GUIDE TO SERVICES

2005
University of California San Francisco
Office of Environmental Health and Safety

Table of Contents

KEY TELEPHONE NUMBERS

For a complete listing of OEH&S staff, see the OEH&S website.

The Office of Environmental Health & Safety is located at

50 Medical Center Way
San Francisco, CA 94143-0942

Campus Mail: Box 0942

Phone: 476-1300

Fax: 476-0581

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1. Introduction

The Office of Environmental Health and Safety (OEH&S) assists the campus community with the evaluation, planning, development, and execution of health, safety and environmental programs.

OEH&S has established safety program concerning radiation, fire and life, occupational health and research, environmental permiting and monitoring, safety management, hazardous materials management and removal of regulated waste. The department acts as University liaison with federal, state, and local regulatory agencies in interpreting the requirements of these agencies, evaluating potential hazards, and correcting violations of safety standards.

OEH&S provides a variety of services to campus departments. These included but are not limited to indoor air monitoring, ergonomic evaluations, instrument calibration, bioassays, wipe tests for contamination, removal of medical, chemical and radioactive waste and laboratory inspections.

OEH&S also provides consultation and training, and makes recommendations for environmental management and applied research, while assisting the University with evaluating the impact of its activities on the environment.

A description of training classes offered by OEH&S is located on the OEH&S website. Course registration can be easily completed online.

The OEH&S Director oversees the inventory and application process for all state and local permits regulating hazardous materials storage, air toxics emissions, sewer discharge, underground storage tanks, waste disposal and other environmental issues.

As needed, OEH&S assists both the UC Office of the President Systemwide Office of Long Range Development and Planning and the UCSF Office of Advancement and Planning with the development of Environmental Assessments and Environmental Impact Reports. OEH&S also coordinates with the Office of the President’s department of Environmental Health and Safety and the Office of General Counsel on legal and regulatory issues.

OEH&S also acts as liaison between UCSF and the neighborhood community and assists the UCSF Public Affairs Office in addressing community environmental issues.

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2. Hazardous Materials Emergency Response Program

OEH&S has established the Hazardous Materials Emergency Response Program to provide 24-hour emergency support to campus and satellite locations.

The on-call Hazardous Material Emergency Responder is an OEH&S Specialist who is available seven days a week, 24 hours a day to provide technical assistance to the UCSF university community. The on-call responder is available by cell phone and pager 24 hours a day either on campus or while traveling in the fully equipped emergency response van and will respond immediately after receiving calls for assistance.

The Hazardous Materials Emergency Response Program complements existing campus policy which specifies that researchers are responsible for the clean up of minor spills. The ERT team generally responds to larger spills.

The Emergency Response Team (ERT) responds to “stabilize the situation” to protect human health and the environment. The ERT does not fully mitigate a hazardous materials spill or release. After stabilizing hazardous materials spills or releases, to minimize risk to human health and the environment, the final mitigation of the situation is the responsibility of the Department, or Principal Investigator.

Hazardous Materials Emergency Response Reporting Procedures

After identifying a spill or release of a hazardous material the following reporting procedure should be followed:

1. Attend to injured or contaminated persons and remove them from exposure. Avoid unnecessary movement in order to prevent the spread of contamination.



2. Alert persons in the immediate area to evacuate.



3. Call UCPD at 476-1414 or 9-911 and provide the following information:
   • name
   • call back phone number
   • location of spill
   • identity of spilled material
   • quantity spilled
   • any other pertinent information

   The UCPD will then contact the OEH&S Hazardous Materials Emergency Responder.

4. Close doors and restrict access to affected area.



5. Have a person knowledgeable with the incident available to assist emergency personnel.

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3. Program Services Chart

Central Administrative Services Program

Chief Administrative Officer
Barbara Harkonen

Contract Administration
Financial Management
Information Systems
Personnel
Purchasing
Recharges

Campus Program Manager
Larry Wong

Animal Care Facility Monitoring
Biosafety Bloodborne Pathogens Training
Biosafety Certifications and Decertifications
Biosafety Consultations and Inspections
Biosafety User Authorization Support
Carcinogen Usage and Registration
Chemical Safety Consultation and Inspections
Chemical Safety Manual\Chemical Hygiene Plan
Controlled Substances Usage and Registration
Ergonomic Evaluations
Fire and Physical Safety Consultation and Inspections
Hazard Communication Program
Hazardous Materials Inventories
Laboratory Accident Investigations
Material Safety Data Sheet Resource Library
Permit Applications
Radiation Consultation and Inspections
Radiation Dosimetry Program
Radiation Safety Certifications and Decertifications
Radiation Training
Radiation User Authorization Support
Safe Shipping of Biohazards Training
Sealed Source Monitoring
Training (Health and Safety)
Workplace Safety Evaluations and Inspections

Hazardous Materials Management

Program Manager
David Belk

Chemical Waste Collection
Chemical Waste Analysis and Consultation
Controlled Substances Receiving
Controlled Substances Collection & Disposal
Due Diligence
Environmental Permits
Hazardous Chemical Waste Removal
Radiation Detection Instrument Calibration
Medical Waste Removal and Contract Oversight
Radioactive Materials Receiving & Delivery
Radioactive Waste Collection
Thyroid & Urine Bioassays
Waste Minimization Program
Wipe Test Service

Clinical Program Manager
Vacant

Agency Liaison
Asbestos Material Sampling
Asbestos Abatement Oversight and Coordination
Asbestos Training and Notification
Community Air Quality and Noise Surveys
Controlled Substances Program
Deluge Shower and Eyewash Station Monitoring
Employee Exposure Evaluation
Emergency Response Program
Ergonomic Evaluations
Facility Plans Review
Fire & Physical Safety Consultations and Inspections
Food, Pest, and Water Inspections
Fume Hood Evaluation
Hospital Safety
Indoor Air Quality Evaluations
Occupational and Environmental Exposure Monitoring
Patient Care Area Monitoring
PCBs, Lead
Respiratory Protection Program
Ventilation System Evaluation

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4. Central Administrative Services Program

CONTACTS:

Chief Administrative Officer:
502-4733

Administrative Services:
476-0539

Contracts/Financial Operations:
476-0539

Recharges:
476-0539

The Environmental Health and Safety Central Administrative Services Program is responsible for accounting and analysis, departmental purchasing, programmatic administrative services, contract administration, recharges and financial management, information services, personnel and payroll.

The program will assist users of OEH&S services in solving recharge, contract and other related financial operational problems.

SERVICES & RESPONSIBILITIES

Accounting and Financial Management. Acts as departmental liaison to the University accounting and budget offices.

Forms
A variety of OEH&S forms, both admin and technical are available on OEH&S web site.

Contract Administration
Monitors departmental vendor contract payments on behalf of the University to ensure contract compliance.

Recharges and Financial Management
Coordinates all recharge activities between Campus OEH&S service users and the Department. This includes both Radioactive Waste Collection Services and Wipe Test Services.

Note: These prices are subject to change as a result of regulatory surcharges imposed on disposal facilities. Wipe Test Services. Wipe Test Services are contracted by individual departments through OEH&S Financial Operations (476-0539). The recharge rate is $1.02 per wipe.

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5. Campus Program

CONTACTS:

Program Manager:
514-2824

Department Safety Advisors (DSAs):
476-1300

The Campus Program supports the research and administrative departments of UCSF for all environmental, health, and safety issues. The program is built around the concept of a Department Safety Advisor (DSA).

Each department on campus is assigned an OEH&S specialist as the single point of contact for all OEH&S issues and activities. The DSA, works closely with the Department Head, Chief Administrative Officer, Principal Investigators (PI) and their laboratory managers to identify and mitigate workplace hazards, and to ensure compliance with applicable environmental and health and safety regulations.

The DSA can either provide or obtain resources within OEH&S to address all health and safety issues.

The Campus Program supports the Radiation, the Biosafety, the Chemical committees and their associated officers. The Campus Group interfaces with the Environmental Health and Safety (OEH&S) User Committee to ensure that the OEH&S needs of the Campus community are met.

Program policies are in accordance with the current standards of good practice, the provisions of the University Licenses, the laws of the city of San Francisco and the State of California and the U.S. Government covering environmental, health or safety practices.

It is the responsibility of OEH&S to maintain awareness of applicable policies and regulations, and to provide information on implementation of each to the UCSF community. The OEH&S web site contains links to many government agencies, regulatory agency requirements and professional organizations.

SERVICES & RESPONSIBILITIES

Laboratory Animal Resource Center (LARC) Monitoring
OEH&S has a DSA assigned to the Animal Care Facility. In addition, the Biosafety Officer conducts regular inspections of LARC.

Biosafety and Bloodborne Pathogens Training
The Campus Program offers initial and yearly refresher training for all campus personnel. Training is tailored to the needs of the work assignments.

Biosafety Certification and Decertifications
OEH&S verifies availability of biosafety equipment (biosafety cabinets, autoclaves), facilities suitability and laboratory practices and procedures as appropriate to meet the risk-level of the studies performed at that site.

Biosafety Consultation and Inspections
The DSAs perform regular inspections of laboratories for the purpose of identifying and mitigating biohazards and for assuring the laboratory’s compliance with biosafety policies, guidelines and regulations. The DSAs are also available for consultation in biosafety.

Biological User Authorizations Support
DSAs perform evaluations of laboratory practices, safety equipment and facilities as a part of the Biological Use Authorization (BUA) approval and renewal process. DSAs are also available to assist the investigator with preparation of the BUA application, and to support the Biosafety Committee’s review process.

NOTE: For more information regarding the Biological Safety Program and requirements for using biohazardous materials at UCSF, please see the UCSF Biosafety Manual, distributed by OEH&S and available online at the OEH&S website.

Carcinogen Usage and Registration
OEH&S is responsible for maintaining appropriate registrations for campus users of certain carcinogens, reviewing the work practices of the carcinogen users, coordinating an exposure monitoring and/or medical surveillance program as needed.

Chemical Safety Consultation and Inspections
The DSAs perform regular inspections of laboratories for the purpose of identifying and mitigating chemical hazards and for assuring the laboratory’s compliance with safety policies, guidelines and regulations. The DSAs are also available for consultation in the chemicals and hazardous materials area.

Chemical Safety Manual/Chemical Hygiene Plan
OEH&S prepares and implements the UCSF Chemical Hygiene Plan (CHP). The CHP is embodied in the UCSF Chemical Safety Manual. Chemical Safety Policy is established by the UCSF Chemical Safety Committee, in accord with regulatory requirements. The entire chemical safety manual is available on the OEH&S website.

Controlled Substances Usage and Registration
OEH&S is responsible for recognizing controlled substance hazards, developing safe procedures through peer review, newsletters, and communications with campus users, and maintaining registrations.

Disaster and Emergency Preparedness and Planning
The Campus Program assists in preparation of department Emergency Action Plans, provides training in emergency preparedness, inspects worksites for earthquake preparedness, and is available for consultation on this topic.

Ergonomic Evaluations
DSAs are available to evaluate ergonomic properties of individual work stations and work practices. Training in proper lifting techniques is also available.

Fire and Physical Safety Consultation and Inspections
The DSAs perform regular inspections of all campus facilities for the purpose of identifying and mitigating fire and physical hazards and for assuring compliance with safety policies, guidelines, and regulations. The DSAs are also available for consultations on this topic. DSAs work closely with the Campus Fire Marshal to ensure fire safety requirements are met.

Hazard Communication Program
The DSAs support the implementation of the UCSF Hazard Communication Program. They provide training in chemical labeling, storage and in use of Material Safety Data Sheets. They are available for consultation in identifying and mitigating workplace hazards.

Hazardous Materials Inventories (Business Plan)
The City of San Francisco mandates a complete inventory of hazardous chemicals and other hazardous materials at UCSF biannually. DSAs are available to assist their departments in performing the inventory and providing the appropriate documentation.

Injury and Illness Prevention Program (IIPP)
DSAs support implementation of the UCSF IIPP by helping develop individual department safety committees, and by performing other services described herein.

Laboratory Accident Investigations
OEH&S investigates laboratory accidents, attempting to determine causes and complicating factors, and recommending ways to prevent future occurrence. Lessons learned are communicated to campus personnel during OEH&S training sessions, and via the OEH&S newsletter.

Material Safety Data Sheet (MSDS) Resource Library
The Campus Program is responsible for the availability of MSDSs for all hazardous materials used at UCSF. OEH&S assures hard copy and/or electronic access to MSDSs for all chemicals in the chemical inventory. DSAs can arrange for distribution of MSDSs to users. The OEH&S web site contains links to several MSDS databases so you can find information on materials that may not be located at UCSF.

Permit Applications
OEH&S coordinates and maintains responsibility for all permits required by regulatory agencies, including the City of San Francisco, the State of California, and the Federal Government.

Radiation Dosimetry Program
A Campus Program representative is responsible for distribution, pick-up and all recordkeeping associated with personnel monitoring and area monitoring devices.

Radiation Safety Certifications and Decertifications
OEH&S verifies availability of appropriate safety equipment (shielding, meters, fume hoods), facilities suitability, and laboratory practices and procedures as appropriate to meet the risk-level of the studies performed at the site.

Radiation Safety Consultations and Inspections
DSAs perform regular inspections of laboratories for the purpose of identifying and mitigating radiation hazards and for assuring the laboratory’s compliance with radiation safety policies, guidelines, and regulations. The DSAs are available for consultation in the radiation safety area.

Radiation Safety Training
All personnel who work with radioisotopes must be trained to understand the associated hazards and to use proper techniques in working with isotopes. This training must occur before the individual can begin use of radioisotopes. The Campus Group provides this training twice weekly at OEH&S. Radioisotope users must be retrained biannually; the Campus Group provides this training on a regularly scheduled basis.

Radiation Use Authorization (RUA) Support
DSAs perform evaluations of laboratory practices, safety equipment, and facilities as a part of the RUA approval process. DSAs are also available to assist the investigator with preparation of the RUA application, and to support the Radiation Safety Committee’s review process.

Sealed Source Monitoring
All radioactive sealed sources must be inventoried quarterly, and leak-tested semiannually. DSAs are available to support the inventory and to perform the leak testing.

Training
The Campus Group can provide training for all environmental, health, and safety topics, as necessary for the safety and well-being of all campus employees. Each DSA coordinates the needs and training schedules for assigned departments. For a list of training courses offered by OEH&S go to the OEH&S training webpage.

Safe Shipping of Biohazards
The Biosafety Officer provides initial and biannual refresher training on the safe shipping of biohazardous materials. These sessions include local, state, federal, and international regulations regarding paperwork and shipping containers. A certificate is provided to all those who successfully complete their session. These certificates are legally required if you need to ship by common carrier, and are being required by these carriers before they will accept this category of “dangerous goods”.

Workplace Safety Evaluations and Inspections
The DSAs perform regular inspections of all campus work areas for the purpose of identifying and mitigating hazards not covered by other processes (physical hazards, electrical hazards), and for assuring compliance with employee health and safety regulations. DSAs are also available for consultation on any safety issue.

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6. Hazardous Materials Management Program

CONTACTS:

Program Manager:
476-0568

Environmental Permits:
476-0568

Chemical Waste Operations:
Chemical Waste Minimization
476-0964

Hazardous Materials Services:
Asbestos
PCB and Lead
Due Diligence
Medical Waste Oversight
Controlled Substances Disposal
476-0964

Radioactive Waste Operations:
Wipe Test Services
476-1771

Radiation Technician Operations:
Receiving and Delivery of Radioactive Material

The Hazardous Materials Management Program (HMM) oversees services related to hazardous waste removal; hazardous material services for asbestos, lead and PCBs; radiation survey instrument calibration, radioisotope receiving and delivery, thyroid and urine bioassays, wipe test services, controlled substances receiving, collection and disposal and environmental permits.

The HMM program arranges for the pickup and disposal of hazardous waste from all UCSF locations. This Group is responsible for maintaining the necessary permits, licenses and registrations to operate and manage OEH&S hazardous waste facilities and for overseeing the consolidation, packaging and removal of the waste from UCSF sites.

The HMM program oversees chemical, radioactive and medical waste removal contracts. Audits of vendors are conducted as needed.

SERVICES & RESPONSIBILITIES

Due Diligence
Assists UCSF property managers in performing their due diligence responsibilities prior to leasing rental space by performing a technical review of the property and preparing a written report on findings. The review focuses on environmental issues associated with the prior uses of hazardous materials or hazardous wastes (e.g. chemical, radioactive, and biological materials or wastes).

Environmental Permits
HMM represents UCSF on behalf of EH&S with environmental regulatory agencies and secures needed environmental permits, licenses, and/or registrations. This includes required air, sewer discharge, and underground/above storage tanks permits. Compliance with permit conditions and necessary agency reporting is also provided.

Hazardous Chemical Waste Removal
Collects hazardous (chemical) waste from all UCSF locations. Arranges with vendors for final disposal, maintains shipping manifests, waste removal records, and transporter permits.

Medical Waste Removal
Collects medical waste from UCSF campus research laboratories. Arranges with vendors for final disposal, maintains shipping records and required permits. Oversees UCSF Medical Waste Management Program.

Radioactive Waste Removal
Collects, packages, and arranges for final disposal of radioactive waste from all UCSF locations. Arranges with vendors for final disposal, maintains all required regulatory records including shipping manifests.

Recharge Rates for Radioactive Waste Collection Services
See Administrative Information Services Program page 8.

Radiation Survey Instrument Calibration
HMM picks up, calibrates, and arranges for return of radiation survey meters. The UCSF Radioactive Material License requires annual inspection and calibration of these instruments.

Radioisotope Receiving and Delivery
Radioactive materials are delivered to OEH&S authorized Radioisotope Receiving Area (such as Long-235G, Mission Bay Genentech Hall N121 and Mt. Zion N 130). Shipments are surveyed for contamination, radiation use authorization is verified and the material is delivered to the laboratory for proper storage and use.

Research Controlled Substances Receiving
HMM receives controlled substances at Parnassus and Mission Bay. Upon receipt of the substances from either the Medical Center Pharmacy or from commercial distributors, the documentation of each package is verified for accuracy and completeness. Only registered controlled substance users are allowed to pick-up approved shipments at the receiving laboratory.

Research Controlled Substances Collection and Disposal
Expired and unwanted controlled substances are not allowed to be disintegrated, crushed into powder or dissolved in water. These substances must be surrendered and disposed of properly through the OEH&S Controlled Substances program. HMM staff arrange for proper disposal with approved outside vendors and maintain required shipping and disposal records.

Thyroid and Urine Bioassays
Users of volatile radioactive iodine are required to undergo a thyroid scan on a frequency determined by the UCSF Radioactive Materials License. The scan is performed at the Radioisotope Receiving Area (Long 235G) and at the SFGH Receiving Area following procedures prescribed by the Radiation Safety Officer.

Wipe Test Service
UCSF license requires laboratories using radioactive material to perform wipe testing on a regular basis. HMM provides this service on a recharge basis.

Note: For more information about the UCSF Radiation Safety Program, refer to the UCSF Radiation Safety Manual, available at the OEH&S web site.

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7. Clinical and Industrial Hygiene Program

CONTACTS:

Program Manager:
476-1300

X-Ray Machine and Patient Therapy:
514-2665/502-5388

Industrial Hygiene Safety:
476-3635

The Clinical and Industrial Hygiene Program assists UCSF healthcare facilities in complying with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements, conducts new employee safety orientation for hospital employees, performs industrial hygiene surveys for employees who may be exposed to hazardous working conditions, conducts x-ray machine inspections and oversees the campus sanitation program. The group also coordinates CAL/OSHA inspections and other regulatory inspections.

SERVICES & RESPONSIBILITIES

Asbestos Abatement Project Coordination
Provides technical support to project mangers and assists in the development of written specifications for asbestos abatement projects. Conducts inspections of asbestos abatement projects prior to the beginning of the work, verifies containment procedures during operations, and performs clearance evaluations upon completion of projects. Oversees the disposal of waste material from project site.

Asbestos Material Sampling
Conducts inspections to verify existence of Asbestos Containing Building Material (ACBM) in buildings at UCSF and maintains an inventory of all such locations. Performs material and air sampling for campus departments or upon employee request.

Asbestos Training and Notification
Develops and conducts training on the potential hazards of asbestos and safe work practices for UCSF employees who perform work that may expose them to asbestos. Notifies and conducts training for all UCSF employees in areas where asbestos abatement projects are being conducted or where asbestos materials may be present in the work environment.

Deluge Shower and Eyewash Station Monitoring
A Clinical and Industrial Hygiene Program representative functionally checks all deluge showers and eyewash stations on a monthly basis. On a yearly basis, deluge shower flow rates are verified. OEH&S is available for consultation on selection and appropriate placement of deluge showers and eyewash stations at all UCSF locations.

Facility Plans Review
OEH&S staff and applicable safety officers review plans for new construction and remodeling projects to assure compliance with health and safety standards and regulations.

Fume Hood Evaluation
A Clinical and Industrial Hygiene Program representative is responsible for placement, testing, and function of all fume hoods on the UCSF campuses. Fume hoods are tested and certified yearly.

Inspection and Calibration of Equipment Producing Ionizing Radiation
Equipment inspection on a regular basis is required by the State Bureau of Radiologic Health Branch. Inspection records are kept by Radiation Safety and the department housing the equipment.

Patient Care Area Monitoring
The Patient Injection Area and the Radiopharmaceutical Laboratory are monitored daily for evidence of contamination. Brachytherapy and thyroid therapy patient areas are monitored, and provided special instructions before release.

Occupational Exposure Monitoring
Conducts air monitoring surveys for potentially harmful chemical substances or physical agents. Investigates complaints from all UCSF locations concerning problems associated with nonradioactive chemicals, odors, and noise exposure.

Respiratory Protection Program
Assists departments with the preparation of written respiratory protection programs, annually reviews these programs and conducts fit testing and training for UCSF and UCSF Medical Center employees who may be required to use respiratory protection equipment.

Ventilation Systems Evaluation and Monitoring
Evaluates general mechanical ventilation systems in indoor environments. Monitors and evaluates local exhaust systems including but not limited to canopy hoods, slot hoods, welding booths, and spray booths.

Environmental Sanitation
Food, Pest Control, Water Quality. Inspects and monitors vendor and University-controlled food service operations on campus. Prepares food handler sanitation guidelines. Coordinates the testing of the campus water supply and reviews analytical results. Investigates complaints regarding food sanitation, pest control and water quality for all campus locations.

Emergency Response Team – ERT
Coordinates operations of the Hazardous Materials ERT, provides for routine training and maintains needed equipment and supplies.

Hospital Safety
Assists the UCSF Medical Center, Langley Porter Psychiatric Institute, Mt. Zion Hospital and other off-site facilities in complying with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. Assists the UCSF Medical Center Infection Control Committee with the development of policies and procedures to control and prevent the transmission of infectious microorganisms.

Nonionizing Radiation Equipment
Monitors the use and function of nonionizing radiation-producing equipment. Lasers on campus are inspected upon installation and on an annual basis. Microwave ovens can be inspected upon request. Non-ionizing energy-producing equipment is inspected on request.

The Clinical Program also provides assistance to identify areas containing lead and PCBs and provides technical advice regarding their safe removal and disposal.

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