DEPARTMENT: Engineering and Facility
Management
PAGE: 1 of 3
POLICY DESCRIPTION: Environmental – Waste
Oil Management
REPLACES POLICY DATED: 1/12/99, 11/1/05
(DC.012)
EFFECTIVE DATE: May 1, 2007
POLICY NUMBER: ENV.012
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All Company-affiliated facilities including hospitals, ambulatory surgery centers,
outpatient imaging centers, medical office buildings, home health agencies, physician practices, and
all Corporate Departments, Groups and Divisions and on-site subcontractors.
PURPOSE: To require each facility to manage waste oil handling and disposal in accordance with
applicable Environmental Protection Agency (EPA) regulations.
POLICY:
1. Facilities must manage waste oil handling and disposal in accordance with EPA regulations, as
well as state laws or regulations that may impose additional requirements. Each facility should
consult with Corporate Engineering and Facility Management and the facility’s Operations
Counsel to identify and comply with any such additional requirements.
2. To minimize the waste oil generation onsite, a facility should consider using a commercial garage
for servicing vehicles and retaining credible maintenance contractors to properly handle the waste
oil from boilers and other equipment services.
3. Facilities must not accept waste oil generated by non-Company sources.
4. Facilities are encouraged to participate in the community-wide collection and recycling programs
where agency-administered programs are available. If a permitted used oil recycling firm is
available in the area, a facility should establish a contract for disposal. The Corporate Legal
Department must review the contract.
5. Disposal of used oil as a hazardous waste is the least preferred disposal option.
PROCEDURE:
Analytical Testing
1. A facility is not required to test waste oil if the waste oil collector, recycling firm, or disposal facility
routinely tests the bulked oil. A copy of the test results must be obtained and kept on file.
2. If a facility generates a shipment of waste oil with unique characteristics from a specific project
other than routine maintenance activities, the waste oil must be tested for total halogens. A copy of
the halogen test results should be provided to the recycling firm or fuel blending facility.
4/2007
DEPARTMENT: Engineering and Facility
Management
PAGE: 2 of 3
POLICY DESCRIPTION: Environmental – Waste
Oil Management
REPLACES POLICY DATED: 1/12/99, 11/1/05
(DC.012)
EFFECTIVE DATE: May 1, 2007
POLICY NUMBER: ENV.012
APPROVED BY: Ethics and Compliance Policy Committee
3. A facility must perform or have performed a PCB test in addition to a total halogen test for a batch
of waste oil generated from an unknown source or process, or with an unspecified date of
generation.
4. If the hazardous waste treatment/disposal facility is used as a last resort, a complete one-time waste
profile will be tested by the contracting facility.
Handling
1. A facility must not dump waste oil on roads or on land for purposes of dust suppression or weed
control. Current regulations prohibit introducing petroleum pollutant into the environment.
2. A facility must not pour waste oil into the sanitary or storm drainage system.
3. A facility must not burn waste oil in the on-site medical waste incinerator. The onsite incinerator is
permitted to burn medical waste only.
4. A facility must not dump waste oil into the underground fuel storage tank. On-site boilers are not
permitted to burn waste oil.
5. A facility must never mix waste oil with other types of waste materials. Waste oil must be
segregated from general trash to be deposited in the county landfill. No matter how minute the
amount, a facility must not pour degreaser solvents, coolant (ethylene glycol), xylene, formaldehyde,
freon, or other hazardous materials into a waste oil container.
6. A facility must use a bulk tank or drums and not small containers for waste oil holding. The holding
area should be equipped with containment to recapture spills. The holding tank and its surroundings
must be inspected periodically. An underground storage tank is not recommended for waste oil
holding. Waste oil should not be held for more than 180 days.
7. A facility must properly label waste oil holding tanks.
Transportation
1. Facility personnel may transport a small amount of waste oil, 20 gallons or less, for a distance of no
more than 30 miles. The facility must to obtain a receipt from the used oil collector as evidence of
disposal.
2. A facility must verify the registration (Department of Transportation and state environmental
4/2007
DEPARTMENT: Engineering and Facility
Management
PAGE: 3 of 3
POLICY DESCRIPTION: Environmental – Waste
Oil Management
REPLACES POLICY DATED: 1/12/99, 11/1/05
(DC.012)
EFFECTIVE DATE: May 1, 2007
POLICY NUMBER: ENV.012
APPROVED BY: Ethics and Compliance Policy Committee
agency) of the waste oil transporter and have the transporter sign the collection logs for each
removal.
Disposal
1. The facility may send used oil to service stations offering a used oil collection program, provided
there is a written agreement with the service station. In some states, service stations collecting used
oil must be registered with the state. The facility must verify that the used oil is ultimately recycled
in accordance with all applicable state and federal requirements.
2. Liquid and sludge/residue removed from fuel tank replacement or tank maintenance projects are
generally non-hazardous and must be sent to a recycler.
3. If a facility has a contract in place with a permitted recycling firm, the facility must use collection
logs or receipts, in lieu of manifests, for the waste oil shipment.
4. If a shipment of waste oil is determined to be hazardous, a facility must manifest it and have a
hazardous waste contractor remove it. The facility must receive an executed manifest, signed and
returned by the treatment/disposal facility within 30 days after removal from the facility. If this
manifest is not received, the facility must call the disposal facility and request the executed manifest.
RECORDKEEPING:
The facility must keep all waste oil related documents in the Plant Operations Department for 3 years
and then archive. A compliance file must include at least:
 inspection log for waste oil storage;
 sampling and analytical testing results;
 proof of registration for commercial recycling firm or disposal facility; and
 waste oil shipping and collection logs or manifests.
REFERENCES:
Federal Regulation 40 CFR 266
4/2007