Annual EHS Report For FY 2021-2022

Attached is an extensive description of current EH&S activities at SFSU that expands upon the data required to be reported to the CSU Systemwide Risk Management office each year. This report introduces a new format that allows the reader to select which topics they would like to know about using drop down menus.

Future reports will follow the same format while providing an annual update of the information.

FY 21-22 was a challenging year for the University in responding to Covid and meeting the demands of online classes and lower enrollments. 

For EH&S it was a simply challenging time. EH&S staff remained on campus each day throughout Covid, providing support, supplies, inspections, and training for Covid in addition to continuing to perform routine EH&S regulatory activities which very little in response to reductions in the onsite campus population.

TRAINING

The campus made significant progress in complaint with overdid EH&S regulatory train requirements as staff and faculty working online from home spent more time focusing not these activities made possible when EH&S star created new online trading options and assigned them through CSU.

Recently progress has slowed and will be address ed when mandatory triangles on CSU Executive Order 1039 - EH&S Policy is assigned in CY 2023.

INSPECTION

During the course of a year, EH&S performs, audits, accompanies inspectors perform, or manages contractors to conduct, more than 25,000 inspections.

Using EH&S-trained student aides, the percentage of required safety and environmental inspections performed internally reached an all-time high.

PROGRAM MAINTENANCE & DEVELEOPMENT

Required program reviews proceeded on schedule with two key exceptions. Programs in Facilities Services addressing Control of Hazardous Energy, (also known as Lockout-Tagout), and Arc Flash Safety are in need of immediate attention.

Program development continues on several fronts most notably in preparation of a Facilities employee and contractor safety handbook. The handbook contains a set of hazardous work permits to ensure proper precautions are in place before particular are inlace before particular hazardous work can take place. Once completed, compliance with the handbook will become a requirement of contractor bidding on requests for proposal packages.

• RESOURCES

The EH&S department currently has 6 staff members: a director, a manager, and 4 senior EHS specialists. This is down 40% from a previous staff of 10 prior to Covid.

Growing EHS regulatory requirements and the construction of new buildings, (Marcus Hall, Manzanita Square, the new Science building, and West Campus Green) puts additional pressure on already stretched EHS resources.

The department supports a team of 10 student aides that help maintain critical programs and regulatory inspection requirements.

EH&S is transitioning emergency-related program responsibilities to the newly created Office of Emergency Services (OES) as they staff up, reducing some pressure on limited EHS resources.

• PROFESSIONAL DEVELOPMENT

Existing staff is striving to “work smarter” with fewer resources through professional development and networking with other CSU EHS departments. As the result of their professional development activities, the current EHS staff has added:

                 - 1 college degree

                 - 1 professional certification as a Certified Safety Professional (CSP)

                 - 1 professional certification as a Certified Hazardous Materials Manager (CHMM)

                 - 2 professional certifications as Certified Chemical Hygiene Officers (NRCC-CCHO)

Two staff members are working towards graduate degrees in the EHS field.

Other staff members are pursuing additional professional certifications.

• PERSONNEL

• ORG CHART

During the course of a year, EH&S performs, audits, accompanies, or manages contractors to conduct, more than 25,000 inspections. Descriptions of the various regulatory agency, safety equipment, laboratory safety, and hazmat area inspections are available below.

REGULATORY AGENCY INSPECTIONS

• Aboveground Storage Tanks (ASTs)
  • Inspection Requirements:
  • FY 21-22 Update:

The CUPA’s AST program regulates aboveground storage tanks that are used to store petroleum products.                                                                                                                             

The goal of the annual AST inspection program is to ensure that aboveground storage tanks are installed and maintained in a safe and responsible manner to prevent spills and releases.

​

•  
  • FY 21-22 Update:

CUPA inspected in FY 21-22 - resulting in no violations or fines assessed.

• Air Compressors
  • Inspection Requirements:

Cal/OSHA requires a permit if the air compressor tank is 1.5 cubic feet in volume or larger, OR when the safety valve is set greater than 150 pounds per square inch (psi). (Tanks with less than 1.5 cubic feet of air AND less than 150 psi ARE EXEMPT.)

CalOSHA requires air tanks requiring a permit to operate to be inspected internally and externally at least once every 3 years for portable tanks and once every 5 years for all other tanks.

SFSU has 29 air tanks that require a permit to operate.

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  • FY 21-22 Update:

Air tank permits and inspections are up to date for FY 21-22

• Air Permits – Boilers
  • Inspection Requirements:

The Bay Area Air Quality Management District, (BAAQMD) inspects the campus annually for compliance with existing air permit conditions for source testing to evaluate boiler emissions.

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  • FY 21-22 Update:

BAAQMD inspected in FY 21-22 - resulting in no violations or fines assessed.

Due to a regulatory change 3 additional boilers have been added to the annual source testing.

• Air Permits - Emergency Generators
  • Inspection Requirements:

The Bay Area Air Quality Management District, (BAAQMD) inspects the campus for compliance with existing air permit conditions such as generator emissions during monthly test running of the generators.

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  • FY 21-22 Update:

BAAQMD inspected in FY 21-22 - resulting in no violations or fines assessed.

• Controlled Substances   
  • Inspection Requirements:

The DEA inspects sites that are licensed to use, and store regulated drugs to ensure drugs are not diverted for improper purposes.                                                                            

Usage tracking logs and storage security are subject to review during inspections.

The manager of the vivarium in the Biology department maintains the usage logs.

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  • FY 21-22 Update:

DEA did not inspect in FY 21-22.

• Elevators
  • Inspection Requirements:

A Facilities contractor conducts monthly inspections of SFSU elevators for satisfactory operation. On the basis of these inspections, Cal/OSHA issues annual elevator permits to operate. Copies of elevator permits are posted in each elevator, with copies maintained by Facilities Services.

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  • FY 21-22 Update:

SFSU elevator permits to operate were updated during In FY 21-22

• Hazardous Materials and Hazardous Waste
  • Inspection Requirements:

The California Environmental Protection Agency, (CalEPA), requires the local CUPA (local agency responsible for compliance), to inspect hazardous materials and hazardous waste areas at least every three years to ensure the proper handling, storage, transportation, and disposal of hazardous materials and hazardous waste.

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  • FY 21-22 Update:

CUPA did not inspect Hazardous Materials / Hazardous Waste in FY 21-22

• Injuries, Illnesses and Safety Complaints
  • Inspection Requirements:

CalOSHA responds to serious injuries and complaints with on-site inspections and/or letters of complaint to the employer that require a written response. Complaints and/or citations are posted in the workplace.

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  • FY 21-22 Update:
• Inspection for electric shock - resulting in no violations or fines assessed.
• Complaint for mold - resulting in no violations or fines assessed.
• Complaint for ventilation - resulting in no violations or fines assessed.
• Complaint for Covid training - resulting in no violations or fines assessed.

• Ionizing Radiation - Radioactive Materials License and Radiation Machine Registration
  • Inspection Requirements:

CDPH-Radiological Health Branch inspects sites to confirm compliance with radioactive materials license requirements, and radiation machine regulatory compliance.

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  • FY 21-22 Update:

CDPH inspected in FY 21-22 - resulting in no violations or fines assessed.

• Medical Waste
  • Inspection Requirements:

SFSU generates medical waste at Mashouf Wellness Center, Student Health Services, and CoSE. Used syringes and sharps from locked sharps waste disposal boxes around campus are periodically collected by EH&S and disposed of at Student Health Services.

The California Medical Waste Management Act (CMWM) authorizes local public health departments (SFPDH) to grant permits, collect fees, and  inspect from facilities that generate medical waste to determine whether those facilities store, treat and dispose of those wastes in a manner that complies with the medical waste requirements of state law.

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  • FY 21-22 Update:

SFDPH did not inspect medical waste in FY 21-22

• Pool Inspections
  • Inspection Requirements:

SFDPH inspects public pools and spas annually a year for compliance with health and safety regulations.                                                                                                                                           

SFSU has pools in the Gymnasium and the Mashouf Wellness Center.

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  • FY 21-22 Update:

In FY 21-22 both pools were closed due to Covid.                                                       

Equipment failures, and supply chain problems in acquiring necessary parts for repairs continue to keep the pools closed in CY 23.

SFDPH inspected pools in FY 21-22 with no violations or fines assessed due to voluntary closure.

• Spill Prevention, Control, and Countermeasure Plan (SPCC)
  • Inspection Requirements:

CUPA requires SFSU to follow the procedures in our SPCC written program.

That program requires us to conduct weekly, monthly, and annual internal inspections to identify leaks, signage, and safe operation of oil containing tanks that are 55 gallons or greater. The CUPA inspects periodically, to confirm that SFSU is adhering to our written procedures. Every five years, the CUPA reviews the SFSU SPCC written plan for accuracy administrative changes to the plan and completeness.

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  • FY 21-22 Update:

CUPA inspected in FY 21-22 - resulting in no violations or fines assessed.

The 5 year written plan review is underway and is due next year.

• Underground Storage Tanks (USTs)
  • Inspection Requirements:

The CUPA’s UST program regulates underground storage tanks that are used to store petroleum products.                                                                                                                             

The goal of the annual UST inspection program is to ensure that underground storage tanks are installed and maintained in a safe and responsible manner to prevent spills and releases.                                                                                                                                                     

SFSU has one underground storage tank in the Corporation Yard containing gasoline.

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  • FY 21-22 Update:

A traffic accident damaged the above ground pump for the gasoline storage tank forcing its temporary closure. Facilities Services has plans to permanently close and remove the underground tank in CY 23.

CUPA inspected in FY 21-22 - resulting in no violations or fines assessed.

SAFETY EQUIPMENT INSPECTIONS

• Automated External Defibrillators (AEDs)
  • Inspection Requirements:

AEDs are used to provide emergency first aid for heart attacks. When properly and promptly used the device can recognize certain heart problems and help restore proper rhythms. EH&S has installed over 260 of these units around campus. Quarterly inspection of these units is required to replace old parts and depleted batteries.

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  • FY 21-22 Update:

EH&S performed bimonthly inspections of each unit to ensure their availability for use.  Over the course of the year, 16 units were stolen. EH&S is working to replace the missing AEDs and improve security.

• BioSafety Cabinets Annual Certification
  • Inspection Requirements:

BioSafety Cabinets are used to protect laboratory workers and the environment from biological agents. They also function to protect the materials inside it from outside contaminants. EH&S is responsible for the arranging for the annual inspection and certification of BioSafety Cabinets by an outside contractor.

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  • FY 21-22 Update:

21 out of 21 (100%) of BioSafety Cabinets were inspected and certified in FY 21-22.

• Chemical Fume Hoods Annual Certification
  • Inspection Requirements:

Chemical Fume Hoods are used to capture and exhaust potentially dangerous chemical fumes and vapors from chemicals used or stored in the fume hood.

EH&S is responsible for the arranging for the annual inspection and certification of chemical fume hoods by an outside contractor.

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  • FY 21-22 Update:

142 out of 145 (98%) of chemical fume hoods were inspected and certified. Note: 3 fume hoods were out of service for repairs and could not be inspected or calibrated.

• Emergency Eyewashes and Deluge Showers
  • Inspection Requirements:

Emergency Eyewash stations and deluge showers are required to be installed in locations where there is a significant potential for exposure to contact with corrosive chemicals.  At SFSU, the Facilities Services group performs the monthly eyewash and deluge shower inspections required by CalOSHA regulations. They also perform any necessary maintenance and repairs to the equipment.

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  • FY 21-22 Update:

Facilities services reported that 3086 out of 3132 (= 98.5%) of required monthly inspections were completed.

• Fire Extinguishers Monthly Inspection
  • Inspection Requirements:

CalOSHA requires monthly inspections of portable fire extinguishers to ensure their readiness in the event of a fire. With more than 1500 extinguishers present on campus, Facilities Services is responsible for more than 18,000 extinguisher inspections per year.

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  • FY 21-22 Update:

Facilities’ fire-life safety manager reports that 100% of extinguisher inspections were performed.

• HVAC Systems – Air Handling Units Annual Inspection
  • Inspection Requirements:

There are 137 air handling units (AHUs) on campus providing heating, ventilation, and air conditioning. At SFSU, Facilities Services performs the annual inspection of each unit required by CalOSHA.

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  • FY 21-22 Update:

Facilities Services reports that all of the AHUs were inspected in FY21-22.

• Local Exhaust Systems
  • Inspection Requirements:

Local exhaust systems (e.g. elephant trunks, canopy hoods, smog hogs etc.) are often used to remove airborne contaminants. Since their effectiveness is significantly affected by their positioning relative to the source of the contaminants, there are no regulatory standards available to evaluate these systems. As an indication of changes to the effectiveness of a given local exhaust system, one can measure the linear air velocity at their opening over time. A significant drop in linear air velocity would be a strong indication that system maintenance is required.

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  • FY 21-22 Update:

A program to require annual measurement of flow rates for local exhaust systems was proposed to the Chancellor’s Office for inclusion in future annual EH&S reports.

At SFSU, annual flow rate monitoring of local exhaust systems is proposed for CY 23.

LABORATORY and HAZMAT AREA INSPECTIONS

• Annual Laboratory Safety Inspection
  • Inspection Requirements:

The regulatory agency with jurisdiction for San Francisco, the Certified Unified Program Agency, (CUPA), requires annual safety inspections of laboratories.

Lab inspections are divided into 10 discrete categories of safety inspection questions. EH&S student aides have been trained to conduct inspections of individual categories using the customized on-line safety inspection tool SFSU EH&S developed with the UC’s RSS group.

Student lab safety inspections are overseen and collated by the EH&S staff chemical hygiene officer, who also tracks inspection findings to closure.

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  • FY 21-22 Update:

98%, (730 out of 740 categories) of required inspection questions covering 74 COSE laboratories were completed in FY 21-22.

Inspections of lab-like areas outside of COSE will be added to the program scope in FY 22-23.

• IACUC Laboratory Safety Inspection
  • Inspection Requirements:

EH&S participates in inspections of laboratories where animals are housed.

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  • FY 21-22 Update:

EHS participation in IACUC inspections were postponed during FY21-22 due to Covid concerns.

• Lab Hazard Assessment
  • Inspection Requirements:

Cal/OSHA requires assessments to identify hazards annually, and when hazards change.

At SFSU, we interpret this requirement to mean that we shall conduct lab hazard assessments at the start of the Spring and Fall semesters in both teaching and research labs. To conduct these assessments, SFSU uses the on-line RSS software tool provided by the Chancellor’s Office. The assessment consists of a series of yes or no questions that will define a lab’s hazards. Once completed, each member of the lab must view and sign-off on the list of hazards identified for the assessment to be “certified”.

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  • FY 21-22 Update:

In FY 21-22, 60% of lab hazard assessments were completed.

• Quarterly HazMat Area Environmental Inspections
  • Inspection Requirements:

The environmental regulatory agency with jurisdiction for San Francisco, the Certified Unified Program Agency, (CUPA), requires quarterly environmental inspections of areas using or storing hazardous materials. With ~ 160 of such areas on campus to be inspected on a quarterly basis, EH&S relies on teams of trained student aides to conduct these inspections using the customized on-line environmental inspection tool SFSU EH&S developed with the UC’s RSS group. Student environmental lab inspections are overseen and collated by the EH&S staff senior environmental specialist, who also tracks inspection findings to closure.

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  • FY 21-22 Update:

In FY 21-22, ~85% of hazmat area inspections were completed each quarter. Covid illnesses among the staff and student aides were a limiting factor. By communicating the issues with the CUPA, EH&S was able to avoid any citations or penalties.

• Weekly HazWaste Central Storage/Accumulation Area Inspection
  • Inspection Requirements:

Environmental regulations require weekly inspections of central hazardous waste accumulation areas. SFSU has 4 such areas located at COSE, LCA, Corp Yard, and RTC.

FY 21-22 Update:

In FY 21-22, 100% of weekly inspections at COSE and RTC were conducted.                              More than 85% of weekly inspections at Corp Yard and LCA were conducted.  Some weekly inspections were missed due to Covid-related staff illnesses.

 ​

PROGRAM REVIEWS

The annual EHS report to the CSU Systemwide Risk Management Office called for periodic program reviews for key safety and health programs. SFSU EH&S was instrumental in defining the environmental program reviews that are now required to be included. Those key programs and others are described below.

SAFETY & HEALTH PROGRAM REVIEWS

• Accident / Incident / Near Miss Reporting and Investigation
  • Program Description:

EHS investigates accidents, incidents, near misses, and reports of hazards from SFSU community. The goal of these investigations is to determine what happened / what could have happened, what could have been potential causes of the event, and what can be done to avoid a similar event anywhere at SFSU, ever again.

In addition, injuries defined as “serious” by CalOSHA must be reported to them within 8 hours of the event. Reports of serious injuries to CalOSHA are made by the EHS Director, or his backup for these matters, the Worker’s Compensation Manager, both of whom are available 24/7 for this purpose.

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  • FY 21-22 Update:

During FY 21-22, one potentially serious injury was reported to CalOSHA as a precaution in order to meet the reporting deadline. Based on a medical assessment, the injury and treatment did not meet the criteria as a “serious” injury per CalOSHA regulations.

• Aerosol Transmissible Diseases (ATD)
  • Program Description:

Aerosol transmissible diseases (ATD) are diseases that can be transmitted by either 1) inhaling particles/droplets; or 2) direct contact between particles/droplets and mucous membranes in the respiratory tract or eyes. Cal/OSHA requires employers to develop an exposure control plan to prevent work-related illness from exposure to pathogens present in aerosols. There are three departments or groups at SFSU subject to the ATD standard:

• University Police Department and other “referring” employers
• Biology Research and Academic Labs (i.e., Microbiology, Zoonotic research)
• Student Health Services
• FY 21-22 Update:
• Student Health Services uses a CSU Learn course in its ATD curriculum.
• This year, University Police, were assigned a campus-created ATD course for University.
• Due to the impact of COVID on in-person lab courses and research, the use of the bacterium covered by the ATD standard was temporarily halted. We expect it to resume in Spring 2023.

• Asbestos
  • Program Description:

The purpose of the SFSU asbestos program is to minimize exposure to airborne asbestos fibers. To this end, Facilities employees undergo annual asbestos awareness training to empower them to identify and avoid any potential fiber-forming asbestos containing building materials on campus. Additionally, all employees receive a copy of the annual asbestos notification memo that describes the location and type of known asbestos-containing building materials. SFSU policy prohibits employees from conducting asbestos abatement work. Such work, when necessary, is conducted by appropriately certified contractors, approved by EHS. Their work requires an approved SFSU asbestos abatement permit, and air monitoring by an independent third party contractor. A copy of the Asbestos Program is readily available on the EHS website.

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  • FY 21-22 Update:

During FY 21-22 asbestos abatement work was conducted following the procedures described above.

• Bloodborne Pathogens (BBP)
  • Program Description:

Cal/OSHA’s Bloodborne Pathogens standard covers employees with occupational exposure to human blood or other potentially infectious materials. Employers are required to identify job categories with potential exposure and to develop a written Exposure Control Plan designed to eliminate or minimize employee exposure.

SFSU EH&S worked with groups on campus to craft customized exposure control plans.   

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  • FY 21-22 Update:

In FY 21-22 Exposure Control Plans were reviewed and updated.

• Confined Space Entry - Permit-Required
  • Program Description:

Entering permit-required confined spaces is an Immediately Dangerous to Life or Health (IDLH) scenario. As such, SFSU employees are not allowed to enter permit-required confined spaces. When such entries are necessary, a qualified contractor with emergency response capability is hired. Contractors are required to provide appropriate documentation of their qualifications for entry and their emergency rescue capabilities to EH&S for review and approval before commencing work. Contractors are not allowed to rely on local Fire Department rescue teams, since these teams cannot commit to “stand by” during an entry if an emergency occurs somewhere else.

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  • FY 21-22 Update:

N/A

• Covid -19 Injury & Illness Prevention Program
  • Program Description:

CalOSHA requires businesses to have a Covid-19 IIPP that describes how the organization meets the requirements have an effective Covid-19 health & safety program in place. A copy of SFSU’s Covid-19 IIPP is available on the EH&S website under “Programs” beginning with the letter “C”

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  • FY 21-22 Update:

The Covid-19 IIPP will be rolled into the SFSU IIPP in 2023.

• Covid-19 Inspection
  • Program Description:

During the Covid shutdown of the campus, EH&S was responsible for providing personal protective equipment and sanitizing supplies for people remaining on campus. As part of this activity, EH&S staff and students conducted inspections of the areas they visited to ensure that adequate supplies were available and were being used as required.

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  • FY 21-22 Update:

As FY 21-22 was ending, responsibility for supplying personal protective equipment and sanitizing supplies shifted to the new Office of Emergency Services.

• Chemical Inventory Barcoding
  • Program Description:

Maintaining an accurate chemical inventory is required by multiple regulations. Fire departments need to know what chemical hazards (and quantities thereof) they might encounter before entering a burning building. A chemical inventory is required to ensure employees are properly trained on the chemical hazards they might encounter on the job. Environmental regulations require a chemical inventory to determine environmental hazards, required emergency plans, and appropriate regulatory storage fees.

To facilitate maintaining an accurate chemical inventory, the CSU has provided campuses with RSS barcoding software. SFSU labs, with help from EH&S, are in the process of barcoding their inventories and maintaining them online. The software also assists in by producing several required regulatory reports saving many hours of labor.

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  • FY 21-22 Update:

In FY 21-22, approximately 50 % of SFSU labs migrated to maintaining their chemical inventories using RSS software and barcoding.

• EH&S Purchasing Controls on Chemicals and Equipment
  • Program Description:

In order to maintain compliance with a variety of regulatory requirements, EH&S has instituted controls over the acquisition and use of certain types of hazardous materials, and equipment in cooperation with SFSU’s Procurement and Accounts Payable departments.

For example, EHS must approve the purchase of radioactive materials since they must be reported to the government and recorded on the university’s radioactive materials license by EHS’s radiation safety officer.

Likewise, EHS must approve the purchase of other materials such as known human carcinogens, toxic compressed gases, and pyrophoric materials.

EHS must approve the purchase of certain types of equipment such as fire extinguishers, chemical fume hoods, biosafety cabinets, and emergency generators since these items must be added to required inspection programs and facility maps which must be submitted to the government.

Forms to apply for approval to purchase restricted items can be found on the EHS website under the heading, “Restricted Chemicals And Equipment Purchasing”

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  • FY 21-22 Update:

During FY21-22, an emergency generator was purchased without EHS approval.

Quick action by the EHS department prevented the use of the generator before citations and fines were incurred from the Bay Area Air Quality Management District for failing to obtain a “Permit to Construct” and a “Permit to Operate” this regulated type of equipment.

• Electrical Safety - Arc Flash Protection
  • Program Description:

CalOSHA §2940.11. Protection From Flames and Electric Arcs requires employers to assess arc flash hazards their employees may be exposed to.

• FY 21-22 Update:

Facilities Services has issued a request for proposals to select a contractor to perform a sitewide identification, assessment, and labeling of arc flash hazards.

EH&S contracted a vendor who conducted arc flash training for potentially affected Facilities Services’ employees. Appropriate PPE was provided to affected employees.

• • Emergency Action Plan (EAP)
  • Program Description:

Cal/OSHA requires employers to create and maintain an emergency action plan for evacuations and responding to different types of emergencies in the workplace. The EAP must be workplace-specific and must be updated whenever procedures or policies change. The EAP program is available on the EHS website.

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  • FY 21-22 Update:

The EAP program was reviewed and updated. As of Feb 2022, The Office of Emergency Services has assumed responsibility for the EAP.

• Field Research Safety Program 
  • Program Description:

When research includes “field work”, i.e. work outside the classroom, and may involve potentially hazardous environments, additional measures are necessary to identify hazards and appropriate safety precautions as part of an effective Injury-Illness Prevention Program.

To address many of these issues, EHS provides a “Field Research - Safety Guidelines” program guide on the EHS website.

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  • FY 21-22 Update:

No update in FY21-22.

• Fire Prevention Plan (FPP) JM
  • Program Description:
  • FY 21-22 Update:

• Food Safety Program
  • Program Description:

The Food Safety Program establishes acceptable operating standards for food service at temporary events, including meetings, conferences, and other special events.  These requirements shall apply when any organization or individual proposes to sell, give away or vend food or beverages in any manner at temporary events.

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  • FY 21-22 Update:

Last updated November 2022, available via the EHS website, and managed by Student Affairs and Enrollment Management (SAEM), the Food Safety Permit is evolving with best practices mutually agreed upon by SAEM and EHS.

• Hazard Communication Program (HAZCOM) 
  • Program Description:

Cal/OSHA requires employers to have a written Hazard Communication Program that describes how the requirements of the regulation will be met.

A copy of SFSU’s written Hazard Communication Program is available on the EHS website

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  • • FY 21-22 Update:

SFSU’s written Hazard Communication program was reviewed and revised as necessary

• Hazardous Work Permits Program
  • Program Description:

Certain types of potentially dangerous work require a properly completed and approved hazardous work permit to ensure that all proper precautions have been taken prior to work beginning on campus.

This applies equally to work performed by employees or contractors.

Examples of types of work that requires a hazardous work permit include: Hot Work, Permit Required Confined Space Entry, Mobile Crane or Helicopter Lifts, Live Electrical Work, Radiography, Asbestos, Lead Paint, or Mold Abatement, Scaffold Erection, and Excavation.

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  • FY 21-22 Update:

Hazardous Work Permits were in use by employees in Facilities and CPDC as well as their contractors.

• Hazardous Waste Operations and Emergency Response (HAZWOPER)
  • Program Description:

SFSU activities fall under the ER (Emergency Response) requirements in the HAZWOPER regulations. Some COSE SFSU staff provide emergency response and minor spill clean-up services for spills and releases in labs.

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  • FY 21-22 Update:

HAZWOPER trained staff attended annual refresher training in February and April of 2022.

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  • Needs Attention:

In the past, SFSU had a 10-12 person Facilities HAZWOPER-trained spill response team to evaluate and respond to campus spills before calling an outside contractor. This team’s training is no longer up to date due to Covid, so the campus must rely on contractor services for minor hazardous material spills.

• Hearing Conservation 
  • Program Description:

Cal/OSHA’s Hearing Conservation standard defines requirements to protect employees against occupational hearing loss.

Areas that produce significant noise levels are identified and labeled.                       Employees who work in high noise areas are enrolled in a hearing conservation program that includes annual training on the proper use of hearing protection, and annual audiometric (hearing) tests.

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  • FY 21-22 Update:

The program was reviewed In FY 21-22

• Heat Illness Prevention Program (HIPP)
  • Program Description:

Cal/OSHA’s Heat Illness Prevention in Outdoor Places of Employment standard describes precautions for employees who work outdoors in hot environments. It requires employers to develop and implement written procedures, provide shade and water, and train employees and supervisors about heat illness prevention. The written SFSU HIPP is available on the EHS website.

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  • FY 21-22 Update:

The heat illness prevention program was reviewed in FY21-22.

The CSU-HIPP program for students and athletes will be implemented in CY 2023

• Hot Work (Cutting/Welding)
  • Program Description:

SFSU’s Hot Work Program includes a Hot Work – Hazardous Work Permit which provides written procedures to prevent the outbreak of fire, fire alarm activations, and smoke/odor migration in buildings resulting from work that produces heat, sparks, or involves open flames. This includes, but is not limited to, brazing, cutting, grinding, torch soldering, thawing pipes, and torch-applied roofing and welding.

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  • FY 21-22 Update:

The program was reviewed in FY 21-22.

• Indoor Air Quality (IAQ) Program 
  • Program Description:

This program describes SFSU’s EH&S processes for maintaining healthy indoor air quality.

Indoor air quality is defined in comparison to set standards for comfort measured by temperature, humidity, oxygen, carbon dioxide, carbon monoxide and particulates in the air. Odors are separate component of indoor air quality for which comfort standards don't exist. 

Initial concerns about indoor air issue are addressed by the Facilities Services HVAC unit. If Facilities Services cannot identify the source of the problem, or they have determined that the problem is not coming from their equipment, then EH&S is contacted to investigate further.

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  • FY 21-22 Update:

The program was reviewed in FY 21-22.

• Injury & Illness Prevention Program (IIPP)
  • Program Description:

Cal/OSHA requires businesses to have a written IIPP that describes how the organization meets the requirement to have the basic elements of an effective health & Safety program in place. A copy of SFSU’s IIPP is available on the EH&S website under “Programs” beginning with the letter “I”

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  • FY 21-22 Update:

The IIPP was reviewed and updated for FY 21-22.

• Laboratory Safety - Chemical Hygiene Plan (CHP)
  • Program Description:

Cal/OSHA’s Occupational Exposure to Hazardous Chemicals in Laboratories standard requires employers to develop and implement a Chemical Hygiene Plan (CHP). A CHP is a written program which sets forth procedures, equipment, PPE, and work practices that are capable of protecting employees from the health hazards presented by hazardous chemicals used in that particular workplace

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  • FY 21-22 Update:

The Chemical Hygiene Plan for the campus was reviewed and minor updates were made to the written plan. The CHP will be available on the EHS website later in CY 23.

• Laser Safety Program 
  • Program Description:

Cal/OSHA incorporates the ANSI Z136 Laser Safety Standard by reference. The SFSU laser safety program follows the recommended practices described in the ANSI standard as it applies to Class 3B or Class 4 lasers. Laser safety training is provided. A Laser Safety Committee meets as needed.

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  • FY 21-22 Update:

The use of Class 3B and Class 4 lasers covered by the program was halted due to COVID.

• Control of Hazardous Energy / Lockout-Tagout 
  • Program Description:

The control of hazardous energy commonly called a Lockout/Tagout (LOTO), protects SFSU Employees from injury or death due to the unintended start-up or release of stored energy while performing maintenance and repair on machines, processes, and systems. The hazardous energy may be electrical, hydraulic, pneumatic, mechanical, chemical, thermal, potential, residual, or from other sources.  CalOSHA requires employers to have written equipment-specific lockout procedures for all equipment.  “Plug and cord” equipment in which the employee has complete personal control of the sole energy source is excluded from the requirement for written procedures. Annual training on the program is required.

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  • FY 21-22 Update:

The Control of Hazardous Energy program was reviewed in FY 21-22.

Annual training was provided by EHS.

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  • Needs Attention:

An inspection of control of hazardous energy procedures indicates that there is a shortage of necessary equipment-specific written procedures and they are not being reviewed annually are required.

In CY 23, EHS will work with Facilities Services management to train Facilities employees to be able to write equipment-specific lockout procedures to address this issue.

• Medical Monitoring Program
  • Program Description:

On occasion, regulations and best practices require medical monitoring of employees’ reaction to potentially hazardous exposures on the job, such as noise, radiation, or air contaminants.

SFSU’s Employee Medical Monitoring Program is posted on the EHS website.

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  • FY 21-22 Update:

In FY21-22 the program was reviewed and updated.

• Mold Prevention & Abatement – Response to Water Damage
  • Program Description:

This program presents guidelines for the abatement/cleanup of mold and moisture problems on the SFSU campus. It should serve as a reference for potential mold and moisture remediators.               

Using this program, individuals with little or no experience with mold abatement should be able to reasonably judge whether the situation can be handled in-house. In addition, it will help those in charge of maintenance to evaluate an in-house remediation plan or a remediation plan submitted by an outside contractor.

Finally, contractors and professionals who respond to mold and moisture situations on the SFSU campus must complete SFSU’s Mold Abatement Hazardous Work permit.

FY 21-22 Update:

A draft of the new Mold Prevention & Abatement – Response to Water Damage program was created and will be introduced in CY 23.

• Personal Protective Equipment (PPE)
  • Program Description:

Cal/OSHA’s Personal Protective Devices standard requires employers to conduct hazard assessments to determine if hazards are present which necessitate the use of personal protective equipment (PPE). PPE must be able to provide adequate protection against the hazards for which they are designed and required PPE must be offered at no charge to employees. Facilities services has a completed a hazard assessment to define PPE needs for their activities. Laboratories use RSS software to conduct hazard assessments before the start of the Fall and Spring semesters.

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  • FY 21-22 Update:

In FY 21-22, 60% of lab hazard assessments were completed.

• Powered Industrial Truck (PIT) / Forklift
  • Program Description:

This program applies to the operation of all powered industrial trucks, motorized hand trucks, or other specialized industrial trucks by university employees.

Classroom training, hours of supervised driving, a written test, and a hands-on driving test are required before employees are authorized to drive the vehicles described.

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  • FY 21-22 Update:

In FY21-22 the program was reviewed

• Radiation (Ionizing) Safety
  • Program Description:

The CA Dept of Public Health – Radiologic Health Branch (RHB) regulates the use of ionizing radiation sources. Ionizing radiation safety at SFSU consists of two separate programs: radioactive materials and radiation producing equipment. Facilities licensed to use radioactive materials must develop and implement an approved written radiation safety program and provide training to personnel using radioactive materials. Every radiation-producing machine (i.e., x-ray machines and electron microscopes) must be registered with the CA RHB. Annual registration fees are applied. SFSU’s written Radiation Safety Program is available on the EHS website.

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  • FY 21-22 Update:

SFSU was inspected by the Radiologic Health Branch in June 2022. No violations resulted from the inspection of the radioactive materials program. Annual fees were paid on time.

• Respiratory Protection Program
  • Program Description:

To protect employees from occupational respiratory exposure to potentially harmful chemical, physical and biological agents, including airborne dusts, fumes, mists, gases, and vapors, Cal/OSHA’s Respiratory Protection standard requires employers to evaluate the workplace for these hazards. When engineering and administrative controls are not sufficient to eliminate or maintain exposures to below established permissible exposure limits, respiratory protection must be made available to employees at no cost to them. Employers must implement a written respiratory protection program, including annual medical surveillance, fit-testing and training. SFSU’s written Respiratory Protection Program is available on the EHS website.

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  • FY 21-22 Update:

In FY21-22 the program was reviewed and updated.

Annual medical surveillance, fit-testing and training was postponed until FY 22-23.

• Safety Committees
  • Program Description:

SFSU has several safety committees:

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  •  
    • Campus Safety Committee

The Campus safety committee has been meeting each month since early 2015

Attendance is open to all, and participation from all major campus groups is actively sought. De-facto members include personnel from EH&S, ERM, OES, and UPD, as well as all active Building Emergency Response Coordinators, (BERCs), and Building Coordinators, (BCs). Meetings have moved on-line in response to Covid, and to facilitate the participation of members from off the main campus locations. Minutes of the meetings are posted on the EH&S website.

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  •  
    • Facilities Services Safety Committee

The Facilities safety committee meets on an ad-hoc basis to discuss safety issues specific to their operations. EH&S attends but does not lead or facilitate these meetings.

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  •  
    • Non-ionizing Radiation (Laser) Safety Committee

The Laser safety committee meets at least annually and as necessary to address laser safety issues and the administration of Laser Use Authorizations, (LUAs), which govern how lasers are allowed to be used on campus.

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  •  
    • Ionizing Radiation Safety Committee

Due to a change from broad scope license to an academic-specific license, the Radiation Safety Committee now serves as an advisory group and meets as needed.

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  •  
    • Biosafety Committee

The Biosafety committee meets at least annually and as necessary to address biosafety issues and the administration of Biological Use Authorizations, (BUAs), which govern how biologic agents are allowed to be used on campus.

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  •  
    • Chemical Safety Committee

The Chemical safety committee meets on an ad-hoc basis to address chemical safety issues as they arrive and to assist EH&S in setting chemical safety policies and procedures.

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  •  
    • Institutional Animal Care & Use Committee (IACUC)

The Institutional Animal Care & Use Committee is a part of the Office of Research and Sponsored Programs, (ORSP). They meet to address issues related to animal care and use. EH&S attends to support the committee in its goals.

https://research.sfsu.edu/hap_IACUC

https://research.sfsu.edu/sites/default/files/documents/Institutional_A…

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  • FY 21-22 Update:

Committees met in FY 21-22 as described above

• Wildfire Smoke
  • Program Description:

This program guides SFSU management in implementing appropriate measures to protect campus occupants from wildfire smoke, poor air quality, and related issues. The guidelines are consistent with the California Code of Regulations (CCR), Title 8, 5141.1 Protection from Wildfire Smoke. As part of the program. EHS has installed Purple Air Monitoring Stations on our campuses with real time air monitoring results visible on the internet.

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  • FY 21-22 Update:

The SFSU Wildfire Smoke program become a responsibility of the SFSU Office of Emergency Services (OES) in February 2022.

ENVIRONMENTAL PROGRAM REVIEWS

• Air Permits 
  • Program Description:

San Francisco State University (SFSU) is subject to the Bay Area Air Quality Management District's (BAAQMD) air permits program, which regulates and oversees emissions of air pollutants from stationary sources, such as boilers and emergency generators. The program requires SFSU to obtain permits for equipment that has the potential to emit air pollutants above certain thresholds, comply with permit conditions, and maintain accurate records of emissions and compliance activities. The program also includes requirements for regular inspections and testing, enforcement measures, and employee training.

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  • FY 21-22 Update:

Both boilers and emergency generators inspections are discussed elsewhere in this document. They were inspected in FY 21-22 - resulting in no violations or fines assessed.

• Biennial Report 
  • Program Description:

As a hazardous waste generator, SFSU is required to submit an electronic report of its hazardous waste activities every two years. 

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  • FY 21-22 Update:

The biennial report was submitted on time.

• E-Waste Recycling 
  • Program Description:

EH&S runs an E-Waste collection program to ensure the safe and environmentally responsible disposal of electronic waste. The program collects e-waste from faculty, staff, and students, arranges for proper disposal and recycling, and offers education and outreach to promote responsible e-waste disposal.

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  • FY 21-22 Update:

About 30,000 pounds of e-waste was recycled by this program in FY 21-22.

• Environmental Releases 
  • Program Description:

Various environmental regulatory agencies require businesses to report chemical releases to the environment (e.g, air, ground, ground water, sewer system, etc.) that are in excess of threshold amounts.

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  • FY 21-22 Update:

SFSU had no reportable environmental releases in FY 21-22.

• Hazardous Materials Business Plan/ Hazardous Materials Inventory Statement 
  • Program Description:

The HMBP is a regulatory requirement for businesses that handle hazardous material, hazardous waste, and extremely hazardous substances as defined in CFR Title 40 Section 355.61.

The HMBP includes a hazardous material inventory statement (HMIS), an emergency response plan, hazardous materials training, and a site map with emergency supplies shown. SFSU is required to submit electronic reporting of the HMBP via CERS, California Environmental Reporting System

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  • FY 21-22 Update:

The HMBP for FY 21-22 was submitted via CERS and accepted by the regulator

• Hazardous Waste 
  • Program Description:

SFSU’s main campus is classified as a Large Quantity Generator (LQG) of hazardous wastes. As such the site can accumulate hazardous waste for up to 90 days. The Romberg Tiburon Center (RTC) is classified as a Small Quantity Generator (SQG) that can accumulate waste up to 180 days. Each campus has been assigned a hazardous waste generator EPA ID number used to track wastes generated at the site. EHS’ environmental compliance specialists arrange for periodic disposal of the waste using licensed contractors that deliver the waste to permitted disposal facilities. EHS’ environmental compliance specialists are responsible for signing the hazardous waste manifest for each shipment and all of the related program activities such as: record keeping, contracting, paying bills and regulatory fees, scheduling, permitting, completing annual regulatory reports, etc.

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  • FY 21-22 Update:

Hazardous waste pickups continued throughout FY 21-22 but at a slightly less frequent pace due to a reduction of waste produced during Covid.

• Medical Waste Management Plan 
  • Program Description:

Under the California Medical Waste Management Act, SFSU is a Large Quantity Generator (LQG) generating ≥ 200 pounds of medical waste per month and is required to implement procedures for handling, storing, treating, transporting, and disposing of medical waste.

The plan has to be reviewed and updated annually.

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  • FY 21-22 Update:

The plan was updated in FY 21-22

• Medical Waste 
  • Program Description:

SFSU generates medical/biohazardous waste from COSE, Student Health Services, Mashouf Wellness Center and from locked sharps waste disposal boxes around campus. EHS’ Environmental Compliance Specialist, arranges for the required weekly disposal of the campus’ medical/biohazardous wastes by a licensed disposal contractor and permitted disposal facility.

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  • FY 21-22 Update:

Weekly pickups continued as needed in FY 21-22

• Radioactive Waste
  • Program Description:

EHS’ RSO, arranges for the disposal of SFSU’s radioactive wastes as needed.

SFSU is permitted to store radioactive waste on-site until regulated off-site disposal is available.

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  • FY 21-22 Update:

EHS has worked with the faculty to reduce the amount and type of radioactive materials used on campus. No radioactive waste was disposed of this fiscal year. A pick-up is planned for 2023.

• Spill Prevention, Control, and Countermeasure Plan (SPCC) 
  • Program Description:

The SPCC program, is designed to prevent oil spills from reaching navigable waters of the United States or adjoining shorelines. The program applies to facilities that store, handle, or use oil products above certain thresholds, and requires those facilities to develop and implement a Spill Prevention, Control, and Countermeasure Plan (SPCC Plan). The SPCC Plan includes a detailed description of the facility's operations and the measures that will be taken to prevent spills, as well as procedures for spill response and cleanup. The SPCC program also includes requirements for regular inspections and testing, recordkeeping and reporting, and training of personnel.

The CUPA requires SFSU to follow the procedures in our SPCC written program.

That program requires us to conduct weekly, monthly, and annual internal inspections to identify leaks, signage, and safe operation of oil containing tanks that are 55 gallons or greater. Every five years, the CUPA reviews the SFSU SPCC written plan for accuracy administrative changes to the plan and completeness.

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  • FY 21-22 Update:

EH&S is preparing for the five year program review that is due this year.

• Stormwater Pollution Prevention Plan (SWPPP) 
  • Program Description:

All of the campus’ stormwater and wastewater flows to the SF sanitary sewer system for treatment before release. Therefore, SFSU is exempt from MS-4 permit requirements, and we do not require a SWPPP.

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  • FY 21-22 Update:

N/A

• Total Regulated Waste 
  • Program Description:

EHS tracks the cost and amount of the total regulated waste, (including universal waste, chemical waste, biological waste, and radioactive waste) generated from a variety of processes.  All have strict regulations concerning their collection, treatment, storage, and disposal. Regulated wastes are strictly forbidden from being thrown into the regular trash or disposed of down the drain.

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  • FY 21-22 Update:

See graph below

• Universal Waste 
  • Program Description:

Universal waste is a special category of hazardous waste. Generally speaking, universal wastes do not pose a hazard when used in their normal manner but DO pose a hazard if disposed of improperly. For instance, universal wastes must never be thrown in the trash.

Each type of universal waste has its own disposal process. Types of universal waste managed at SFSU include: metal halide, sodium, and neon light bulbs, fluorescent light bulbs, high intensity discharge bulbs, batteries, mercury containing devices, aerosol cans, paint, and electronic waste. SFSU has designated locations and universal waste labels for disposing of each kind of universal waste.

FY 21-22 Update:

No changes to the program were made in FY 21-22

• Waste Minimization (SB14) 
  • Program Description:

The Hazardous Waste Reduction and Management Review Act of 1989 (SB-14), requires hazardous waste generators to document their waste reduction efforts in compliance with the regulation on a four year cycle.

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  • FY 21-22 Update:

Waste reduction plans for 2014 and 2018 are complete. The plan for 2019-2022 was in preparation at the time of this writing.

• Waste Tires Program 
  • Program Description:

San Francisco State University (SFSU) has a waste tire program to ensure the proper disposal of used and discarded tires. The program collects waste tires from campus, stores them in a secure location, and arranges for transportation to a certified tire recycling.

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  • FY 21-22 Update:

Due to Covid, only 38 tires were recycled as part of this program n FY 21-22.

• Wastewater Permits 
  • Program Description:

Compliance with the Federal Clean Water Act is administered in San Francisco by the Bay Area Regional Water Quality Control Board. The program requires that any discharge of wastewaters to surface water needs a permit. The permits set limits on the quality of the wastewater and require monitoring. All sewage treatment plants have permits. Stormwater is also covered by permits. All wastewater and stormwater from campus drains to the municipal sewer system which goes to a treatment facility that has its own wastewater permit.

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  • FY 21-22 Update:

On March 9, 2021 the local water quality control board inspector declined to renew the SFSU wastewater discharge permit stating that the campus no longer requires one.