334 ll?l
239 05 1217 1059 180
254 05 1113 980 190
269 05 102t 902 200
28S 0~
300 0G 8GS ?73 200
31S 06 800 919 1
*Usually s~fe for < 1 hour relem~e~ Longer relea~e~ or ~udden u~ind shift~
:~my require ~ l~rgec width or different direction ~or 'the evmouation zone.
See Chapters 5 mhd l~ of the guide ~or detail~. Source height speoifi~d
by the user for '~hi.~ scenario was 4 feet,
· TOXIC VAPOR DISPERSION ANALYSIS RESULTS
Downwind Distance Contal~inant Ar'rival Time Contaminant Departure Time
............................ at [)ownwind Location at Downwind Location
(feet) (mikes) (minutes) (minute~)
100 .02 .2 1.4.
147
20~ .04 4 t,8
239 ,05 S 1,9
2S4 .05 S 2
2~9 .0~ S 2
28S ,06 ,~ 2.1
300 ,OG .B 2.t
315
C~UTION: See guide for' assumptions used in estimating these times.
INPUT P~RRMETER SUMM~RY
PHYSIOCHEMICf~L PROPERTIES OF M~TERIRL
MOLECULAR WEIGHT = 44.0~
TOXIC V~POR LIMIT = 8~¢ ppm
CONT6INER CHRRROTERISTICS
TEMP OF CONTAINER CONTENTS = 7~ degrees F
ENV IRONMENT~L/LOCST I ON CHaRaCTERISTICS
BMBIENT TEMPERBTURE = '7~ degrees F
WIND VELOCITY = 6,4 mph
aTMOSPHERIC STABILITY OL~SS = F
V~POR/G~S DISCHARGE HEIGHT = 4 ¢ee't
KEY RESULTS PROVIDED BY USER INSTEAD OF BY EV~LU6TION METHODS
V~POR EVOLUTION RaTE = ~? lb/min
V~POR EVOLUTION BURaTION = '1 minutes
KEY RESULTS OVERRIDDEN BY USER ~T SOME POINT ~FTER COMPUTATION
NONE OBSERUEO
HBZAROOUS MATERIAL = e%hylene oxide
ADDRESS \ LOCATION = SanJoaquin Hospi'~al
DATE OF F~SSESSMENT = '7.-3e--ge
N~NE OF DISK FILE = 1.hSF
~, SCENARIO DESCRIPTION
3.4.1b/re.tn fop 5 mir~
~¢~**~ TOXIC U~POR DISPERSION hN~LYSIS RESULTS
Do~m~nd distance ~o concen~a't~on of 8~ ppm
--- at gr'oundlevel = No~. observed
-- at discharge height = ~e4 fee~
No~e: Flinimum computable answmc is 33 fee~!
~c~ual hazard distance may be less.
Peak concen'[r'm~ion on ground ~a 3,88 ppm
at a dowr~wind distance of ~SS8 fee~ for
eleva~ed em~,5~,ion source specified by user.
See a~;t, ached ~able(s) for fur'[her details.
TOXIC VAPOR DISPERSION ANALYSIS'RESULTS
Downwind Distance 6roundtevel Source Height Initial Evacuation
...................... Concentration Concentration Zone Width*
(feet) (miles) (ppm) (ppm) (feet)
t01 .02 0 850 50
101 .02 0 847 48
101 .02 0 843 46
101 .02 0 8~9 44
t02 02 0 835 42
!02 02 0 831
102 02 0 827
102 02 0 824 34.
103 02 0 820
tOJ 02 0 8~6 28
103 02 0 812 24
104 02 0 805 14
*Usually safe for' < 1 hour release. Longer releases or' sudden wind shifts
may require a larger width or different direction for' the evacuation zone.
See Chapters 5 and 12 of the guide for" details, Source heigh'~ specified
by the user for this scenario was 40 feet.
TOXIC VAPOR DISPERSION ANALYSIS RESULTS
Downwind Distance Contaminant Arrival .Time Contaminant Departure ]'i~e
........................ at Downwind L. ocatiofl at Downwind Location
(feet) (mile~) (minutes) (minutes)
t00 02 .2 · 5.4
101 02 ,2 5,4.
101 02 .2 5.4
101 02 .2 5.4
t0t 02 ,2 5.4.
'i 02 02 .2 5.4
102 02 .2 5.4
102 02 ,2
t02 02 ,Z 5.4
103 02 .2 5.4
105 02 ,2 5.4
103 02 ,2 5.4
103 02 .2 5.4
104 .02 ~ 5.4
104 ,02 ,2 5.4
CAUTION: See guide for assumption~ used in estimating these times.
HAZF4ROOUS M( IAL = ethylene oxide
]oFODRES~SI~j-LTO'C~hq~IOI'~----~ a n J o a q u ~ n
DATE OF ASSESSMENT = 7-30-90
NhME OF DISK FILE = 1.hSF
**~ SOENhRIO OESORIPTION
17 lb/min for 1 min.
~****** TOXIC VAPOR OISPERStON ANALYSIS RESULTS
Downwind distance 'to concentration of 888 ppm
..... at groundlevel = Not observed
..... at discharge height = 237 fee~
Note: Minimum computable answer is
Actual hazard distance may be less.
Peak concentration on ground
at a downwind distance of 1532 feet for
elevated emission source specified by user.
See attached table(s) for further details.
TOXIC' OAPO'R ' O ISPE-RS IO'N AN~LYS'I S ' RESULTS
Oownwirld Oist,~.~.nce Groundlevei Source Height Ini~;ial Evacuation'
........................ Concen~ra't ion Concentr'~t ion Zone Width*
(feet) (miles) (ppm) (ppm) ( '¢e~ ) r
189 , ~2 8 4278 7~ '
t~0 .0~ 0 258B
14~ .8~ 8 lBS1
~ 59 . 8~ 8 1'72S 1
188 . 84 8 1244
198 .64 0 t t28 1S9
217' .05 0 ' 943
'227 . 05 0 887 140
257 ,05 ~' 8~
*Usually safe for < 1 hour releaae, Longer releases or' sudden wind shifts
may require a larger widt~ or df'Ffiererl~' d'irec~ion for the evacuation zone.
See Chmp~er"s 3 and T2 o'¢ the guide for details. Source heigh~ specified
by the user for 'this scenario was 4e
TOXIO VAPOR DISPERSION ANALYSIS RESULTS
Downwind Distance Contaminant Arrival Tirqe Contar~inan'~ Departure T'l~e
........................... at Obwnwind Location at Downwind Location
( feet ) <miles ) (minL~te~) (~inut',e5)
110 05 ,2 t .4
139 03 ,3 1.S
189 04 .3 1.7
t 78 94 , 4 1 · 7
t98 e4 .4 I .8
288 84 .4 1.8
17 .8S .4 1 8
227 .05 .4 1.9
237 .eS .S 1 .9
OGUTION: See guide for s~sump~ions used.in estima~ir',g these
INPUT PARAMETER SUMMARY
PHYSIOCHEMICAL PROPERTIES OF MATERIAL
MOLECULAR WEIGHT = 44.05
TOXIC VAPOR LIMIT = 800 ppm
OONTAINER CHARACTERISTICS
TEMP OF CONTAINER CONTENTS 70 degree~ F
ENVIRONMENTGL/LOC~TION CHaRaCTERISTICS
~MBIENT TEMPERATURE = 70. degrees F
WIND VELOCITY = B.4 mph
ATMOSPHERIC STABILITY CLASS = F
V~POR/G~S DISCHARGE HEIGHT' = 40 fee~
KEY RESULTS PROVIDED BY USER INSTEAD OF BY EVaLUaTION METHODS
V~POR EVOLUTION RATE = 17 lb/mir
UGPOR EVOLUTION O(JRh'flON = I minLt'te5
KEY RESULTS OVERRIODEN BY USER ~T SOME POINT' AFTER COMPUTGTION
NONE OBSERVED
~i'~'~?'~'~.~t~,''~;~,'' ~'~",' "~ .~:~:'i'~,~.'~ .~:~',I~:: Ci;< 'ii:?.[? %'~:~' ~ ~. t '~;,v~: ~ "~""'"'
~ '~..-:'..-' ,~, -3 ..;, ..~: .,~ ,.2 .,~ ,.:' ~:= ..~.,~, 2, ,.~. ,, ~ ,2-,',~
.~..e. x~., ,...~ .,, .~.. ~. ,, ,~..<. ,,~, .~ .~,~ ~= -, ,~ ~vv ?{ "5' ~ ..y
.... , ~ ~ ,.. ..,...~, .....: ._? ,.:: ,..:., :..,,
I
HAZARDOUS-MATERIALS-NETWORK CONTRACT
This Contract is entered into as of this day of
4 , 1992, by and between the CITY OF BAKERSFIELD, a
California charter city (hereinafter called "City") and SAN
JOAQUINCO~MUlqITY HOSPITAL, a California non-profit corporation
6
(hereinafter called "Hospital").
7
8
RECITALS:
9
A. City's Fire Department has created, and maintains,
11 a "hazardous-materials computer-network" (hereinafter called
12 "said network" ) .
13 B. Said network contains information respecting about
14 2,500 .chemicals (which chemicals are "hazardous materials" as
15 defined by various statutes). City believes the information
16 covers all hazardous. materials used or stored in Kern County.
17 City arranges for the "update" of the information through a
~8 "service contract" with Material Safety Data Systems, a
19 California corporation. The information includes medical
20 protocolS respecting exposures of human beings to certain of the
21 chemicals. City makes no warranty or representation as to the
22 accuracy or adequacy of the information.
23 C. The information in said network is "accessible" by
24 telephone modem and compatible computer software (hereinafter
25 called "PC and modem").
~26 D. City uses its best efforts to maintain said
27
JDC\CORRES V\HAZMAT. CON ~k
28
DEPARTMENT
network on a full-time, 24-hour basis, but does not warrant that
it can or will maintain said network on a full-time, 24-hour
basis.
3
4
NOW THEREFORE,
$
For a valuable consideration, the receipt of which each
6
7 party hereto acknowledges, City and Hospital agree as follows:
9 1. PERMISSION TO ACCESS:
10 City agrees to permit Hospital to "access" The "Hazardous
11 Materials Chemical" section of said network.
13 2. INSTALLATION:
14 Hospital agrees to install, at Hospital's property, a PC and
15 modem of the type and quality to be specified by City.
16
17 3. TRAINING:
18 City agrees to provide "hands-on" training to familiarize
19 Hospital's employees with the application and use of the PC and
20 modem.
21
n 4. DONATION FOR PURCHASE:
23 Before this Agreement becomes effective, Hospital shall
24 donate to city, for use by the City's Fire Department, the non-
25 refundable sum of $2900. City agrees to use said $2900. for the
26 purchase of computer equipment.
27
~C\C0~ESV\~ZMAT.CON 2
28
DEPARTMENT
5. COSTS:
!
City expects the only cost to Hospital will be that for
maintaining Hospital's computer, software, modem, and telephone
line.
4
6. WARRANTIES:
6
7 Hospital warrants as follows:
(1) Hospital is duly organized and existing under the
9 laws of the state of California, and ~
(2) The execution, delivery, and performance of this
!0
11 Agreement:
12 (a) are all within Hospital's corporate powers;
!3 (b) have been duly authorized by the Board of
14 Directors and Shareholders as required by the
15 Articles of Corporation and Bylaws; and
16 (C) are not in violation of the law or any terms
17 of Hospital's Articles of Incorporation,
~8 Bylaws, or other incorporation papers, or any
19 other indenture, agreement, or undertaking to
20 which Hospital is a party or by which it is
2! bound.
23 7. EVENTS OF DEFAULT:
24 Hospital shall be in material default hereunder (upon the
25 happening of such defaults, City may immediately terminate this
26 Agreement by giving written notice thereof to Hospital) if any of
2?
JDC\C0~ESV\~ZMAT.CON 3
28
DEPARTMENT
the following come to pass:
(a) Hospital makes any false or misleading
3 representation, warranty, or statement in
connection with this Agreement;
(b) Hospital's dissolution, termination of existence,
6 insolvency, business failure, appointment of a
7 receiver of any part of its property, assignment
s for the benefit of creditors, or commencement of
9 any proceeding under any bankruptcy or insolvency
i0 (laws by or against Hospital or any guarantor or
11 surety for Hospital's obligations);
12 (c) Hospital breaches any term of this or any other
13 Agreement between Hospital and City; or
14 (d) Hospital fails to immediately notify City, in
15 writing, of any change in Hospital's place of
16 business or of the discontinuance of any such
17 place or places of business.
19 8. NON-WAIVER OF RIGHTS:
20 No delay or omission on the part of City, in exercising any
21 of its rights hereunder, nor the acquiescence in or waiver by
22 City of a breach of any term, covenant, or condition of this
23 Agreement shall be deemed or construed to operate as a waiver of
24 such rights or acquiescence thereto except in the specific
25 instance for which given.
26
27
JDC~C0~ES V~ZMAT.CON
28
DEPARTMENT
9. NOTICES:
Notices to either party shall, be in writing and shall be
delivered personally or by certified mail, return receipt
requested, to Hospital; at Hospital's address set forth on
Exhibit "A" or to City, at City's address, and to the attention
of the person whose name is set forth5 on Exhibit "B". Mailed
notices shall be deemed communicated as of'the date of the
delivery shown on the return ~eceipt, or five days after mailing,
whichever first occurs. Each party may change its address by
written notice delivered in accordance with this paragraph.
~2 10. INTEGRATION CLAUSE:
13 The parties intend this writing to be a complete and
14 exclusive statement of the terms of agreement and a final
15 expression of the Agreement. The terms of this .Agreement are the
~6 reSult of negotiation by and between the 'parties and in no event
17 are to be construed in f~vor of one party as against the other.
19 11. PARTIAL INVALIDITY:
2o Should any part of this Agreement, for any reason, be
21 declared or adjudicated to be void or invalid, such determination
22 shall not affect the validity of any remaining portion. Such
23 remaining portion shall remain in force and effect as if this
24 Agreement had been executed with the invalid portion eliminated.
25 The~ parties declare they would have executed the remaining
26 portion of this Agreement, without including a~y suCh part or
27
JDC\CORRES V\HAZMAT. C0N 5
28
LEGAL DEPARTMENT
parts hereafter declared or adjudicated to be invalid.
2
12. PARAGRAPH HEADINGS:
3
The captions of ~'paragraphs of this Agreement are for
4
reference only, and are not to be construed in any way as a part
of this Agreement. ~
6
13. CHOICE OF LAW:
This Agreement shall be governed by and construed in
.'accordance with the laws of the State of California. Should
Hospital bring suit to enforce any of the terms hereof, or for..
damages for the breach hereOf, Hospital shall file, and~maintain,
such suit in Kern County.
14
15 14. ASSIGNMENT AND DELEGATION:
16 Hospital acknowledges that one of the considerations
17 perSuading City to execut'e this Agreement is the skill and
18. reputation possessed bY'Hospital, city is relying upon such
19 skill and reputation to insure that Hospital performs the
20 covenants on Hospital's part hereunder to be performed. With
21 that in mind, Hospital may not assign this Agreement, or any
22 interest therein, or delegate any of Hospital's duties, in whole
23 Or in part, voluntarily or involuntarily, by operation of law or
24 otherwise, except with City's previous consent in writing, whic. h
25 con'sent, however, shall not be unreasonably refused or withheld;
26 provided further, however, that despite'~any such assignment or
27
~C\C0~ES V\~mT.C0N 6
28
R"rM ENT
delegation, Hospital shall remain responsible for the faithful
performance of each and every term, covenant and condition of
this Agreement; and provided, further, that no assignee or
delegatee, shall have the right to make any further assignment or
delegation of any kind affecting this Agreement without first
obtaining City's previous written con~ent as aforesaid. Hospital
specifically agrees and understands that any assignment or
delegation, or attempted assignment or delegation, contrary to
the provisions of this paragraph, shall b'e void and shall be a
material breach of this Agreement.
12 15. SUCCESSORS AND ASSIC~NS:
13 Subject to the provision prohibiting HOspital from assigning
14 and delegating its rights and duties hereunder, this Agreement
15 shall be binding upon, and shall inure to the benefit of, the
16 parties hereto, their respective heirs, executors,
17 administrators, and assigns.
~ 9 1 6. ATTORNEY FEES:
20 If any action at law or in equity, including an action for-
21 declaratory relief, is brought to enforce or interpret the
n provisions of this Agreement, the prevailing party shall be
23 entitled to a reasonable attorney fee, which may be set by the
24 Court, in the same action or in a separate action brought for
25 that purpose, in addition 'to any other relief of damages to which
26 such party may be entitled.
27
~c\c0~s V\~mT.C0~ 7
28
LEGAL DEPARTMENT
17. INDEMNIFICATION:
Hospital shall indemnify, defend and hold harmless City, its
officers, agents, and employees, against any and all liability,
3
claims, actions, causes of action, or demands whatsoever, against
4
them, or any of them, for injuries to, or death, of persons, or
damage to property, arising out of, or connected with, or caused
6
7 by Hospital, Hospital's employees, agents or independent
contractors in the performanc~ of (or in any way arising from)
the terms and provisions of this contract.
9
10
18. TERMINATION:
12 Either party may terminate this Agreement on 30 days" notice
13 to the other party. City will, however, use its best good-faith
14 efforts to aVoid acting to terminate this Agreement for the first
i$ twelve months.
16
17 IN WITNESS WHEREOF the parties hereto have executed this
~8 instrument as of the date first hereinabove set forth.
19
20 CITY OF BAKERSFIELD SAN JOAQUIN COMMUNITY
HOSPITAL:
22
by. by,
23".... CLARENCE E. MEDDERS
:..~ Mayor
24
26 by. by.
Attest Attesu
27
JDC\CORRES V\HAZMAT. C0N 8
28
R'TM F'NT
3 Approved as to form:
LA~RE~cE M. LUNARDINI
4 City Attorney
6
By
7
8
9
10
12
13
14
15
16
17
-18
19
20
21
22
24
25
26
27 o~C~CORRES V~HAZMAT . CON
9
DEPARTMENT
EXHIBIT "A"
2
HAZARDOUS MATERIALS NETWORK CONTRACT
3
4
Address of Hospital:
$
SAN JOAQUIN COMMUNITY HOSPITAL
6 2615 Eye Street '
Bakersfield, CA 93301
7
Attention:
8
10
11
13
15
16
17
18
19
2O
21
22
25
27 JDC'\CORRES V\.HAZMAT. C0N
l0
28
DEPARTMENT
EXHIBIT "B"
HAZARDOUS MATERIALS NETWORK CONTRACT
4
Address of City:'
6
CITY OF BAKERSFIELD
1501 Truxtun Avenue
7
Bakersfield, CA 93301
Attention: Fire Chief Steve Johnson
9
10
14
15
16
19
20
21
27 JDC~CORRES V~HAZMAT. C0N
11
28
LIC"G A L. DEPARTMENT
.\
,i
Co~ ~ ~ -& ~cc~3¢ ecu~
FIRE DEPARTMENT 210: H STREET
D. S. NEEDHAM BAKERSFIELD. 93301
FIRE CHIEF 326-3911
June 4., 1990
Ms. Anne Harrington
FPE Group
3687 Mt. Diablo Blvd., Suite 200
Lafayette, CA 93549
Dear Ms. Harrington,
I have reviewed the draft RMPP that you submitted
for the ethylene oxide sterilization system at San Joaquin
Community Hospital. The blueprints of the construction were
helpful to me in gaining an understanding of the system
configuration. However, it will be necessary for you to
develop a schematic diagram bf the system to be used to
facilitate understanding of information contained in the risk
analysis and the final RMPP.
The summary of the risk analysis which you provided
outlines your conclusions regarding the worst case scenarios.
'I need to review the actual hazard identification study in
order to determine if I agree with these conclusions. The
Cype of hazard analysis that this Administering Agency
equires is one which evaluates failure scenarios for each
component of a system. The probability of occurrence and the
severity of predicted consequence should be estimated for
each scenario in order to qualitatively define the risk
high, medium or'low. A systematic Haz-OP study will often
reveal weaknesses in a system which pose less threat than a
worst case incident but do have significant onsite ..
~onsequence.
The following subjects are not-addressed in the summary
that you submitted.
1. The potential for human error during delivery and
set up of cylinders that may damage the system due to
confined space in the Sterilizer room. The possible
~ exposure to a person in the sterilizer room at the
time of an accident and possibility for escape.
2. Leaks that might occur in lines, regulators and.
fittings.
3. Possibility of building air supply contamination if
the vent pipe ruptured before it reaches the roof. JQ~f ~ ~,/7
.
4. The fire and explosion hazards presented by the
separation of ethylene oxide and freon once released
as a gas into a'confined space.
5. The National Weather Service statistics indicate that
the average wind speed in Bakersfield is 6.4 mph.
6. Onsite consequence analysis.
Please provide me with the support documentation of the
risk analysis and address these issues. You may also want to
obtain information about the May 10p 1990 California Air
Resources Board ruling regulating ethylene oxide sterilizers.
Once adopted by the local district, this regulation will
require substantial reductions in routine ethylene oxide
emissions . During this system renovation, your client may
'want to plan ahead for this new requirement.
Please call me if I can be of any assistance. I
appreciate the prompt action and good start that has been
made toward the completion of this RMPP.
Sincerely,
Barbara Brenner
Hazardous Materials Planning Technician
' H~Y 21 '90 ~39:30 'FPE LAF.CA. P. 1
'~ - ~ RECEIVED
': ?,)ff,'~ 8687 MC, Diablo Blvd., Ste. 200, Bafayette, CA 94~49 {4151 283-8860 Fax; (415) ~88-~72~
SAN JOAQUIN COMMUNITY HOSPITAL
Ethylene Oxid~ Risk Ma~gem~nt and Pr~wntion Program
Job Number 905047
San Joaquin Community Hospital was identified by the Bakersfield Fire
Department as a handler of ethylene oxide which is an acutely hazardous
material (AHM). The City of Bakersfield's Fire Department determined
that SJCH~s operations could pose an acutely hazardous materials accident
risk, therefore it would be required to submit a Risk Management and
Prevention Program (RMPP) pursuant to section 25534 of the Health and
Safety Code,
The purpose of a RMPP is to establish and maintain a comprehensive
management program to assess and prevent, to the greatest degree
possible, th~ risk of a release of acutely hazardous materials , in a
manner which might cause harm to the safety and health of the community
and the environment.
San Joaqutn Community Hospital is a 162 bed facility and employs
approximately 500 employees.. The main hospital is 133,289 square feet.
Th~ Central Service Department is located in the basement of the main
hospital and is 2,160 square f~et in area.
A. Storage and Quantities Used
Currently, SJCH uses Penngas, a 12 percent ethylene oxide (EtO) 88
percent dichtorodifluoromethane gas (CFC-12) for sterilization
purpos~So CFC-12 is used as a diluent to render the 12/88 mixture
non-flammable and non-explosive. The gas mixture is supplied by
Pennsylvania Engineering Company and is shipped in 140 pound 12" by
38" high cylinders aa a liquid under 70 psig,
MAY 21 '90 09:~1FPE LAF.~A.
The hospital uses approximately one 140 lb. 12:88 EtO cylinder every
three weeks, or approximately 17 cylinders a year. This amounts to
approximately 1.8 pounds of EtO used daily and for our purposes ~.~,
discharged daily. Annual use of EtO is calculated to be
approximately 657 pounds,
At any one time there is a maximum of four full cylinders (15[ pounds
of EtO) on hospital property: two behind the sterilizer in the
basement in Central Supply and two outside the main hospital in a
covered, fenced, and locked, storage area approximately 300 feet
away. The cylinders are chained to prevent accidental falls and the
valves are recessed to prevent accidental release during a fall.
,
One of the EtO cylinders in Central is "on-line" and connected to the
gas' sterilizer. About every three weeks Central Supply notifies
engineering the tanks need to be changed, an engineer picks up a
reserve tank form the outside storage area with a dolly, transports
it to Central and exchanges the tanks in the area behind the
sterilizer unit.
Sterilization Process and Emission Releases
The sterilization process involves EtO gas, relative humidity
(moisture), proper exposure time, and temperature. The relationship
of these four elements depends on the sterilizer and materials to be
sterilized. After the materials are humidified and gasified, excess
gases and moisture are eliminated by vacuum, exhaust, and purge
cycles. SJCH has one AMSCO sterilizer Model No~ 2048 which has a 24
cubic foot capacity and an AMSCO Aerator. The AMSCO sterilizer is
San Joaquin Community Hospital
Ethylen~ Oxide RMPP -2- May 11~ iggO
MA'Y 70 09:32 F~E I. p. ~
$4x years old and it and the aerator are is serviced every other
month by an AMSCO service technician, In addition to this service
the hospital has ~as Monitoring, Inco come out quarterly and check
the ~,~SCO sterilizer and AMSCO Aerator for leaks with Miran IA
Spectrophotometer during operation.
The hospital currently runs one sterilization load a day for a total
cycle period of 4 hours (actual sterilization time is 1,75 hrs.),
crack the sterilizer door for 15 mine,, load it into the aerator for
12 hours and then prepare it for redistribution, Emissions of EtO
occur primarily during the latter part of the 1.75-hour sterilization
cycle and during transfer of the load to the aerator,
Construction workers working in the vicinity of the sterilizer were
recently monitored for EtO exposures. All results were well below
the current Cal/OSHA permissible exposure limit (PEL) of 1,0 part per
mill~:~ (ppm), Central Supply employees past short-term exposure
levels (STEL) to EtO are in the range of 0.49 to 0,75 ppm which is
'well below the Cal/OSHA 15 min, STEL of 5 ppm,
C: EtO and G~ner~l Ventilation
The hospital is now in the process of modifying the exhaust
ventilation system which services the sterilizer area. For your
reference addended to this report you will find the reduced
bluepriit~,J ~f the modifications to the mechanical system servicing
Central Supply. Basically, the exhaust will now become a dedicated
system for Central Supply and a new canopy hood type exhaust will be
installed to keep the sterilizer, aerator and gas cylinders under
negative pressure at all times, A 12" round exhaust duct will be run
up through the first three floors will be directly exhausted to the
outside through a blower with a 14" square duct outlet through the
San Joaquin Community Hospital
Ethylene Oxide RMPP :3: May 11, 1990
MA' _gO 09: ~o .... FPE LAF. CA. P. 5
~hird floor roof at least 25 feet away from any outside intake,
~perable windows or personnel passage.
When completed the central supply room will have 13 air changes per
hour (ach/hr) and the sterilizer equipment room will have 22 ach/hr.
Additionally, an alarm relay system has been installed which alerts
personnel in Central to the fact that the sterilizer equipment cannot
be operated if the non-recirculating mechanical exhaust system is not
operating,
D. Accidental Releases
SJCH has an EtO Gastech Alarm with 4 sensors which alarms at levels
greater than 5 ppmo SJCH has had no accidents within the last three
years with EtO. However~ on 2/26/90, Sensors #1 & 3 alarmed, The
AMSCO technician was called and found no leaks. The Gastech alarm is
qot specific for EtO or Freon but also reacts to alcohols, perfume,
and auto exhaust and that is what apparently happened on this day.
CWith all the s~fety features beinq installed in SCJH's Central Supply
Area________~ccid.n~.l releases of EtO will be unltkmly. The EtO cylinders
are designed to resist breakage and leakage. The sterilizer and
aerator cannot operate if the mechanical exhaust system fails. A
Gastech Alarm system with four remote sensors alarms if leaks of
~ are detected and the hospital then notifies the AMSCO Service
~5 ~ Representative to find out if in fact there is a leak or not. 0
Employees who may be potentially exposed to ethylene oxide are
',U~ trained at the time of initial ~s$ignment and at least annually on
7¢~the proper use of the sterilizer, hand]trig techniques and
precautions, emergency procedures, and the right ~o medical
m~ surv~ill~nce~ Attached to this report is a copy of San Jo~quin
(-(~ Community Hospital's "Ethyl~n~ Oxide: Employee Training ~nd
r One'
S~n Ooaqu~n Community
Ethylene Oxide RMP~ ,~.- May i!, 1990
Communications Program" which is just a small part of their on-going
~AZAEp.~.M&T_~RIAL MANAGEMENT PROGRAM.
In fact, even though ethylene oxide is widely used, serious systemic
poisonings from EtO are rare in the literature, The immediately
Dangerous to Life and Health (IDLH) level for humans for EtO is 800
ppm, High concentrations of EtO gas are both irritating to the
mucous membranes and depressing to the central nervous system,
Guinea pigs exposed to Sl,O00 to 64,000 ppm of EtO for 10 minutes
died within 24 hours of lung edema. Ethylene oxide is'carcinogenic
in animal studies and is a suspect human carcinogen.
If a rupture of one full cylinder occurred in the sterilizer
equipment room after the canopy exhaust hood is installed then
theoretically because the room will be under negative pressure no EtO
will be exhausted to the outside. If a cylinder ruptured and the
alarm was not working which would allow to shut off the main
prior to a total leak and the ventilation system wasn't operating and
the EtO was confined to Central Supply (volume of area is 21,160
ft3), the concentration in the room would be approximately 13,517
ppm, which would produce a hazardous condition. Thus immediate
evacuation and isolation of the area (most likely the entire
basement) would be imperative until the area could be aerat~do No
one would be able to enter the area without the use of a self-
contained breathing apparatus (SCBA) and impervious protective
clothing (such as polychlorinated ethylene) as EtO is quite
irritating to the skin. This is the worst case scenario from an
employee and patient exposure standpoint, --- ($ ~r~ ~p~
sJCH has a standby Survivair SCBA outside the immediate Central
Supply Area. In order to assure that this emergency equipment
used properly during an EtO spill or rupture; personnel on all three
shifts will need to be trained to respond to acutely hazardous
materials emergencies by learning how to don protective equipmc~?.
San Joaquin Community Hospital
Ethylene Oxide RMPP ,.5. May 11, 1990
/ 21 '90 09:34 FPE ',LAF.CA. P.7
/ .:L:' ~.~'~oup
operate an SCBA. This hazardous materials training should be at
!~;; ~-~ ~ours and be repeated annually.
Catastrophic Releases
In the event of an 8.3 earthquake several different scenarios are
possible. We have used an EPI CodeTM software program to evaluate
the atmospheric release of EtO using air dispersion modeling. In the
first scenario all four of the cylinders could rupture (2 in the
hospital and 2 outside) and volatize to the environment. Based on a
wind speed condition of 15 mph and a 30 minute ground level release
of 152 pounds of £tO over a 150 foot radius area the peak
concentration of EtO would be 2.8 ppm at a distance of .05 miles (264
feet). In the second scenario two cylinders rupture in the hospital~
the ventilation system doesn't work and a total of 76 pounds of EtO
~s dispersed directly into the Central Supply Area the EtO
concentration would be 2.6 ppm at a distance of .05 miles° In th:~
third scenario all for cylinders rupture inside the sterilizer are~
and th~ mechanical exhaust does not work~ the conrnntr~tlon ~:~ :;~' ~t
~ distance of <0,06 miles (317 feet) would be 77 ppm which i~? ~,.~'
above the P~L but way below the IDLH, In the fourth scena~' ',
· '~.vlinders rupture and the gas is exhausted to the third flo~ '.~
,,~,: ,.: this results in a downwind concentration ,- ~
~.:~tanc~ of 0.0~ miles.
i:it i~ ciear from this air dispersion modeliF
~.~ earthquake~ ethylene oxide exPosure to ~n~ hospl~' ~ the
~mpl'oyees and the children attending the daycare wou*i~i be
concern but would not be the top priority in a list of emergmr,,~
~onses to a catastrophe of this magnitude,
San Joaquin Community Hospital
Ethylene Oxide RMPP -6- May
CITY of BAKERSFIELD
'~_*~~// "WE CARE"
FIRE DEPARTMENT 2101 H STREET
D. S. NEEDHAM BAKERSFIELD, 93301
FIRE CHIEF 326-3911
April 25, &990
Ms. Anne C. Harrington
The ~.P. Eo Broup
368? Mt. Diablo Blvd., Suite 200
Demr Ms. Harrington:
Per your request an extension to submit the R.M.P.P. for San
Joaquin Community Hospital is hereby granted. As we have
discussed, ninety days should be adequate to complete the R. M. P. P.,
therefore an extension of the due date until July 24, 1~90 should
be appropriate.
We have also reviewed the qualifications of F.P.£. Group to
certify the R. M. P.P. as complete. We find these qualifications to
be adequate and do accept you as the "qualified person."
If I can be of any further assistance please do not hesitate
to call. I do look forward to the completion of the San Josquin
Community Hospital Risk Management and Prevention Progrmm.
Sincerely Yours,
H. Kelly
L. Kollenborn
B. Brenner
W. Evert
The FPE Group
- . 3687 Mt. Diablo Blvd., Ste. 200, Lafayette, CA 94549 (415)283-8860 Fax: (415) 283-5727
April 19, 1990
File No. 905047
Mr. Ralph E. Huey
Hazardous Materials Coordinator
Bakersfield Fire Department
Hazardous Materials Division
2101H Street
Bakersfield, CA 93301
Subject: The FPE Group's Qualifications and a Request For an Extension for
the San Joaquin Community Hospital RMPP
Dear Ralph:
It was nice meeting you last week. Per your request I am sending you The
FPE Group's company brochure and submitting resumes of individuals in our
firm who may be involved in this project. I will be the project manager
and although I have not completed an RMPP before I believe my past air
sampling experience with ethylene oxide, my background in industrial
hygiene, my industrial ventilation experience, and the fact that I am a
Registered Environmental Assessor (as is Jeff Jones) is enough for you to
accept me as the "qualified person".
Additionally, we would be most grateful if you could extend San Joaquin
Community Hospital an extension to submit their RMPP. I apreciate your
time and cooperation. Please feel free to call me if you need additional
information from me about my firm or about my qualifications. My phone
number is (415) 283-8860. Thank you.
Sincerely, ~..~.
Anne C. Harrington, RN, MPH,(~_~H
Senior Consultant
Industrial Hygiene & Environmental Health
ACH
ach/905047/1 tr/RHuey4.19
Enclosures
cc: Will Evert
JEFFREY R. JONES, CIH, MPH
Assistant Vice President
Industrial Hygiene & Environmental Health
Jeffrey Jones' diverse background includes
hazardous chemical control, govemment and
regulatory affairs, cumulative trauma disor-
ders (ergonomics), occupational medicine,
epidemiology, electromagnetic radiation, and
indoor air pollution. His responsibilities have
encompassed program management, labor
issues, and the training of professional and lay
audiences.
Within the scope of the Industrial Hygiene
Division, Mr. Jones has the primary responsi-
bility for supervising the activities of the
Industrial Hygiene staffon major projects. He
oversees all aspects of project planning such
as sampling strategy, worker and tenant health Cai-OSHA at public hearings and advisory
and safety, client liability, and risk communi- committees, to interpret occupational health
cation, as well as the more technical aspects standards and develop regulatory policy, and
of his profession. His extensive experience to interface with public, labor, industry and
allows him to advise clients on many subjects other government agencies. Earlier in his
of environmental or industrial concern from career, Mr. Jones was a research assistant at
asbestos-containing materials to property the Center for Ergonomics, University of
transfer. Michigm, and supervised new drug research
support staff at Syntex Research.
Before coming to The FPE Group, Mr. Jones
worked as an industrial hygienist for the Cali- Mr. Jones received his B.A. degree in Biology
fomia Department of Health Services. He was in 1974. In 1981 he earned a Master of Public
involved in investigating and correcting new Health, Epidemiology, and in 1982, an M.S. in
or unexplained causes of occupational illness Industrial Health, both from the University of
in California. Prior to this, Mr. Jones taught Michigan. He is a member of the American
industrial hygiene principles and practice to Industrial Hygiene Association and the Ameri-
medical, nursing and industrial hygiene stu- can Conference of Governmental Industrial
dents at the University of California, San Hygienists. Mr. Jones is a certified industrial
Francisco. He also provided consultation to hygienist. He has been involved in numerous
the Occupational Health Clinic's clients, presentations and workshops sponsored by
the University of California, the American
As associate industrial hygienist in the Lung Association, the American Cancer
Research and Standards Development Unit Society, the National Safety Council, and
for California OSHA, Mr. Jones represented various professional organizations.
DANIEL D. COX, Ph.D., CIH
Senior Vice President
Dr. Cox brings a comprehensive background
in chemistry and occupational and environ-
mental health to his position. Strong in the
technical aspects of industrial hygiene, he
works well at managing and solving clients'
problems. Dr. Cox adds expertise in asbestos
abatement issues to his industry experience,
which has ranged from forestry products to
plastics and from indoor air quality problems
in small offices to large industrial Complexes.
He has spent many years involved in the iden-
tification, evaluation, and control of loss-pro-
ducing conditions such as work-related and
environmental illnesses, product liability, and
gradual environmental impairment.
Currently Dr. Cox is involved in the manage-
ment and control of hazardous materials. His
clients include prominent building owners and Dr. Cox has lectured at the Northern Califor-
managers, utilities, public agencies, and both nia Occupational Health Center, the Pacific
large and small industry. In addition to sur- Asbestos Information Center at Cal State,
veying and determining the existence andextent Fresno and at the University of Califomia,
of hazardous materials, he devises manage- Berkeley, Masters Program in Industrial
ment plans, conducts training in personal Hygiene.
protective equipment such as respirators, as-
sists clients in complying with OSHA and He served as a member of the Cal-OSHA
EPA regulations, provides expert witness, and Committee on Asbestos, is a member of the
helps limit client liability for workers' com- San Francisco Council on Workplace Health
pensation, torts, and products, and Safety, the Occupational Health Commit-
tee of the American Lung Association of San
Before coming to The FPE Group, Dr. Cox Francisco, the American Industrial Hygiene
was the lead industrial hygienist in Northern Association, the American Chemical Society,
California for the State Compensation Insur- Chemical Health and Safety Division, and the
ance Fund, based in San Francisco. He di- National Asbestos Council.
rected field work for industrial hygienists and
obtained American Industrial Hygiene Asso- A Certified Industrial Hygienist by the Ameri-
ciation accreditation for, and directed, the can Board of Industrial Hygiene, Dr. Cox
company's laboratory. Earlier in his career, holdsaPh. D. in chemistry from the Massachu-
Dr. Cox synthesized research pharmaceuticals setts Institute of Technology and a Bachelor of
as a medicinal chemist for SRI Intemational in Science degree in chemistry from Yale
Menlo Park, California. University.
ANNE C. HARRINGTON, RN, MPH, CIH
Senior Consultant
Anne Harrington is an occupational/environ-
mental health specialist with training in nurs-
ing and industrial hygiene. She has extensive
experience in field investigations, training and
technical consulting.
Ms. Harrington joined The FPE Group in
1987. She provides consultative services in
the recognition, evaluation, and control of
health-related hazards in the workplace. Her
services include on-site investigations to iden-
tify hazardous conditions, including toxic
chemicals, physical agents, and dangerous
work practices. She also monitors worker
exposure to chemicals such as asbestos,
organic solvents, toxic metals, PCBs, and
formaldehyde. In addition, she investigates
complaints of building-related illnesses,
including "tight-building syndrome," and
makes recommendations to control com-
plaints. She evaluates exposure to physical
agents such as noise and heat. Ms. Harrington
advises clients on the management of
asbestos-containing buildings, from identifi- trial Hygiene Department. In 1986, Ms. Har-
cation to removal, rington chaired the Advisory Committee
meetings for proposed revisions to the Cai-
Training is an integral part of occupational and OSHA Asbestos Standard. She was also an
environmental health and safety, and one Ms. associate industrial hygienist for the Depart-
Harrington specializes in. She develops and ment of Health Services, Cai-OSHA, and for
conducts programs in occupational health the State Compensation Insurance Fund.
awareness, use and selection of personal pro-
tective equipment, and the handling of hazard- Ms. Harrington holds a Bachelor of Science
ous materials. She assists clients in meeting degree in Nursing from San Diego State Uni-
OSHA and EPA regulations in order to pre- versity and a Master of Public Health (MPH)
vent future liability, degree in Industrial Hygiene from the Univer-
sity of California at Berkeley. She is a Certi-
Before she joined The FPE Grou p, fiedlndustrial Hygienist. Ms. Harrington is a
Ms. Harrington was the industrial hygiene member of the American Industrial Hygiene
manager for Med-Tox Associates and was re- Association and the American Academy of
sponsible for the administration of the Indus- Industrial Hygienists.
SAN JOAOUlN
COMMUNITY HOSPITAL
.April 5, 1990
Ralph Huey
Hazardous Material Coordinator
Bakersfield Fire Department
2130 "G" Street
Bakersfield, CA 93301
Dear Mr. Huey,
! have reviewed with our consultant the requirements for
facilities which have to submit an RMPP and have come to the
conclusion that we are not subject to this law.
In appendix C on page C-1 the following is stated:
"California's Acutely Hazardous Materials (AHM) are identical to
the Federal Extremely Hazardous -Substances (EHS). The Federal
Government will annually review the federal list of EHS and make
appropriate changes. On January 1, 1990 the thresholds for
submitting an RMPP Registration Form will change from 1) any
facility handling AFM in a quantity equal to or greater than the
minimum thresholds of 500 pounds, 55 gallons, or 200 cubic feet
of gas, calculated at Standard Temperature and Pressure (STP),
may have to develop an RMPP for the facility, to 2) any facility
which handles SHM in quantities equal to or greater than the
Federal Threshold Planning Quantities for Extremely Hazardous
Substances shall submit an RMPP Registration Form."
According to the table on page I-3, the Federal Threshold
Planning Quantity for Ethylene Oxide is 1,000.
The hospital is currently storing no more than 4 tanks in the
building at any one time. Each tank contains 141 pounds of
sterilant in the following ratio:
Freon 12 88% = 124.08 pounds
EtO 12% = 16.92 pounds-
A Member of Adventist Health System/%Vest
2615 Eye §u'eet
Post Office Box 2615
Bakersfield, California 93303-2615
805/395-3000
SAN JOAOUlN
COMMUNITY HOSPITAL
April 5, 1990
Page 2
This means that at any one time, we have no more than 67.68
pounds in the building. Since EtO weighs 86 pounds per cubic
foot, this represents .1976 cubic feet per tank. This would give
us a total of .7904 cubic feet of gas in the building at any
time. For your infomation, we currently are using! about 1 tank
every three weeks. ,
Please contact me should you disagree with these findings.
Sincerely,
W. Evert
Administrative Director,
Facilities
A Member of Adventist Health System/West
2615 Eye Street
Post Office Box 2615
Bakersfield, California 93303-2615
805/395-3000
March 22~ 1990
TO: M.R. Kelly, Deputy Fire Chief
FROM: Ralph E. Huey, Hazardous Materials Coordinator
SUBJECT: RMPP due for San Joaquin ~ospital
Per our conversation (eh Route to Visa. lia) on Monday
March 19, 1990, with regard to San Joaquin Hospital, I have
reviewed their files and verified that a Risk Management and
Prevention Program (RMPP) is due on May 25, 1990. Bill Martin
wss notified on May 25, 1989 that their operation may present an
acutely hazardous materials accident risk with regard to their
handling of Ethylene Oxide, and therefore pursuant to section
25534 of the Health and Safety Code they will be required to
submit a RMPP. They were also informed that they had 12 months
from the time of the request to complete and implement the plan,
which make May 25, 1990 the due date.
In a subsequent meeting with Bill Martin and Linda Breadmont
held in September we reviewed the requirements of the RMPP and
the requirements for a "qualified" person to certify the RMPP is
complete. In this meeting I advised that whoever was to complete
their RMPP should first complete a Hazard and Operability Study
and Off Site Consequence analysis then review those results with
our office before completing the RMPP. We have not heard from
them since that time.
cc: D. Needham
FIRE DEPARTMENT 2101 H STREET
D. S. NEEDHAM BAKERSFIELD, 93301
FIRE CHIEF May Z~, 1 ~8~] 326-3911
Bill Martin, Director o{ Security
San Joaquin Hospital
Z61S Eye S~reet
Bakersfield, Ca. 93301
Oear Mr. Martin:
Your business San Joaquin Hospital, located at ZG1S Eye '.:'..
S%reet, ham been identi¢ied as a handler o¢ Acutely ,Hazardous
Materials. It ham been determined that your o~eration -'eay
present an acutely hazardous material~ accident risk and
there¢ore pursuan~ to section Z553~ o¢ the Health and Sarety Code '?'~::::'::i':'"'
you ~il! be r~uired ~o sub~i~ a R~sk Management and Prevention =============================
For Ethytene Oxide:
The RMPP shall include the {ollo~ir~j elements;
~ DES6RIPTION OF EA6H ACCIDENT INVOLVIN6 ACUTELY H~Z~RDOUS : -. : ....-!..--
MATERIALS WHICH HAS OCCURRED AT THE BUSINESS OY FACILITY :'":':"..'
WITHIN THREE YEARS FROM THE DATE OF THE REQUEST' MADE . ,
PURSUANT TO SUBDIVISION (A), TOGETHER WITH A DESCRIPTION OF
THE UNDERLYING CAUSES OF THE ACCIDENT AND THE MEASURES
TAKEN, IF ANY, TO AVOID A RECURRENCE OF A SIMILAR ACCIDENT.
A REPORT SPECIFYING THE NATURE, AGE, AND CONDITION OF THE ' '
EQUIPMENT USED TO HANDLE ACUTELY HAZARDOUS MATERIALS AT THE -
BUSINESS OF FACILITY AND ANY SCHEDULES FOR TESTIN6 AND
MAINTENANCE.
DESIGN, OPERATING, ANO MAINTENANCE CONTROLS WHICH MINIMIZE
THE RISK OF AN ACCIDENT INVOLVING ACUTELY HAZAROOUS
MATERIALS.
DETECTION, MONITORING, OR AUTOMATIC CONTROL SYSTEMS TO
MINIMIZE POTENTIAL ACUTELY HAZAROOUS MATERIALS ACCIDENT
RISKS.
A SCHEDULE FOR IMPLEMENTIN6 MDOITIONAL STEPS TO BE TAKEN BY
THE BUSINESS, IN RESPONSE TO THE FINOINGS OF THE ASSESSMENT
PERFORMED PURSUANT TO SUBOIVISION (O), TO REDUCE THE RISK OF
AN ACCIDENT INVOLVING ACUTELY HAZARDOUS MATERIALS. THESE
ACTIONS MAY INCLUDE ANY OF THE FOLLOWING:
Risk Managemen't and Prevention Program
INSTALLATION OF ALARM, DETECTION, MONITORING, OR
AUTOMATI{] CONTROL OEVICES.
EQUIPMENT MODIFICATIONS, REPAIRS, OR AODITIONS.
CHANGES IN THE OPERATIONS, PROCEDURES, MAINTENANCE
SCHEDULES, OR FACILITY DESIGN.
AUDITING AND INSPECTION PROGRAMS DESIGNED TO ALLOW THE
HANDLER TO CONFIRM THAT THE RISK MANAGEMENT AND PREVENTION
PROGRAM IS EFFECTIVELY CARRIED OUT.
RECOROKEEPIN6 PROCEDURES FOR THE RISK MANAGEMENT AND
PREVENTION PROGRAM.
THE RMPP SHALL BE BASED UPON AN ASSESSMENT OF THE PROCESSES,
OPERATIONS, AND PROCEDURES OF THE BUSINESS, AND SHALL
CONSIDER ALL OF THE FOLLOWING:
~THE RESULTS OF A HAZARO ANO OPERABILITY STUDY WHICH
IDENTIFIES THE HAZARDS ASSOCIATED WITH THE HANDLING OF AN
-~ACUTELY HAZARDOUS M~TERIAL DUE TO OPERATING ERROR, EQUIPMENT
FAILURE, AND EXTERNAL EVENTS, WHICH MAY PRESENT AN ACUTELY
CHAZARDOUS MATERIALS ACCIDENT RISK.
FOR THE HAZARDS IDENTIFIED IN THE HAZARD AND OPERABILITY
STUOIES, AN OFFSITE CONSEQUENCE ANALYSIS WHICH, FOR THE MOST
LIKELY HAZARDS, ASSUMES PESSIMISTIC AIR DISPERSION AND OTHER
ADVERSE ENVIRONMENTAL CONDITIONS.
THE RISK MANAGEMENT AND PREVENTION PROGRAM SHALL IDENTIFY, BY
TITLE, ALL PERSONNEL AT THE BUSINESS WHO ARE RESPONSIBLE FOR
CARRYING OUT THE SPECIFIC ELEMENTS OF THE RMPP, AND THEIR
RESPECTIVE RESPONSIBILITIES, AND THE RMPP SHALL INCLUDE fl
DETAILED TRAINING PROGRAM TO ENSURE THAT THOSE PERSONS ARE ABLE
TO IMPLEMENT THE RMPP.
THE HANDLER SHALL REVIEW THE RISK MANAGEMENT AND PREVENTION
PROGRAM, AND SHALL MAKE NECESSARY REVISIONS TO THE RMPP AT LEAST
EVERY THREE YEARS~ BUT, IN ANY EVENT, WITHIN 80 DAYS FOLLOWING A
MODIFICATION WHICH WOULD MATERIALLY AFFECT THE HANDLING OF AN
ACUTELY HAZARDOUS MATERIAL.
THE RISK MANAGEMENT AND PREVENTION PROGRAM, ANO ANY REVISION
REQUIRED BY SUBDIVISION (H), SHALL BE CERTIFIED AS COMPLETE BY A
QUALIFIED PERSON AND THE FACILITY OPERATOR.
Ri~k Manage~en~ and Preven$ion Pregra~
The Health and Sa{ety Code provides that ail existing
businesses required 'to submit an RMPP have 1Z months fro~ the
~iMe o{ ~he reques~ to co.plebe and i~ple~ent the plan. This
plan should there{ore be sub~i~ted to ~his office ~ithin one year
{ro~ this da~e.
If I can be o{ any assistance please don't hesitate ~o call.
I can be reached, a~
Sincerely Yours,
Ralph E. Huey
Hazardous Materials Coordinator
REH:vp
RMPP.DOC
ACUTELY HAZARDOUS MATERIALS REGi I RATION FORM
THIS FORM MUST BE COMPLETED BY THE OWNER OR OPERATOR OF EACH BUSINESS IN
CALIFORNIA WHICH AT ANY TIME HANDLES ANY ACUTELY HAZARDOUS MATERIAL IN
QUANTITIES GREATER THAN 500 POUNDS, 55 GALLONS OR 200 CUBIC FEET OF GAS AT
STp. 1 THIS FORM SHALL BE COMPLETED AND SUBMITTED TO YOUR LOCAL
ADMINISTERING AGENCY. ({}25533 &: 25536 Health &: Safety Code)
Ngte instructions on r~ver~e
Business Name SAN JOAOUI~'J CO~_~[UNITY HOSPITAL
Business Site Address ?.6'l 5 EYE STREET; BAKERSFIELD CALIFORNIA
Business Mailing Address (if different)
Business Phone ~805'1 395-3000 Business Plan Submission Date2 JUL 10, 1987
Process Designation3 STERILIZER
ACUTELY HAZARDOUS MATERIALS HANDLED4 .USE ADDITIONAL PAGES IF NECESSARY-
CHEMICAL NAME QUANTITY
ETHYLENE OXIDE, EPOXYETHANE, OXIRANE .5 TANI4.q ~0 CF.
qJENERAL DESCRIPTION OF PROI;E$~E$ AND PRINCIPAL EQI,IIPMENTS:
R"PTqYT,V..NV. (q'ZTI'IV, .q'T'V,T~TT,T~7, F,R TS T,OADRI)w'rTT~ GOODS TO BE
PROCESSED, DOOR IS CLOSED, [~!ACHINE STARTED WITH A PUSH OF
A BUTTON. THE LOAD SITS IN CONDITION FOR APPROX. 1 ER.,
AT T~TT.q T/MR, TI4E STERILANT IS RELEA.~;;ED INTO THE CHAM..BER
THE STERILANT ( ETHYLENE OXIDE ) STAYS IN THE CHA~-[BER FOR
A]:)~)RC3'Z_ ] ~_: A'Pq~v.R q~T~ ] l~. THE S¥STE~![ WILL EXHAUST.
SIG NATUR ~E~~..~,l .~~~~ TITLE c..R_ ]~ A]x-~ A C~ER
PRINTED NAME ,/--//u/42//' ~.,~.K'~z_/2/~//./~'- DATE opm. ] 7, '19RR
California Office of Emergency Sell/ices FORM HM 3777 (1-1So88)
INSTRUCTIONS:
Superscripts:
1. Quantities for RMPP compliance are "equal to or greater than" the minimum criteria and apply to chemicals handled
"at any one time".
2. Businesses handling reportable quantifies of Acutely Ha:mrdous Materials that have not submitted a business plan
MUST contact local Administering Agencies. The business plan submissio, n date will assure the Administering
Agency that a business plan has been submitted and is on f'fle. This will also immediately identify businesses that
have not submitted business plans.
3. 'Process Designation" is provided as a reporting option (with the approval of the Administering Agency) for
facilities that can most easily report by process. Thus, facility RMPP registration data could be submitted in a
similar format to a business plan that is divided by process. "~y process" data can initiate an. em_ergency
r~ponse to a process incident rather than a general emergency response to a major facility. Process designation
can simplify inspections for major facilities and improve future emergency response.
4. Refer to the EPA list of Exlremely Hazardous Substances from the Federal Register (Volume 52, No. 77, p. 13397
et. sea_., April 22, 1987). Each chemical has a threshold planning quantity. This list may be changed by EPA on
an annual basis. Updates of this list may be available early in 1988. To comply with this element, you may attach
a copy of the inventory submitted to your Administering Agency from your business plan and highlight all Acutely
Hazardous Materiah. It is recommended that facilities list all extremely l~?~rdous chemicals handled in quantities
equal to or in excess of 1) 500 pounds, and 2) any EPA threshold planning quantity less than $00 pounds.
5. Do not include Trade Secret information in these descriptions.
General:
For emexgency response purposes, it would be desirable to describe the following to the Administering Agency:
1. Batch Process:
a. What raw materials?
b. What operating presau~ range?
c. What operating tem~ range?
d. Batch capacity rating?
e. Product characteristics? (e.g., chemical state, flammability, toxicity, etc.)
f. Critical process points and characmrisfics?
-~-2~Continuous process: (si .milar information as above.)
NOTE: - ' ..............
"Pursuant to §25534, the Administering Agency may require thc submission of a Risk Management Prevention Program
(RMi:'P), if thc Administering Agency determines that the handler's operation may present an acutely hn-ardous materials
accident risk. The handler shall prepare thc RMPP in accordance with sulxlivision (c) [of §25534]. The RMPP shall be
pmpamA within 12 months following the reqaest made by the Adminismring Agency pursuant to this section."
(§ 25534 (a) Health and Safety Code)
An amendment to thc RMPP must be submitted to the Administering Agency within 30 days of: 1. Any additional handling of acutely b~,Tnrdous materials.
2. Any material or substantial alterations to business activities.
3. Change of address, business ownership, or business name. (§ 25533 (c) Health & Safety Code)
· EVERY BUSINESS REQUIRED TO SUBMIT AN RMPP SHALL IMPLEMENT THE APPROVED RMPP
California Office of Emergency Services FORM HM 3777 (1-15-88)
FIRE DEPARTMENT 2101 H STREET
D. S. NEEDHAM BAKERSFILED, 93301
FIRE CHIEF 326-3911
OCTOBER 13, 1988
SAN '~OAQUIN COMMUNITY HOSPITAL
2615 EYE ST.
BAKERSFIELD, CA 93301
DEAR MR. BILL MARTIN: ..
THE ENCLOSED "ACUTELY HAZARDOUS MATERIALS REGISTRATION FORM" "
MUST BE COMPLETED BY ANY BUSINESS, HANDLING ABOVE THE MINIMUM ....
REPORTING QUANTITY OF ANY MATERIAL ON THE EPA LIST OF ..... -'~':'.
EXTREMELY HAZARDOUS SUBSTANCES. (FED. REGISTER VOL. 52, NO... ....
77, P. 13397). YOUR COMPANY HAS REPORTED HANDLING THE ...... .'~
FOLLOWING ACUTELY HAZARDOUS MATERIALS: ':
ETHYLENE OXIDE
PLEASE RETURN THE COMPLETED ACUTELY HAZARDOUS MATERI~LS '"'? '"'?'.':
REGISTRATION FORM TO:
HAZARDOUS MATERIALS DIVISION
2130 G STREET :
BAKERSFIELD, CA 93301
IF YOU HAVE ANY QUESTIONS REGARDING THIS FORM PLEASE CALL
RALPH HUEY AT 326-3979.
SINCERELY YOURS,
RALPH E. HUEY
HAZARDOUS MATERIALS COORDINATOR
REH/ed
ENCLOSURE
STATE OF CALIFORNIA--CALIFORNIA PROTECTION AGENCY PETE WILSON, Governor
~DEPARTMENT OF TOXIC SUBSTANCES CONTROL
~.~ P.O. sox
SACRAMENTO. CA 95812-0806
(916) 323-5871
April 6, 1995
EPA ID: CAD074328048
SAN JOAQUIN COMMUNITY HOSPITAL For facility located at:
BRIAN GEORGE
2615 EYE ST 2615 EYE ST
BAKERSFIELD, CA 93303-2615 BAKERSFIELD, CA 93303-2615
Authorization Date: April 6, 1995
Dear Conditionally Authorized and/or Conditionally Exempt Facility:
ACKNOWLEDGEMENT OF UNITS OPERATING UNDER CONDITIONAL AUTHORIZATION AND/OR
CONDITIONAL EXEMPTION
The Department of Toxic Substances Control (DTSC) has received your facility specific notification (form
DTSC 1772) and forms for Conditional Authorization and/or Conditional Exemption for Specified Wastestreams (form
DTSC 1772B and/or 1772C). Your notifications are administratively complete, but have not been reviewed for technical
adequacy. A technical review of your notifications will be conducted when an inspection is performed. At any time,
you may be inspected and will be subject to penalty if violations of laws or regulations are found.
The Department acknowledges receipt of your completed notification for the treatment unit(s) listed on the last
page of this letter. These units operating under Conditional Authorization or Conditional Exemption are authorized by
California law without additional Department action, pursuant to Health and Safety Code sections 25200.3 and 25201.5.
Your authorization to operate continues until you notify DTSC that you have stopped treating waste and have fully closed
the unit(s). You will be charged annual fees calculated on a calendar year basis for each year you operate and have not
notified DTSC that the units have been closed.
You must notify the DTSC 60 days before first treating hazardous wastes in any new unit. You must also
notify the DTSC whenever any of the information you provided in these notifications changes. To revise information,
mail a cover letter to the above address explaining the changes, attach only the pages of your notification package that
have changed, and re-sign and date at the signature space on page 3 of form 1772.
Your status to operate under Conditional Authorization and/or Conditional Exemption is contingent upon the
accuracy of information submitted by you in the notifications mentioned above, and your compliance with all applicable
requirements in the Health and Safety Code. Any misrepresentation or any failure to fully disclose all relevant facts
shall render your authorization to operate null and void.
You are also required to properly close any treatment unit. Additional guidance on closure will be issued and
distributed to all authorized onsite facilities later this .year.
Page 2 EPA ID: CAD074328048
If you have any questions regarding this letter, or have questions on operating requirements for your facility,
please contact the nearest DTSC regional office, or this office at the letterhead address or phone number.
Sincerely,
Michael S. Homer, Chief
Onsite Hazardous Waste Treatment Unit
Permit Streamlining Branch
Hazardous Waste Management Program
Enclosure
cc: ASTRID JOHNSON
DTSC REGION 1
STATE REGULATORY PROGRAM
1515 TOLLHOUSE
CLOVIS, CA 9361!
STEVE MCCALLEY
KERN COUNTY
ENVIRON. HEALTH SERVICES DEPT
2700 M STREET, SUITE 300
BAKERSFIELD, CA 93301
Page 3 EPA ID: CAD074328048
ENCLOSURE 1
Units authorized to operate at this location:
UNDER CONDITIONAL AUTHORIZATION:
UNDER CONDITIONAL EXEMPI'ION:
1
COMMUNITY HOSPITAL . .
February 16, 1995
Department of Toxic Substance Control
Program Data Management Section
400 P Street, 4th Floor, Room 4453
P.O. Box 806
Sacramento, CA 95812-0806
Dear DTSC:
Mr. David L. Shumate of your Fresno office conducted an inspection of our facility on
January 25, 1995. A copy of the "Checklist and Initial Verification Inspection Report" is
attached for reference only.
In response our department has now in place a source reduction checklist with our
compliance manual. The department is currently operating radiographic processors at
what it believes to be achieving maximum waste minimization at the most economically
practicable method. The department is watching the developing technology market
and where feasible will responded with equipment purchases that will further reduce
our waste.
In our renovation of our Cardiac Cath Lab Department we failed to report to your office
in a timely fashion the close out of Unit #2. As of July 1994, the reclaimer unit was
removed and returned to the owner, Sigma Medical Imaging of Fresno. The spent fixer
is now collected in approved containers and batch processed at Unit #1 with the Siltech
recycler unit. A completed amendment form, 1772, with the corrections made is
enclosed for your records.
In addition, changes to our department will occur on or about April 1, 1995, as Unit #1
is relocated in the department just down the hall about 40' from its current location.
Enclosed is two plot maps for your records.
The explanation is as follows. The Diagnostic Imaging Services Department is
undergoing major renovation. A new location for the main darkroom will occur. The
current treatment plan, i.e., Siltech recycler, batch processing, super canisters, etc. will
remain in effect as our records indicate. Only the location will change. Plot map "B"
provides the current and new locations.
A Member of Adventist Health SystemNVest
2615 Eye Street
Post Office Box 2615
Bakersfield, California 93303-2615
805/395-3000
Next a very small back-up darkroom is being made in the old radiology office. All spent
fixer is to be collected in an approved container and batch processed at Unit #1. Plot
map "A" is provided to identify the location of this darkroom.
In review there will be only one treatment site at this facility, Unit #1, and four
containers. Those containers are located at the Cardiac Cath Lab, surgical processor,
small darkroom processor, and of course at Unit #1.
Should you have any further questions, please feel free to contact me at (805)326-4115
for my assistance.
Thank you for your assistance and time.
Sincerely,
Brian K. George
Supervisor, DIS
pc: David L. Shumate, DTSC
,K~~-n ~County-Environmental"Health:S~r~ices
Billy Martin, SJCH, Safety Department
sT~UFORNIA-ENVIRONMENTAL. PROTECTION AGENCY PETE WILSON, Governor
DI~*ART~ii~T OF TOXIC
C~C~T ~ ~~ ~~CATION ~S~iON ~PORT ~OR
P~t by ~ule, Con~Uon~ly Autbo~ed~ ~d Condition~ly Exempt Notifiers
FACILITY N~: ~ ~~: ~o~. .... :/~ ~/~/./ EPA ID NU~ER: c~ oTy~
FACILITY CO~A~-N~E: ~, ~e~.~ PHONE: ~) ~g-
SIC CODE(S): ~v ~SPEC~ON DA~: ~. ~ /77~ ~al ~
NOTIFIED ~ff COUNT: PBR. CA. C~W ~ C~QT. TOT~ ,.~ ~
CO~ U~T COUNT: PBR CA . C~W ]... C~QT ....... TOT~ ~ /
~ ~ and i~on re~ id~tify violation'of ~tg law r~arding o~ite trote~ of ~do~ w~e,
ope~tlng ~d~ ~n omite pe~iRing ti~. ~ im~ion v~fl~ the info~ation provided on fora DTSC 1772. It
~ve~ gen~tor r~en~, although a separate eh~ may be reed for those requir~. A ch~ark indi~t~
vlolatlou of th~ ~w, w~ ar~ ~plalned ~ mor~ d~[I on the a~ehed note shee~. ~e governing laws are the ~lth and
Safety Code ~ ~d Title 22 of the California C~e ot Rgulatio~ (22 CCR).
G~erat~r St~d~:
~ ~p~ agen~ ~ ~e ~eir o~ g~r~or ~pe~on ~e~t or prot~oh, w~ are s~z~ below. ~ ~11
~luation ~ ~ ~ ~ d~ O ~.c~ua~ ~ng the Ve~fi~ion l~pection, units se~o~ d~cienci~ are s~pect~.
~ ~1~08 ~n~g~y p~ ~.~n p~ (ad~lY m~ ~lea~, ~s ~co~u~caHon
' ~---~ A8~.~ · ~J~g~g~Y ~ipm~t.~ pho~ humors for emerge~y coo~to~).
~ '~ ~'-' "'~"~~, d~~ ~d.r~r~ pr~p~ for employe~ ~di~g h~ous waste.
--. ". =~: cpn~.~ ~t s~ds (stooge t~e l~u. closed, la~ll~, compat~bfl~.
~.= .-. ? ~?; }~~;w~y,~ ~ .g~ ~3tlon, w~ t~bl~acuv~ 50 fcct from pro~ I~).
~ :~'.. :'~?~sc'~e I~a~H~,~ compatibili~, ~ted daily, in g~ conaition, wire
?~:' '~ ~"S:~:~; ~.~~ ~e pro.il identified.
~~:It~F~ty Wide: ~d~i~ ~ s~b~ ~ r~ Fom ~ ~o co~ ~.on or o~ssio~.)
6.0K All units under PBR, CA, and CE arc properly ~dicatcd on Fo~ DTSC 1772. (Add any now
u~u with u~t sheets or co~cct tier on ~c unit sheet.)
_ 7.0~ All tcncrator identification i~o~ation on Fo~ DTSC 1772 is cogcct.
_ 8.0~ The submitted plot plan/map adequately shows ~e location of all re~lated units.
.. 9.6L ~ere are records d~umenting complianca wi~ sewer agency pretreatment ~dards and
industrial waste discharge requirements, where applicable.
~ 10. Generator has prepared/maintained source reduction documents requirements (SB 14/SB
~ 1726). For many wastes, a chec~ist or plan is required o~y if a~ual h~ardous waste volume
is over 5,~ kilograms (approx l l,~ pounds or 1,350 gallons). HSC 252~. 15, 252~. 19-.21
For CA or PBR notifiers:
11. Thc generator has an a~ual ~vaste minimization certification, iPBR submit ~¥ifi~
Omite ChecUist (A) Page 1 '6f / August 2, 1994
.......... ,.-,.,.,.,. ,.o~,~.cnu I '=~, I lut~ AUIrNCY PETE ~LSON, Oover~
~¢~.~ ~ .* ~ . ~.,, ..
"ARTMENT OF TOXI~ s~.~S~NbES coNTRoL ~ *-*:"~ ''~
C~CKL~ ~ ~~ ~~CAT[OH ~SP~CT;OH ~PORT
Pe~t by Rule, Co~ditio,~ly Authored, ~d Condition~ly ~xempt Notifiers
Complete one unit sheet, for each unit either listed in the notification or identified during the inspection.
Unit Numl~er: / Unit Name: /7~ ~ ~
Notified Tier: E,q3to Correct Tier: C ~ ~
Notified Device Couni: Tanks -~ Containers / ~
Correct Device Count: Tanks ~-C--_' Containers _~
For each Unit:
NO
12.0't, All hazardOus wastes treated arc, generated onsite.
~ 13. The unit notification ia accurate a~ lo the number of tank(s) and/or container(s).
147 The estimated notification monthly treatment volume is appropriate for the indicated tier.
· ' 15. ~The waste identification/evaluation ia appropriate for the tier indicated.
', 16. [The Wa.q:~~(S). given on th~ n°tification form are appropriate for thc tier.
17.~:The treal~il~'iii~., ess(e~)'given on the notification form are appropriate for the tier.
_ -. 18J~ The ~ddi__i_~!~" ,ah~e~,gn,'~ti,'-i~f~* O~a.'fion on the~form is co.ect and documented for thc unit.
~- 19~" The~ iridi~t~aSl~r nM~'~e~'l[edexal permit on. the notification form is correct.
~, .... 20.t~ Ther~ are ~en. ~p,,~.:atinK~,ctlgns and a record of the dates, volume, s, restdual
..... -21 ~ Th;rlii~ts~rla~~6ii*~uie (containers-weekly and la~-daUy).
~ ;. ~. 22 ~1~. The. re~ a-tnrH~en liisp~tl~n log maintained of the mspecttons conducted. '
23.'~ If th~ ~nirl~s ;~ closed~ ihe generator has notified DTSC and the local agency of the
cioSUi-e.:' '
For each'CA or PBR unit:
24.~,q' The generator has secondary containment for 'treatment in containers.
For each PBR unit:
25. There is a waste analysis plan
26.//"~There are waste analysis records.
27. There is a Closure plan for the unit.
Ullit Comments/Observations: (If this i~ a unit that was not included on the notij~cadon fo/Tn, the violation is operating
CiI~~T AB ~ITIAI, V~IFICATION ~SPE~'ION R~RT FOR "
~l by Ru~,-Cou~lio~Hy Aulhm~d, and Cou~tlo~fly ~~ Nol~e~
Cotnpl~tt o~ ~t ~t ~r t~h ~dt rider i~t~ in t~ not~c~ion br ~t~ during t/~ h~p~ctlon,
NoiSed ~v~ Count: Ta~ -- Coulalu~. /
Cor~t ~vi~ Couut~ Ta~ . _ Conta~c~ _
For aU Uulis:
12. All lazardous wastes Ireata, I ax~ leuerated o~qite.
' 13. The unit notificaiio, information is accurate as to the number of lauk(:i) ur cuntala~:r(s).
" 14. Thc ~limaltd notification mOuihly Irealmeut volume is appropriate for thc indicated tier.
: - 15. Thc waste identification/evaluation is appmprial~ for thc tier indicatr, d.
16. Thc wa.~aeatrr, am(s) given on thc notification form are appropriate for thc lief.
17. Th~: Ireattueut procea.~(ea) ltiv~ on thc notification form arc apprupriat~ foe the tier.
-- 18. TI~: realduala mauallcmeut information on thc form is corre, ct ~md documcutr, d for thc unit.
' ' .19. Th~ iudicalt, d baala for ual ueedlug n federal permit oil th~: notification form ia corral.
i 20. -" 'rhcr¢ are wrfi'leu operalhql iu~lruclioas aud & r~curd of thc dart. s, volume, a, tcaidual
'"' .. maaa$¢me, t, and' lYp~ of wastes trr. ate, d in the unil.-'
. . :.:~.. 2 I::' There i~ a Wrllle6' libl~e, ctlua ~:hedule (containcr~'-w~kly and tan_ks-daily),.
._.._..~ . 22 Tl~¢r¢ I~ a wr[Ueu iimpectluu Io~ of thc inspections c~uductr, d.
,.". 23.' if thc unit has beb..n~dl~acd, ~11¢ i~e. ncratur baa uulified DTSC a,d rite local allency of the
closure. '
For ea~.h 'CA or PBR uuil~
24.//,q Thc generator has st. coudary coatalmueut for Irealmeut
For e. acl~ PBR uuil:
25..,, 'l'hct'¢ is a w~te auulysi, s plau and wa~t~ analysis recor~.
26.~ ~'hcre is a cl~m~ platt for Ih~ unit.
fl,~ilc Chcckli~l lB) Page 2 of ~,_ February 10, 1994
Onsite Recycling: Only answer.if thi~ facility recycle~ .more than I00 kilograms/month of hazardou~ waste on,itc.
NO
28. The appropriate local agency has been notified. HSC 25143.10
29. ~'g Activities claimed under the onsite recycling exemption are appropriate. HSC 25143.2 et sec.
Releases: If there ha~ been 'a retease, provide the following information: number of retease~, date(s), type(s) and quantity of
material~/waste, and the cause(s). Use unit sheet or attach additionat pag~.
........ 30. Within the last three years, were there any unauthorized or accidental releases to the
environment of hazardous waste or hazardous waste constituents from onsite treatment units?
31. Within the last three years, were there any unauthorized or accidental releases
to the environment of hazardous waste or hazardous waste constituents from any location at
this facility?
For purposes of a Tiered Permitting inspection, an unauthorized and/or accidental
release to the environment does not include spills contained within containment systems.
This report may identify conditions observed this date that are alleged to be violations of one or
more sections at the California Health and Safety Code (HSC) or the California Code of Regulations,
Title 22 (22 CCR) relating to the management, of hazardous waste.' The violations may be described in
more detail on the attached note sheets. If any violations are noted, the facility ii required to the submit
a signed Certification of Return to Compliance within 60 days, unless otherwise specified. (A
certification form is provided.) If any corrections are needed to the initial notification, the facility will
submit a revised notification within 30 days to the Department of Toxic Substances Control with a copy
to the local enforcement agency.
Inspector(s):
Lead Inspector: '_~" a~ Other Inspector:
Signature: _~-~.,~.£ ~ 7,.--.--~,', Signature:
Phone Number: o2r ?) ~ ~ 7-_e75'c. Phone Number:
Facility Representative:
Your signature acknosHedges receipt of this report and does not imply agreement with the findings.
Onsite Checklist (C) Page / of / August 2, 1994
.,;ALIFORNIA-ENVIRONMENTAL PROTECTION AGENCY PETE WILSON, Govmnor
uEPARTMENT OF.TOXIC SUB~NCES CONTROL
CHECKLIST AND INITIAL VERIFICATION INSPECTION REPORT FOR
Permit by Rule, Conditionally Authorized, and Conditionally Exempt Notifiers
NOTE S~ET
This sheet includes inspector observation& and e. xpand~ upon the violations identified on the checklist (by number). In some
ca~es, it indicates how the facility should correct the violation&. It also includes the names of any others participating in this Inspection.
Il ! · --
: ot Au~st'2, 19~
O~it~ Ch6c~list (~) Page ~ /
~S.T~:rE ~,, CALIFORNIA-ENVIRONMENTAL PROTECTION AGENCY PETE WILSON, Governor
TOXIC
DEPARTMENT OF CONTROL
TIERED PERMrFrING ~
CERTIFICATION OF RETURN TO COMPLIANCE
For Permit by Rule, Conditionally Authorized, and Conditionally Exempt Notifiers
In the matter of the Violation cited on ·. O///zo"'/~,.<''
As Identified in the Inspection Report dated V/_/z,.~//~''
Conducted by' ,.~aw,'d' ~/. oc,~uma,'l~-., ~) /-,5 d.., (agency(s))
I certify under penalty of law that:
1. Respondent has corrected the violations specified in the notice of violation
cited above.
2. I have personally examined any documentation attached to the certification to
establish that the violations have been corrected.
3. Based on my examination of the attached documentation and inquiry of the
individuals who prepared or obtained it, I believe that the information is tree,
accurate, and complete.
4. I am authorized to file this certification on behalf of the Respondent.
5. I am aware that there are significant penalties for submitting false information,
including the possibility of t-me and imprisonment for knowing violations.
Name (Print or Type) Title
gign~ture .// c~ Date Signed
Company Name r EPA ID. Number
DTSC-RETCOMP,CRT (8/94)
ONSITE-HAZARDOUS WASTE TREATMENT NOTIFICATION FORM
FACILITY SPECIFIC NOTIFICATION -
For Use by F~-~,dou.s Wa.~ Generators Performl-s Treatmen~ n In/tial
Under Conditiot~l Exemption and Conditiot~l Authorization, ri Reacw~
and by Permit By Rule Facilities
Pleare refer to the attached bL~trttctiotl~ before completing ~ form. You may notify for more than on~ permitting tier by a~ing thlt
notification form. DTSC 1772. You mart attach a separate unit ~t~cific notification forrn for each unit at thit tocmion. ~;tere are
di~erent unit specij~¢ notiflcat(on formr for each of the four categorie~ and an additional notification form for tran~rMble trextzment
unitx ~7j'$}. Yott only haw'to labrnit for#lx for th~ tier(s) that cover your ttnit($). Dixcard or recycl~ tl~ other tmared forn~.
Number each page of your completed not,cation tn~kage and indicate the total number of page$ at the top of each page at the
'Page ~ of ~: Put your EPA ID Number on each page. Ple~e provide all of the information requested; all fieldr mu~t be
completed except thate that' state 'if different' or 'if available'. Please type the information provided on thi~ form and any
attachrnentx.
~ notij~cationfee$ are tar.~e.r$ed on the bari~ of the number oftier$ the notifier will operate under, and will be colleaed by the State
Board of Equalization. DO tOT StaND
NOTIFICATION CATEGOILIES
Indicate the number of unizr you operate in each tier. ]7~ix will alzo be the number of unit specific notij~cation formr you mu~t attach.
Number of units and attache4 unit specific notificatio,z for each tier reported.
A. Conditionally Exempt-Small Quantity Treatment D. Permit by Rule
B. / Conditionally Exempt-Specified Wasteztream E. Commercial Laundry
C. Conditionally Auehotized F. Variance (Section 25143)
rt. Gsa, r .roe mv rnncAxmN
EPA m NUMBER CA~. fl( '7 ..~'--g 2- ..~ ,~ ..~._~ BOE NUMBER (if available) H__HQ_
(DSA-Do~8 l~i~s~ A~)
CONTACT PERSON '~r {ti z'~ ~:) ~r~.~. PHONE NUMBER(~D~'") ..~2A, ,, ,-
MAILING ADDRESS, IF DIFFERENt.:
COMPANY NAME For OTSC U~ O~y'
CITY ~ ZIP -
COUNTRY
CONTACT PERSON · PHONE NUMBER( )_..~'
(Fire Nar~) ~ Nan.)
DT$C 177~ (1/9~) pig6 1
has operational control and performs deci~ion-maidngfunctionr that govern operation of the fadllty (per ~'~tlt 22, Caltfo~nia
Code of Regulatioar (CCR) Section 66270.11}. All three copie~ mm't have odginal ~ignmure~ .
Waste Minlmizati0~ I certify that [ have a program in place to reduce the volume, ~uantity, and toxicity of wa~ g~n~erated to the
degree ! have determined to be economically practicable and that I have s~lected the practicable method of treatment, storage, or
disposal currently available to me which minimizes the pre.~nt and future threat to human health and the environment.
Tiered P~rm|ttin~ Certiflgati0n I certify that the unit or units d~cribed in the.~ documenC~ meet the eligibility and operating
requirements of state statutes and regulations for the indicated permitting tier, including generator and __~condary containment
requirements. I understand that i.f any of the units operate under Permit by Rule or Conditional Authorizalion, I will. also be required
to provide r~quired Rnattcial assurance for closu~ of the tr~xnent unit by January 1, 1993.
I certify under penalty of law that this document and all attachments were prepat~ under my direction or ~ision ia ~_ccordance
with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry
of the person or persoas who manage the system, or thos~ directly r~ponsible for gathering the information, the information is, to
the beat of my knowledge and b~lief, true, accurate, and complete.
I am aware that there a~ substantial l:nmalties for submitting fal~ information, including the 'possibility of fines and imprisoma~
for knowing violations.
D~te Signed
OPERATING REQUIREMENTS:
Pleare note that generator~ treating hazardous warte otuite are required to comply with a number of operating requirement~ which
differ depending on the tier(s). These operating requirements are set forth in the statutes and regulations, some of which are
referenced in the ~Ter-~pecific Fact Sheet~ available from the Department's regional and headquarter~ o.~ces.
SUBMISSION PROCEDURES:
You must submit t~o copies of thi~ completed notification by certified mail, return receipt requested, to:
Department of Toxic Substanc~ Control
Program Data Matmgement Section
400 P. Street, 4th Floor, Room 4455 (walk in only)
P.O. BaxS06
Sacramento, CA 95812-0806.
You must also ~brnlt one co?? of the notification and attachment~ to the local regulatory agency in your jurisdiction ar listed in
Appendix 2 of the iartruction materials. You must also retain a copy az part of your operating record.
~4ll three forint mu~ luzve orieinal signature~, not photocopie~.
, DTSC 1772 (1/95) Page
' it,?'- ~:- ........................................ ' ..............................................................................
CONDI~ION~LY EXEMF1~- SPECIFIED ~STESTREAMS
' UNIT SPECIFIC NOTIFICATION
- (pursuant to Health and Safety Code Section 25201.5(c)) -
The Tier-Specific Fact Sheets contain a summary of the operafinE requirem~ts for tiffs category. Please
review those requirements carefully before completing or submitting this notification package.
uNrr NAM~ ~? ~'r~ U~UT ~D NUM~F~ ~//
NUMBI~ OF TRF~TM~2~ DEVICES: , ~' Tank(s) ~ Co~ia~s)lCoa~;m~r Treatm~ A-~O)
yt
Each unit mtart be clearly identified and labeled on the plot plan attached to Form 1772. Arvign your own unique number to each
unit.· The number can be sequential (I. 2. 3) or using any ~xtem you choose.
Enter the e~timated monthly total volum~ of hazardous, warte treated by thi~ unit. ~ should be tl~ ~ or highest
treated in any month. Indicate in the narrative (Section II) if yo. ur operations have seaxonal variations.
WA~TESIREAMS AND TRF_ATMENT PROCKSS~:
Estimated Monthly Total Volume Treated: pounds and/or /,-~'~ gallonz
Estimated Monthly Total Volume Stored: pounds and/or gallo~
Y£$ NO
[-'] [~ la the wazte treated ia this unit radioactive?
[--] ~[ Ia the wazte treated in this unit a bio-ha-ard/infectious/medical wazte?
[--i [] Iz remotely generated hazardous wazto (H$C 25110.10} treated ia this unit?
The following are the eligible wozt~treanu and treatment procex, e~. Ptease check all applicable boxe. v:
I'-! 1. Treats resins mixed or cured in accordance with the manufacturer's instructions (including one-part and
pre-impregnated materials).
["'! 2. Treat containera of 110 gallons or les~ capacity that contained b-n~,rdou~ waste by rinsing or physical
processes, such as crushing, shredding, grinding, or puncturing.
[--I 3. Drying special waztes, as claszified by the depa~hdent purtaaant to Title 22, CCR, Section 66261.124, by
pressing or by passive or heat-aided evaporation to remove water.
i'-] 4. Magnetic separation or screening to remove components from special waste, az classified by the depaxhaent
pursuant to Title 22, CCR, Section 66261.124.
*NOTE* $. NO AUTHORrZATIQN IS NEEDED to neutraG~ acidic or alkaline (base) wasps from the
r~generation of ion exchange media used to _donlneralize water. {This waste ~mnot ~amtaln more
than 10 percent acid or base by weight to be eli~'ble for this exemption.)
i'-i 6. Neutralize acidic or alkaline (bane) wastes from the food processing industry.
[~ 7. Recovery of silver from photofini~hlng. The volume limit for conditional exemption is 500 gallons per
generator (at the same location} in any calendar month.
*NOTE* Recovery of 10 gallons or less per month of silver from photoflnl.qhlng is
completely exempt from permitting; this form need not be submitted.
DT$C 1772B (1/95) Page 10
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