Facility Personnel Must Test Or Supervise the Testing of Potentially-Affected Equipment

Facility Personnel Must Test Or Supervise the Testing of Potentially-Affected Equipment

DEPARTMENT: Design and Construction –Facility Management and Engineering Services Department / PROCEDURE DESCRIPTION: Environmental – Polychlorinated Biphenyls (PCBs) Handling
PAGE:1 of 2 / REPLACES POLICY DATED: 1/12/1999
EFFECTIVE DATE: November 1, 2005 / REFERENCE NUMBER: DC.002
SCOPE: All Company-affiliated facilities, including but not limited to, hospitals, ambulatory surgery centers, outpatient imaging centers, home health agencies, physician practices, service centers, and all Corporate Departments, Groups and Divisions and on-site subcontractors.
PURPOSE: To require each facility to address the handling of PCBs in compliance with this policy and applicable environmental regulations.
POLICY: PCBs were used from 1929-1976 to make cooling oils in electrical transformers, hydraulic equipment, capacitors, and other equipment nonflammable. Due to their adverse environmental and suspected impact on human health, PCBs are no longer manufactured and must be removed from service.
  1. Facility personnel must test or supervise the testing of potentially-affected equipment and, if appropriate, label the equipment to indicate it contains PCB material or is PCB-contaminated. Facility personnel must follow regulatory procedures to clean up PCB spills and dispose of PCB-contaminated wastes.
  1. This policy addresses federal regulatory requirements for handling PCBs. State or local laws or regulations may impose additional requirements. Each facility must consult with the Corporate Facility Management and Engineering Services Department and the facility’s Operations Counsel to identify and comply with any additional state or local requirements.
DEFINITIONS:
PCB – Polychlorinated Biphenyls;dielectric fluid; a family of chlorinated aromatic compounds frequently added to reduce the flammability of oil or other fluids.
PCB Equipment - Any piece of equipment containing PCBs in a concentration greater than 50 parts per million (ppm) by volume. Equipment with greater than 500 ppm PCB is required by law to be labeled PCB equipment. If the concentration of PCBs is 50-500 ppm, the equipment may be labeled PCB-contaminated equipment.
Responsible Manager – The individual at each facility charged with keeping the facility in compliance with federal, state, and local environmental statutes and regulations. The Responsible Manager may be a designated Environmental Compliance Officer, ES&H manager, facility manager, or plant operations manager depending on the local organizational structure and management roles and responsibilities.
PROCEDURE:
  1. The Responsible Manager or designee must conduct sampling and laboratory analysis to determine if liquid-filled medical or research equipment, or hydraulically-operated equipment that is owned or leasedby the facility contains PCBs.
  1. The Responsible Manager must ensure that equipment, once tested, is properly labeled to indicate whether PCBs arepresent or absent forall equipment containing hydraulic or transformer fluid.
  1. The Responsible Manager must request that the utility company test and label utility company equipment located at the facility. The utility company is responsible for any testing, identification, and spill clean upfor its equipment. If labels are missing or in the event of a leak or spill, the Responsible Manager must contact the utility company to report the condition.
  1. The Responsible Manager must retain a qualified consultant, approved by the CorporateFacility Management and Engineering Services Department, to remediate any release of fluid from hydraulic equipment. The consultant must test the soil or surface materials for PCB content. PCB-containing waste must be disposed of at a treatment or disposal facility specially permitted to take this waste. PCB-containing waste must not be placed in the regular trash.
  1. The Responsible Manager must verify state and local codes governing fluorescent light ballast disposal. Often, old fluorescent light ballasts and small capacitors containingvery small amounts of PCBs may be disposed as municipal solid waste.
  1. The Responsible Manager must ensure that the following documentsare maintained in the facility’s PCB compliance file:
  • An inventory of PCB and PCB-containing equipment;
  • PCB waste manifests or disposal records; and
  • Preventive maintenance records for electric equipment.

REFERENCES:

Federal Regulations 40 CFR 750 and 761, Management and Disposal ofPCBs

10/2005

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