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UNCLASIFIED
PUEBLO CHEMICAL DEPOT
LEAD MANAGEMENT PLAN
Prepared by
Pueblo Chemical Depot Environmental Management Office
December 2011
Prepared by: Keith L. Phillips
UNCLASIFIED
Page0
PUEBLO CHEMICAL DEPOT
ASBESTOS MANAGEMENT PLAN
Prepared by
Pueblo Chemical Depot Environmental Management Office
December 2011
Prepared by: Keith L. Phillips
UNCONTROLED IF PRINTED PCD EMS Manual
1-1
Prepared by: Keith L. Phillips
December 2011
Pueblo Chemical Depot
EEMMSS MMaannuuaall
August 2009
UNCONTROLED IF PRINTED PCD EMS Manual
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Prepared by: Keith L. Phillips
Table of Contents
1. Introduction to the Pueblo Chemical Depot (PCD) EMS Manual........................................................................... 1-3
1.1 Purpose of the EMS Manual...................................................................................................................................... 1-3
1.2 EMS Manual Maintenance........................................................................................................................................ 1-3
1.3 EMS Implementation at PCD .................................................................................................................................... 1-3
1.4 EMS Glossary............................................................................................................................................................ 1-4
1.5 EMS Acronyms .......................................................................................................................................................... 1-9
2. PCD Scope and Characteristics .................................................................................................................................. 2-1
2.1 PCD Background & Mission..................................................................................................................................... 2-1
2.2 PCD Facility Description.......................................................................................................................................... 2-2
2.3 PCD Significant Environmental Aspects ................................................................................................................. 2-4
3. PCD Environmental Policy ......................................................................................................................................... 3-1
4. EMS Procedures........................................................................................................................................................... 4-4
4.1 Identifying Significant Environmental Aspects ........................................................................................................ 4-6
4.2 PCD EMS Audit Program ....................................................................................................................................... 4-15
4.3 PCD EMS Procedure for Internal and External Communications.......................................................................... 4-31
4.4 PCD EMS Procedure for Document Control and Documentation.......................................................................... 4-34
4.5 PCD EMS Procedure for Environmental Management Programs and Operational Controls ............................... 4-36
4.6 PCD EMS Procedure for Addressing Emergency Preparedness and Response ..................................................... 4-41
4.7 PCD EMS Procedure for Legal and Other Requirements....................................................................................... 4-43
4.8 PCD EMS Procedure for Monitoring and Measurement ........................................................................................ 4-45
4.9 PCD EMS Procedure for EMS Management Review.............................................................................................. 4-47
4.10 PCD EMS Procedure for Nonconformity, Corrective and Preventive action......................................................... 4-49
4.11 PCD E MS Procedure for Setting Objectives and Targets...................................................................................... 4-51
4.12 PCD EMS Procedure for the Control of Records ................................................................................................... 4-54
4.13 PCD EMS Procedure for Competency Training..................................................................................................... 4-56
5. EMS Records................................................................................................................................................................ 5-1
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1. Introduction to the Pueblo Chemical Depot (PCD) EMS Manual
The original requirement for an Environmental Management System (EMS) was issued by
Executive Order (EO) 13148, “Greening the Government through Leadership in Environmental
Management.” Army Memorandum, ACSIM, DAIM-ZA, 10 July 2003, SAB requires EMS
implementation via International Organization for Standardization (ISO) 14001. The Pueblo
Chemical Depot (PCD) Policy Statement Number 20, 17 September, 2011, defines PCD’s
environmental goals and mission. This manual defines PCD’s implementation, roles,
responsibilities, and procedures for defining and maintaining the PCD EMS.
1.1 Purpose of the EMS Manual
This Environmental Management System Manual serves as a repository for documentation related to the
Pueblo Chemical Depot (PCD) Environmental Management System (EMS) and includes:
a. EMS Procedures that describe how to carry out key tasks within the EMS such as training,
tracking legal and other requirements, or managing records.
b. Programs & Controls that operate under the EMS, such as programs for achieving EMS
objectives and targets or for carrying out EMS audits.
c. EMS Records that confirm the completion of specific EMS activities such as the
identification of environmental aspects, the conduct of EMS training, or that management
reviews were completed.
d. Definitions and References that provide additional information useful to individuals
reviewing or learning about the EMS.
1.2 EMS Manual Maintenance
a. This EMS Manual is maintained by: PCD EMS Manager or someone designated by him.
b. The formal version of this EMS Manual is located in the Environmental Management Office,
PCD.
c. This EMS Manual was last updated on: June 2010
d. In addition to the tables created to identify significant aspects and objectives and targets, the
EMS Manual contains the EMS Audit Program, the EMS Procedures, EMS records, and
other descriptive information useful to anyone being introduced to the EMS or to those
responsible for the EMS.
1.3 EMS Implementation at PCD
The Pueblo Chemical Depot (PCD) has implemented an Environmental Management System (EMS) to
ensure it fulfills the commitments to its Environmental Policy. The scope of the PCD EMS includes the
following facilities and organizations within the Pueblo Chemical Depot (PCD. The EMS is modeled on
the specifications found in the international standard for environmental management in organizations, ISO-
14001:2004. Specific benefits provided to PCD from implementing a formal management discipline
include:
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a. The systematic approach to managing PCD’s potential impacts on the environment.
b. Enabling PCD environmental concerns to be managed to accord with mission goals.
c. Providing documentation of existing processes so that results can be repeated. Institutional
knowledge is captured so it is not subject to personnel flux.
d. Providing a structured approach to identify potential impacts that could otherwise result in
costs, embarrassments, and threats to mission.
e. Having the potential to provide employees with a sense of empowerment that can translate to
enhanced performance on the job.
f. Providing the site with a means to track and measure environmental and operational
performance by instituting metrics.
g. Providing greater discipline and assurance in tracking and analyzing environmental
requirements thus ensuring a higher level of compliance.
h. Allowing PCD to use a risk management approach ensuring the site focuses and allocates its
resources to those that have the greatest probability and worst potential consequences.
i. Providing for greater sharing of knowledge and responsibilities across all levels and
functions.
j. Supporting reporting under Government Performance Results Act (GPRA).
1.4 EMS Glossary
Adequacy: Refers to the sufficiency of the resources for the EMS.
Auditor Training: Training provided to those individuals that will fulfill the role of internal EMS
auditors at PCD. This includes basic EMS training, familiarization with the organization's own EMS, as
well as training on how to prepare, conduct and conclude the internal audit, including writing the audit
report and overseeing the completion of corrective actions on the audit findings.
Competence Training: Training provided to personnel that are associated with significant
environmental aspects. Such training is indicated when the individual is not considered competent on
the basis of previous training, education, or experience to address the responsibilities he/she has been
charged with relative to the significant environmental aspect in question.
Compliance Audit: A periodic audit of compliance with regulatory and other requirements that are
imposed on the organization. Findings are expressed as non-compliances. The search for root causes in
a typical compliance audit may not be as intense as it should be during an EMS audit.
Continual Improvement: Process of enhancing the EMS to achieve improvements in overall
environmental performance in line with the organization’s environmental policy. (Note: Continual
implies that there will be periods where improvement will be flat.)
Correction: The totality of immediate and long-term steps taken to mitigate the consequences of a
nonconformity (e.g., cleanup of spilled hazardous material; remediation of groundwater; natural habitat
restoration). The correction does not by itself remove the underlying cause of the nonconformity.
Corrective Action: Action to address the underlying cause of an actual event that has been identified as
a non-conformity through an audit.
EMO Program Manager: An individual in the Environmental Management Office (EMO) appointed
to manage specific environmental programs and/or plans for media protection and resource conservation
such as air, groundwater, surface water, soil, cultural resources, and pollution prevention.
Effectiveness: Refers to the accomplishment of the objectives and targets set for the EMS.
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Environmental Impact: Any change to the environment, whether adverse or beneficial, wholly or
partially resulting from the facility’s aspects. (Note: A potential environmental impact is equivalent to
the concept of risk, in safety, which assigns a probability and consequence to the possible negative event
that may result from a hazard.)
Environmental Aspect: An element of an activity that can interact with the environment. (Note: The
environmental aspect of an activity is that part of the activity that creates the possibility for an
environmental impact. As such, it is equivalent to the concept of hazard, in safety, which is also defined
as the mere possibility of a negative event.)
Environmental Management Programs: Are a management tool used to document the tasks,
responsibilities, and other operational details that are implemented to achieve the objectives and targets
that are set for the significant aspect. They include timelines, resources, and responsibilities for
achieving
those objectives and targets and are amended as necessary with changing environmental, organizational,
and legal requirements, as well as aspects and operations within the organization.
EMPs incorporate a number of other EMS components including:
 The significant environmental aspect that is being addressed;
 The objective(s) and target(s) that were set for the significant aspect;
 The program indicators to be used to measure progress in achieving the objectives and
targets;
 The factors that gave rise to the significance of the aspect;
 The programmatic tasks needed to achieve the objectives and targets;
 The roles and responsibilities of individuals responsible for the tasks;
 Declarations of employee competency;
 Specification of records to be produced by executing the management plan;
 Reference to other documents used with the management plan; and
 Operational controls that are implemented to ensure that the objectives and targets will be
achieved as planned.
Environmental Management System Manager: An individual appointed by top management to serve
as management representative and coordinator ensuring that the EMS is established, implemented and
maintained in accordance with the requirements of the ISO 14001:2004, and also report to top
management on the performance of the EMS for review, including recommendations for improvement.
Environmental Objective: Overall environmental goal, arising from the environmental policy that an
organization sets for itself to achieve, and which is quantified where practicable.
Environmental Performance: Measurable results of the EMS, related to an organization’s control of
its environmental aspects, based on its environmental policy and objectives and targets.
Environmental Policy: Statement by the organization of its intentions and principles in relation to its
overall environmental performance that also provides a framework for action and for setting of its
objectives and targets.
Environmental Program Indicator: A specific datum selected, such as volume of a chemical used,
which will provide measurable information regarding progress toward meeting a specific environmental
objective and target.
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Environmental Target: Detailed performance requirement, quantified where practicable, applicable to
the organization or parts thereof, that arises from the environmental objectives and that needs to be set
and met in order to achieve those objectives.
Executive Overview Course: A briefing provided to the relevant officer staff and other top
management at PCD on the EMS. This briefing familiarizes these individuals with general EMS
concepts and with selected elements of the EMS that they ought to be familiar with. Most specifically, it
lays out their roles and responsibilities with respect to the EMS, including their roles in establishing the
PCD Environmental Policy and in conducting the periodic Management Reviews.
External communication: Communication to parties or organizations external to PCD’s physical site
boundaries or its functions and activities.
External interested party: Individual or group concerned with or affected by the environmental
performance of PCD.
General Environmental Awareness Training: Training that is provided to all personnel irrespective
of whether they are associated with significant environmental aspects.
Implementation Training: Training provided, if needed, to those responsible for implementing or
supporting the EMS. This course instructs attendees on the basic principles of the EMS, provides
sample procedures that can be adapted by the organization, suggests the use of certain templates that
simplify implementation, and discusses the resources and organizational support required for the EMS
development and implementation effort.
Incident or Emergency: Constitutes more than a mere nonconformity in the EMS. Any event that
invokes the ISCP. For purposes of the EMS, nonconformities that do not invoke the ISCP will be
corrected through the provisions of the PCD “Non-conformance and Corrective and Preventive Action
Procedure.” Responses to emergencies such as fires, floods, and earthquakes are managed through the
National Incident Management System (NIMS), Incident Command System (ICS). If the emergency is
severe or long lasting, the PCD Emergency Operations Center (EOC) may be activated.
Inputs, Products, and Services: Term used to encompass the everyday activities of an installation.
Includes, but is not limited to training on ranges; munitions testing; construction and renovation of real
property; manufacturing activities; commercial services such as dry cleaning, photo processing, etc.;
wash rack operations; grounds maintenance; vehicle maintenance; etc. (In this procedure the term
Inputs will be used in place of the full term Inputs, products and services and is synonymous to the term
“activities” found in the ISO-14001:2004 standard)
Installation Spill Contingency Plan (ISPC): A plan implemented immediately whenever there is a
potential or an actual event such as fire explosion or release of oil or hazardous substances/waste. The
ISCP meets the requirements of 40 CFR 264 (RCRA).
Installation Sustainability Team (IST): Team of facility personnel representing various installation
activities and tenants selected by their organizational leader to serve as representatives for the various
functional areas on the installation. The team’s responsibilities are to gather, organize, and disseminate
information; help to develop EMS procedures; advise, coordinate, facilitate, and monitor EMS
implementation; and assist the EMS Program Manager with EMS-related matters.
Interested Party: Individual or group concerned with, or affected by the environmental performance of
an organization.
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Internal Communication: Communication within PCD that is intended for personnel to further the
EMS goals.
Internal EMS Audit: A periodic audit of the EMS to verify that it is properly implemented and that it
continues to conform to planned arrangements for environmental management. It is an audit of the
system and findings are expressed as non-conformities. Audit conclusions are based on the findings and
focus on the root causes that led to the non-conformities. It is appropriate to seek the root causes of
known compliance findings during an EMS audit, since these may reflect EMS deficiencies.
Legal Requirements: EMS legal and other requirements encompass all the constraints imposed on PCD
to control its environmental aspects and operations. These constraints include federal, state, and local
laws and regulations, environmental permits, registrations, executive orders, and consent decrees. In
addition, internal organizational procedural requirements pertaining to environmental aspects such as
military (e.g., Department of Defense [DoD] and Department of Army [DA]) instructions, directives,
manuals, and policy decisions also apply. These internal requirements take on the same importance as
legal requirements and are expected to receive the same degree of commitment to compliance.
Non-compliance: Failure to meet regulatory or other requirements that have been imposed on the
organization.
Non-conformity: Any deviations from established procedures, programs and other elements of the
EMS. They may include non-compliance with regulations, but not all instances of non-compliance are
necessarily non-conformities of the EMS.
Operational Controls (OCs): Mechanisms (technological or administrative) used to maintain a desired
level of environmental performance. OCs are applied to PCD Inputs to prevent the environmental
aspect they exhibit from occurring. Shop Environmental Instructions will be develop to inform
personnel of environmental responsibilities. Examples of OCs include those built into technology (e.g.,
motion sensors, sleep mode for electronics, etc.), those requiring operator intervention (e.g., selecting
duplex printing, electronic documents, etc.), and those that are incorporated in standard operating
procedures (SOPs) (e.g., procedure for storage and disposal of hazardous waste).
 Each significant environmental aspect shall be reviewed in conjunction with its inputs to
determine whether OCs (either technological or administrative) are needed for those inputs.
 In doing the review, special attention shall be given to those characteristics of Inputs that
necessitate OCs.
 Where applicable, documentation on the OCs will specify the operating criteria (including
maintenance) and the actions to be taken when they are interrupted, or when they might
otherwise fail.
 When necessary, OCs will also be applied to the identifiable significant environmental
aspects of goods and services that are received from external sources and used at PCD.
When appropriate, OCs that need to be implemented by the external source shall be duly
communicated to those sources. (Refer to EMS Communications Procedure, if applicable)
 Operations managers are responsible to ensure that OCs are implemented for those inputs
that are within their purview and that contain significant environmental aspects. OCs will be
integrated into Shop Environmental Instructions (SEIs) as those are developed and
implemented across operations at PCD.
Personnel: All persons working at PCD, including contractors that are on PCD for greater than 6
months.
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Preventive Action: Action to prevent potential problems before they occur at other areas or functions
of the organization that may have similar vulnerabilities to that which caused the original non-
conformity. . Preventive action can be focused on identifying negative trends and addressing them
before they become significant.
Record: A document stating results achieved or providing evidence of inputs performed (ISO
14001:2004 definition). A record is a permanent document that typically is not revised. Records will
include:
 Information on compliance with applicable legal requirements and other requirements to
which the organization subscribes,
 Details of nonconformities and corrective and preventive actions,
 Results of environmental management system audits and management reviews, information
on environmental attributes of products (e.g. chemical composition and properties),
 Evidence of fulfillment of objectives/targets,
 Information on participation in training,
 Permits, licenses or other forms of legal authorization,
 Results of inspection and calibration activity, and
 Results of operational controls (maintenance, design, manufacture).
Relevant Communications: Verbal or written inquiries deemed appropriate for response based on
installation policy and concern for confidentiality.
Root Cause Analysis: Root cause analysis is the method used to identify immediate, underlying and
root causes of an incident. The analysis of the root causes aims to find the proper corrective and
preventive actions to apply to remove those causes and thereby prevent both a recurrence of the incident
and its potential future occurrence in other parts of the organization.
Significant Environmental Aspect: An environmental aspect that has, or can have, a significant
environmental or mission impact (i.e., one that can potentially cause a significant environmental or
operational impact).
Spill Prevention, Control and Countermeasures Plan (SPCCP): The plan are required by Section
311(j) of the Clean Water Act to establish procedures and guidance for the prevention, detection, and
response to releases, accidents, and spills involving oils or hazardous substances at Pueblo Chemical
Depot.
Suitability: Refers to whether the EMS continues to accord with the nature of the organization.
Suppliers and contractors: Organizations or individuals that provide supplies, materials, services and
other tangible goods to PCD.
Top management: For purposes of this procedure, top management will include, at a minimum, the
Depot Commander or Deputy Commander and other members of the Command Staff.
Verification: A follow-up visit by the audit team to ascertain that corrections, and corrective and
preventive actions have been appropriately completed. The decision to do this is based upon the
frequency, severity, and/or risk of continued nonconformity, as well as on whether the finding was either
a major or critical audit finding.
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1.5 EMS Acronyms
AAR after-action review
ABC activity-based costing
ACSIM Assistant Chief of Staff for Installation Management
AEDB-EQ Army Environmental Database - Environmental Quality
ANSI American National Standards Institute
AR Army Regulation
ARIM Army Reserves Installation Management
ARNG Army National Guard
ARTEP Army Readiness Training Evaluation Programs
BACM best available control measures
BACT best available control technology
BADT best available demonstrated technology
BMP best management practice
CAA Clean Air Act
CAAA Clean Air Act amendments
CAIRA Chemical accident/incident response and assistance
CAR corrective action report
CDPHE Colorado Department of Health and the Environment
CBT computer-based training
CDR commander
CERCLA Comprehensive Environmental Response, Compensation and Liability Act
CFCs chlorofluorocarbon
CFR Code of Federal Regulations
CFT cross-functional team
CONUS Continental United States
COTS commercial off-the-shelf
CWA Clean Water Act
DDMS Digital Document Management System
DENIX Defense Environmental Network Information Exchange
DFE Design for the environment
DoD Department of Defense
DPW directorate of public works
DSERTS Defense Site Environmental Restoration Tracking System
DTC Document Tracking Center
EAP environmental action plan
ECOs environmental compliance officers
EMO Environmental Management Office
EMP environmental management programs
EMS environmental management system
EMSMR environmental management system management representative
EMSR Environmental Management System Representative
ENFs enforcement actions
EO Executive Order
EPA U.S. Environmental Protection Agency
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EPAS Environmental Program Assessment System
EPCRA Emergency Planning and Community Right-To-Know Act
EPI environmental performance indicators
EPR Environmental Program Requirements
EQCC environmental quality control committee
ESA Endangered Species Act
FAT facilities, activities and tasks
FIFRA Federal Insecticide, Fungicide, and Rodenticide Act
FRP Facility response plan
FY fiscal year
GC Garrison Commander
GIS global information system
GOCO government-owned, contractor-operated
GPS global positioning system
HAP hazardous air pollutant
HAPPS hazardous air pollution prioritization system
HAZMAT hazardous material
HAZWOPER Hazardous Waste Operations and Emergency Response
HMTA Hazardous Materials Transportation Act
HOA homeowners association
HW hazardous waste
HWDMS hazardous waste data management system
ICAPs installation compliance action plans
ICS incident control center
IESIS Installation Environmental Support Information System
IMA Installation Management Agency
IMRO installation management regional office
IPR in-process review
ISO International Organization for Standardization
ISR Installation Status Report
IT information technology
METL mission-essential task list
MSDSs material safety data sheets
NAAQS national ambient air quality standards
NCA Noise Control Act
NEPA National Environmental Policy Act
NFA no further action
NLT no later than
NOV notices of violation
NOx nitrogen oxides
NPDES national pollutant discharge elimination system
OB/OD open burn/open detonation
OCONUS Outside Continental United States
ODCs ozone depleting chemicals
OFEE Office of the Federal Environmental Executive
P2 Pollution Prevention
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PAO public affairs office
PAIO Program Analysis and Integration office
PCD Pueblo Chemical Depot
PL Public Law
PM2.5 particulate matter with diameter less than or equal to 2.5 microns
POC point of contact
POL petroleum, oil, or lubricant
POTW publicly owned treatment works
RCRA Resource Conservation and Recovery Act
RDT&E Research, development, testing, and evaluation
REOs regional environmental offices
RRC Regional Readiness Commands
SCP Spill contingency plan
SDWA Safe Drinking Water Act
SOP standard operating procedure
SOx sulfur oxides
SPCC Spill Prevention, Control, and Countermeasures
SPCCP Spill Prevention, Control, and Countermeasures Plan
SRS Strategic Readiness System
SS significance score
SVOC, Semi-Volatile Organic Compound
TDA Table of Distribution and Allowances
TEAM The Environmental Assessment Manual
TOE Table of Organization and Equipment
TSCA Toxic Substances Control Act
USAEC U.S. Army Environmental Center
USAES U.S. Army Engineer School
USC United States Code
UXO Unexploded Ordinance
VOC volatile organic compounds
WREO Western Regional Environmental Office – US Army
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2. PCD Scope and Characteristics
2.1 PCD Background & Mission
The Pueblo Chemical Depot is located in Pueblo County, Colorado, about 100 miles southeast of
Denver and 14 miles east of Pueblo; the Arkansas River is approximately one mile south of the activity.
The facility encompasses 22,654 acres and is situated on flat to gently sloped prairie. The surrounding
lands are mostly undeveloped ranchlands used for grazing, with some light commercial and residential
zoned areas to the south.
The depot houses a chemical stockpile which comprises about 8 percent of the nation’s original
chemical materiel stockpile. This stockpile is scheduled for future destruction under the Department of
Defense Assembled Chemical Weapons Alternatives program. The depot’s current mission is the safe
and secure storage and monitoring of the chemical stockpile, preparation for destruction of the chemical
stockpile and preparation for depot closure.
Construction of the depot began in February 1942. The installation was originally named Pueblo
Ordnance Depot, and the first carload of ammunition was received in August 1942. Although originally
planned for the storage and supply of ammunition, facilities were expanded almost immediately to
receive, store, and issue general supplies to support World War II.
In 1946, Pueblo Ordnance Depot was assigned the mission of maintaining and overhauling artillery, fire
control, and optical equipment. Two years later, ammunition renovation and demilitarization were added
to that mission.
During the Korean War, shipments of general supplies and ammunition increased, and the depot reached
its highest civilian strength of nearly 8,000 employees. Missile maintenance was added to the depot’s
mission in the 1950s and in 1962, the depot was renamed Pueblo Army Depot.
The missile maintenance mission at Pueblo, with the exception of maintenance of the Pershing missile,
was transferred to Letterkenny Army Depot in 1974. In 1976, Pueblo was given depot activity status and
assigned to the Tooele Army Depot Complex.
In December 1987, the United States and the former Soviet Union entered into the Intermediate-Range
Nuclear Forces (INF) Treaty. Pueblo was assigned to disassembly and elimination activities. Pueblo
completed its INF and Pershing mission in May 1991.
Pueblo Depot Activity was in the forefront of support to Operation Desert Shield and Desert Storm,
shipping a large part of contingency stocks in addition to ammunition and supplies to Southwest Asia.
The Base Realignment and Closure Commission designated the depot for realignment in 1988. The
installation was renamed U.S. Army Pueblo Chemical Depot in 1996.
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2.2 PCD Facility Description
Approximate Total number of employees: 330 Army civilian and military employees
Approximate Total number of buildings or
structures:
2,200
Approximate Property acreage: 22,654 acres
Activities that occur outside site boundaries: None
Size of EMS team: Approximately 10, including all the Environmental
Management Office personnel and individuals
representing various functions and tenant groups at
the Depot
EMS Implementation Start Date November 27, 2006
Composition of EMS team: Led by the EMS Manager with representatives from
other functions
The scope of the PCD EMS includes the following facilities and organizations within the PCD: Pueblo Chemical
Depot (PCD), Pueblo Chemical Agent-Destruction Pilot Plant (PCAPP).
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Establishment of ISO 14001 EMS at Pueblo Chemical Depot
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2.3 PCD Significant Environmental Aspects (See section 4.1 of this manual on the development of
the following list and its abbreviations.)
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3. PCD Environmental Policy
The PCD Environmental Policy is a declaration of top management’s commitment to the environment and serves
as the foundation for the EMS. Everyone in the organization is expected to be familiar with and understand the
policy. The policy is considered when setting EMS objectives and targets, and it is understood that the
implementation of the EMS serves to make the commitments in the policy operational. The environmental policy
statement is, therefore, a vehicle for communicating the organization’s aspirations for environmental protection as
well as a functional tool for establishing the operational boundaries of the EMS. The environmental policy aligns
with the organization’s core mission and must include commitments to continual improvement, pollution
prevention, and regulatory compliance. The environmental policy statement should reflect a management
consensus on its contents and aims, and should be formalized through the signature of top management. Red
River’s environmental policy is:
Pueblo Chemical Depot's environmental policy is an integral part of our mission, and is the core of the Depot's
Environmental Management System. This policy states in broad terms the environmental commitments of Pueblo
Chemical Depot now and into the future. Pueblo Chemical Depot strives to be one of the national leaders in
environmental, energy and natural resource stewardship. Red River's primary focus areas are prevention,
compliance, restoration and conservation. The EMS program manager, Environmental Division is responsible for
Pueblo Chemical Depot's Environmental Management System. However, environmental stewardship is the
responsibility of every member of the work force, as well as its strategic partners and residents. Depot personnel
consider many environmental aspects when assessing current and upcoming projects. Personnel consider
environmental impacts of operations and activities through setting objectives and targets relevant to
environmental aspects, planning, monitoring and revisions to achieve continuous improvement of our
Environmental Management System. Pueblo Chemical Depot implements and will continue to implement new
and innovative ways to prevent pollution, minimize waste, manage natural resources and to conserve energy.
Pueblo Chemical Depot's personnel ensure that all activities comply with relevant environmental legislation,
regulations and policies. We will continue to maintain a positive relationship with the local community,
regulators and other governmental agencies.
PCD’s Environmental Policy is supplemented by specific requirements and provisions in the following additional
documents:
 AR 200-1 – Army Regulation 200-1 Environmental Protection and Enhancement
• Army Regulation 200-2, Environmental Affects of Army Actions
• Army Regulation 200-3, National Resources – Land, Forest, and Wildlife Management
• Army Regulation 200-4, Cultural Resources Management
• Air Pollution Prevention and Control Act (Clean Air Act [CAA] of 1977, as amended 42 United
States Code [USC] § 7401 et seq.)
• National Ambient Air Quality Standards, Title 40 Code of Federal Regulations (CFR) Part 50
(CAA § 109).
• Colorado Department of Health and the Environment Regulations
• Designation, Reportable Quantities, and Notification, 40 CFR 302 (CERCLA § 103)
• Emergency Planning and Community Right to Know Act (EPCRA) of 1986 (42 USC § 11001) -
Title III of the Superfund Amendments and Reauthorization Act, (Public law [PL] 99-499,
October 17, 1986, as amended by PL 102-389, October 6, 1992)
• Emergency Planning and Notification, 40 CFR 355 (EPCRA § 312)
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• Executive Order 13148 - Greening the Government through Leadership in Environmental
Management
• Executive Order 13423 – Strengthening Federal Environmental, Energy, and Transportation
Management
• Executive Order 13514 – Federal Leadership in Environmental, Energy, and Economic
Performance
• Hazardous Chemical Reporting: Community Right to Know, 40 CFR 370 (EPCRA § 312)
• Federal Water Pollution Control Act (Clean Water Act [CWA] of 1972, as amended [33 USC §
1251 et seq.])
• Storm water discharges associated with industrial activity, (40 CFR 122.26 (b)(14)(i)-(xi))
• General Provisions, 40 CFR 401
• Oil Pollution Prevention, 40 CFR 112 (CWA § 311)
• Hazardous Materials Transportation Act of 1974, as amended (49 USC § 5100 et seq.)
• General Information, Regulations, and Definitions, 49 CFR 171 Hazardous Materials
• Information and Training Requirements 49 CFR 172
• General Requirements for Shipments and Packaging 49 CFR 173
• Training, 49 CFR Part 172, Subpart H
• National Environmental Policy Act (NEPA) of 1969 (42 USC § 4321 et seq.)
• Resource Conservation and Recovery Act (RCRA) of 1976, as amended (42 USC § 6901 et seq.)
• Hazardous Waste Management System: General 40 CFR 260
• Identification and Listing of Hazardous Waste, 40 CFR 261
• Standards Applicable to Generators of Hazardous Waste, 40 CFR 262
• Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal
Facilities, 40 CFR 264
• Standards for Management of Used Oil, 40 CFR 279.
 Near Real Time Monitoring Systems SOP-PU-0000-R-491(and incorporated references)
 Toxic Chemical Laboratory Analytical Operating Procedures SOP-PU-0000-R-465 (and
incorporated references)
 PCD Site-Specific Laboratory Quality Control Plan (and incorporated references)
 PCD Regulation 385-61-2 Chemical Hygiene Plan (and incorporated references)
 PCD SOP PU-0000-M-486 Chemical Operations (and incorporated references)
 PCD CAIRA Plan (and incorporated references)
3.1 EMS Implementation
The Pueblo Chemical Depot (PCD) has implemented an Environmental Management System
(EMS) to ensure it fulfills the commitments to its Environmental Policy. The scope of the PCD
EMS includes the following PCD and all tenants The EMS is modeled on the specifications
found in the international standard for environmental management in organizations, ISO-
14001:2004. Specific benefits provided to PCD from implementing a formal management
discipline include:
a. The systematic approach to managing PCD’s potential impacts on the environment.
b. Enabling PCD environmental concerns to be managed to accord with mission goals.
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c. Providing documentation of existing processes so that results can be repeated.
Institutional knowledge is captured so it is not subject to personnel flux.
d. Providing a structured approach to identify potential impacts that could otherwise
result in costs, embarrassments, and threats to mission.
e. Having the potential to provide employees with a sense of empowerment that can
translate to enhanced performance on the job.
f. Providing the site with a means to track and measure environmental and
operational performance by instituting metrics.
g. Providing greater discipline and assurance in tracking and analyzing environmental
requirements thus ensuring a higher level of compliance.
h. Allowing PCD to use a risk management approach ensuring the site focuses and
allocates its resources to those that have the greatest probability and worst potential
consequences.
i. Providing for greater sharing of knowledge and responsibilities across all levels and
functions.
j. Supporting reporting under Government Performance Results Act (GPRA).
3.1.1 Summary of Pertinent EMS Concepts
3.1.1.1 Background
Formal Environmental Management Systems (EMS) emerged in the early 1990s to provide
organizations with a proactive, systematic approach for managing the potential environmental
consequences of their operations. Such systems have been widely adopted by industry and
government and have been effective at improving regulatory compliance and environmental
performance.
In April 2000, President Clinton signed Executive Order (E.O.) 13148, “Greening the
Government through Leadership in Environmental Management” that established a 5-year
EMS implementation goal for all Federal Facilities.
3.1.1.2 EMS Model
Although several recognized EMS frameworks exist, most are based on the International
Organization for Standardization’s ISO-14001 EMS standard. As a result, ISO-14001 is the
framework on which organizations most frequently choose to base their EMS, and this has
proven to be the case with U.S. federal facilities.
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1. Phase 1: Planning
The organization identifies how its
operations might harm the
environment, and develops measures
to reduce this harm.
2. Phase 2: Doing
The organization implements the
systemic measures to minimize
harm across all levels and
functions of its operations.
3. Phase 3: Checking
The organization assesses the
effectiveness of the systematic
measures for minimizing both the
potential harm to the environment
and its consequential impacts to
mission.
Phase 4: Acting
Based on its assessment of the implemented systemic measures, the organization undertakes actions
to make system adjustments and to promote continual improvement.
.
The findings of Phase 4 may indicate that adjustments to measures already in place are
necessary or that entirely new approaches are needed to achieve desired environmental
objectives. Output from this phase is fed back into Phase 1 Planning, to make necessary
changes and additions designed to bring the EMS to the desired level of effectiveness. This
system feedback propels the continual improvement of the EMS.
The EMS continually moves through this cycle, fine-tuning its management of those areas of
the organization’s operations that harm the environment. This “continual improvement cycle”
is a fundamental characteristic of the EMS; it allows the system to adapt to the dynamic nature
of the organization’s operations and to remain relevant and viable for its intended purposes.
4. EMS Procedures
Chapter 4 contains PCD’s EMS Procedures. Each procedure describes the methodology used by PCD to execute
various elements of an integrated EMS. The purpose of these procedures is to enable those who maintain the
EMS to understand the requirements of the EMS and to ensure a reliable and consistent execution of those
ACT
Management
Review
CHECK-Checking &
Corrective Action
• Monitoring & measurement
• Non-conformance,
corrective & preventative
action
• Records
• EMS audit
PLAN-Planning
• Environmental aspects
• Legal & other requirements
objectives & targets
• Environmental management
program
DO-Implementation & Operation
• Structure & responsibility
• Training, awareness & Competence
• EMS documentation
• Operational control
• Emergency preparedness & response
Figure 1: ISO14001 EMS Model
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requirements for an effective system. This chapter contains the authorized verbatim version of these procedures.
Copies may be distributed to relevant functions and levels at PCD so that they are available to those individuals
that need to reference them.
This chapter contains the following EMS Procedures:
a. Identifying Significant Environment Aspects
b. EMS Audit Program and Compliance Status
c. Communications
d. Document Control
e. Environmental Management Programs/Operational Controls
f. Emergency Preparedness and Response
g. Legal and Other Requirements
h. Monitoring and Measurement
i. Management Review
j. Nonconformity, Corrective and Preventive Action
k. Objectives and Targets
l. Control of Records
m. Awareness and Competency Training
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4.1 Identifying Significant Environmental Aspects
1. 0 Purpose and Scope
The purpose of this procedure is to identify the significant environmental aspects of the inputs
associated with PCD’s activities, products, processes, and/or services in order to set objectives and
targets for PCD’s Environmental Management System (EMS). The objectives and targets for significant
environmental aspects will then be achieved through the implementation of Environmental Management
Programs (EMPs).
This procedure will be applied to all Inputs within the scope of the EMS that have aspects that are under
the direct control or influence of PCD. It is applied equally to those aspects within the scope of the
EMS at PCD that may originate from external sources.
2.0 Definitions
For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4.
3.0 Procedure
The following approach will be implemented by the EMS Manager, in coordination with Environmental
Management Office (EMO) personnel, to identify the significant environmental aspects associated with
installation Inputs.
3.1 Define/Identify PCD Activities and Inputs
Initial identification of activates will be based on the Depot’s mission. Initial identification of Inputs for
those activities will begin with the EMS Manager identifying every organization that resides at PCD.
They will create a baseline of the Inputs that are within the scope of the EMS and that have the
possibility of interacting with the environment together with their environmental aspects and potential
impacts. Each activity will have at least one Input. Each Input will have one or more aspects associated
with it; likewise, each Input and aspect will have one or more environmental impacts identified.
The baseline list, in spreadsheet format (see Attachment A), will include Inputs that exhibit aspects that
will be further considered for their significance. Any aspects that result from Inputs controlled or
influenced by the installation or tenant will be evaluated for significance. In addition to identifying each
Input and aspect, the baseline list must also include information on the potential environmental
impact(s) associated with each Input.
A number of sources may contain relevant and applicable information that can be used to assist in the
development of the baseline list. These sources include, but are not limited to installation operation
plans; records of emergency response activities; environmental release incidents; environmental impact
statements; range assessments; permit applications; outsourcing documentation; etc.
Additional information regarding environmental aspects will be collected by:
 Brainstorming – Functional managers with a detailed knowledge of PCD’s specific Inputs will
be assembled. This brainstorming team will meet to review PCD’s operations and reflect upon
the likely sources of environmental implications (the aspects). Daily installation Inputs will be
considered first, followed by Inputs that occur on a less frequent basis. Functional managers
assembled for the brainstorming will include at a minimum: Environmental Program managers.
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 Facility Walk Through – A physical walk-through of all areas and operations serves as a visual
“trigger” to ensure that Inputs that should be included in the analysis are not inadvertently
overlooked. The walk-through team will visit each work area within PCD and visually identify
all of the Inputs that contribute environmental aspects, and make any necessary adjustments to
the initial list. After the walk-through, the team will compare its list of “contributors” against the
initial list and make necessary adjustments.
The following Inputs must be included in the baseline list of Inputs:
 Inputs that have obvious regulatory or other requirements.
 Inputs that have visible impacts on the environment.
 Inputs that may not have visible impacts but are known to potentially cause harm to the
environment or human health.
The following Inputs do not need to be included in the baseline list of Inputs:
 Inputs that have minor and temporary impact on the environment.
 Inputs that have been previously declared by qualified, competent experts to be insignificant.
 Inputs that do not satisfy any of the criteria as outlined above.
3.2 Define/Identify PCD Aspects and Impacts
Once the baseline spreadsheet of Inputs and their associated environmental aspects and impacts is
completed, it is provided to all program managers of PCD’s Environmental Management Office (EMO)
for review. The program managers will review this baseline list against existing environmental
programs to determine its accuracy and provide feedback on baseline environmental aspects. The EMO
will also assist the EMS Manager in refining the description of each of the potential environmental
impacts associated with the aspects identified in the baseline list.
The aspects related to inputs that should be cataloged include both those that can be directly controlled
as well as those that can be influenced. It is important to remember that these aspects are only those
from the organization’s Inputs that fall within the scope of the EMS. The determination of aspects is
made by following a sequence of questions:
1) What is the scope of the EMS?
2) What are the Inputs within that scope?
3) What are the aspects of these Inputs?
4) Which of these aspects can be directly controlled?
5) Which of these aspects can be influenced? Those that can neither be directly controlled nor
influenced should not be included in the EMS.
PCD will also identify and address any impacts that may have a cumulative effect. This is especially
important because a large number of different Inputs may produce a common impact. Individually, the
impacts from these Inputs may be low, but in some cases, the cumulative impact may be significant.
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3.3 Identifying PCD Significant Aspects
3.3.1 Having identified the environmental aspects of PCD Inputs, the EMS Manager with assistance
from the IST will evaluate their significance. In general, all aspects that have a legal or other
regulatory requirement will be considered to be significant environmental aspects.
Other factors that bear on significance will consider the severity of environmental, mission, and
community impacts if the aspect were to occur and actually cause its greatest potential negative
consequences. If one of these other factors is given a “high” severity score then the aspect will be
considered a significant aspect irrespective of the existence of any applicable legal or other
requirements. Inputs that score “high” on any of the impact categories will be listed in the
Operational Control section of the EMPs. These other significance factors will be scored using the
following criteria:
1. Positive or Negative Impact to the Environment:
 (3) High: Environmental consequences are serious but reversible over time.
Environmental benefits to ecology or to human health and welfare are moderate.
 (2) Medium: Environmental consequences are noticeable but brief or totally correctable
in a relatively short time period. Environmental benefits to ecology or to human health
and welfare are minimal.
 (1) Low: Environmental consequences are immediately reversible and and/or
administrative, brief and totally correctable. Environmental benefits to ecology or to
human health and welfare are minimal or non-existent.
2. Positive or Negative Impact to Mission Capability:
 (3) High: Interruption of normal mission operation (e.g. line stoppage) is likely and
severe and could result in fines or remediation. Benefit to the organization or mission
capability is substantially improved.
 (2) Medium: Interruption of normal mission operation (e.g. line stoppage) is likely but
recoverable without significant repercussions or the cost of a fine or remediation is
moderate. Benefit to the organization is moderate or mission capability is moderately
improved.
 (1) Low: Interruption of normal mission operation is either unlikely or the consequences
are very slight or easily corrected. Benefit to the organization or mission capability is
minimally improved.
3. Positive or Negative Impact to the Community:
 (3) High: Community would become concerned/aware but not unified in its opposition.
Would produce media coverage and may or may not lead to legal action, political
pressure, or significant embarrassment to PCD.
 (2) Medium: Community may or may not become concerned/aware but would not be
concerned and not likely to result in media coverage, legal action, political pressure or
significant embarrassment to PCD.
 (1) Low: Transparent to community and not a concern, not likely to result in media
coverage, legal actions, or political pressure to PCD.
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3.3.2 The updated spreadsheet (an example sheet is enclosed as Attachment D – Significant Aspects
Identification Table) that documents the significant aspects will be sorted by organization and
distributed to the leaders for review and comment. The last updated spreadsheet can be found in
section 2.3 of this manual.
3.3.3 The EMS Manager will finalize the list and staff it to the Depot Commander for approval.
3.3.4 Once finalized and approved, the list becomes input to the EMS Procedure for Objectives and
Targets.
3.4 Keeping the List of Aspects Updated
This procedure will be applied as necessary to ensure that the PCD EMS identifies all significant aspects
and will be reapplied every 18 months to maintain the currency of the EMS.
4.0 Guidance for Creating the Aspects Spreadsheet
4.1 Consolidate Inputs Within Each Significant Aspect and Determine Need for Subgroups.
The resulting list of significant aspects and their corresponding Inputs may be sub-divided into
subgroups. In general, determining whether or not to split significant aspects into subgroups is
based on management considerations for ease of tracking, for clarity in the assignment of
responsibilities, and for operational considerations including the setting of objectives and targets and
the development and implementation of EMPs. For example, the split may be made along
organizational lines or to highlight a particular source:
• Organizational Differentiation: It may be that one part of the organization contributes a
considerably greater proportion to the significant aspect than all of the other parts combined. In
this instance, it would make sense to have a subgroup for that part of PCD (with the objective to
improve on its performance) and a subgroup for the other parts (with the objective to maintain
their performance).
• Source Differentiation: It may be that there are two (or more) distinct classifications of
sources that contribute to a common significant aspect. For example, painting and degreasing
operations (generating volatile organic compounds) and internal combustion engine operations
(generating Sox, Nox, and CO emissions) may both contribute to the aspect on Air Emissions.
In this instance, it would make sense to split them into two subgroups since each would have a
different strategy to improve its own performance.
4.2 Evaluating New/Modified Inputs
The EMO Director and/or EMS Manager will attend Production Planning Meetings (PPM). PPM
meetings discuss new and changing functions within the Directorate for Maintenance. An additional
method of notification that may be utilized is whenever a new Input is initiated, or an existing Input
is modified, the relevant organization shall notify the EMS Manager by routing information on the
new or modified Input to the Environmental Division.
The NEPA Coordinator in EMO will also route pertinent information on new or modified projects to
the affected EMO staff for an evaluation to ascertain if any significant environmental aspects have
been introduced and/or modified, and to make necessary adjustments in the EMPs.
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Newly identified significant aspects will be added to the EMS in accordance will all applicable EMS
procedures.
4.3 Evaluating Aspects from External Sources
This procedure is also applied to Inputs that originate from external sources (e.g., suppliers).
Significant environmental aspects at PCD that originate from such sources shall be managed like all
other significant environmental aspects. PCD may take steps to notify those external parties over
which it has some influence to mitigate any aspects that may reasonably be mitigated at the source.
Where no such influence exists or where mitigation at the source is infeasible, PCD will address
such aspects within its own EMS.
5.0 Records
The PCD EMS Manager will keep and maintain the following records that result from this procedure
(the information may be organized into separate lists or into one or more tables to facilitate access and
presentation):
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Attachment A: Operational Inputs and Associated Aspects and Impacts (sample)
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Attachment B: Significant Environmental Aspects List
1. Air Emissions (ODS (CFCs in building chiller systems), VOCs (fugitive emissions from vehicle
fueling operations, chemical cleaning, parts washing, painting, etc.), criteria pollutants (machinery
operations, vehicle operations, etc.), dust, particulates, odors)
2. Solid Waste Generation (other)
a. Paper/Cardboard Generation
b. Wood Pallet Generation
c. Scrap Metal Generation
d. Tire Generation
3. Hazardous/Regulated Industrial Waste Generation (laboratory or degreasing solvents, hazardous
batteries, empty chemical containers, used oil, paint filters)
4. Universal Waste Generation (waste paints, blast media, florescent lights, batteries, etc.)
5. Chemical Spills/Leaks to Surface or Ground Water (fuel, hydraulic leaks, POL, storage tank
leaks, perchlorate, cadmium, other heavy metals etc.)
6. Toxics Releases (TRI and TIER 2 inventories)
7. PCB Releases
8. Asbestos Releases
9. Lead Based Paint Releases
10. Pesticide Applications (grounds maintenance, pest control)
11. Liquid Discharges (point and non-point) to surface and/or ground waters [(industrial wastewater
contributions from painting operations, metal etching/plating, X-ray activities, vehicle maintenance
areas), sewage, wash-racks, air dryers, and storm-water]
12. Electricity Consumption (high electricity use operations)
13. Fuel Consumption (petroleum products, natural gas, and other alternative fuels)
14. Water Consumption (high water use operations)
15. Ecological Disturbance (NEPA, hydrological alteration, vegetation alteration, habitats, wetlands,
threatened and endangered species, invasive species, etc.)
16. Cultural Resource Disturbance (historic properties, graveyards)
17. Generation of Noise or Nuisances (testing operations, vehicle operation, vibration, visual
impairment)
18. Soil Erosion (construction activities and ground clearing)
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Attachment C: Sample Environmental Impacts
 Toxics contamination or addition to air, land, waterway
 Reduced visibility
 Air pollution (smog, acid rain, dust, visual impairment)
 Human health impact
 Landfill depletion
 Resource depletion
 Soil contamination
 Groundwater contamination
 Surface water contamination
 Hazardous material damage
 Biological material damage
 Ecological damage
 Ozone depletion
 Greenhouse gas release
 Habitat alteration
 Introduction of non-native species
 Pesticide damage
 Cultural resource property-damage
 Sedimentation of water courses
 Increased runoff / stream flow
 Watershed alterations
 Soil compaction
 Wind erosion
 Water erosion
 Loss or damage to threatened and endangered species
 Noise damage
 Vibration damage
 Heat damage
 Radiation damage
 Odor nuisance
 Nuisance to community
 Loss of indigenous species
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4.2 PCD EMS Audit Program
1.0 Purpose and Scope
The PCD EMS Audit Program is implemented to ensure the organization allocates resources, provides
qualified auditors, plans the execution of audits and otherwise arranges for the efficient and effective
conduct of internal EMS audits in support of the EMS. Internal EMS audits support the EMS and
provide a periodic check of its status so that management can make decisions regarding its continuing
suitability, adequacy and effectiveness. Internal EMS audits also assess conformance to the
requirements of the ISO-14001:2004 standard and are used to verify that the organization periodically
does compliance status checks. The PCD Audit Program is based on the ISO-19011 standard.
2.0 Definitions
For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4.
3.0 Approach
3.1 Audit Program Chart: International Organization for Standardization. (Final Draft 2002). ISO-
19011: Guidelines for quality and/or environmental management systems auditing. ISO/FBIS 19011:
2002(E).
Authority for the audit
program
Establish the audit program
• Objectives and extent
• Responsibilities
• Resources
• Procedures
Implementing the audit Program
• Evaluating auditors
• Selecting audit teams
• Directing audit activities
• Recording
Monitoring and reviewing
the audit program
• Identify opportunities for
improvement
Competence
of Auditors
Improving the
Audit Program Audit
Activities
P
L
A
N
D
O
C
H
E
C
K
A
C
T
3.2 Audit Program Manager Responsibilities - The EMS Manager also acts as the Audit Program
Manager for internal EMS audits and internal compliance audits. The EMS Manager has the following
responsibilities:
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a. Ensures adequate resources have been allocated in relevant budgets for the conduct of planned
internal EMS audits.
b. At the beginning of each fiscal year, plans the audit strategy (e.g., functions to be audited,
elements to be audited, schedule of audits, team members for each audit, lead auditor for each
audit, etc.).
c. Ensures sufficient auditors will be available and that they remain competent through further
training or other means of maintaining competency.
d. Stores and manages all documentation from previous audits (e.g., audit reports, records of
corrective actions, etc.).
e. Maintains Audit templates and checklists of criteria for use by the audit teams.
f. Evaluates auditors and makes decisions on qualifying additional individuals as competent
internal auditors.
g. Works with the lead auditor assigned to a given audit to establish the objectives for that audit and
to ensure that the proper resources and information are available to conduct the audit.
h. Ensures that the audit team conducts and completes the audit.
3.3 Frequency of EMS Audits
Internal EMS audits shall be scheduled on the basis of need as reflected by the importance of Inputs
or the results of previous audits, but not less than annually, in order to verify that the system is
implemented and functioning as expected. An individual audit may be limited to a sampling of EMS
elements or areas and can be both random and/or focused on certain Inputs based on their
importance and/or results of previous audits. The audit program manager will decide on the strategy
to be pursued in the audit at the beginning of each fiscal year.
3.4 Scope of EMS Audits
On an annual basis, internal EMS audits assess all operations and facilities described within the
scope of the EMS to determine conformance for these operations and facilities against the
requirements of ISO-14001:2004, and the organization’s internal performance objectives. Every
organization will be audited at least once annually. Depending on the results of previous audits, the
EMS Manager may opt to conduct one yearly audit or a series of audits that focus only on specific
elements.
3.5 Selection of Audit Team
The audit team shall be designated by the Depot Commander and shall consist of personnel that have
received internal EMS auditor training and are deemed competent to conduct such audits. The PCD
EMS Manager is responsible for overseeing the EMS Audit Program. He or she is also responsible
for selecting the lead auditor for a given audit. The designated lead auditor is responsible for
ensuring that the audit team conducts and completes the audit as planned. The Audit Program
Manager shall not be a member of the audit team.
The EMO Director may also bring in an outside contracted audit team to perform an internal audit or
periodically, as needed, to get a fresh perspective and overview of whether the EMS is meeting
established goals and functionality.
3.6 Internal Audit Procedure
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The internal audit will be conducted in accordance with the Internal EMS Audit Procedure (for
details, please refer to that procedure below). EMS internal audits shall be conducted against pre-
established audit criteria (see below). The audit criteria may be based on the sample audit criteria
provided below which can be tailored to suit the specific needs and goals of the organization based
on input from the EMS Manager and the lead auditor.
Audit criteria shall consist of questions based upon the specified arrangements for the EMS, and
shall be designed to elicit evidence of conformity with the organization’s EMS requirements. The
focus of the EMS audit is to ascertain whether the EMS has been effectively implemented and is
functioning in accordance with established PCD-specific arrangements.
Audit findings must be based on objective evidence that is properly corroborated and authenticated.
(Auditors shall avoid reaching conclusions on the basis of hearsay or opinion.)
3.7 Compliance Status
The EMS audit may also be used to verify that the compliance status has been established as
arranged. The compliance status may be based on the results of a recent internal compliance audit
(EPAS) that may have occurred. All internal compliance audits will utilize the most current EPAS
Team Guide. PCD will rely on the internal EPAS compliance audits to ascertain its compliance
status. Ongoing compliance checks will be conducted via routine walk-around inspections
performed by the environmental division personnel.
The internal EMS auditor shall ascertain that the organization has previously conducted a
compliance status check as required by the ISO-14001:2004 standard.
3.8 Corrective Action
After conferring with the EMS Manager, the appropriate area or functional manager will address
findings within a specified number of days by developing corrective actions which will be included
in the summary response to the corrective action request.
If a nonconformity relates to the EMS itself, the EMS Manager will have the primary responsibility
to apply the corrective and preventive actions. In this instance, the audit team ensures that the
corrective and preventive actions have been completed when the next scheduled audit is conducted.
3.9 Preventive Action
Preventive action is undertaken to avoid repetition of the nonconformity in other areas or functions
of the organization that may have similar vulnerabilities that caused the original non-conformity. It
is the responsibility of the EMS Manager to initiate preventive actions as specified in the EMS
procedure for Nonconformity, Corrective and Preventive Actions. The execution of preventive
actions may be recorded in the Corrective Action Request report or it may be documented
separately.
For more detailed information, refer to the organization’s procedure for Nonconformity, Corrective
and Preventive Action.
3.10 Follow-Up
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At the conclusion of the audit, the audit team will determine whether any findings require follow-up
after the corrective and preventive actions are applied. This will be based upon the frequency,
severity, and/or risk of continued or potential nonconformities, as well as on whether the finding was
either a major or critical audit finding.
3.11 Closing the Audit
EMS audits are closed when the audit team leader establishes that the corrective and preventive
actions have been completed.
3.12 Input to Management Review and to Next EMS Audit
The Audit Report and actions taken to address findings will be inputs to the Management Review.
For more detailed information on the purpose and content of the Management Review, please refer
to the Management Review Procedure. (The audit report, corrective action requests and records of
corrective and preventive actions will also be available to auditors that will be preparing the next
scheduled audit.)
3.13 Audit Process Documentation
Documentation that result from the conduct of an EMS audit may include the items listed below.
The audit program manager provides proper templates for these items to the audit teams for their use
on audits:
i. Audit Plan
j. Audit Criteria
k. Internal Audit Report
l. Detailed Audit Findings and Conclusions
m. Completed corrective action.
3.14 Audit Resources
PCD management should be able to demonstrate that it has committed to allocate the resources
necessary to support the continual improvement of the EMS by providing budget and staff resources
necessary to maintain this EMS Audit Program. In addition, it should be able to show that auditor
training will be provided for the audit team as necessary and that contracted resources may also be
utilized, if necessary, to perform internal audits.
Attachments to Audit Program and Compliance Status:
1. Audit Work Flow
2. Audit Procedure
3. Audit Criteria
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Attachment 1 to Audit Program and Compliance Status: Audit Work Flow
to audit)
Attachment 2: Audit Work Plan
Initiating the Audit
Appointing the audit team
leaderDefinition of objectives, scope and
criteriaDetermination of the feasibility of the
auditEstablishing the audit
teamInitial contact
with the
audite
e
On site Audit
ActivitiesConducting opening
meetingCollecting and verifying
informationGenerate audit
findingsCommunicating during
the auditPreparing audit
conclusionsConducting closing
meeting
Reporting on the Audit
Audit report
preparationReport approval and
distributionRetention of
documents
Audit Completion
Audit Follow-up
Initiating the Audit
Appointing the audit team
leaderDefinition of objectives, scope and criteria
Determination of the feasibility of the
auditEstablishing the audit team
Initial contact
with he
Onsite Audit
ActivitiesConducting opening meeting
Collecting and verifying
informationGenerate audit findings
Communicating during the audit
Preparing audit conclusions
Conducting closing meeting
Reporting on the Audit
Audit report
preparationReport approval and
distributionRetention of documents
Audit Completion
Audit Follow-up

Document
Review of relevant management
documents and records and
determination of their adequacy
Audit Planning
Onsite
Activities
Audit
Completion
Preparing for Onsite Audit
Preparing the audit plan
Audit teamwork assignments
Preparation of work documents



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Attachment 2 to Audit Program and Compliance Status: Internal EMS Audit Procedure
Purpose and Scope
This procedure specifies the requirements for performing Internal Environmental Management
System (EMS) Audits at the Pueblo Chemical Depot (PCD). These audits are a part of the PCD
EMS and are conducted periodically to ascertain that the EMS is properly implemented and
continues to conform to planned arrangements for environmental management, including the
requirements of ISO-14001:2004.
Scope
An individual audit may be limited to a sampling of EMS elements or areas within the PCD, and can
be both random and/or focused on certain Inputs based on their importance and/or results of previous
audits.
Definitions
For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4.
Approach
Responsibilities:
The audit team shall be designated in writing and shall consist of personnel that have received
internal EMS auditor training and are deemed competent to conduct such audits. The PCD EMS
Manager is responsible for overseeing the EMS Audit Program. He or she is also responsible for
selecting the lead auditor for a given audit. A designated auditor will be responsible for ensuring
that the audit team conducts and completes the audit as planned.
Audit Planning:
Each audit requires an audit plan (see attached Audit Plan template) that is prepared by the lead
auditor for that audit. The audit plan addresses the following preparatory matters:
 Audit scope and objectives;
 Audit criteria to be applied;
 Contacts and coordination with the auditee(s);
 Audit dates, times, and other logistics;
 Review of previous audits, records, and descriptions (e.g., programs, operations, etc.);
 Protocol for conducting the audit (e.g., interviews, access, coordination, safety, resolution of
findings, etc.); and
 Responsibilities for writing the audit report and for follow-up actions.
Requirements:
 Individuals on the audit team must receive internal auditor training and be designated as
competent to conduct internal EMS audits;
 EMS audits will be conducted against pre-established audit criteria;
 The audit criteria shall be developed jointly by the entire PCD audit team, and approved by
the EMO Director;
 Audit criteria shall consist of questions based upon the specified arrangements for the EMS,
and shall be designed to elicit evidence of conformity with ISO-14001:2004 and PCD
arrangements for environmental management.
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4-21
 The focus of the EMS audit is to ascertain that the EMS has been effectively implemented
and is functioning in accordance with established arrangements; and
 Audit findings must be based on objective evidence that is properly corroborated and
authenticated. (Note: Auditors should avoid reaching conclusions on the basis of hearsay or
opinion.)
On-Site Audit Process:
 EMS audits will be conducted primarily through interviews with personnel;
 EMS audits may include sampling. For example, compliance data may be sampled to
ascertain that compliance programs are achieving their intended objectives;
 The EMS auditors may also rely on records for information related to the functioning of the
EMS and its objectives and targets;
 The EMS auditors may also rely on observations of operating conditions to gauge
environmental status and conditions, where appropriate and efficacious;
 The audit team will conduct opening and closing meetings with responsible management of
the areas being audited;
 The audit team will document corrective actions. Responsibility for corrective actions will
reside with management in the area where the findings occurred. If a corrective action
relates to the EMS itself, the PCD EMS Manager will have primary responsibility to arrange
for the correction to be made. The audit team validates that the corrective and preventive
actions have been completed by the auditee.
Regulatory Compliance Status:
The regulatory compliance status at PCD is established periodically through the external EPAS
audits, internal compliance audits, routine walk-around inspections, state audits, EPA audits and
other external audits.
Audit Report:
When the audit is complete, the audit team will complete the audit details. After audit details have
been completed they will be available to the PCD EMS Manager and the manager for the area
audited.
Closing the Audit:
The audit team will monitor the auditee’s completion of corrective and preventive actions for a
proper closing of the audit. The EMS audit is closed when the audit leader establishes that the
corrective and preventive actions have been accomplished.
Input to Management Review:
The results of the audit and the status of the corrective actions are to be presented at the next
scheduled Management Review meeting.
Records
Records generated by this procedure are maintained by EMS Program Manager and include the
following information:
1. Audit planning information
2. Audit criteria
3. Audit findings and conclusions
4. Completion of corrective and preventive actions.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
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Attachment 3 to Audit Program and Compliance Status: Audit Criteria, ISO-14001:2004
4.2,1 Environmental Management System Audit Criteria ISO 14001:2004
Purpose
The purpose of this document is to provide the criteria for the internal audit of the Environmental
Management System (EMS) implemented at PCD as required by Executive Order 13423.
Findings categories:
Major nonconformity finding: A significant number of minor findings against one element of the EMS
or a completely missing element.
Minor nonconformity finding: A single nonconformity against an element of the EMS.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
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Sample Audit Checklist
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
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4.3 PCD EMS Procedure for Internal and External Communications
1.0 Purpose and Scope
The purpose of this procedure is to establish a reliable and consistent process for addressing and
documenting communications pertinent to the Pueblo Chemical Depot (PCD) Environmental
Management System (EMS). Specifically, this procedure is used:
 To enumerate the internal communication tools and processes for communicating EMS-related
information between levels and functions inside PCD;
 For receiving, documenting and responding to relevant information and requests from external
interested parties; and
 To communicate information and/or requirements related to the identified significant environmental
aspects of goods and services (used or outsourced at PCD) to suppliers and contractors in accordance
with the requirements of PCD’s EMS.
This procedure is applied to all internal and external communications regarding the PCD EMS,
including communications initiated by PCD as well as communications from PCD in response to
external requests for information.
2.0 Definitions
For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4.
3.0 Approach
3.1 Internal Communications:
PCD utilizes several “information tools” as a means of maintaining a high level of information flow
between all levels of the Depot’s structure. These include: Intranet web sites, e-mails, telephone,
memorandums, recurring meetings, etc. All personnel are strongly encouraged to use these methods to
exchange ideas, discuss problems and ask questions from supervisors and other Depot members. Major
topics of internal communication include, but are not limited to:
 Environmental policy, objectives, and targets;
 Environmental roles and responsibilities;
 Environmental regulatory requirements;
 Environmental performance compared to objectives and targets;
 Environmental policies and procedures; and,
 Hazards and emergency response procedures.
The Depot Commander is responsible for communicating the installation’s environmental policy. The
proponent for all other internal environmental communications is the Environmental Division.
However, dissemination of environmental information to all installation personnel is the responsibility
of all levels of management. Conversely, all installation personnel are encouraged to provide feedback
through their appropriate chain of command on issues that could impact the environmental performance
of the installation.
1. The following actions promote internal communication regarding the PCD EMS:
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
4-32
 The PCD Environmental Policy will be communicated to all PCD personnel. A hardcopy of
the most current policy statement will be posted on all “official” PCD message boards
 EMS Training:
o Awareness Training – All PCD personnel will receive EMS Awareness Training. (New
personnel will receive this training during the New Employee Orientation.)
o Competence Training – For personnel whose work may involve significant
environmental impacts, PCD will evaluate competence and deliver training targeted to
the person’s job function, if that is deemed necessary to upgrade his or her skills.
o Outreach campaign – As necessary, EMS outreach efforts will be undertaken to promote
the EMS awareness (e.g., Earth Day activities, etc.).
o Contractors working on the depot for more than 6 months will be required to attend an
EMS Awareness training session. If their work may involve a significant impact, the
contractor will evaluate competence and deliver training targeted to the person’s job
function, as appropriate.
3.2 External Communications:
1. Consistent with its commitments in the Environmental Policy statement, PCD will communicate
relevant information regarding its EMS. Specifically, PCD will take the following actions under
its EMS:
 Make its Environmental Policy available to the public via the Environmental Monitor
quarterly news letter; the AQWA/PCD Web Site or upon request;
 Report all environmental information required by regulation to the appropriate authorities;
and
 PCD has considered the external communication of its significant environmental aspects and
will do so fully as required by law.
2. Regarding non-regulatory inputs from external interested parties, PCD has instituted the
following process:
 All written, non-regulatory external inquiries concerning environmental performance, are
received or routed to the PCD Public Affairs Office (PAO). A determination of Freedom of
information Act (FOIA) is made. If the inquiry is determined to be FIOA then it is
forwarded to the FIOA Office for processing.
 The SME provides documentation and generates the OPSEC review forms for staffing the
response prior to release from the Depot.
 The PAO shall ensure that the response is timely.
 The EMS Manager and Environmental Program Managers will consider all external
communications when establishing and reviewing environmental objectives and targets for
the EMS and will initiate any necessary changes to the EMS.
 All responses to inquiries from members of Congress will be coordinated through PCD Legal
Office and staffed through PAO for Depot Commander’s signature.
 PAO prepares responses to inquiries from the media will be coordinated through the PAO
and routed through the Legal Office and the Office of the Commander.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
4-33
3. Regarding regulatory written correspondence and requests, PCD has instituted the following
process:
 All regulatory requests concerning environmental performance are received or routed to the
EMO Director.
 The EMO Director may obtain input or task the appropriate EMO Program Manager to
prepare a response to the regulatory body.
 The EMO Director approves the response, and either signs it, or routes it for appropriate
signature either to the Director of Public Works, Legal Office or to the Depot Commander.
 Formal communications will be entered into the EISIS system or maintained in the EMO
master files.
3.3 Communications with Suppliers and Contractors:
1. PCD will communicate the following information to appropriate suppliers and contractors,
including contractors used for outsourcing:
 PCD is concerned about environmental issues and desires to conduct its business operations
in an environmentally sound manner.
 Relevant significant aspects will be communicated to contractors (including those used for
outsourcing) and suppliers through the bid package. It will also be applied to contractors
working onsite at the depot for more than 6 months.
 PCD has implemented an EMS, which is based on ISO-14001:2004.
 PCD expects its suppliers and contractors to provide, at the same quality and price, products
and services that have the least environmental consequence of all available options.
 Where a supplier’s product is causing a significant environmental aspect at PCD, PCD will
communicate to that supplier that wherever possible, they should select the available option
that minimizes the potential environmental impact of that product.
2. Where a supplier or contractor is supplying goods or services associated with significant
environmental aspects, the affected PCD manager will work with the appropriate procurement
representative to inform that supplier or contractor of applicable procedures and requirements to
mitigate, minimize, or otherwise control the potential environmental impacts associated with
those significant environmental aspects. This will also be applied to contractors used for
outsourcing.
3. Communications with suppliers and contractors shall be documented in accordance with PCD
procurement procedures.
4.0 Records
Records generated from the execution of this procedure will be maintained in electronic form and in
hard copy and include:
 Records of submissions to regulatory authorities;
 Records of environmental reports to the public if any;
 Copies of requests and responses to external parties;
 Copies of sent and received communications from suppliers and contractors.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
4-34
4.4 PCD EMS Procedure for Document Control and Documentation
1. 0 Purpose and Scope
The purpose of this procedure is to provide a standard method for controlling documents that support the
operation of the Pueblo Chemical Depot Environmental Management System (EMS). This procedure
provides instructions, and assigns responsibilities for the establishment, review, authorization, issue,
distribution, and revision of controlled documents and records.
This procedure applies to the creation, revision, approval, distribution and version control of all
documents associated with the EMS.
2.0 Procedure
Personnel with specific EMS document responsibilities will ensure that documents are current, available
to personnel that need them, and are removed when they no longer apply or have been rendered obsolete
by updated versions.
Controlled documents, such as SOPs or management plans, are accessible through the intranet website.
Printed copies of these controlled documents will be marked with the statement “Controlled Document,
Uncontrolled if Printed.” Further detail of this procedure for approval and version control is
supplemented by specific requirements.
Other documents and records may exist outside the system and are not considered official controlled
documents. These documents may exist as information transport tools to final record locations and/or
may be developed and used for personal use only.
3.0 EMS Documentation
EMS documentation provides a standardized structure for organizing PCD’s EMS programs,
procedures, work instructions, and records. The structure of the documentation is as follows:
 The EMS Manual - describes the core elements of the management system, including their
interrelationships. The manual provides an overview of the EMS. It refers to, and cross-
references, related documentation such as EMS Procedures, and EMPs. EMS Procedures detail
specific EMS requirements and the roles, responsibilities and authorities to fulfill the
requirements. As appropriate, procedures reference related documentation such as EMPs and
work instructions. EMPs included in chapter 5 of the manual are included for reference only and
will be replaced with the most recent version only when the EMS manual is updated. These
procedures and programs are applicable to the operations at Pueblo Chemical Depot. The EMS
Manual details requirements and guidelines for implementation. (The EMS Manual is available
in electronic media at relevant workstations).
 Depot Level Documents – PCD Regulations, Commander’s Policy Statements, Pamphlets, and
other directives published at the depot level that supports the EMS Manual requirements and
guidelines are located on the Depot Intranet.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
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 Policy and Instructions (P&Is), Standing Operating Procedures (SOPs), Operating
Instructions (OIs) – Internal organizational Policy and Instructions, Standing Operating
Procedures, and other Operating Instructions.
 EISIS Database – the following EMS documentation will be maintained in the EISIS Database:
o List of environmental aspects associated with PCD Inputs
o Routine Recurring tasks outlined in the EMPs
o EMS records not managed by Environmental Program Managers
o Training information
4.0 Records
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
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4.5 PCD EMS Procedure for Environmental Management Programs and
Operational Controls
1.0 Purpose and Scope
The purpose of this procedure is to establish a reliable and consistent approach for creating and
documenting the Environmental Management Programs (EMPs) associated with the Pueblo Chemical
Depot (PCD) Environmental Management System (EMS). EMPs provide the guidance, information,
and references necessary for the efficient and effective accomplishment of the objectives and targets that
are set for the PCD EMS. PCD documents its EMPs in order to avoid confusion and ambiguity about
what needs to be done and who is responsible for doing it. This EMS procedure also provides guidance
for applying Operational Controls (OCs) to PCD’s Inputs with the potential for significant
environmental impacts.
PCD’s EMO staff applies this procedure to develop and document the EMPs that they create, update,
and implement to achieve the objectives and targets of the PCD EMS. Objectives and targets are set
through the execution of the EMS Procedure for Setting Objectives and Targets.
2.0 Definitions
For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4.
3.0 Approach
PCD uses the EMP Template (See attached EMP Template) as a guide to structure existing and new
EMPs. The EMPs also demonstrate the different elements of the EMS and their interaction. Existing
PCD programs are periodically reviewed to ensure they contain the programmatic information elements
shown in the EMP Template. Once completed, the EMP templates are reviewed by the Environmental
Management Office Director. EMPs will be reviewed and updated if needed by each program manager
at least one time a year and are available to the Office of the Commander. The official version of the
EMPs will be maintained by Environmental Management Office.
4.0 Records
EMPs generate a variety of EMS records. In most instances, the EMP template itself serves as a record:
1. The previous 3 years of completed EMP templates (Starting May 2006);
2. Records that reflect the status of objectives and targets as measured during the course of
program implementation, where applicable;
3. Records that reflect the assignment of roles and responsibilities, when used;
4. Records that reflect the allocation of other resources, when used;
5. Records other than the EMP that substantiate declarations of employee competency, when
used;
6. Records of maintenance performed on operational controls;
7. Records of any Corrective Actions taken in the event of interrupted or failed controls;
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
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8. Records of operational controls that were communicated to external sources of goods and
services; and contractors working on site or doing outsourced work and
9. Records that demonstrate the functioning of operational controls, either ongoing or periodic
depending on what is appropriate and actually implemented.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
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Example Environmental Management Plan (EMP)
Significant Aspect: Tracking Number
Department/Area(s): Date:
Objective: Process/Activity:
Potential Impacts: Target:
Legal and Other Requirements:
Task Responsible
Party
Schedule/Resources Key Characteristics/Performance
Criteria
.
Approvals: Submit to the Environmental Quality Control Committee (EQCC) for review and approval.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
4-39
Guidance for Completing the EMP Template
This guidance complements the information in the EMS Procedure for creating environmental
management programs (EMPs) and their associated operational controls (OCs). Specifically it provides
guidance for completing the EMP template which is designed to capture programmatic, management
summary information for a more structured, consistent and documented management of environmental
programs at PCD. The EMP template is designed to not only to incorporate all the main elements of the
EMS and document their interaction, but actually be a usable tool in managing PCD’s Significant
Environmental Aspects.
Field 1. Significant Aspect: The aspect listed here may be generic (e.g., air emissions), it may be by
criteria (e.g., particulates), or it may be specific to a function or Input (e.g., CFC emissions from
refrigeration). The aspect needs to be as specific as is required to manage it efficiently and
effectively. The degree of granularity and specificity in categorizing aspects is therefore dependent
on how they will be managed and on how best to communicate that information in the EMP
documentation. It is not useful to aggregate dissimilar aspects when their management requires
different protocols and controls. Such agglomeration may result in lack of clarity and increase the
likelihood of mismanagement of the environmental aspect in question.
Field 2. Tracking Number: This designator is a unique number used by EMO to control document
version as a means to ensure that only the authorized and currently valid version is in use.
Field 3. Department/Area(s): This is the name by which this program will be known in the
organization.
Field 4. Date: This is the date when the document was last revised. Such information may be of value
to different users of the EMP. It may be used, for example, to archive previous versions of the EMP.
Field 5. Objective: The objectives listed here are those that the organization has set for itself with
respect to the environmental aspect that is treated in this EMP. The number of the objective is set by
the EMS manager and should remain the same. If the number of the objective changes the EMS
manager will notify all program managers via e-mail. (See EMS Procedure for Setting Objectives
and Targets for an explanation of what they signify.)
Field 6. Process/Activity: The information recorded here should signify the reason why each impact is
“significant” (e.g., regulation; mission impact; environmental impact). It should provide sufficient
detail to inform prospective users on the full consequences of each individual impact. This is
valuable insight that underlies the importance of the EMP and should not be assumed to be
“obvious” to newcomers that are not familiar with the issue. For example: Noise is a significant
aspect because it is regulated and because complaints from the adjoining community could cause a
shutdown a major operation at the Depot.
December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual
4-40
Field 7. Potential Impacts: These are the potential impacts enumerated through the execution of the
EMS Aspects Identification Procedure. Their documentation within the EMP allows for a fuller
description of these potential impacts.
Field 8. Target: : The targets listed are those that have been set by the organization to achieve the
objectives specified. Once a target has been completed the word completed should follow the target
where one would normally identify the target date of completion. Once this completed target has
remained for one update it should then be deleted from the EMP. This will insure that a record of
compulsion will de documented on the EMP.
Program indicators should be specified for all the targets. Program indicators should have been
selected during the setting of objectives and targets while the nature of the objectives and targets are
fresh on the minds of the EMO Program Managers. EMP leads should ensure that a complete list of
program indicators that correspond to the targets is shown in this field; normally, there is a one-to-
one correspondence between them.
Field 9. Legal and Other Requirements: This field contains details on the applicable legal and other
requirements derived through execution of the EMS Procedure on Legal and Other Requirements.
These are the legal and other requirements that apply to the Inputs that exhibit the environmental
aspect in question. The level of detail for legal and other requirements should be as complete as
possible. That detail is necessary if the organization expects to maintain compliance with legal and
other requirements. This field should, therefore, list all the detailed legal and other requirements that
apply to this environmental aspect for the Inputs listed in field 11 below.
Field 10. Task: This field describes what controls are to be implemented to achieve target goals of the
EMP.
Field 11. Responsible Party: This field contains the name or names of organizations within PCD that
have been given the responsibility to operate or otherwise implement the operational controls.
Field 12. Schedule/Resources: This field sets forth the date the target goal is to be achieve and any
resources needed.
Field 13. Key Characteristics/Performance Criteria: The information in this field of the EMP
should be as detailed as necessary to ensure effective control of the Inputs that exhibit the environmental
aspect in question so as to prevent that aspect from occurring.
Field 14. Approvals: The approving authority for PCD is the EQCC for all EMP’s.
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Lead asbestos mgmt plan -ems

  • 1. UNCLASIFIED PUEBLO CHEMICAL DEPOT LEAD MANAGEMENT PLAN Prepared by Pueblo Chemical Depot Environmental Management Office December 2011 Prepared by: Keith L. Phillips
  • 2. UNCLASIFIED Page0 PUEBLO CHEMICAL DEPOT ASBESTOS MANAGEMENT PLAN Prepared by Pueblo Chemical Depot Environmental Management Office December 2011 Prepared by: Keith L. Phillips
  • 3. UNCONTROLED IF PRINTED PCD EMS Manual 1-1 Prepared by: Keith L. Phillips December 2011 Pueblo Chemical Depot EEMMSS MMaannuuaall August 2009
  • 4. UNCONTROLED IF PRINTED PCD EMS Manual 1-2 Prepared by: Keith L. Phillips Table of Contents 1. Introduction to the Pueblo Chemical Depot (PCD) EMS Manual........................................................................... 1-3 1.1 Purpose of the EMS Manual...................................................................................................................................... 1-3 1.2 EMS Manual Maintenance........................................................................................................................................ 1-3 1.3 EMS Implementation at PCD .................................................................................................................................... 1-3 1.4 EMS Glossary............................................................................................................................................................ 1-4 1.5 EMS Acronyms .......................................................................................................................................................... 1-9 2. PCD Scope and Characteristics .................................................................................................................................. 2-1 2.1 PCD Background & Mission..................................................................................................................................... 2-1 2.2 PCD Facility Description.......................................................................................................................................... 2-2 2.3 PCD Significant Environmental Aspects ................................................................................................................. 2-4 3. PCD Environmental Policy ......................................................................................................................................... 3-1 4. EMS Procedures........................................................................................................................................................... 4-4 4.1 Identifying Significant Environmental Aspects ........................................................................................................ 4-6 4.2 PCD EMS Audit Program ....................................................................................................................................... 4-15 4.3 PCD EMS Procedure for Internal and External Communications.......................................................................... 4-31 4.4 PCD EMS Procedure for Document Control and Documentation.......................................................................... 4-34 4.5 PCD EMS Procedure for Environmental Management Programs and Operational Controls ............................... 4-36 4.6 PCD EMS Procedure for Addressing Emergency Preparedness and Response ..................................................... 4-41 4.7 PCD EMS Procedure for Legal and Other Requirements....................................................................................... 4-43 4.8 PCD EMS Procedure for Monitoring and Measurement ........................................................................................ 4-45 4.9 PCD EMS Procedure for EMS Management Review.............................................................................................. 4-47 4.10 PCD EMS Procedure for Nonconformity, Corrective and Preventive action......................................................... 4-49 4.11 PCD E MS Procedure for Setting Objectives and Targets...................................................................................... 4-51 4.12 PCD EMS Procedure for the Control of Records ................................................................................................... 4-54 4.13 PCD EMS Procedure for Competency Training..................................................................................................... 4-56 5. EMS Records................................................................................................................................................................ 5-1
  • 5. UNCONTROLED IF PRINTED PCD EMS Manual 1-3 Prepared by: Keith L. Phillips 1. Introduction to the Pueblo Chemical Depot (PCD) EMS Manual The original requirement for an Environmental Management System (EMS) was issued by Executive Order (EO) 13148, “Greening the Government through Leadership in Environmental Management.” Army Memorandum, ACSIM, DAIM-ZA, 10 July 2003, SAB requires EMS implementation via International Organization for Standardization (ISO) 14001. The Pueblo Chemical Depot (PCD) Policy Statement Number 20, 17 September, 2011, defines PCD’s environmental goals and mission. This manual defines PCD’s implementation, roles, responsibilities, and procedures for defining and maintaining the PCD EMS. 1.1 Purpose of the EMS Manual This Environmental Management System Manual serves as a repository for documentation related to the Pueblo Chemical Depot (PCD) Environmental Management System (EMS) and includes: a. EMS Procedures that describe how to carry out key tasks within the EMS such as training, tracking legal and other requirements, or managing records. b. Programs & Controls that operate under the EMS, such as programs for achieving EMS objectives and targets or for carrying out EMS audits. c. EMS Records that confirm the completion of specific EMS activities such as the identification of environmental aspects, the conduct of EMS training, or that management reviews were completed. d. Definitions and References that provide additional information useful to individuals reviewing or learning about the EMS. 1.2 EMS Manual Maintenance a. This EMS Manual is maintained by: PCD EMS Manager or someone designated by him. b. The formal version of this EMS Manual is located in the Environmental Management Office, PCD. c. This EMS Manual was last updated on: June 2010 d. In addition to the tables created to identify significant aspects and objectives and targets, the EMS Manual contains the EMS Audit Program, the EMS Procedures, EMS records, and other descriptive information useful to anyone being introduced to the EMS or to those responsible for the EMS. 1.3 EMS Implementation at PCD The Pueblo Chemical Depot (PCD) has implemented an Environmental Management System (EMS) to ensure it fulfills the commitments to its Environmental Policy. The scope of the PCD EMS includes the following facilities and organizations within the Pueblo Chemical Depot (PCD. The EMS is modeled on the specifications found in the international standard for environmental management in organizations, ISO- 14001:2004. Specific benefits provided to PCD from implementing a formal management discipline include:
  • 6. UNCONTROLED IF PRINTED PCD EMS Manual 1-4 Prepared by: Keith L. Phillips a. The systematic approach to managing PCD’s potential impacts on the environment. b. Enabling PCD environmental concerns to be managed to accord with mission goals. c. Providing documentation of existing processes so that results can be repeated. Institutional knowledge is captured so it is not subject to personnel flux. d. Providing a structured approach to identify potential impacts that could otherwise result in costs, embarrassments, and threats to mission. e. Having the potential to provide employees with a sense of empowerment that can translate to enhanced performance on the job. f. Providing the site with a means to track and measure environmental and operational performance by instituting metrics. g. Providing greater discipline and assurance in tracking and analyzing environmental requirements thus ensuring a higher level of compliance. h. Allowing PCD to use a risk management approach ensuring the site focuses and allocates its resources to those that have the greatest probability and worst potential consequences. i. Providing for greater sharing of knowledge and responsibilities across all levels and functions. j. Supporting reporting under Government Performance Results Act (GPRA). 1.4 EMS Glossary Adequacy: Refers to the sufficiency of the resources for the EMS. Auditor Training: Training provided to those individuals that will fulfill the role of internal EMS auditors at PCD. This includes basic EMS training, familiarization with the organization's own EMS, as well as training on how to prepare, conduct and conclude the internal audit, including writing the audit report and overseeing the completion of corrective actions on the audit findings. Competence Training: Training provided to personnel that are associated with significant environmental aspects. Such training is indicated when the individual is not considered competent on the basis of previous training, education, or experience to address the responsibilities he/she has been charged with relative to the significant environmental aspect in question. Compliance Audit: A periodic audit of compliance with regulatory and other requirements that are imposed on the organization. Findings are expressed as non-compliances. The search for root causes in a typical compliance audit may not be as intense as it should be during an EMS audit. Continual Improvement: Process of enhancing the EMS to achieve improvements in overall environmental performance in line with the organization’s environmental policy. (Note: Continual implies that there will be periods where improvement will be flat.) Correction: The totality of immediate and long-term steps taken to mitigate the consequences of a nonconformity (e.g., cleanup of spilled hazardous material; remediation of groundwater; natural habitat restoration). The correction does not by itself remove the underlying cause of the nonconformity. Corrective Action: Action to address the underlying cause of an actual event that has been identified as a non-conformity through an audit. EMO Program Manager: An individual in the Environmental Management Office (EMO) appointed to manage specific environmental programs and/or plans for media protection and resource conservation such as air, groundwater, surface water, soil, cultural resources, and pollution prevention. Effectiveness: Refers to the accomplishment of the objectives and targets set for the EMS.
  • 7. UNCONTROLED IF PRINTED PCD EMS Manual 1-5 Prepared by: Keith L. Phillips Environmental Impact: Any change to the environment, whether adverse or beneficial, wholly or partially resulting from the facility’s aspects. (Note: A potential environmental impact is equivalent to the concept of risk, in safety, which assigns a probability and consequence to the possible negative event that may result from a hazard.) Environmental Aspect: An element of an activity that can interact with the environment. (Note: The environmental aspect of an activity is that part of the activity that creates the possibility for an environmental impact. As such, it is equivalent to the concept of hazard, in safety, which is also defined as the mere possibility of a negative event.) Environmental Management Programs: Are a management tool used to document the tasks, responsibilities, and other operational details that are implemented to achieve the objectives and targets that are set for the significant aspect. They include timelines, resources, and responsibilities for achieving those objectives and targets and are amended as necessary with changing environmental, organizational, and legal requirements, as well as aspects and operations within the organization. EMPs incorporate a number of other EMS components including:  The significant environmental aspect that is being addressed;  The objective(s) and target(s) that were set for the significant aspect;  The program indicators to be used to measure progress in achieving the objectives and targets;  The factors that gave rise to the significance of the aspect;  The programmatic tasks needed to achieve the objectives and targets;  The roles and responsibilities of individuals responsible for the tasks;  Declarations of employee competency;  Specification of records to be produced by executing the management plan;  Reference to other documents used with the management plan; and  Operational controls that are implemented to ensure that the objectives and targets will be achieved as planned. Environmental Management System Manager: An individual appointed by top management to serve as management representative and coordinator ensuring that the EMS is established, implemented and maintained in accordance with the requirements of the ISO 14001:2004, and also report to top management on the performance of the EMS for review, including recommendations for improvement. Environmental Objective: Overall environmental goal, arising from the environmental policy that an organization sets for itself to achieve, and which is quantified where practicable. Environmental Performance: Measurable results of the EMS, related to an organization’s control of its environmental aspects, based on its environmental policy and objectives and targets. Environmental Policy: Statement by the organization of its intentions and principles in relation to its overall environmental performance that also provides a framework for action and for setting of its objectives and targets. Environmental Program Indicator: A specific datum selected, such as volume of a chemical used, which will provide measurable information regarding progress toward meeting a specific environmental objective and target.
  • 8. UNCONTROLED IF PRINTED PCD EMS Manual 1-6 Prepared by: Keith L. Phillips Environmental Target: Detailed performance requirement, quantified where practicable, applicable to the organization or parts thereof, that arises from the environmental objectives and that needs to be set and met in order to achieve those objectives. Executive Overview Course: A briefing provided to the relevant officer staff and other top management at PCD on the EMS. This briefing familiarizes these individuals with general EMS concepts and with selected elements of the EMS that they ought to be familiar with. Most specifically, it lays out their roles and responsibilities with respect to the EMS, including their roles in establishing the PCD Environmental Policy and in conducting the periodic Management Reviews. External communication: Communication to parties or organizations external to PCD’s physical site boundaries or its functions and activities. External interested party: Individual or group concerned with or affected by the environmental performance of PCD. General Environmental Awareness Training: Training that is provided to all personnel irrespective of whether they are associated with significant environmental aspects. Implementation Training: Training provided, if needed, to those responsible for implementing or supporting the EMS. This course instructs attendees on the basic principles of the EMS, provides sample procedures that can be adapted by the organization, suggests the use of certain templates that simplify implementation, and discusses the resources and organizational support required for the EMS development and implementation effort. Incident or Emergency: Constitutes more than a mere nonconformity in the EMS. Any event that invokes the ISCP. For purposes of the EMS, nonconformities that do not invoke the ISCP will be corrected through the provisions of the PCD “Non-conformance and Corrective and Preventive Action Procedure.” Responses to emergencies such as fires, floods, and earthquakes are managed through the National Incident Management System (NIMS), Incident Command System (ICS). If the emergency is severe or long lasting, the PCD Emergency Operations Center (EOC) may be activated. Inputs, Products, and Services: Term used to encompass the everyday activities of an installation. Includes, but is not limited to training on ranges; munitions testing; construction and renovation of real property; manufacturing activities; commercial services such as dry cleaning, photo processing, etc.; wash rack operations; grounds maintenance; vehicle maintenance; etc. (In this procedure the term Inputs will be used in place of the full term Inputs, products and services and is synonymous to the term “activities” found in the ISO-14001:2004 standard) Installation Spill Contingency Plan (ISPC): A plan implemented immediately whenever there is a potential or an actual event such as fire explosion or release of oil or hazardous substances/waste. The ISCP meets the requirements of 40 CFR 264 (RCRA). Installation Sustainability Team (IST): Team of facility personnel representing various installation activities and tenants selected by their organizational leader to serve as representatives for the various functional areas on the installation. The team’s responsibilities are to gather, organize, and disseminate information; help to develop EMS procedures; advise, coordinate, facilitate, and monitor EMS implementation; and assist the EMS Program Manager with EMS-related matters. Interested Party: Individual or group concerned with, or affected by the environmental performance of an organization.
  • 9. UNCONTROLED IF PRINTED PCD EMS Manual 1-7 Prepared by: Keith L. Phillips Internal Communication: Communication within PCD that is intended for personnel to further the EMS goals. Internal EMS Audit: A periodic audit of the EMS to verify that it is properly implemented and that it continues to conform to planned arrangements for environmental management. It is an audit of the system and findings are expressed as non-conformities. Audit conclusions are based on the findings and focus on the root causes that led to the non-conformities. It is appropriate to seek the root causes of known compliance findings during an EMS audit, since these may reflect EMS deficiencies. Legal Requirements: EMS legal and other requirements encompass all the constraints imposed on PCD to control its environmental aspects and operations. These constraints include federal, state, and local laws and regulations, environmental permits, registrations, executive orders, and consent decrees. In addition, internal organizational procedural requirements pertaining to environmental aspects such as military (e.g., Department of Defense [DoD] and Department of Army [DA]) instructions, directives, manuals, and policy decisions also apply. These internal requirements take on the same importance as legal requirements and are expected to receive the same degree of commitment to compliance. Non-compliance: Failure to meet regulatory or other requirements that have been imposed on the organization. Non-conformity: Any deviations from established procedures, programs and other elements of the EMS. They may include non-compliance with regulations, but not all instances of non-compliance are necessarily non-conformities of the EMS. Operational Controls (OCs): Mechanisms (technological or administrative) used to maintain a desired level of environmental performance. OCs are applied to PCD Inputs to prevent the environmental aspect they exhibit from occurring. Shop Environmental Instructions will be develop to inform personnel of environmental responsibilities. Examples of OCs include those built into technology (e.g., motion sensors, sleep mode for electronics, etc.), those requiring operator intervention (e.g., selecting duplex printing, electronic documents, etc.), and those that are incorporated in standard operating procedures (SOPs) (e.g., procedure for storage and disposal of hazardous waste).  Each significant environmental aspect shall be reviewed in conjunction with its inputs to determine whether OCs (either technological or administrative) are needed for those inputs.  In doing the review, special attention shall be given to those characteristics of Inputs that necessitate OCs.  Where applicable, documentation on the OCs will specify the operating criteria (including maintenance) and the actions to be taken when they are interrupted, or when they might otherwise fail.  When necessary, OCs will also be applied to the identifiable significant environmental aspects of goods and services that are received from external sources and used at PCD. When appropriate, OCs that need to be implemented by the external source shall be duly communicated to those sources. (Refer to EMS Communications Procedure, if applicable)  Operations managers are responsible to ensure that OCs are implemented for those inputs that are within their purview and that contain significant environmental aspects. OCs will be integrated into Shop Environmental Instructions (SEIs) as those are developed and implemented across operations at PCD. Personnel: All persons working at PCD, including contractors that are on PCD for greater than 6 months.
  • 10. UNCONTROLED IF PRINTED PCD EMS Manual 1-8 Prepared by: Keith L. Phillips Preventive Action: Action to prevent potential problems before they occur at other areas or functions of the organization that may have similar vulnerabilities to that which caused the original non- conformity. . Preventive action can be focused on identifying negative trends and addressing them before they become significant. Record: A document stating results achieved or providing evidence of inputs performed (ISO 14001:2004 definition). A record is a permanent document that typically is not revised. Records will include:  Information on compliance with applicable legal requirements and other requirements to which the organization subscribes,  Details of nonconformities and corrective and preventive actions,  Results of environmental management system audits and management reviews, information on environmental attributes of products (e.g. chemical composition and properties),  Evidence of fulfillment of objectives/targets,  Information on participation in training,  Permits, licenses or other forms of legal authorization,  Results of inspection and calibration activity, and  Results of operational controls (maintenance, design, manufacture). Relevant Communications: Verbal or written inquiries deemed appropriate for response based on installation policy and concern for confidentiality. Root Cause Analysis: Root cause analysis is the method used to identify immediate, underlying and root causes of an incident. The analysis of the root causes aims to find the proper corrective and preventive actions to apply to remove those causes and thereby prevent both a recurrence of the incident and its potential future occurrence in other parts of the organization. Significant Environmental Aspect: An environmental aspect that has, or can have, a significant environmental or mission impact (i.e., one that can potentially cause a significant environmental or operational impact). Spill Prevention, Control and Countermeasures Plan (SPCCP): The plan are required by Section 311(j) of the Clean Water Act to establish procedures and guidance for the prevention, detection, and response to releases, accidents, and spills involving oils or hazardous substances at Pueblo Chemical Depot. Suitability: Refers to whether the EMS continues to accord with the nature of the organization. Suppliers and contractors: Organizations or individuals that provide supplies, materials, services and other tangible goods to PCD. Top management: For purposes of this procedure, top management will include, at a minimum, the Depot Commander or Deputy Commander and other members of the Command Staff. Verification: A follow-up visit by the audit team to ascertain that corrections, and corrective and preventive actions have been appropriately completed. The decision to do this is based upon the frequency, severity, and/or risk of continued nonconformity, as well as on whether the finding was either a major or critical audit finding.
  • 11. UNCONTROLED IF PRINTED PCD EMS Manual 1-9 Prepared by: Keith L. Phillips 1.5 EMS Acronyms AAR after-action review ABC activity-based costing ACSIM Assistant Chief of Staff for Installation Management AEDB-EQ Army Environmental Database - Environmental Quality ANSI American National Standards Institute AR Army Regulation ARIM Army Reserves Installation Management ARNG Army National Guard ARTEP Army Readiness Training Evaluation Programs BACM best available control measures BACT best available control technology BADT best available demonstrated technology BMP best management practice CAA Clean Air Act CAAA Clean Air Act amendments CAIRA Chemical accident/incident response and assistance CAR corrective action report CDPHE Colorado Department of Health and the Environment CBT computer-based training CDR commander CERCLA Comprehensive Environmental Response, Compensation and Liability Act CFCs chlorofluorocarbon CFR Code of Federal Regulations CFT cross-functional team CONUS Continental United States COTS commercial off-the-shelf CWA Clean Water Act DDMS Digital Document Management System DENIX Defense Environmental Network Information Exchange DFE Design for the environment DoD Department of Defense DPW directorate of public works DSERTS Defense Site Environmental Restoration Tracking System DTC Document Tracking Center EAP environmental action plan ECOs environmental compliance officers EMO Environmental Management Office EMP environmental management programs EMS environmental management system EMSMR environmental management system management representative EMSR Environmental Management System Representative ENFs enforcement actions EO Executive Order EPA U.S. Environmental Protection Agency
  • 12. UNCONTROLED IF PRINTED PCD EMS Manual 1-10 Prepared by: Keith L. Phillips EPAS Environmental Program Assessment System EPCRA Emergency Planning and Community Right-To-Know Act EPI environmental performance indicators EPR Environmental Program Requirements EQCC environmental quality control committee ESA Endangered Species Act FAT facilities, activities and tasks FIFRA Federal Insecticide, Fungicide, and Rodenticide Act FRP Facility response plan FY fiscal year GC Garrison Commander GIS global information system GOCO government-owned, contractor-operated GPS global positioning system HAP hazardous air pollutant HAPPS hazardous air pollution prioritization system HAZMAT hazardous material HAZWOPER Hazardous Waste Operations and Emergency Response HMTA Hazardous Materials Transportation Act HOA homeowners association HW hazardous waste HWDMS hazardous waste data management system ICAPs installation compliance action plans ICS incident control center IESIS Installation Environmental Support Information System IMA Installation Management Agency IMRO installation management regional office IPR in-process review ISO International Organization for Standardization ISR Installation Status Report IT information technology METL mission-essential task list MSDSs material safety data sheets NAAQS national ambient air quality standards NCA Noise Control Act NEPA National Environmental Policy Act NFA no further action NLT no later than NOV notices of violation NOx nitrogen oxides NPDES national pollutant discharge elimination system OB/OD open burn/open detonation OCONUS Outside Continental United States ODCs ozone depleting chemicals OFEE Office of the Federal Environmental Executive P2 Pollution Prevention
  • 13. UNCONTROLED IF PRINTED PCD EMS Manual 1-11 Prepared by: Keith L. Phillips PAO public affairs office PAIO Program Analysis and Integration office PCD Pueblo Chemical Depot PL Public Law PM2.5 particulate matter with diameter less than or equal to 2.5 microns POC point of contact POL petroleum, oil, or lubricant POTW publicly owned treatment works RCRA Resource Conservation and Recovery Act RDT&E Research, development, testing, and evaluation REOs regional environmental offices RRC Regional Readiness Commands SCP Spill contingency plan SDWA Safe Drinking Water Act SOP standard operating procedure SOx sulfur oxides SPCC Spill Prevention, Control, and Countermeasures SPCCP Spill Prevention, Control, and Countermeasures Plan SRS Strategic Readiness System SS significance score SVOC, Semi-Volatile Organic Compound TDA Table of Distribution and Allowances TEAM The Environmental Assessment Manual TOE Table of Organization and Equipment TSCA Toxic Substances Control Act USAEC U.S. Army Environmental Center USAES U.S. Army Engineer School USC United States Code UXO Unexploded Ordinance VOC volatile organic compounds WREO Western Regional Environmental Office – US Army
  • 14. UNCONTROLED IF PRINTED PCD EMS Manual 2-1 2. PCD Scope and Characteristics 2.1 PCD Background & Mission The Pueblo Chemical Depot is located in Pueblo County, Colorado, about 100 miles southeast of Denver and 14 miles east of Pueblo; the Arkansas River is approximately one mile south of the activity. The facility encompasses 22,654 acres and is situated on flat to gently sloped prairie. The surrounding lands are mostly undeveloped ranchlands used for grazing, with some light commercial and residential zoned areas to the south. The depot houses a chemical stockpile which comprises about 8 percent of the nation’s original chemical materiel stockpile. This stockpile is scheduled for future destruction under the Department of Defense Assembled Chemical Weapons Alternatives program. The depot’s current mission is the safe and secure storage and monitoring of the chemical stockpile, preparation for destruction of the chemical stockpile and preparation for depot closure. Construction of the depot began in February 1942. The installation was originally named Pueblo Ordnance Depot, and the first carload of ammunition was received in August 1942. Although originally planned for the storage and supply of ammunition, facilities were expanded almost immediately to receive, store, and issue general supplies to support World War II. In 1946, Pueblo Ordnance Depot was assigned the mission of maintaining and overhauling artillery, fire control, and optical equipment. Two years later, ammunition renovation and demilitarization were added to that mission. During the Korean War, shipments of general supplies and ammunition increased, and the depot reached its highest civilian strength of nearly 8,000 employees. Missile maintenance was added to the depot’s mission in the 1950s and in 1962, the depot was renamed Pueblo Army Depot. The missile maintenance mission at Pueblo, with the exception of maintenance of the Pershing missile, was transferred to Letterkenny Army Depot in 1974. In 1976, Pueblo was given depot activity status and assigned to the Tooele Army Depot Complex. In December 1987, the United States and the former Soviet Union entered into the Intermediate-Range Nuclear Forces (INF) Treaty. Pueblo was assigned to disassembly and elimination activities. Pueblo completed its INF and Pershing mission in May 1991. Pueblo Depot Activity was in the forefront of support to Operation Desert Shield and Desert Storm, shipping a large part of contingency stocks in addition to ammunition and supplies to Southwest Asia. The Base Realignment and Closure Commission designated the depot for realignment in 1988. The installation was renamed U.S. Army Pueblo Chemical Depot in 1996.
  • 15. UNCONTROLED IF PRINTED PCD EMS Manual 2-2 2.2 PCD Facility Description Approximate Total number of employees: 330 Army civilian and military employees Approximate Total number of buildings or structures: 2,200 Approximate Property acreage: 22,654 acres Activities that occur outside site boundaries: None Size of EMS team: Approximately 10, including all the Environmental Management Office personnel and individuals representing various functions and tenant groups at the Depot EMS Implementation Start Date November 27, 2006 Composition of EMS team: Led by the EMS Manager with representatives from other functions The scope of the PCD EMS includes the following facilities and organizations within the PCD: Pueblo Chemical Depot (PCD), Pueblo Chemical Agent-Destruction Pilot Plant (PCAPP).
  • 16. UNCONTROLED IF PRINTED PCD EMS Manual 2-3 Establishment of ISO 14001 EMS at Pueblo Chemical Depot
  • 17. UNCONTROLED IF PRINTED PCD EMS Manual 2-4 2.3 PCD Significant Environmental Aspects (See section 4.1 of this manual on the development of the following list and its abbreviations.)
  • 18. UNCONTROLED IF PRINTED PCD EMS Manual 3-1 3. PCD Environmental Policy The PCD Environmental Policy is a declaration of top management’s commitment to the environment and serves as the foundation for the EMS. Everyone in the organization is expected to be familiar with and understand the policy. The policy is considered when setting EMS objectives and targets, and it is understood that the implementation of the EMS serves to make the commitments in the policy operational. The environmental policy statement is, therefore, a vehicle for communicating the organization’s aspirations for environmental protection as well as a functional tool for establishing the operational boundaries of the EMS. The environmental policy aligns with the organization’s core mission and must include commitments to continual improvement, pollution prevention, and regulatory compliance. The environmental policy statement should reflect a management consensus on its contents and aims, and should be formalized through the signature of top management. Red River’s environmental policy is: Pueblo Chemical Depot's environmental policy is an integral part of our mission, and is the core of the Depot's Environmental Management System. This policy states in broad terms the environmental commitments of Pueblo Chemical Depot now and into the future. Pueblo Chemical Depot strives to be one of the national leaders in environmental, energy and natural resource stewardship. Red River's primary focus areas are prevention, compliance, restoration and conservation. The EMS program manager, Environmental Division is responsible for Pueblo Chemical Depot's Environmental Management System. However, environmental stewardship is the responsibility of every member of the work force, as well as its strategic partners and residents. Depot personnel consider many environmental aspects when assessing current and upcoming projects. Personnel consider environmental impacts of operations and activities through setting objectives and targets relevant to environmental aspects, planning, monitoring and revisions to achieve continuous improvement of our Environmental Management System. Pueblo Chemical Depot implements and will continue to implement new and innovative ways to prevent pollution, minimize waste, manage natural resources and to conserve energy. Pueblo Chemical Depot's personnel ensure that all activities comply with relevant environmental legislation, regulations and policies. We will continue to maintain a positive relationship with the local community, regulators and other governmental agencies. PCD’s Environmental Policy is supplemented by specific requirements and provisions in the following additional documents:  AR 200-1 – Army Regulation 200-1 Environmental Protection and Enhancement • Army Regulation 200-2, Environmental Affects of Army Actions • Army Regulation 200-3, National Resources – Land, Forest, and Wildlife Management • Army Regulation 200-4, Cultural Resources Management • Air Pollution Prevention and Control Act (Clean Air Act [CAA] of 1977, as amended 42 United States Code [USC] § 7401 et seq.) • National Ambient Air Quality Standards, Title 40 Code of Federal Regulations (CFR) Part 50 (CAA § 109). • Colorado Department of Health and the Environment Regulations • Designation, Reportable Quantities, and Notification, 40 CFR 302 (CERCLA § 103) • Emergency Planning and Community Right to Know Act (EPCRA) of 1986 (42 USC § 11001) - Title III of the Superfund Amendments and Reauthorization Act, (Public law [PL] 99-499, October 17, 1986, as amended by PL 102-389, October 6, 1992) • Emergency Planning and Notification, 40 CFR 355 (EPCRA § 312)
  • 19. UNCONTROLED IF PRINTED PCD EMS Manual 3-2 • Executive Order 13148 - Greening the Government through Leadership in Environmental Management • Executive Order 13423 – Strengthening Federal Environmental, Energy, and Transportation Management • Executive Order 13514 – Federal Leadership in Environmental, Energy, and Economic Performance • Hazardous Chemical Reporting: Community Right to Know, 40 CFR 370 (EPCRA § 312) • Federal Water Pollution Control Act (Clean Water Act [CWA] of 1972, as amended [33 USC § 1251 et seq.]) • Storm water discharges associated with industrial activity, (40 CFR 122.26 (b)(14)(i)-(xi)) • General Provisions, 40 CFR 401 • Oil Pollution Prevention, 40 CFR 112 (CWA § 311) • Hazardous Materials Transportation Act of 1974, as amended (49 USC § 5100 et seq.) • General Information, Regulations, and Definitions, 49 CFR 171 Hazardous Materials • Information and Training Requirements 49 CFR 172 • General Requirements for Shipments and Packaging 49 CFR 173 • Training, 49 CFR Part 172, Subpart H • National Environmental Policy Act (NEPA) of 1969 (42 USC § 4321 et seq.) • Resource Conservation and Recovery Act (RCRA) of 1976, as amended (42 USC § 6901 et seq.) • Hazardous Waste Management System: General 40 CFR 260 • Identification and Listing of Hazardous Waste, 40 CFR 261 • Standards Applicable to Generators of Hazardous Waste, 40 CFR 262 • Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities, 40 CFR 264 • Standards for Management of Used Oil, 40 CFR 279.  Near Real Time Monitoring Systems SOP-PU-0000-R-491(and incorporated references)  Toxic Chemical Laboratory Analytical Operating Procedures SOP-PU-0000-R-465 (and incorporated references)  PCD Site-Specific Laboratory Quality Control Plan (and incorporated references)  PCD Regulation 385-61-2 Chemical Hygiene Plan (and incorporated references)  PCD SOP PU-0000-M-486 Chemical Operations (and incorporated references)  PCD CAIRA Plan (and incorporated references) 3.1 EMS Implementation The Pueblo Chemical Depot (PCD) has implemented an Environmental Management System (EMS) to ensure it fulfills the commitments to its Environmental Policy. The scope of the PCD EMS includes the following PCD and all tenants The EMS is modeled on the specifications found in the international standard for environmental management in organizations, ISO- 14001:2004. Specific benefits provided to PCD from implementing a formal management discipline include: a. The systematic approach to managing PCD’s potential impacts on the environment. b. Enabling PCD environmental concerns to be managed to accord with mission goals.
  • 20. UNCONTROLED IF PRINTED PCD EMS Manual 3-3 c. Providing documentation of existing processes so that results can be repeated. Institutional knowledge is captured so it is not subject to personnel flux. d. Providing a structured approach to identify potential impacts that could otherwise result in costs, embarrassments, and threats to mission. e. Having the potential to provide employees with a sense of empowerment that can translate to enhanced performance on the job. f. Providing the site with a means to track and measure environmental and operational performance by instituting metrics. g. Providing greater discipline and assurance in tracking and analyzing environmental requirements thus ensuring a higher level of compliance. h. Allowing PCD to use a risk management approach ensuring the site focuses and allocates its resources to those that have the greatest probability and worst potential consequences. i. Providing for greater sharing of knowledge and responsibilities across all levels and functions. j. Supporting reporting under Government Performance Results Act (GPRA). 3.1.1 Summary of Pertinent EMS Concepts 3.1.1.1 Background Formal Environmental Management Systems (EMS) emerged in the early 1990s to provide organizations with a proactive, systematic approach for managing the potential environmental consequences of their operations. Such systems have been widely adopted by industry and government and have been effective at improving regulatory compliance and environmental performance. In April 2000, President Clinton signed Executive Order (E.O.) 13148, “Greening the Government through Leadership in Environmental Management” that established a 5-year EMS implementation goal for all Federal Facilities. 3.1.1.2 EMS Model Although several recognized EMS frameworks exist, most are based on the International Organization for Standardization’s ISO-14001 EMS standard. As a result, ISO-14001 is the framework on which organizations most frequently choose to base their EMS, and this has proven to be the case with U.S. federal facilities.
  • 21. UNCONTROLED IF PRINTED PCD EMS Manual 4-4 1. Phase 1: Planning The organization identifies how its operations might harm the environment, and develops measures to reduce this harm. 2. Phase 2: Doing The organization implements the systemic measures to minimize harm across all levels and functions of its operations. 3. Phase 3: Checking The organization assesses the effectiveness of the systematic measures for minimizing both the potential harm to the environment and its consequential impacts to mission. Phase 4: Acting Based on its assessment of the implemented systemic measures, the organization undertakes actions to make system adjustments and to promote continual improvement. . The findings of Phase 4 may indicate that adjustments to measures already in place are necessary or that entirely new approaches are needed to achieve desired environmental objectives. Output from this phase is fed back into Phase 1 Planning, to make necessary changes and additions designed to bring the EMS to the desired level of effectiveness. This system feedback propels the continual improvement of the EMS. The EMS continually moves through this cycle, fine-tuning its management of those areas of the organization’s operations that harm the environment. This “continual improvement cycle” is a fundamental characteristic of the EMS; it allows the system to adapt to the dynamic nature of the organization’s operations and to remain relevant and viable for its intended purposes. 4. EMS Procedures Chapter 4 contains PCD’s EMS Procedures. Each procedure describes the methodology used by PCD to execute various elements of an integrated EMS. The purpose of these procedures is to enable those who maintain the EMS to understand the requirements of the EMS and to ensure a reliable and consistent execution of those ACT Management Review CHECK-Checking & Corrective Action • Monitoring & measurement • Non-conformance, corrective & preventative action • Records • EMS audit PLAN-Planning • Environmental aspects • Legal & other requirements objectives & targets • Environmental management program DO-Implementation & Operation • Structure & responsibility • Training, awareness & Competence • EMS documentation • Operational control • Emergency preparedness & response Figure 1: ISO14001 EMS Model
  • 22. UNCONTROLED IF PRINTED PCD EMS Manual 4-5 requirements for an effective system. This chapter contains the authorized verbatim version of these procedures. Copies may be distributed to relevant functions and levels at PCD so that they are available to those individuals that need to reference them. This chapter contains the following EMS Procedures: a. Identifying Significant Environment Aspects b. EMS Audit Program and Compliance Status c. Communications d. Document Control e. Environmental Management Programs/Operational Controls f. Emergency Preparedness and Response g. Legal and Other Requirements h. Monitoring and Measurement i. Management Review j. Nonconformity, Corrective and Preventive Action k. Objectives and Targets l. Control of Records m. Awareness and Competency Training
  • 23. UNCONTROLED IF PRINTED PCD EMS Manual 4-6 4.1 Identifying Significant Environmental Aspects 1. 0 Purpose and Scope The purpose of this procedure is to identify the significant environmental aspects of the inputs associated with PCD’s activities, products, processes, and/or services in order to set objectives and targets for PCD’s Environmental Management System (EMS). The objectives and targets for significant environmental aspects will then be achieved through the implementation of Environmental Management Programs (EMPs). This procedure will be applied to all Inputs within the scope of the EMS that have aspects that are under the direct control or influence of PCD. It is applied equally to those aspects within the scope of the EMS at PCD that may originate from external sources. 2.0 Definitions For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4. 3.0 Procedure The following approach will be implemented by the EMS Manager, in coordination with Environmental Management Office (EMO) personnel, to identify the significant environmental aspects associated with installation Inputs. 3.1 Define/Identify PCD Activities and Inputs Initial identification of activates will be based on the Depot’s mission. Initial identification of Inputs for those activities will begin with the EMS Manager identifying every organization that resides at PCD. They will create a baseline of the Inputs that are within the scope of the EMS and that have the possibility of interacting with the environment together with their environmental aspects and potential impacts. Each activity will have at least one Input. Each Input will have one or more aspects associated with it; likewise, each Input and aspect will have one or more environmental impacts identified. The baseline list, in spreadsheet format (see Attachment A), will include Inputs that exhibit aspects that will be further considered for their significance. Any aspects that result from Inputs controlled or influenced by the installation or tenant will be evaluated for significance. In addition to identifying each Input and aspect, the baseline list must also include information on the potential environmental impact(s) associated with each Input. A number of sources may contain relevant and applicable information that can be used to assist in the development of the baseline list. These sources include, but are not limited to installation operation plans; records of emergency response activities; environmental release incidents; environmental impact statements; range assessments; permit applications; outsourcing documentation; etc. Additional information regarding environmental aspects will be collected by:  Brainstorming – Functional managers with a detailed knowledge of PCD’s specific Inputs will be assembled. This brainstorming team will meet to review PCD’s operations and reflect upon the likely sources of environmental implications (the aspects). Daily installation Inputs will be considered first, followed by Inputs that occur on a less frequent basis. Functional managers assembled for the brainstorming will include at a minimum: Environmental Program managers.
  • 24. UNCONTROLED IF PRINTED PCD EMS Manual 4-7  Facility Walk Through – A physical walk-through of all areas and operations serves as a visual “trigger” to ensure that Inputs that should be included in the analysis are not inadvertently overlooked. The walk-through team will visit each work area within PCD and visually identify all of the Inputs that contribute environmental aspects, and make any necessary adjustments to the initial list. After the walk-through, the team will compare its list of “contributors” against the initial list and make necessary adjustments. The following Inputs must be included in the baseline list of Inputs:  Inputs that have obvious regulatory or other requirements.  Inputs that have visible impacts on the environment.  Inputs that may not have visible impacts but are known to potentially cause harm to the environment or human health. The following Inputs do not need to be included in the baseline list of Inputs:  Inputs that have minor and temporary impact on the environment.  Inputs that have been previously declared by qualified, competent experts to be insignificant.  Inputs that do not satisfy any of the criteria as outlined above. 3.2 Define/Identify PCD Aspects and Impacts Once the baseline spreadsheet of Inputs and their associated environmental aspects and impacts is completed, it is provided to all program managers of PCD’s Environmental Management Office (EMO) for review. The program managers will review this baseline list against existing environmental programs to determine its accuracy and provide feedback on baseline environmental aspects. The EMO will also assist the EMS Manager in refining the description of each of the potential environmental impacts associated with the aspects identified in the baseline list. The aspects related to inputs that should be cataloged include both those that can be directly controlled as well as those that can be influenced. It is important to remember that these aspects are only those from the organization’s Inputs that fall within the scope of the EMS. The determination of aspects is made by following a sequence of questions: 1) What is the scope of the EMS? 2) What are the Inputs within that scope? 3) What are the aspects of these Inputs? 4) Which of these aspects can be directly controlled? 5) Which of these aspects can be influenced? Those that can neither be directly controlled nor influenced should not be included in the EMS. PCD will also identify and address any impacts that may have a cumulative effect. This is especially important because a large number of different Inputs may produce a common impact. Individually, the impacts from these Inputs may be low, but in some cases, the cumulative impact may be significant.
  • 25. UNCONTROLED IF PRINTED PCD EMS Manual 4-8 3.3 Identifying PCD Significant Aspects 3.3.1 Having identified the environmental aspects of PCD Inputs, the EMS Manager with assistance from the IST will evaluate their significance. In general, all aspects that have a legal or other regulatory requirement will be considered to be significant environmental aspects. Other factors that bear on significance will consider the severity of environmental, mission, and community impacts if the aspect were to occur and actually cause its greatest potential negative consequences. If one of these other factors is given a “high” severity score then the aspect will be considered a significant aspect irrespective of the existence of any applicable legal or other requirements. Inputs that score “high” on any of the impact categories will be listed in the Operational Control section of the EMPs. These other significance factors will be scored using the following criteria: 1. Positive or Negative Impact to the Environment:  (3) High: Environmental consequences are serious but reversible over time. Environmental benefits to ecology or to human health and welfare are moderate.  (2) Medium: Environmental consequences are noticeable but brief or totally correctable in a relatively short time period. Environmental benefits to ecology or to human health and welfare are minimal.  (1) Low: Environmental consequences are immediately reversible and and/or administrative, brief and totally correctable. Environmental benefits to ecology or to human health and welfare are minimal or non-existent. 2. Positive or Negative Impact to Mission Capability:  (3) High: Interruption of normal mission operation (e.g. line stoppage) is likely and severe and could result in fines or remediation. Benefit to the organization or mission capability is substantially improved.  (2) Medium: Interruption of normal mission operation (e.g. line stoppage) is likely but recoverable without significant repercussions or the cost of a fine or remediation is moderate. Benefit to the organization is moderate or mission capability is moderately improved.  (1) Low: Interruption of normal mission operation is either unlikely or the consequences are very slight or easily corrected. Benefit to the organization or mission capability is minimally improved. 3. Positive or Negative Impact to the Community:  (3) High: Community would become concerned/aware but not unified in its opposition. Would produce media coverage and may or may not lead to legal action, political pressure, or significant embarrassment to PCD.  (2) Medium: Community may or may not become concerned/aware but would not be concerned and not likely to result in media coverage, legal action, political pressure or significant embarrassment to PCD.  (1) Low: Transparent to community and not a concern, not likely to result in media coverage, legal actions, or political pressure to PCD.
  • 26. UNCONTROLED IF PRINTED PCD EMS Manual 4-9 3.3.2 The updated spreadsheet (an example sheet is enclosed as Attachment D – Significant Aspects Identification Table) that documents the significant aspects will be sorted by organization and distributed to the leaders for review and comment. The last updated spreadsheet can be found in section 2.3 of this manual. 3.3.3 The EMS Manager will finalize the list and staff it to the Depot Commander for approval. 3.3.4 Once finalized and approved, the list becomes input to the EMS Procedure for Objectives and Targets. 3.4 Keeping the List of Aspects Updated This procedure will be applied as necessary to ensure that the PCD EMS identifies all significant aspects and will be reapplied every 18 months to maintain the currency of the EMS. 4.0 Guidance for Creating the Aspects Spreadsheet 4.1 Consolidate Inputs Within Each Significant Aspect and Determine Need for Subgroups. The resulting list of significant aspects and their corresponding Inputs may be sub-divided into subgroups. In general, determining whether or not to split significant aspects into subgroups is based on management considerations for ease of tracking, for clarity in the assignment of responsibilities, and for operational considerations including the setting of objectives and targets and the development and implementation of EMPs. For example, the split may be made along organizational lines or to highlight a particular source: • Organizational Differentiation: It may be that one part of the organization contributes a considerably greater proportion to the significant aspect than all of the other parts combined. In this instance, it would make sense to have a subgroup for that part of PCD (with the objective to improve on its performance) and a subgroup for the other parts (with the objective to maintain their performance). • Source Differentiation: It may be that there are two (or more) distinct classifications of sources that contribute to a common significant aspect. For example, painting and degreasing operations (generating volatile organic compounds) and internal combustion engine operations (generating Sox, Nox, and CO emissions) may both contribute to the aspect on Air Emissions. In this instance, it would make sense to split them into two subgroups since each would have a different strategy to improve its own performance. 4.2 Evaluating New/Modified Inputs The EMO Director and/or EMS Manager will attend Production Planning Meetings (PPM). PPM meetings discuss new and changing functions within the Directorate for Maintenance. An additional method of notification that may be utilized is whenever a new Input is initiated, or an existing Input is modified, the relevant organization shall notify the EMS Manager by routing information on the new or modified Input to the Environmental Division. The NEPA Coordinator in EMO will also route pertinent information on new or modified projects to the affected EMO staff for an evaluation to ascertain if any significant environmental aspects have been introduced and/or modified, and to make necessary adjustments in the EMPs.
  • 27. UNCONTROLED IF PRINTED PCD EMS Manual 4-10 Newly identified significant aspects will be added to the EMS in accordance will all applicable EMS procedures. 4.3 Evaluating Aspects from External Sources This procedure is also applied to Inputs that originate from external sources (e.g., suppliers). Significant environmental aspects at PCD that originate from such sources shall be managed like all other significant environmental aspects. PCD may take steps to notify those external parties over which it has some influence to mitigate any aspects that may reasonably be mitigated at the source. Where no such influence exists or where mitigation at the source is infeasible, PCD will address such aspects within its own EMS. 5.0 Records The PCD EMS Manager will keep and maintain the following records that result from this procedure (the information may be organized into separate lists or into one or more tables to facilitate access and presentation):
  • 28. UNCONTROLED IF PRINTED PCD EMS Manual 4-11 Attachment A: Operational Inputs and Associated Aspects and Impacts (sample)
  • 29. UNCONTROLED IF PRINTED PCD EMS Manual 4-12
  • 30. UNCONTROLED IF PRINTED PCD EMS Manual 4-13 Attachment B: Significant Environmental Aspects List 1. Air Emissions (ODS (CFCs in building chiller systems), VOCs (fugitive emissions from vehicle fueling operations, chemical cleaning, parts washing, painting, etc.), criteria pollutants (machinery operations, vehicle operations, etc.), dust, particulates, odors) 2. Solid Waste Generation (other) a. Paper/Cardboard Generation b. Wood Pallet Generation c. Scrap Metal Generation d. Tire Generation 3. Hazardous/Regulated Industrial Waste Generation (laboratory or degreasing solvents, hazardous batteries, empty chemical containers, used oil, paint filters) 4. Universal Waste Generation (waste paints, blast media, florescent lights, batteries, etc.) 5. Chemical Spills/Leaks to Surface or Ground Water (fuel, hydraulic leaks, POL, storage tank leaks, perchlorate, cadmium, other heavy metals etc.) 6. Toxics Releases (TRI and TIER 2 inventories) 7. PCB Releases 8. Asbestos Releases 9. Lead Based Paint Releases 10. Pesticide Applications (grounds maintenance, pest control) 11. Liquid Discharges (point and non-point) to surface and/or ground waters [(industrial wastewater contributions from painting operations, metal etching/plating, X-ray activities, vehicle maintenance areas), sewage, wash-racks, air dryers, and storm-water] 12. Electricity Consumption (high electricity use operations) 13. Fuel Consumption (petroleum products, natural gas, and other alternative fuels) 14. Water Consumption (high water use operations) 15. Ecological Disturbance (NEPA, hydrological alteration, vegetation alteration, habitats, wetlands, threatened and endangered species, invasive species, etc.) 16. Cultural Resource Disturbance (historic properties, graveyards) 17. Generation of Noise or Nuisances (testing operations, vehicle operation, vibration, visual impairment) 18. Soil Erosion (construction activities and ground clearing)
  • 31. UNCONTROLED IF PRINTED PCD EMS Manual 4-14 Attachment C: Sample Environmental Impacts  Toxics contamination or addition to air, land, waterway  Reduced visibility  Air pollution (smog, acid rain, dust, visual impairment)  Human health impact  Landfill depletion  Resource depletion  Soil contamination  Groundwater contamination  Surface water contamination  Hazardous material damage  Biological material damage  Ecological damage  Ozone depletion  Greenhouse gas release  Habitat alteration  Introduction of non-native species  Pesticide damage  Cultural resource property-damage  Sedimentation of water courses  Increased runoff / stream flow  Watershed alterations  Soil compaction  Wind erosion  Water erosion  Loss or damage to threatened and endangered species  Noise damage  Vibration damage  Heat damage  Radiation damage  Odor nuisance  Nuisance to community  Loss of indigenous species
  • 32. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-15 4.2 PCD EMS Audit Program 1.0 Purpose and Scope The PCD EMS Audit Program is implemented to ensure the organization allocates resources, provides qualified auditors, plans the execution of audits and otherwise arranges for the efficient and effective conduct of internal EMS audits in support of the EMS. Internal EMS audits support the EMS and provide a periodic check of its status so that management can make decisions regarding its continuing suitability, adequacy and effectiveness. Internal EMS audits also assess conformance to the requirements of the ISO-14001:2004 standard and are used to verify that the organization periodically does compliance status checks. The PCD Audit Program is based on the ISO-19011 standard. 2.0 Definitions For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4. 3.0 Approach 3.1 Audit Program Chart: International Organization for Standardization. (Final Draft 2002). ISO- 19011: Guidelines for quality and/or environmental management systems auditing. ISO/FBIS 19011: 2002(E). Authority for the audit program Establish the audit program • Objectives and extent • Responsibilities • Resources • Procedures Implementing the audit Program • Evaluating auditors • Selecting audit teams • Directing audit activities • Recording Monitoring and reviewing the audit program • Identify opportunities for improvement Competence of Auditors Improving the Audit Program Audit Activities P L A N D O C H E C K A C T 3.2 Audit Program Manager Responsibilities - The EMS Manager also acts as the Audit Program Manager for internal EMS audits and internal compliance audits. The EMS Manager has the following responsibilities:
  • 33. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-16 a. Ensures adequate resources have been allocated in relevant budgets for the conduct of planned internal EMS audits. b. At the beginning of each fiscal year, plans the audit strategy (e.g., functions to be audited, elements to be audited, schedule of audits, team members for each audit, lead auditor for each audit, etc.). c. Ensures sufficient auditors will be available and that they remain competent through further training or other means of maintaining competency. d. Stores and manages all documentation from previous audits (e.g., audit reports, records of corrective actions, etc.). e. Maintains Audit templates and checklists of criteria for use by the audit teams. f. Evaluates auditors and makes decisions on qualifying additional individuals as competent internal auditors. g. Works with the lead auditor assigned to a given audit to establish the objectives for that audit and to ensure that the proper resources and information are available to conduct the audit. h. Ensures that the audit team conducts and completes the audit. 3.3 Frequency of EMS Audits Internal EMS audits shall be scheduled on the basis of need as reflected by the importance of Inputs or the results of previous audits, but not less than annually, in order to verify that the system is implemented and functioning as expected. An individual audit may be limited to a sampling of EMS elements or areas and can be both random and/or focused on certain Inputs based on their importance and/or results of previous audits. The audit program manager will decide on the strategy to be pursued in the audit at the beginning of each fiscal year. 3.4 Scope of EMS Audits On an annual basis, internal EMS audits assess all operations and facilities described within the scope of the EMS to determine conformance for these operations and facilities against the requirements of ISO-14001:2004, and the organization’s internal performance objectives. Every organization will be audited at least once annually. Depending on the results of previous audits, the EMS Manager may opt to conduct one yearly audit or a series of audits that focus only on specific elements. 3.5 Selection of Audit Team The audit team shall be designated by the Depot Commander and shall consist of personnel that have received internal EMS auditor training and are deemed competent to conduct such audits. The PCD EMS Manager is responsible for overseeing the EMS Audit Program. He or she is also responsible for selecting the lead auditor for a given audit. The designated lead auditor is responsible for ensuring that the audit team conducts and completes the audit as planned. The Audit Program Manager shall not be a member of the audit team. The EMO Director may also bring in an outside contracted audit team to perform an internal audit or periodically, as needed, to get a fresh perspective and overview of whether the EMS is meeting established goals and functionality. 3.6 Internal Audit Procedure
  • 34. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-17 The internal audit will be conducted in accordance with the Internal EMS Audit Procedure (for details, please refer to that procedure below). EMS internal audits shall be conducted against pre- established audit criteria (see below). The audit criteria may be based on the sample audit criteria provided below which can be tailored to suit the specific needs and goals of the organization based on input from the EMS Manager and the lead auditor. Audit criteria shall consist of questions based upon the specified arrangements for the EMS, and shall be designed to elicit evidence of conformity with the organization’s EMS requirements. The focus of the EMS audit is to ascertain whether the EMS has been effectively implemented and is functioning in accordance with established PCD-specific arrangements. Audit findings must be based on objective evidence that is properly corroborated and authenticated. (Auditors shall avoid reaching conclusions on the basis of hearsay or opinion.) 3.7 Compliance Status The EMS audit may also be used to verify that the compliance status has been established as arranged. The compliance status may be based on the results of a recent internal compliance audit (EPAS) that may have occurred. All internal compliance audits will utilize the most current EPAS Team Guide. PCD will rely on the internal EPAS compliance audits to ascertain its compliance status. Ongoing compliance checks will be conducted via routine walk-around inspections performed by the environmental division personnel. The internal EMS auditor shall ascertain that the organization has previously conducted a compliance status check as required by the ISO-14001:2004 standard. 3.8 Corrective Action After conferring with the EMS Manager, the appropriate area or functional manager will address findings within a specified number of days by developing corrective actions which will be included in the summary response to the corrective action request. If a nonconformity relates to the EMS itself, the EMS Manager will have the primary responsibility to apply the corrective and preventive actions. In this instance, the audit team ensures that the corrective and preventive actions have been completed when the next scheduled audit is conducted. 3.9 Preventive Action Preventive action is undertaken to avoid repetition of the nonconformity in other areas or functions of the organization that may have similar vulnerabilities that caused the original non-conformity. It is the responsibility of the EMS Manager to initiate preventive actions as specified in the EMS procedure for Nonconformity, Corrective and Preventive Actions. The execution of preventive actions may be recorded in the Corrective Action Request report or it may be documented separately. For more detailed information, refer to the organization’s procedure for Nonconformity, Corrective and Preventive Action. 3.10 Follow-Up
  • 35. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-18 At the conclusion of the audit, the audit team will determine whether any findings require follow-up after the corrective and preventive actions are applied. This will be based upon the frequency, severity, and/or risk of continued or potential nonconformities, as well as on whether the finding was either a major or critical audit finding. 3.11 Closing the Audit EMS audits are closed when the audit team leader establishes that the corrective and preventive actions have been completed. 3.12 Input to Management Review and to Next EMS Audit The Audit Report and actions taken to address findings will be inputs to the Management Review. For more detailed information on the purpose and content of the Management Review, please refer to the Management Review Procedure. (The audit report, corrective action requests and records of corrective and preventive actions will also be available to auditors that will be preparing the next scheduled audit.) 3.13 Audit Process Documentation Documentation that result from the conduct of an EMS audit may include the items listed below. The audit program manager provides proper templates for these items to the audit teams for their use on audits: i. Audit Plan j. Audit Criteria k. Internal Audit Report l. Detailed Audit Findings and Conclusions m. Completed corrective action. 3.14 Audit Resources PCD management should be able to demonstrate that it has committed to allocate the resources necessary to support the continual improvement of the EMS by providing budget and staff resources necessary to maintain this EMS Audit Program. In addition, it should be able to show that auditor training will be provided for the audit team as necessary and that contracted resources may also be utilized, if necessary, to perform internal audits. Attachments to Audit Program and Compliance Status: 1. Audit Work Flow 2. Audit Procedure 3. Audit Criteria
  • 36. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-19 Attachment 1 to Audit Program and Compliance Status: Audit Work Flow to audit) Attachment 2: Audit Work Plan Initiating the Audit Appointing the audit team leaderDefinition of objectives, scope and criteriaDetermination of the feasibility of the auditEstablishing the audit teamInitial contact with the audite e On site Audit ActivitiesConducting opening meetingCollecting and verifying informationGenerate audit findingsCommunicating during the auditPreparing audit conclusionsConducting closing meeting Reporting on the Audit Audit report preparationReport approval and distributionRetention of documents Audit Completion Audit Follow-up Initiating the Audit Appointing the audit team leaderDefinition of objectives, scope and criteria Determination of the feasibility of the auditEstablishing the audit team Initial contact with he Onsite Audit ActivitiesConducting opening meeting Collecting and verifying informationGenerate audit findings Communicating during the audit Preparing audit conclusions Conducting closing meeting Reporting on the Audit Audit report preparationReport approval and distributionRetention of documents Audit Completion Audit Follow-up  Document Review of relevant management documents and records and determination of their adequacy Audit Planning Onsite Activities Audit Completion Preparing for Onsite Audit Preparing the audit plan Audit teamwork assignments Preparation of work documents   
  • 37. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-20 Attachment 2 to Audit Program and Compliance Status: Internal EMS Audit Procedure Purpose and Scope This procedure specifies the requirements for performing Internal Environmental Management System (EMS) Audits at the Pueblo Chemical Depot (PCD). These audits are a part of the PCD EMS and are conducted periodically to ascertain that the EMS is properly implemented and continues to conform to planned arrangements for environmental management, including the requirements of ISO-14001:2004. Scope An individual audit may be limited to a sampling of EMS elements or areas within the PCD, and can be both random and/or focused on certain Inputs based on their importance and/or results of previous audits. Definitions For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4. Approach Responsibilities: The audit team shall be designated in writing and shall consist of personnel that have received internal EMS auditor training and are deemed competent to conduct such audits. The PCD EMS Manager is responsible for overseeing the EMS Audit Program. He or she is also responsible for selecting the lead auditor for a given audit. A designated auditor will be responsible for ensuring that the audit team conducts and completes the audit as planned. Audit Planning: Each audit requires an audit plan (see attached Audit Plan template) that is prepared by the lead auditor for that audit. The audit plan addresses the following preparatory matters:  Audit scope and objectives;  Audit criteria to be applied;  Contacts and coordination with the auditee(s);  Audit dates, times, and other logistics;  Review of previous audits, records, and descriptions (e.g., programs, operations, etc.);  Protocol for conducting the audit (e.g., interviews, access, coordination, safety, resolution of findings, etc.); and  Responsibilities for writing the audit report and for follow-up actions. Requirements:  Individuals on the audit team must receive internal auditor training and be designated as competent to conduct internal EMS audits;  EMS audits will be conducted against pre-established audit criteria;  The audit criteria shall be developed jointly by the entire PCD audit team, and approved by the EMO Director;  Audit criteria shall consist of questions based upon the specified arrangements for the EMS, and shall be designed to elicit evidence of conformity with ISO-14001:2004 and PCD arrangements for environmental management.
  • 38. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-21  The focus of the EMS audit is to ascertain that the EMS has been effectively implemented and is functioning in accordance with established arrangements; and  Audit findings must be based on objective evidence that is properly corroborated and authenticated. (Note: Auditors should avoid reaching conclusions on the basis of hearsay or opinion.) On-Site Audit Process:  EMS audits will be conducted primarily through interviews with personnel;  EMS audits may include sampling. For example, compliance data may be sampled to ascertain that compliance programs are achieving their intended objectives;  The EMS auditors may also rely on records for information related to the functioning of the EMS and its objectives and targets;  The EMS auditors may also rely on observations of operating conditions to gauge environmental status and conditions, where appropriate and efficacious;  The audit team will conduct opening and closing meetings with responsible management of the areas being audited;  The audit team will document corrective actions. Responsibility for corrective actions will reside with management in the area where the findings occurred. If a corrective action relates to the EMS itself, the PCD EMS Manager will have primary responsibility to arrange for the correction to be made. The audit team validates that the corrective and preventive actions have been completed by the auditee. Regulatory Compliance Status: The regulatory compliance status at PCD is established periodically through the external EPAS audits, internal compliance audits, routine walk-around inspections, state audits, EPA audits and other external audits. Audit Report: When the audit is complete, the audit team will complete the audit details. After audit details have been completed they will be available to the PCD EMS Manager and the manager for the area audited. Closing the Audit: The audit team will monitor the auditee’s completion of corrective and preventive actions for a proper closing of the audit. The EMS audit is closed when the audit leader establishes that the corrective and preventive actions have been accomplished. Input to Management Review: The results of the audit and the status of the corrective actions are to be presented at the next scheduled Management Review meeting. Records Records generated by this procedure are maintained by EMS Program Manager and include the following information: 1. Audit planning information 2. Audit criteria 3. Audit findings and conclusions 4. Completion of corrective and preventive actions.
  • 39. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-22 Attachment 3 to Audit Program and Compliance Status: Audit Criteria, ISO-14001:2004 4.2,1 Environmental Management System Audit Criteria ISO 14001:2004 Purpose The purpose of this document is to provide the criteria for the internal audit of the Environmental Management System (EMS) implemented at PCD as required by Executive Order 13423. Findings categories: Major nonconformity finding: A significant number of minor findings against one element of the EMS or a completely missing element. Minor nonconformity finding: A single nonconformity against an element of the EMS.
  • 40. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-23 Sample Audit Checklist
  • 41. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-24
  • 42. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-25
  • 43. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-26
  • 44. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-27
  • 45. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-28
  • 46. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-29
  • 47. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-30
  • 48. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-31 4.3 PCD EMS Procedure for Internal and External Communications 1.0 Purpose and Scope The purpose of this procedure is to establish a reliable and consistent process for addressing and documenting communications pertinent to the Pueblo Chemical Depot (PCD) Environmental Management System (EMS). Specifically, this procedure is used:  To enumerate the internal communication tools and processes for communicating EMS-related information between levels and functions inside PCD;  For receiving, documenting and responding to relevant information and requests from external interested parties; and  To communicate information and/or requirements related to the identified significant environmental aspects of goods and services (used or outsourced at PCD) to suppliers and contractors in accordance with the requirements of PCD’s EMS. This procedure is applied to all internal and external communications regarding the PCD EMS, including communications initiated by PCD as well as communications from PCD in response to external requests for information. 2.0 Definitions For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4. 3.0 Approach 3.1 Internal Communications: PCD utilizes several “information tools” as a means of maintaining a high level of information flow between all levels of the Depot’s structure. These include: Intranet web sites, e-mails, telephone, memorandums, recurring meetings, etc. All personnel are strongly encouraged to use these methods to exchange ideas, discuss problems and ask questions from supervisors and other Depot members. Major topics of internal communication include, but are not limited to:  Environmental policy, objectives, and targets;  Environmental roles and responsibilities;  Environmental regulatory requirements;  Environmental performance compared to objectives and targets;  Environmental policies and procedures; and,  Hazards and emergency response procedures. The Depot Commander is responsible for communicating the installation’s environmental policy. The proponent for all other internal environmental communications is the Environmental Division. However, dissemination of environmental information to all installation personnel is the responsibility of all levels of management. Conversely, all installation personnel are encouraged to provide feedback through their appropriate chain of command on issues that could impact the environmental performance of the installation. 1. The following actions promote internal communication regarding the PCD EMS:
  • 49. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-32  The PCD Environmental Policy will be communicated to all PCD personnel. A hardcopy of the most current policy statement will be posted on all “official” PCD message boards  EMS Training: o Awareness Training – All PCD personnel will receive EMS Awareness Training. (New personnel will receive this training during the New Employee Orientation.) o Competence Training – For personnel whose work may involve significant environmental impacts, PCD will evaluate competence and deliver training targeted to the person’s job function, if that is deemed necessary to upgrade his or her skills. o Outreach campaign – As necessary, EMS outreach efforts will be undertaken to promote the EMS awareness (e.g., Earth Day activities, etc.). o Contractors working on the depot for more than 6 months will be required to attend an EMS Awareness training session. If their work may involve a significant impact, the contractor will evaluate competence and deliver training targeted to the person’s job function, as appropriate. 3.2 External Communications: 1. Consistent with its commitments in the Environmental Policy statement, PCD will communicate relevant information regarding its EMS. Specifically, PCD will take the following actions under its EMS:  Make its Environmental Policy available to the public via the Environmental Monitor quarterly news letter; the AQWA/PCD Web Site or upon request;  Report all environmental information required by regulation to the appropriate authorities; and  PCD has considered the external communication of its significant environmental aspects and will do so fully as required by law. 2. Regarding non-regulatory inputs from external interested parties, PCD has instituted the following process:  All written, non-regulatory external inquiries concerning environmental performance, are received or routed to the PCD Public Affairs Office (PAO). A determination of Freedom of information Act (FOIA) is made. If the inquiry is determined to be FIOA then it is forwarded to the FIOA Office for processing.  The SME provides documentation and generates the OPSEC review forms for staffing the response prior to release from the Depot.  The PAO shall ensure that the response is timely.  The EMS Manager and Environmental Program Managers will consider all external communications when establishing and reviewing environmental objectives and targets for the EMS and will initiate any necessary changes to the EMS.  All responses to inquiries from members of Congress will be coordinated through PCD Legal Office and staffed through PAO for Depot Commander’s signature.  PAO prepares responses to inquiries from the media will be coordinated through the PAO and routed through the Legal Office and the Office of the Commander.
  • 50. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-33 3. Regarding regulatory written correspondence and requests, PCD has instituted the following process:  All regulatory requests concerning environmental performance are received or routed to the EMO Director.  The EMO Director may obtain input or task the appropriate EMO Program Manager to prepare a response to the regulatory body.  The EMO Director approves the response, and either signs it, or routes it for appropriate signature either to the Director of Public Works, Legal Office or to the Depot Commander.  Formal communications will be entered into the EISIS system or maintained in the EMO master files. 3.3 Communications with Suppliers and Contractors: 1. PCD will communicate the following information to appropriate suppliers and contractors, including contractors used for outsourcing:  PCD is concerned about environmental issues and desires to conduct its business operations in an environmentally sound manner.  Relevant significant aspects will be communicated to contractors (including those used for outsourcing) and suppliers through the bid package. It will also be applied to contractors working onsite at the depot for more than 6 months.  PCD has implemented an EMS, which is based on ISO-14001:2004.  PCD expects its suppliers and contractors to provide, at the same quality and price, products and services that have the least environmental consequence of all available options.  Where a supplier’s product is causing a significant environmental aspect at PCD, PCD will communicate to that supplier that wherever possible, they should select the available option that minimizes the potential environmental impact of that product. 2. Where a supplier or contractor is supplying goods or services associated with significant environmental aspects, the affected PCD manager will work with the appropriate procurement representative to inform that supplier or contractor of applicable procedures and requirements to mitigate, minimize, or otherwise control the potential environmental impacts associated with those significant environmental aspects. This will also be applied to contractors used for outsourcing. 3. Communications with suppliers and contractors shall be documented in accordance with PCD procurement procedures. 4.0 Records Records generated from the execution of this procedure will be maintained in electronic form and in hard copy and include:  Records of submissions to regulatory authorities;  Records of environmental reports to the public if any;  Copies of requests and responses to external parties;  Copies of sent and received communications from suppliers and contractors.
  • 51. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-34 4.4 PCD EMS Procedure for Document Control and Documentation 1. 0 Purpose and Scope The purpose of this procedure is to provide a standard method for controlling documents that support the operation of the Pueblo Chemical Depot Environmental Management System (EMS). This procedure provides instructions, and assigns responsibilities for the establishment, review, authorization, issue, distribution, and revision of controlled documents and records. This procedure applies to the creation, revision, approval, distribution and version control of all documents associated with the EMS. 2.0 Procedure Personnel with specific EMS document responsibilities will ensure that documents are current, available to personnel that need them, and are removed when they no longer apply or have been rendered obsolete by updated versions. Controlled documents, such as SOPs or management plans, are accessible through the intranet website. Printed copies of these controlled documents will be marked with the statement “Controlled Document, Uncontrolled if Printed.” Further detail of this procedure for approval and version control is supplemented by specific requirements. Other documents and records may exist outside the system and are not considered official controlled documents. These documents may exist as information transport tools to final record locations and/or may be developed and used for personal use only. 3.0 EMS Documentation EMS documentation provides a standardized structure for organizing PCD’s EMS programs, procedures, work instructions, and records. The structure of the documentation is as follows:  The EMS Manual - describes the core elements of the management system, including their interrelationships. The manual provides an overview of the EMS. It refers to, and cross- references, related documentation such as EMS Procedures, and EMPs. EMS Procedures detail specific EMS requirements and the roles, responsibilities and authorities to fulfill the requirements. As appropriate, procedures reference related documentation such as EMPs and work instructions. EMPs included in chapter 5 of the manual are included for reference only and will be replaced with the most recent version only when the EMS manual is updated. These procedures and programs are applicable to the operations at Pueblo Chemical Depot. The EMS Manual details requirements and guidelines for implementation. (The EMS Manual is available in electronic media at relevant workstations).  Depot Level Documents – PCD Regulations, Commander’s Policy Statements, Pamphlets, and other directives published at the depot level that supports the EMS Manual requirements and guidelines are located on the Depot Intranet.
  • 52. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-35  Policy and Instructions (P&Is), Standing Operating Procedures (SOPs), Operating Instructions (OIs) – Internal organizational Policy and Instructions, Standing Operating Procedures, and other Operating Instructions.  EISIS Database – the following EMS documentation will be maintained in the EISIS Database: o List of environmental aspects associated with PCD Inputs o Routine Recurring tasks outlined in the EMPs o EMS records not managed by Environmental Program Managers o Training information 4.0 Records
  • 53. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-36 4.5 PCD EMS Procedure for Environmental Management Programs and Operational Controls 1.0 Purpose and Scope The purpose of this procedure is to establish a reliable and consistent approach for creating and documenting the Environmental Management Programs (EMPs) associated with the Pueblo Chemical Depot (PCD) Environmental Management System (EMS). EMPs provide the guidance, information, and references necessary for the efficient and effective accomplishment of the objectives and targets that are set for the PCD EMS. PCD documents its EMPs in order to avoid confusion and ambiguity about what needs to be done and who is responsible for doing it. This EMS procedure also provides guidance for applying Operational Controls (OCs) to PCD’s Inputs with the potential for significant environmental impacts. PCD’s EMO staff applies this procedure to develop and document the EMPs that they create, update, and implement to achieve the objectives and targets of the PCD EMS. Objectives and targets are set through the execution of the EMS Procedure for Setting Objectives and Targets. 2.0 Definitions For definitions meant to help explain terms used throughout this procedure, see Chapter 1, Section 4. 3.0 Approach PCD uses the EMP Template (See attached EMP Template) as a guide to structure existing and new EMPs. The EMPs also demonstrate the different elements of the EMS and their interaction. Existing PCD programs are periodically reviewed to ensure they contain the programmatic information elements shown in the EMP Template. Once completed, the EMP templates are reviewed by the Environmental Management Office Director. EMPs will be reviewed and updated if needed by each program manager at least one time a year and are available to the Office of the Commander. The official version of the EMPs will be maintained by Environmental Management Office. 4.0 Records EMPs generate a variety of EMS records. In most instances, the EMP template itself serves as a record: 1. The previous 3 years of completed EMP templates (Starting May 2006); 2. Records that reflect the status of objectives and targets as measured during the course of program implementation, where applicable; 3. Records that reflect the assignment of roles and responsibilities, when used; 4. Records that reflect the allocation of other resources, when used; 5. Records other than the EMP that substantiate declarations of employee competency, when used; 6. Records of maintenance performed on operational controls; 7. Records of any Corrective Actions taken in the event of interrupted or failed controls;
  • 54. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-37 8. Records of operational controls that were communicated to external sources of goods and services; and contractors working on site or doing outsourced work and 9. Records that demonstrate the functioning of operational controls, either ongoing or periodic depending on what is appropriate and actually implemented.
  • 55. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-38 Example Environmental Management Plan (EMP) Significant Aspect: Tracking Number Department/Area(s): Date: Objective: Process/Activity: Potential Impacts: Target: Legal and Other Requirements: Task Responsible Party Schedule/Resources Key Characteristics/Performance Criteria . Approvals: Submit to the Environmental Quality Control Committee (EQCC) for review and approval.
  • 56. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-39 Guidance for Completing the EMP Template This guidance complements the information in the EMS Procedure for creating environmental management programs (EMPs) and their associated operational controls (OCs). Specifically it provides guidance for completing the EMP template which is designed to capture programmatic, management summary information for a more structured, consistent and documented management of environmental programs at PCD. The EMP template is designed to not only to incorporate all the main elements of the EMS and document their interaction, but actually be a usable tool in managing PCD’s Significant Environmental Aspects. Field 1. Significant Aspect: The aspect listed here may be generic (e.g., air emissions), it may be by criteria (e.g., particulates), or it may be specific to a function or Input (e.g., CFC emissions from refrigeration). The aspect needs to be as specific as is required to manage it efficiently and effectively. The degree of granularity and specificity in categorizing aspects is therefore dependent on how they will be managed and on how best to communicate that information in the EMP documentation. It is not useful to aggregate dissimilar aspects when their management requires different protocols and controls. Such agglomeration may result in lack of clarity and increase the likelihood of mismanagement of the environmental aspect in question. Field 2. Tracking Number: This designator is a unique number used by EMO to control document version as a means to ensure that only the authorized and currently valid version is in use. Field 3. Department/Area(s): This is the name by which this program will be known in the organization. Field 4. Date: This is the date when the document was last revised. Such information may be of value to different users of the EMP. It may be used, for example, to archive previous versions of the EMP. Field 5. Objective: The objectives listed here are those that the organization has set for itself with respect to the environmental aspect that is treated in this EMP. The number of the objective is set by the EMS manager and should remain the same. If the number of the objective changes the EMS manager will notify all program managers via e-mail. (See EMS Procedure for Setting Objectives and Targets for an explanation of what they signify.) Field 6. Process/Activity: The information recorded here should signify the reason why each impact is “significant” (e.g., regulation; mission impact; environmental impact). It should provide sufficient detail to inform prospective users on the full consequences of each individual impact. This is valuable insight that underlies the importance of the EMP and should not be assumed to be “obvious” to newcomers that are not familiar with the issue. For example: Noise is a significant aspect because it is regulated and because complaints from the adjoining community could cause a shutdown a major operation at the Depot.
  • 57. December 2011 Draft UNCONTROLED IF PRINTED PCD EMS Manual 4-40 Field 7. Potential Impacts: These are the potential impacts enumerated through the execution of the EMS Aspects Identification Procedure. Their documentation within the EMP allows for a fuller description of these potential impacts. Field 8. Target: : The targets listed are those that have been set by the organization to achieve the objectives specified. Once a target has been completed the word completed should follow the target where one would normally identify the target date of completion. Once this completed target has remained for one update it should then be deleted from the EMP. This will insure that a record of compulsion will de documented on the EMP. Program indicators should be specified for all the targets. Program indicators should have been selected during the setting of objectives and targets while the nature of the objectives and targets are fresh on the minds of the EMO Program Managers. EMP leads should ensure that a complete list of program indicators that correspond to the targets is shown in this field; normally, there is a one-to- one correspondence between them. Field 9. Legal and Other Requirements: This field contains details on the applicable legal and other requirements derived through execution of the EMS Procedure on Legal and Other Requirements. These are the legal and other requirements that apply to the Inputs that exhibit the environmental aspect in question. The level of detail for legal and other requirements should be as complete as possible. That detail is necessary if the organization expects to maintain compliance with legal and other requirements. This field should, therefore, list all the detailed legal and other requirements that apply to this environmental aspect for the Inputs listed in field 11 below. Field 10. Task: This field describes what controls are to be implemented to achieve target goals of the EMP. Field 11. Responsible Party: This field contains the name or names of organizations within PCD that have been given the responsibility to operate or otherwise implement the operational controls. Field 12. Schedule/Resources: This field sets forth the date the target goal is to be achieve and any resources needed. Field 13. Key Characteristics/Performance Criteria: The information in this field of the EMP should be as detailed as necessary to ensure effective control of the Inputs that exhibit the environmental aspect in question so as to prevent that aspect from occurring. Field 14. Approvals: The approving authority for PCD is the EQCC for all EMP’s.