DEPARTMENT: Design and Construction PAGE: 1 of 2 EFFECTIVE DATE: January 12, 1999 POLICY DESCRIPTION: Environmental – Asbestos Containing Material (ACM) Management REPLACES POLICY DATED: REFERENCE NUMBER: DC.005 SCOPE: All Company facilities, including but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices, and all Corporate Departments, Groups and Divisions. PURPOSE: To require facilities to manage asbestos containing building materials (ACM) in compliance with applicable Environmental Protection Agency (EPA) and Occupational Safety and Health Administration (OSHA) regulations. POLICY: Facilities that identify materials containing asbestos must avoid disturbing and potentially exposing ACM to any occupant. Facilities must prepare an Asbestos Operations and Maintenance Plan (sample attached) and have it certified by an Industrial Hygienist or Professional Engineer. All plant operation, building management, maintenance and custodial personnel and occupants in the immediate work areas where ACM is located must read and abide by the Plan. Facility personnel must take all necessary precautions to prevent asbestos fiber releases or resuspension of already released fibers, within the facility. This policy addresses federal regulatory requirements. State laws or regulations may impose additional requirements. Each facility should consult with Corporate Engineering Services and the facility’s Operations Counsel to identify and comply with any such additional requirements. PROCEDURE: 1. Unless the area is under a planned abatement project, no employee or outside contractor may disturb ACM. Disturb means any activity that will cause the material to be damaged or become airborne. 2. Anyone with evidence of any disturbance or damage of ACM must report it to the Facility Manager or Director. 3. Only maintenance workers properly trained and certified in accordance with the applicable OSHA Standards may perform necessary preventive and emergency operations and maintenance procedures other than visual inspection. 4. A licensed asbestos abatement contractor must be retained by facility Administration to perform operations and maintenance tasks in lieu of trained workers. The telephone number of the contractor must be kept readily available by facility Administration and the Plant Operations Department in the event that emergency clean up or repair is needed. 5. Confirmatory asbestos testing must be performed prior to any renovation or demolition activities in a building that was built prior to 1981. DEPARTMENT: Design and Construction PAGE: 2 of 2 EFFECTIVE DATE: January 12, 1999 POLICY DESCRIPTION: Environmental – Asbestos Containing Material (ACM) Management REPLACES POLICY DATED: REFERENCE NUMBER: DC.005 6. Only state-certified facility workers may perform “minor” abatement work related to smallscale, short duration repair duties in a facility. The facility must retain qualified outside abatement contractors to perform asbestos abatement projects (non-maintenance) in accordance with applicable state regulations. If the total amount of friable asbestos materials in a facility being demolished exceeds 260 linear feet on pipes or exceeds 160 square feet on other materials, the appropriate state agency should be notified prior to beginning the abatement project. 7. If a facility needs assistance in selecting an abatement contractor, it should contact the Corporate Environmental Manager. REFERENCES: Occupational Safety and Health Administration (OSHA) 29 CFR 1910-1001 Asbestos Operations and Maintenance Plan (attached) ASBESTOS OPERATIONS AND MAINTENANCE PLAN Facility Name Address Plan Overview Asbestos Management Summary: Certain asbestos containing materials (ACMs) exist in a facility building. A set of drawings/ plans must accompany this O&M Plan. A copy of the Preliminary Asbestos Survey report is available in the facility’s Plant Operations Department. Any contractors and/or employees conducting repair, renovation, or construction work on campus that have the potential to disturb ACMs (such as drilling, telephone cable installation, computer cable routing, etc.) must obtain clearance from the Director of Plant Operations. The Director of Plant Operation or Safety Director must advise the construction and maintenance contractors and Plant Operation employees of the asbestos material, location and hazard; then have the contractor or employee sign an acknowledgment of the disclosure. For any regulated asbestos abatement work, facility staff will retain “qualified” and state-certified abatement contractors to conduct the work. If the facility needs assistance in selecting an abatement contractor, it will contact the Corporate Environmental Manager. Wastes generated during an asbestos abatement project must be manifested and removed by the abatement contractors. Waste manifests and project close-out documents must be kept in the Plant Operations Department. Training manuals, training video tapes, and compliance records should be kept in the Plant Operations Department. Department/contact person responsible for asbestos Department: management and maintaining the compliance file: Contact Person: Based on the preliminary survey conducted at the facility in ______(year), the following building materials contain asbestos at this facility (Sample, please revise for your facility): ACM Material Location spray-on fireproofing throughout the buildings pipe and insulation boiler/mechanical rooms building fire proofing electrical room pipe joint insulation ground floor/above ceiling transite board boiler room and cooling tower floor tiles and mastic throughout the building fire door core various areas The Asbestos Management Compliance File Records A copy of this O&M Plan the most recent set of drawings showing the locations of ACMs all asbestos survey reports, including the preliminary survey and any subsequent confirmatory sampling results all written notifications to agencies for asbestos abatement projects close out document package for each abatement project (It is acceptable to archive, but never destroy, the abatement close-out documents) Documents routinely all manifests, receipts, or equivalent documents updated monthly or bi-monthly visual inspection (by facility personnel) logs personnel training records Attachment to DC.005 ASBESTOS OPERATIONS AND MAINTENANCE PLAN Facility Name Address Objectives: identify and document the location of any existing asbestos containing materials (ACMs) establish an Asbestos Operations and Maintenance Program to provide for routine inspection and appropriate maintenance; and if necessary, arrange for the repair or abatement of ACMs. This Operations and Maintenance Plan has been developed to manage presumed asbestos containing materials and/or identified asbestos containing building materials (ACM) at Facility Name. The materials listed in the summary sheet have been tested to contain more than 1% of asbestos by a laboratory. To comply with Occupational Safety and Health Administration (OSHA) standards at 29 CFR 1910-1001, unless an area has received a homogeneous sampling and testing, we are required to assume that the materials listed below may contain asbestos, and treat them as ACM. Although the “asbestos manufacturing ban” occurred in 1977-1978, building materials containing asbestos in stock at that time were used for construction until 1981. Unless tested negative, any material, especially floor tiles or vinyl sheets, installed prior to 1981 should be treated as presumed ACM. The ACM stated in this Plan is a collective term including both the confirmed and presumed asbestos containing materials. cement pipes cement wallboard cement siding asphalt floor tile vinyl floor tiles vinyl sheet flooring acoustical plaster decorative plaster textured paints/coating adhesives/mastics ceiling tiles/lay-in panels spray-applied insulation blown-in insulation fireproofing materials thermal taping compounds high-temperature gaskets laboratory hood/table tops laboratory gloves fire blanket fire curtains elevator brake shoes/panel HVAC duct insulation duct work flexible connects boiler insulation breaching insulation transite cooling towers pipe insulation heating and electrical ducts electrical panel partitions chalkboard roofing shingle roof base flashing thermal paper products firedoors caulking/putties transite wall board specking compounds joint compound packing (wall/floor penetrations) vinyl wall coverings The inhalation of asbestos fibers may cause serious health problems. Asbestos materials should not represent a health hazard when left in place and undisturbed. To avoid the disturbance of ACM, all plant operation, building management, maintenance, custodial, and occupants in the immediate work areas where this material is located will read and abide by this Operations and Maintenance Plan. This plan is intended to prevent asbestos fiber releases or re-suspension of already released fibers and to control fiber releases quickly and safely if they do occur. Unless the area is under a planned abatement project, no employee or outside contractor may disturb ACM. Disturb means any activity that will cause the material to generate dust. Anyone with evidence of any disturbance or damage will report it to the Facility Manager or Director. Only maintenance workers properly trained and certified in accordance with applicable OSHA standards will perform necessary preventive and emergency operations and maintenance procedures other than visual inspection. A licensed asbestos abatement contractor will be retained by facility Administration to perform operations and maintenance tasks in lieu of trained workers. This telephone number will be kept readily available by facility Administration and Plant Operation Departments in case Attachment to DC.005 emergency clean up or repair is needed. An emergency may be from a fire, flood, pipe break, earthquake, hurricane, civil disorder or other causes. Confirmatory asbestos testing will be performed prior to any renovation or demolition activities in a building that was built prior to 1981. Facility Name will employ a state-certified Plant Operation worker to perform “minor” abatement work related to small-scale, short duration repair duties in the facility. The facility will retain qualified abatement contractors to perform asbestos abatement projects in accordance with applicable state regulations. If the total amount of friable asbestos materials being demolished in the facility exceeds 260 linear feet on pipes or exceeds 160 square feet on other materials, the facility will notify the appropriate state agency prior to beginning abatement. If the facility needs assistance in selecting an abatement contractor, it will contact the Corporate Environmental Manager. Attachment to DC.005 ASBESTOS ABATEMENT MANAGEMENT If an ACM must be removed as a result of a demolition of renovation project, or if the surface condition of an ACM has deteriorated to the degree that asbestos exposure is possible, the facility will initiate an asbestos abatement project. For repair, “minor” asbestos abatement, or emergency response, the facility will get a local asbestos abatement contractor licensed by the appropriate state agency to perform these small projects. Minor abatement is defined as removal of asbestos material under 160 square feet or 260 feet of piping. If the quantities exceeded the limits, the abatement work is considered “regulated.” For a regulated abatement project, a local firm/contractor will conduct a confirmatory asbestos testing in the area(s) to be repaired or renovated. A confirmatory testing report should include the quantity of each type of ACM found in separate building areas. The facility will check the firm’s or contractor’s state license and insurance before it contracts with them. If the facility needs assistance in selecting an abatement contractor, it will contact the Corporate Environmental Manager. For those regulated abatement projects, the insurance requirements are listed in the following table. The facility will require the consultant and contractor to provide a copy of an insurance certificate with the project contract. Form of Coverage Limits Worker’s Compensation Employer’s Liability Statutory $1,000,000 Comprehensive General Liability (including Primary, Excess, and Blanket Contractual Liability Insurance and $1,000,000 completed operations): Combined single limit of not less than Comprehensive Automobile Liability: $1,000,000 per occurrence for all damages Bodily Injury/Property Damage/Personal Injury including coverage for owned, hired, and nonowned automobiles. Professional Service Liability Insurance covering the $1,000,000 each occurrence Work under each applicable Project Contract including $1,000,000 in the aggregate Project Site Specific or Blanket Contractor’s Pollution Legal Liability Coverage Using the results/quantities of ACM obtained from the confirmatory testing and a set of plans and specifications prepared by a qualified consultant, the facility will select an abatement contractor through competitive bidding. The asbestos consultant may perform this bidding process for the facility for a reasonable fee. The contractor must file a notice with appropriate state and local agencies, and pay permitting fees prior to beginning an abatement project. OSHA compliance monitoring for abatement worker protection should be performed by the contractor. During execution of an abatement project, the independent air sampling and site inspection should be conducted by the consultant. Other construction or renovation work may start after asbestos abatement is complete. Waste derived from the asbestos abatement project must be removed, labeled, transported, and disposed of properly by the contractor. Waste manifests must be signed by either the CEO, Facility Manager or Director, or Safety Director at the facility as the “Owner Representative.” All completed manifests should be returned to the facility in 45 days by the landfill operator. The manifests, as part of the close-out documents, must be keep in the “Asbestos Compliance File” in the Plant Operation Department. Attachment to DC.005 A minimum of 10% of the project payment will be withheld from both the consultant and the contractor until the close-out document has been received by the facility. After an abatement project is complete, the facility will require the consultant/contractor to submit close-out documents. This document package will be kept in the facility’s Plant Operations Department. Upon receipt of the close-out documents, the facility may issue the final payment. . Attachment to DC.005 SAMPLE FORM: ACCESS TO NON-PUBLIC AREA REQUEST Facility Name [This form needs to be used when employees or contractors are about to enter areas where potential exists for exposure to friable ACM.] PLEASE READ BEFORE YOU SIGN IN By signature below, I hereby certify that I am aware that the area I am entering contains asbestos containing materials (ACM). I certify that I have been informed of the location and hazards of ACM; that I have received training in the proper precautions to take when working around ACM; that I will comply with proper work practices and that I possess, and have been taught about the use, wearing and disposal of proper personal protective equipment. Print Name Signature Affiliation Date Attachment to DC.005 SAMPLE FORM: PERSONNEL TRAINING RECORD Facility Name [The facility needs to keep track of the hazard communication and personnel training for those facility Plant Operation or Housekeeping personnel who work around ACM. The need and frequency of training should be determined jointly by the Risk Manager, Safety Director and Plant Operation Director, and a form such as this should be used to track the training.] Asbestos Management ATTENDEE SIGNATURE Purpose of Training/Name of Trainer(s) DATE Attachment to DC.005 SAMPLE FORM: INSPECTION RECORD Facility Name [This form, or its equivalent, should be used to keep track of visual inspection of the surface condition of ACM. A computerized preventive maintenance program may be used in lieu of this form.] Asbestos Management Inspection Items(e.g., ceiling Type of inspection # Condition of ACM tile in OR, etc.) Good, Fair, Poor (monthly, quarterly, semiannual, emergency) # # # Inspected by Date For sprayed-on fire proofing and ceiling tile: inspect these materials for damage or deterioration at least every 3 months. Corrective action: initiate an abatement project by qualified contractor, or have a qualified contractor encapsulate the material. For floor tile and mastics, duct mastic, and roof materials: inspect these materials for damage or deterioration at least every 6 months. Corrective actions include: repair or abatement project. For general muffler insulation, pipe elbow insulation, pipe insulation, tank insulation, and valve cover: inspect all insulation for damage or deterioration at least every 6 months. Corrective actions include: glove bag removal or abatement project. Attachment to DC.005 SAMPLE FORM: ASBESTOS ABATEMENT/MAINTENANCE RECORD Facility Name [This form, or its equivalent, should be used to keep track of any preventive or corrective maintenance/repair/abatement work conducted. A computerized preventive maintenance program may be used in lieu of this form.] Asbestos Management Location/Unit(e.g., boiler room, OR, etc.) Maintenance/Improvement Item Performed by DATE (e.g., pipe insulation removal, etc.) (name of firm) Attachment to DC.005