Hazardous and Radioactive Materials Management and Health and Safety Practices
/ DOECAP Checklist: 6Rev. 4.4Effective Date: March 2017Page 1 of 34
Audit ID: Laboratory: Auditor:
U. S. Department of Energy
Consolidated Audit Program
Checklist 6
Hazardous and Radioactive Materials Management
Revision 4.4
March 2017
Use of this DOECAP checklist is authorized only if the user has satisfied the copyright restrictions associated with TNI-EL-V1-2009 and ISO 17025:2005. DOECAP does not control or restrict the use of copyrighted standards that have been incorporated into this checklist; however, TNI and ISO do restrict use of their standards.
Audit ID: / Date:Areas of Review During Audit
____SOPs/Waste Management Plan / __ Radioactive Materials Management and Control
__Analytical Process Waste and Excess Sample Material / __ Waste Storage Area
__Waste Container Management / __ Chemical Hygiene Plan
__Laboratory Contingency Plan and Emergency Procedures / __ Laboratory Facility Safety
__Sample Receiving / __ Sample Control and Building Security
A = Acceptable U = Unacceptable NA = Not Applicable NO = Not Observed
F = Finding O = Observation
Referenced regulations are accessible at the following URLs:
NOTE:
- When audit findings are written against site-specific documents (i.e., SOPs, QA Plans, licenses, permits, etc.), a copyof the pertinent requirement text from that document must be attached to this checklist for retention in DOECAP files.
- Fully document any deviation from the LOI or the requirements of QSM
- Refer to Page 32for the record of revision.
- Refer to Errata Document 10-25 for interim changes to the QSM Rev.5.0 requirements
Item Number / Line of Inquiry / Status / Summary of Observations/Objective Evidence
Reviewed Audit Notes
1.0 / Radioactive Materials Management and Control
1.1 / Does the laboratory comply with all applicable federal and state regulations governingradioactive materials control and radiological protection?
QSM Rev. 5.0, Section6.1.1
1.2 / Does the radioactive materials license authorize possession of isotopes, quantity, physical form,and use of radioactive material and is it sufficient for the laboratory’s scope of work in support of DOEsites?
QSM Rev. 5.0, Section6.1.2
1.3 / Does the laboratory have facilities and procedures in place to handle the isotopes, quantity, and physical form of radioactive material specified on the radioactive material license?
Does the laboratory ensure adherence to all radioactive materials license and procedural requirements?
QSM Rev. 5.0, Section 6.1.3
1.4 / Is the Radiation Safety Officer (RSO) listed in the Radioactive Materials License and is the RSO available to monitor the radioactive materials and control programs and provide rapid response to any radiological emergencies?
QSM Rev. 5.0, Section6.1.4
1.5 / Does the laboratory have an alternate or backup RSO who has the necessary training and experience to perform the duties of the RSO in the event that the RSO is not available?
QSM Rev. 5.0, Section 6.1.4
1.6 / Does the laboratory have in place a radioactive materials inventory program capable of trackingstandards, tracers, and all radiological samples?
QSM Rev. 5.0, Section6.1.5
1.7 / Is the radioactive material inventoryupdated according to the schedule established by laboratory Radioactive Material License?
QSM Rev. 5.0, Section 6.1.5
1.8 / If noschedule is established by the license, does the laboratory update the inventory withinseven days of receipt of radioactive materials?
QSM Rev. 5.0, Section 6.1.5
1.9 / Are the radioactive and mixed wastes segregated from non-radioactive waste?
QSM Rev. 5.0, Section6.1.6
1.10 / Are the roles, responsibilities, and qualifications for the Radiation Safety Officer (RSO) and the backup RSO been well defined and does the person filling the RSO position meet those requirements?
10 CFR 30.33 (a)(3)
1.11 / Does the laboratory review, at least annually, the radiation protection program content and implementation, and do they maintain records of audits, reviews, and inspections for the last three years?
10 CFR 20.1101, Section 2103a
1.12 / Is a survey or monitoring program in place to assess the extent of potential radiological hazards?
10 CFR 20.1501(a)
11.13 / Does the facility have a calibrated, backup radiological survey meter that can be used in the event that the other survey meter is inoperative or that the calibration has exceeded?
QSM Rev. 5.0, Module 2, Section 5.8.4 c) v). The requirement is amended to the Errata Document, Revision 3, November 30, 2016
1.14 / Does the laboratory monitor external exposure for those employees likely to receive, in one year from sources external to the body, a dose in excess of 10% of the limits in 10 CFR 20.1201(a)?
Note: Review the laboratory process and documentation.
10 CFR 20.1502(a)
1.15 / Does the laboratory monitor internal exposure of those employees likely to receive, in one year, an intake in excess of 10% of the applicable Annual Limit(s) on Intake [ALI(s)]?
10 CFR 20.1502(b)
1.16 / Are the Total Effective Dose Equivalents (TEDE) and Total Organ Dose Equivalents (TODE) within limits, i.e., summing internal and external dose?
10 CFR 20.1201 and 1202
1.17 / Are all individuals in or frequenting any portion of a restricted area instructed in the health protection problems associated with exposure to radioactive materials or radiation, precautions/procedures to minimize exposure, and the purpose and functions of protective devices employed?
10 CFR 19.12(a)(2)
1.18 / Has the laboratory developed and implemented a program of radiological controls and procedures for radioactive material handling, emergency action plan, and use of instrumentation?
10 CFR 20.1101a
1.19 / Is licensed material secure from unauthorized access or removal?
10 CFR 20.1801 and 1802
1.20 / Are instrument and equipment calibration records showing the results of daily calibration checks and calibrations for radiation daily checks of instruments maintained and retained for three years?
10 CFR 20.2103(a)
1.21 / Are airborne releases of radioactivity to the environment monitored, evaluated, and controlled?
10 CFR 20.1501(a) and 1701, EPA NESHAPS
1.22 / Does the effluent released to the sanitary sewer meet these four provisions of 10 CFR 20.2003, i.e.:
•Is it readily soluble?
•Does the quantity released into the sewer not exceed concentration listed in Appendix B to Part 20,
•Have fractional limits been determined, and
•Have the sum of those fractions for each radionuclide beendetermined?
10 CFR 20.2003
1.23 / Are waste packaging, control, and tracking performed in accordance with 10CFR20 Appendix G, Section III requirements, i.e., classification, labeling, QC program, and preparing/ forwarding manifests?
10 CFR 20.2006(d)
1.24 / Does the laboratory remove or deface all sample container labels prior to container disposal such that they are rendered illegible?
QSM Rev. 5.0, Section 6.4.4; 10 CFR 20.1904(b)
1.25 / Are laboratory operations involving material release, effluent release, and waste disposal implemented in accordance with a documented policy such that any potential resulting dose to individual members of the public is maintained within regulatory limits and minimized to the extent reasonably achievable?
10 CFR 20.1101(b)(d); 10 CFR 20.1301
1.26 / Are waste shipments transferred to qualified facility/person specifically licensed to receive waste?
10 CFR 20.2001(a)
1.27 / Are records of waste disposal maintained?
10 CFR 20.2108
1.28 / Does the facility maintain certificates of disposal or destruction for all DOE samples and wastes submitted to a TSDF?
Errata Document, Revision 3, 11/30/2016 Addendum t QSM 5.8.9
1.29 / Are areas of radioactive material handling and contaminationposted according to 10 CFR 20.1902? Are conspicuous signs bearing the radiation symbol and the words “CAUTION-RADIATION AREA”, “CAUTION-HIGH RADIATION AREA”, and “CAUTION-VERY HIGH RADIATION AREA” used?
10 CFR 20.1902
2.0 / Toxic Substances Control Act (TSCA) Material
2.1 / Does the laboratory comply with all federal regulations governing TSCA materials control andprotection?
QSM Rev. 5.0, Section6.2.1
2.2 / Does the laboratory segregate all radioactive TSCA materials from all other analytical samplesand residues?
QSM Rev. 5.0, Section 6.2.2
2.3 / Does the laboratory have a procedure for return of radioactive TSCA materials for which there isno commercial treatment or disposal options to the customer?
QSM Rev. 5.0, Section6.2.3
2.4 / Is TSCA PCB waste stored for less than one year from the date the material was first placed in storage?
40 CFR 761.65(a)
2.5 / Are TSCA PCB waste containers labeled with the accumulation start date?
40 CFR 262.34(a)(2)
2.6 / Does the TSCA one-year waste storage area meet the storage facility requirements for PCB waste? (floor curbing, above 100 year flood plain, no floor drains, etc.)
40 CFR 761.65(b)
Item
Number / Line of Inquiry / Status / Summary of Observations/Objective
Evidence Reviewed Audit Notes
3.0 / Laboratory Safety and Health
3.1 / Does the laboratory comply with all state and federal regulations governing laboratory health and safety?
QSM Rev. 5.0, Section6.3.1
3.2 / Is a laboratory safety inspection program in place?
QSM Rev. 5.0, Section6.3.2
3.3 / Does the program include routine inspections of laboratory areas for safety related concerns?
QSM Rev. 5.0, Section 6.3.2
3.4 / Are chemical hazards labeling on chemical containers in accordance with the laboratory’sapproved Chemical Hygiene Plan?
QSM Rev. 5.0, Section6.3.3
3.5 / On an annual frequency, do all visitors, maintenance personnel, and auditors have a recordedsafety orientation prior to entering the laboratory?
QSM Rev. 5.0, Section6.3.4
3.6 / Are all visitors briefed on the safetypractices and policies?
QSM Rev. 5.0, Section 6.3.4
3.7 / Does the laboratory have a Hazardous Waste Operator and Emergency Response(HAZWOPER) trained person on staff?
QSM Rev. 5.0, Section6.3.5
3.8 / Do backup personnel have appropriate training (HAZWOPER) for Emergency Response?
QSM Rev. 5.0, Section 6.3.5
3.9 / Does the laboratory have reentry procedures defined in the Emergency Action Plan?
QSM REV. 5.0, Section6.3.6
Item
Number / Line of Inquiry / Status / Summary of Observations/Objective
Evidence Reviewed Audit Notes
4.0 / Waste Management and Disposal
4.1 / Does the laboratory comply with all federal and state regulations governing waste managementand disposal?
QSM Rev. 5.0, Section6.4.1
4.2 / Does the laboratory have a waste management plan in place which is capable of:
a) Identifying all waste streams generated by the laboratory including universalwastes such as batteries, thermostats, etc.;
b) Identifying the process for management and disposal of the various wastestreams; and
c) Tracking the disposition of waste samples by Sample Delivery Group (SDG)?
QSM Rev. 5.0, Section 6.4.2
4.3 / Does the waste management plan include the following:
a) Administrative programs to demonstrate compliance for effluent discharges asrequired by regulatory agencies and applicable DOE Orders;
b) Training procedures, schedules, and management of training records in theareas of waste management, shipping, waste handling, and radioactivematerialscontrol;
c) Radioactive volumetric and surface release policies;
d) Permits and licenses to handle hazardous and radioactive waste;
e) Policy or direction on how to conduct waste brokering and Transport, Storage,and Disposal Facility (TSDF) evaluation to ensure proper disposition of waste;
f) Tracking of individual sample container from receipt to final disposition; and
g) Waste minimization and pollution prevention programs including substitution(when permitted), segregation, and recycling?
QSM Rev. 5.0, Section6.4.3
4.4 / Are waste brokering and TSDF evaluation based upon the results of a site visit to the wastefacility or a desktop review that includes information from audits of the facilities conducted bystate or federal agencies?
QSM Rev. 5.0, Section 6.4.3
4.5 / Does the evaluation include liability coverage, financial stability, anyNotices of violations (NOVs) from the last three years, relevant permits and licenses to acceptthe waste, and other relevant information?
QSM Rev. 5.0, Section 6.4.3
4.6 / Arereviews of waste brokering and TSDF evaluationsperformed every three years, unless there are changes in the facilities operations thatrequire the reviews to be conducted on a more frequent basis (e.g., NOVs, change ofownership, notices of fines, and penalties)?
QSM Rev. 5.0, Section 6.4.3
4.7 / Has the laboratory developed criteria for theevaluation of waste brokers and TSDFs?
QSM Rev. 5.0, Section 6.4.3
4.8 / Is documentation of the evaluations maintained?
QSM Rev. 5.0, Section 6.4.3
4.9 / Does the laboratory maintain a list of the facilities that are approved?
QSM Rev. 5.0, Section 6.4.3
4.10 / Note: Refer to EPA public domainEnforcement and History Online (ECHO) and “Envirofacts” websites for information on TSDFs.
4.11 / Is analytical process waste segregated and removed to a designated storage area tominimize the potential for cross contamination?
QSM Rev. 5.0, Section6.4.5
4.12 / Is laboratory analysis derived waste characterization repeated at a frequency adequateto account for all known variation in the waste streams?
QSM Rev. 5.0, Section6.4.6
4.13 / Are samples that are consumed during analysis included in the sample accountabilitytracking?
QSM Rev. 5.0, Section6.4.7
4.14 / Does the laboratory have provisions for the disposition of excess samples?
QSM Rev. 5.0, Section6.4.8
4.15 / Is the laboratory aware of therequirements for the receiving Publicly Owned Treatment Works (POTW) or wastewatertreatment system for excess samples that are bulked and drain disposed?
QSM Rev. 5.0, Section6.4.9
4.16 / Does the laboratory have a program that meets and demonstrates compliance with theserequirements?
QSM Rev. 5.0, Section 6.4.9
4.17 / Are characterization records, including analytical test results and process knowledge determinations, kept for at least three years?
40 CFR 252.40
4.18 / Are laboratories accumulating no more than 55 gallons of hazardous and mixed waste or no more than one quart of acutely hazardous waste at, or near, any point of generation (satellite point)?
40 CFR 262.34c
4.19 / Are wastes from samples containing PCBs at greater than 50 ppm segregated from other laboratory wastes as TSCA regulated waste?
(NOTE: This does not apply to the extracted sample residual, BUT it does apply to the extract and other laboratory process wastes.)
40 CFR 761
4.20 / Are laboratory-generated TSCA PCB wastes stored in a Temporary Storage Area more than 30 days from the time of generation without being placed in an area that meets one year storage facility requirements?
40 CFR 761.65
4.21 / Are TSCA PCB waste containers and sample storage areas marked with the required TSCA PCB labeling as identified in 40 CFR 761.45?
40 CFR 761.45
4.22 / Are radioactive and mixed wastes generated during laboratory sample processing properly labeled as Radioactive?
10 CFR 20.1904
Item
Number / Line of Inquiry / Status / Summary of Observations/Objective
Evidence Reviewed Audit Notes
5.0 / Waste Storage Areas
5.1 / For RCRA Large Quantity Generators:
Are waste containersstored over 90 days in the accumulation/storage area?
40 CFR 262.34(a) and (b)
5.2 / For RCRA Small Quantity Generators:
Are waste containers stored over 180 days (270 days if transported over 200 miles) in the accumulation/storage area?
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 262.34(d)(e)
5.3 / Are waste storage containers:
- labeled with the words “Hazardous Waste” or other words that clearly define the contents;
- labeled with the start date upon which each period of accumulation begins
- clearly marked with the accumulation start date and visible for inspection?
40 CFR 262.34(a)(2)(3)
Item
Number / Line of Inquiry / Status / Summary of Observations/Objective
Evidence Reviewed Audit Notes
6.0 / Waste Container Management
6.1 / Are waste storage areas, and containers of waste monitored weekly by an operator or someone knowledgeable in waste operations specific to this facility?
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 265.174
6.2 / Do the user(s) or operator(s) of the satellite accumulation areas understand container/waste compatibility and have they been trained with respect to container selection, waste identification, documentation, and management?
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 265.172 and 177
6.3 / For RCRA Small and Large Quantity Generator waste storage areas:
•isignitable and reactive waste stored at least 50 feet from the property line?
•isincompatible waste stored near other containers or separated by a dike, berm, wall, or other device;
•does the waste storage area provide secondary containment of sufficient capacity for the waste expected to be stored in the areas; and
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 265.176, 177(c) and 193
6.4 / Are outgoing shipments of materials in compliance with 49 CFR 172, 173, 178, and 179 as to placarding, quantity limits, packing requirements, etc.?
(Ask laboratory personnel to walk you through the process and show you the procedures.)
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 262.31-32
6.5 / Are accumulation containers:
•in good condition,
•compatible with the waste,
•kept closed?
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 262.34c; and 40 CFR 265. 171, 172, 173, and 174
Item
Number / Line of Inquiry / Status / Summary of Observations/Objective
Evidence Reviewed Audit Notes
7.0 / Laboratory Contingency Plan and Emergency Procedures
7.1 / For RCRA Large Quantity Generators:
Does the laboratory have a written contingency plan and is a copy available at the facility?
40 CFR 265.50, 51, 52, and 53
7.2 / For RCRA Small Quantity Generators:
Is the following information posted next to the phone in the vicinity of the accumulation area:
•name and number of the emergency coordinator,
•location of fire extinguishers and spill control material, and
•fire department number or a direct alarm?
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 262.34(d)(5)(ii)
7.3 / For Large and Small Quantity Generators:
Is required equipment available at the accumulation/storage area?
Equipment includes, but is not limited to:
•internal communication or alarm system,
•telephone or hand-held two-way radio,
•portable fire extinguishers/fire control equipment,
•spill control equipment, and water at adequate volume and pressure (e.g., 15 minutes of continuous pressure)?
There is an exemption for conditionally exempt small quantity generators. See 40 CFR 261.5
40 CFR 262.34(a)(4) and (d)(4); 40 CFR 265.32
7.4 / Are the following readily available to laboratory personnel:
•medical personnel for advice and consultation on matters of employee health;
•an emergency eye wash within the immediate work area; and
•an emergency shower within the immediate work area?
29 CFR 1910.151(a) and (c)
7.5 / Has the employer provided, mounted, located, identified, and inspected portable fire extinguishers so that they are readily available to all employees without subjecting the employees to possible injury?
29 CFR 1910.157(c)(1) and (e)(1)
7.6 / Has the employer developed a spill control policy, and provided, located, and identified spill kits so that they are readily available to all employees?