TITLE:	ES&H Manual
DOCUMENT ID:	5400 Appendix T1 Summary of ES&H Documentation Requirements

1.0 ESH&Q Documentation Listing

Jefferson Lab prepares documentation and keeps records for various periods of time as defined in agreements, programs, or according to other arrangements. Most documentation and recordkeeping requirements are identified in the Department of Energy (DOE)/Jefferson Associates, LLC (JSA) Contract, and generally serve the function of good business practices.

Documentation and recordkeeping requirements for most Jefferson Lab Environmental, Safety, Health, and Quality (ESH&Q) programs are identified in the following tables. Staff that have specific documentation and recordkeeping responsibilities are referenced with position titles listed in Table 12.

Table 1: Workplace Safety Management

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	29 CFR 1910.1200	Hazard Communication (HAZCOM) Standard A written HAZCOM program for hazardous materials including warning labeling, training, and other information.	· The latest Material Safety Data Sheet (MSDS) for each substance has to be kept on file in the workplace and be readily accessible to employees. [MSDSC] · Identification and inventory of all hazardous chemicals. [IH] · Related employee training policies. [IH] · Exposure Records - see Table 3	· MSDSs for substances used on-site shall be maintained until archived. [MSDSC] · Archived MSDSs are kept for a period of thirty years. [ESH&QRM]
2	ES&H Manual Ch. 5300 (ref. DOE O 232.1(A))	Occurrence Reporting Processing System (ORPS)	Reports required for submittal to the ORPS database for events that meet reporting criteria. The Facility Manager (FM) approves report information for entry into the DOE ORPS database. [ESH&QRM]	Appropriate records are maintained in the ORPS database indefinitely. [ESH&QRM]
3	DOE/JSA Contract	Price Anderson Amendments Act (PAAA)	Reports required for submittal to the PAAA database for events/situations that meet reporting criteria. Senior laboratory management approves report information for entry into the DOE database. [ESH&QRM]	Appropriate records are maintained in the database indefinitely. [ESH&QRM]
4	29 CFR 1904.2 29 CFR 1904.4	Annual Occupational Injuries & Illness Logs and supplementary records	· A log of all recordable occupational injuries and illnesses is required within an identified timeframe after notification. · A summary report, that includes the log of all occupational injuries and illnesses, is required. · A supplemental record has to be completed within six working days of the event or notice of claim. all the above: [ESH&QRM]	Records must be maintained for a period of five years following the end of the recorded year. [ESH&QRM]
5	29 CFR 1904.5	Annual summaries of occupational injuries and illnesses	An annual summary of all occupational illnesses and injuries in the workplace must be compiled and posted in the workplace by the employer. [ESH&QRM]	Information is posted in the workplace for at least the period of February 1 to May 1 of the following year. The information is maintained for five years. [ESH&QRM]
6	Public Law 91-596, Sec. 8 & 11	Facility safety program	Keep records of activities relating to this Act. Occupational Safety and Health Administration (OSHA). [ESH&QRM]	Maintain records for a minimum of 10 years. [ESH&QRM]
7	10 CFR 1008	Records & statistics of personal injury accidents	Records and statistics are gathered by supervisor and collected. The JLab insurance carrier is the document holder. [LC]	Recordkeeping managed by lab insurance carrier. [LC]
8	29 CFR 1904.8 DOE agreement	Fatalities and multiple injury accident reports	· A report submitted to the DOE for any accident resulting in one or more fatalities or in the hospitalization of five or more employees. [ESH&QRM] · Refer to ORPS, item 2 above.	Records and reports must be retained for a period of five years. [ESH&QRM]
9	ES&H Manual Ch. 3310	Operational Safety Procedures (OSPs), and Temporary OSPs (TOSPs)	Procedures that address ESH&Q concerns for work activities. [ESH&QDiv]	Maintain procedures for life of the facility. [original: ESH&QRM]
10	29 CFR 1903	Safety inspection records	Results of division-wide inspections are recorded monthly or as prescribed and maintained. [ESH&Q]	Records are maintained according to division procedures for a minimum of 1 year. [ESH&QDiv]
11	29 CFR 1904.11	Changes in ownership	When a facility changes hands, the former owner is responsible for maintaining records and filing required reports for the period of the remainder of the year that it was the owner. [ESH&QRM]	After the facility changes hands, the new owner must retain records for a period of five years. [ESH&QRM]
12	DOE/JSA Contract	Corrective Action (CA) Database	· JSA/JLab may be required to provide reviewers with a written response to external concerns. All institutional-level ESH&Q findings are recorded and tracked in the SA/QA database. · For ORPS events - refer to item 2 [tracking: SA/QAO]	The SA/QA database records are kept indefinitely. [SA/QAO]

Table 2: Fire Protection Program

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	ES&H Manual 6900 Fire Protection Program Summary DOE/JSA contract	Fire Protection Program (FPP)- General Coordinate design and maintenance of all facilities.	Preparation, implementation, and maintenance of the FPP. [emergency action: EM; rest: FMME/FPE]	Maintain all records for the life of the facility except as identified in specific programs. [FMME/FPE]
a	See above	JLab FPP (ES&H Manual 6900 Fire Protection Program Summary)	· Records of inspection, testing and maintenance for facility fire protection systems. · Alarm, investigation, & incident reports · Fire extinguisher and hose maintenance records- Fire alarm system test records · Records of all system changes, as-built drawings, operation and service manuals, and diagnostic and test reports.	See above
b	See above	Other Referenced Standards: · National Fire Protection Association (NFPA)-National Fire Codes · BOCA-Nat’l Bldg. Code- VA Uniform Statewide Bldg. Code · 29 CFR 1910 · 29 CFR 1926	· Emergency Action Plans · Automatic sprinkler systems basis for design	See above

Table 3: Personal Exposure To Hazardous And Other Materials

ID	Source of Requirement	Record or Document	Documentation	Recordkeeping
1	29 CFR 1910.1020	Employee exposure records	Measure worker exposure to potentially hazardous substances in the workplace according to OSHA/DOE requirements. [measurement: IH; documentation: OMD]	Records of employee exposure must be maintained for a period of at least 75 years, except as noted in OSHA, 29 CFR 1910.1020(d)(1)(ii). [OMD]
	See above		· Standards, operating guides, procedures · Records and investigations on exposures · IH log sheets	Incidents of exposure and results of hazardous substance monitoring are maintained for fifteen years.
2	29 CFR 1910.1020	Periodic medical tests	Test results to monitor health effects of potentially toxic or carcinogenic workplace substances. [OMD]	Retain records for 75 years as noted above. [OMD]
3	40 CFR 763 15 U.S.C. 2605	Asbestos abatement	Maintain records of objective data that demonstrates that products made from or containing asbestos are not capable of releasing fibers of asbestos in concentrations at or above the action level. [EM]	Records must be maintained for the duration of the employer’s reliance on such data. [EM]

Table 4: Radiation-Contamination Control Program

ID	Source of Requirement	Main Document	Documentation	Recordkeeping
1	10 CFR 835	Personnel radiation dose exposure records	Radiation exposure information is tracked and documented. Summary information is provided yearly to each radiation badged individual. [RCM]	These records are maintained for a period of 75 years. [RCM]
	See above		· Equipment calibration · Tracking information	See above
2	10 CFR 835	Radiation Protection Program (RPP)	· Technical standards, operating guides, procedures · Logbooks summarizing shifts and daily activities · Routine radiation and contamination surveys [all: RCM]	These records are maintained for a period of 75 years. [RCM]
a	See above		Recorder charts	3 mo. or purpose served.
b	See above		Reports and engineering studies of unusual radiation or contamination	100 yrs
c	See above		· records of skin and nasal contamination	75 yrs

Table 5: Individual Employee Radiation-Related Health Hazard Information

ID	Source of Requirement	Record or Document	Documentation	Recordkeeping
1	10 CFR 83529 CFR 1910.1020	Employee radiation exposure history	All records [ionizing: RCM; laser and radio frequency (RF)-related: LSO]	75 years [RCM]
	See above		· results of direct measurement of radiation · investigations of various types, including missing or unusual data · bioassay information	See above

Table 6: ESH&Q Management

Table 6a: Radiation

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	10 CFR 835	Jefferson Lab Radiation Protection Program (RPP)	All required documentation is maintained by the Radiation Control Group (RadCon). [RCM]	Records are kept for the periods noted below or as noted in site programs. [RCM]
a	See above		Instrument Calibration Records	75 yrs
b	See above		Radiation Detection Charts	1 yr.
c	See above		Inspections & Audit Information	8 yrs
d	See above		Administrative Documents	Min. 2 yrs
e	See above		Radiation Survey results	Per site programs
f	See above		Environmental monitoring records - Refer to Tables 6b and 6c	(see below)
2	DOE/JSA Contract	Personnel Safety System (PSS)	Inspections, audit records, and system documents. [PSSM] · PSS Certification Procedures · PSS Certification Checklist Information Log · PSS Design Drawings	Retain for life of facility. [PSSM]

Table 6b: Air Programs

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	Clean Air Act &Amendments (CAAA) 40 CFR 82 E.O. 12843 ES&H Manual Ch. 8020	Refrigerant recycling	Persons servicing air-conditioning and refrigeration equipment containing CAAA-identified materials must have appropriate certification to ensure emissions are minimized. [FMME]	Verify that subcontractor and applicable staff certifications and licenses are maintained for a period of three years. [FMME]
2	CAAA 40 CFR 61 40 CFR 63	Hazardous Air Pollutants (HAPs) & National Emission Standards for HAPs (NESHAPs)	Track and document environmental monitoring of ionizing radiation. [RCM]	Records must be maintained for a minimum of five years. [RCM]
3	CAAA 40 CFR 61 40 CFR 63 40 CFR 82	Boiler Air Emissions Monitoring	Records of boiler emissions. [FMME] Emission reports are provided to DEQ, upon request. [ESH&QRM]	Records are maintained for a ten year period. [ESH&QRM]
4	9 VAC 5-40-50 9 VAC 5-60-70	Existing Stationary Sources/ HAP Sources	Maintain a file of all measurements, including continuous monitoring system, monitoring device, and emission measurements. [RCM]	Retain for two years. [ESH&QRM]

Table 6c: Water Programs

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	9 VAC 25-610-10 et. seq. Code of VA, Title 62.1	Permit to Withdraw Groundwater Permit #GW0030800	Daily and monthly groundwater withdrawal values recorded. [FMME] Quarterly reports submitted to DEQ. [ESH&QRM]	Records of calibration and maintenance records and reports are retained for at least three years. [ESH&QRM]
2	9 VAC 25-610-10 et. seq.	Annual Water Usage Report	Data collected monthly and annually. [ESH&QRM]	Reports retained for a five year minimum. [ESH&QRM]
3	Hampton Roads Sanitation District (HRSD) Industrial Wastewater Discharge Regulations ES&H Manual App. 8030-T1	Industrial Wastewater Discharge Permit Permit # 0117	All non-rad data collection performed monthly. [FMME] Rad data recorded upon discharge. [RCM] Permit requirements submitted to HRSD. [ESH&QRM]	Information retained for a minimum of 3 years. [ESH&QRM] Also refer to Table 8e.
a	See above	See above	Monthly non-rad analytical reports, meter readings, and flow calculations.	See above
b	See above	See above	Monthly radiological data.	See above
c	See above	See above	Quarterly radiological reports to HRSD.	See above
d	See above	See above	Annual 7-day meter reading information.	See above
e	See above	See above	Meter calibration records.	See above
4	Code of VA, Title 62.19 VAC 25-31-10 ES&H Manual Ch. 8031	Virginia Pollutant Discharge Elimination System (VPDES) Permit Permit # 0089320	Groundwater quality information is documented. [RCM] Documentation of proper operation and maintenance of all permit-related equipment. [FMME] Permit requirements submitted to VA DEQ. [ESH&QRM]	Analytical information and other items required by the permit are retained for the lifetime of the facility. [ESH&QRM]
a	See above	See above	Quarterly, semi-annual, and annual information is collected per permit terms.	See above
b	See above	See above	Mitigation Plan	See above
5	9 VAC 25-91-10 et. seq. ES&H Manual Ch. 8032	Spill Prevention, Control, and Countermeasures (SPCC) Plan	Documented Plan, copies of Plan, and updates. [ESH&QRO]	The SPCC Plan shall be maintained for the life of the facility. Retain all related documents for at least three years. [ESH&QRM]
a	See above	See above	Written procedures and records of inspections. [ESH&QRO]	See above
b	See above	See above	Maintain records of spill prevention training and exercises. [ESH&QRO]	See above
c	See above	See above	Bi-monthly transformer inspections. [FMEE]	See above
6	40 CFR 280-281 VA UST Regulations	Underground Storage Tanks (UST)	Records of notifications, testing results, upkeep repairs, and site assessment results at permanent closure. [ESH&QRM]	Records must be kept for at least three years. [ESH&QRM]
7	40 CFR 302 9 VAC 25-91-10 et. seq. ES&H Manual Ch. 8032	Aboveground Storage Tanks (AST)	Applicable AST ten year integrity tests. [FMME]	Records kept for life of facility. [ESH&QRM]

Table 6d: Superfund, Emergency Planning and Community Right-To-Know Act (EPCRA) of 1986 Programs

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	Superfund/EPCRA ES&H Manual App. 8010-T2	Emergency Planning with regards to Hazardous Chemicals, including informing local response agencies	MSDS records. [IH] Applicable chemical lists and reports. [ESH&QRM]	Retain all EPCRA documentation for a minimum of 30 years. [ESH&QRM]
a	Section 302	Planning: Extremely Hazardous Substances (EHSs)	Notification of presence of EHSs above Threshold Planning Quantity (TPQ) on Site. [ESH&QRM]	See above
b	Section 304	Response: In the Event of a Release For releases of environmentally harmful materials to the environment	Notification and follow-up of a release of any hazardous substance above the Reporting Quantity. Also documentation requirements under CERCLA, CAAA, and the Clean Water Act may be applicable. [ESH&QRM]	See above
c	Section 311	Planning: MSDSs/ List of hazardous chemicals	MSDSs or a list of hazardous chemicals that exceed the TPQ to be submitted to planning groups. [ESH&QRM]	See above
d	Section 312	Planning: Inventory of Hazardous Chemicals	Annual Tier II Emergency and Hazardous Chemical Inventory form for most recent year chemical storage status. [ESH&QRM]	See above
e	Section 313	Release: Toxic Chemical Usage Reporting	Documentation of applicability to file Form R (Annual Toxic Chemical Release Form) or the Form R itself, if applicable. [ESH&QRM]	See above

Table 6e: General Program Requirements

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	EO 12856	Equipment inspections	Results of inspections are recorded monthly or as prescribed and maintained by line management. [Line Management]	Inspection records are maintained according to division procedures. [Line Management]
2	EO 12856	Routine procurement files	Requisitions and purchase orders must be maintained for the purpose of chemical use, affirmative procurement, and performance measure tracking. [BSM]	Records must be maintained by the Procurement Office for various periods defined in procedures. [BSM
3	EO 12843 EO 12873	Procurement Guidelines For purchasing products with recycled content.	An annual report of Affirmative Procurement activities is submitted to the DOE. [BSM]	Copy retained for at least ten years. [ESH&QRM]

Table 7: Environmental Contamination Measurement Documentation

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	RadCon Manual	Environmental Contamination Measurements	· Procedures which detail methods used and frequency of analysis · Analytical summaries of analyses · Worksheets, logbooks, dosimeter data, etc. · Data gathered to measure residual contamination [RCM]	All records shall be maintained for the life of the facility. [RCM]

Table 8: Hazardous and Non-Hazardous Materials Disposal

Table 8a: Radioactive Waste

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	10 CFR 71 RadCon Manual	Radioactive Wastes	· Records which indicate type of waste and date of disposition · Radiation counter control data [RCM]	All records shall be maintained for the life of the facility. [RCM]

Table 8b: Hazardous Waste

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	9 VAC 20-60-230 et. seq. ES&H Manual Ch. 8061	Waste generators	· SAA/CAA inspection records · SQG determination records [all the above: HWC]	Identified records are maintained for a minimum period of three years. [ESH&QRM]
a	40 CFR 262.40	Waste shipment manifests	Preparation is done by the HWC. Original documentation is kept on file. [ESH&QRM]	All documents related to signed waste manifests are retained for a minimum of three years. [ESH&QRM]
b	40 CFR 262.11 40 CFR 262.40	Test results, waste analyses, or other determinations	Hazardous waste determinations are performed by off-site analytical labs. [HWC]	The hazardous waste analysis documents are maintained for a period of three years from the date the waste was last sent to treatment. [HWC]
c	40 CFR 262.40	Hazardous Waste Manifests	Certification (noted on manifest) that the generator has a waste minimization program in place to reduce the quantity and toxicity of hazardous waste. [HWC]	Manifests are maintained as noted above under Waste Manifests.
d	40 CFR 262.42(b)	Exception Reporting	In the event that the signed hazardous waste manifest is not returned within sixty days, a notification must be sent to the EPA Region III Administrator. [ESH&QRM]	Copies shall be maintained for a period of three years, or until the concern is resolved. [ESH&QRM]
e	40 CFR 262.43	Additional Reporting	Additional reports concerning the wastes may be requested by the EPA Administrator at any time. [ESH&QRM]	Any additional reports shall be maintained for a period of three years. [ESH&QRM]

Table 8c: Medical Wastes

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	9 VAC 20-120-10 et. seq. ES&H Manual Ch. 6800 Regulated Medical Waste Management	Medical Waste	· Generators of medical wastes must maintain copies of tracking forms and shipment logs. · Medical waste manifests are prepared and tracked. [OMD]	· Records must be kept for a period of three years from the date the waste was shipped. · Manifests are maintained for a period of ten years. [ESH&QRM]

Table 8d: Non-Hazardous Material Waste

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	E.O. 12856	Non-hazardous materials recycling	The recycling program is addressed in the Waste Minimization/Pollution Prevention program. It is handled under a subcontract and disposal records are furnished. [FMSSM]	Recycling quantity records are maintained for a minimum period of 2 yrs. [FMSSM] Records are maintained for performance measure tracking for a minimum of 5 years. [ESH&QRM]
2	Virginia Waste Management Act	Non-hazardous materials disposal	Non-hazardous waste disposal information is compiled by the waste hauler and Facilities Management. [FMSSM]	Waste hauling records are maintained for a minimum period of 2 yrs. Records are maintained for performance measure tracking for a minimum of 5 yrs. [ESH&QRM]

Table 8e: Wastewater Disposal

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	HRSD Permit	Industrial Wastewater Discharge Permit	Current version of Permit #0117. [ESH&QRO]	Maintain permit for life of facility. Maintain submittals for at least 3 years. [ESH&QRM]
a			Meter Reading values on a monthly basis. [FMMM]
b			Monthly pH values at Sites D and EF [FMMM]
c			Monthly and Quarterly Activated Water Discharge values [RCM]
d			Annual Meter Certifications [FMMM]
2	HRSD Permit	Pretreatment/ sampling records.	Baseline report including permit and operating information, pollutant measurements, and sampling records for neutralization tanks. [IH]	Records are maintained for the life of the facility. [IH]

Table 9: Hazardous Materials Transportation

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	10 CFR 71	Radioactive Materials	Records of all shipping and packaging requirements for on-site and offsite transport. [RCM]	Records maintained per site procedures. [RCM]
2	49 CFR 171	Other hazardous Materials	Records of all shipping and packaging requirements for onsite transport. [HWC] For offsite transport - refer to Table 8b.	Records maintained per site procedures. [HWC]

Table 10: Medical, First Aid, and Personal Injury Files

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	29 CFR 1910.1020	Medical records for examination and copying; analyses using exposure or medical records	Periodic medical tests are documented to monitor the health effects of potentially toxic or carcinogenic workplace substances. [OMD]	Records must be retained for at least the duration of employment plus thirty years, except as noted in OSHA, 29 CFR 1910.20(d)(1)(i). [OMD]
2	29 CFR 1910.1020	Standard Medical Records	Medical records and related medical documentation [OMD]	Same as noted above. [OMD]

Table 11: Motor Vehicle Operation

ID	Source of Requirement	Main Document & Related Material	Documentation	Recordkeeping
1	City Ordinances DOE/JSA Contract	Motor vehicle Information	· Report Files · Accident Files · Operations Files [FMD]	Records must be maintained for at least three years, and as necessitated by other requirements. [FMD]
			For event reporting - Refer to ORPS - Table 1

For additional information regarding the requirements listed above, consult the cited record or document (available through the staff positions listed, at ESH&Q Reporting in the ESH&Q Division Office in CEBAF Center or in the CEBAF Center Law Library). For other topics that may not be covered in this appendix, reference specific chapters in the ES&H Manual or contact your supervisor or one of the responsible staff referenced in the above tables.

Table 12: Acronym Legend for Positions Having ESH&Q Documentation Responsibilities

ACRONYM	JOB POSITION
ACPC	AC Power Coordinator
AcDMM	Accelerator Division Mechanical Manager
AD	Associate Director-”Division”
BSM	Business Services Manager
DSO	Division Safety Officer-”Division”
ESH&QDIH	ESH&Q Division Industrial Hygiene Staff
ESH&Q-Physics	Physics Division ESH&Q Group or Designee
ESH&QRM	ESH&Q Reporting Manager
ESH&QRO	ESH&Q Reporting Officer
EM	Emergency Manager
ESS-Chair	Electrical Safety Committee Chairperson
FMCM	Facilities Management Construction Manager
FMD	Facilities Management Director
FPE	Fire Protection Engineer
FMME	Facilities Management Mechanical Engineer
HRD	Human Resources Director
HWC	Hazardous Waste Coordinator
IH	Industrial Hygienist
JLRM	Jefferson Lab Records Manager
LC	Legal Counsel*
LSO	Jefferson Lab Laser Safety Officer
MHER	Materials Handling Equipment Representative
MHSR	Materials Handling Safety Representative
MSDSC	MSDS Coordinator
OMD	Occupational Medicine Director
RCM	Radiation Control (RadCon) Manager
RadCon	Radiation Control Group Staff
SO	Security Officer

2.0 Revision Summary

Revision 0.1 – 08/13/14 – Periodic Review – Updated TechPOC from S.Smith to T.Johnson

ISSUING AUTHORITY	TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
ESH&Q Division	Tina Johnson	08/13/14	08/13/17	0.1

This document is controlled as an on line file. It may be printed but the print copy is not a controlled document. It is the user’s responsibility to ensure that the document is the same revision as the current on line file. This copy was printed on 11/5/2014.