NORTHERN SIERRA AIR QUALITY MANAGEMENT DISTRICT

RULE 903 - AIRBORNE ETHYLENE OXIDE CONTROL MEASURE
FOR STERILIZERS AND AERATORS

(Adopted: May 20, 1991)

CONTENTS

PART 1.0 GENERAL

1.1 Purpose

1.2 Applicability

1.3 Exemption, Small User

1.4 Exemption, Emergency


PART 2.0 DEFINITIONS

2.1 Acute Care Facility

2.2 Aeration

2.3 Aeration-only Facility

2.4 Aerator

2.5 Aerator Exhaust Stream

2.6 Back-draft Valve Exhaust Stream

2.7 Control Device

2.8 Control Efficiency

2.9 Date of Compliance

2.10 District

2.11 Ethylene Oxide (EtO)

2.12 Facility

2.13 Facility-Wide Pounds of Ethylene Oxide Used Per Year

2.14 Leak Free

2.15 Local Medical Emergency

2.16 Sterilant Gas

2.17 Sterilizer

2.18 Sterilizer Cycle

2.19 Sterilizer Door Hood Exhaust Stream

2.20 Sterilizer Exhaust Stream

2.21 Sterilizer Exhaust Vacuum Pump


PART 3.0 STANDARDS

3.1 General Requirements

PART 4.0 ADMINISTRATIVE REQUIREMENTS

4.1 Compliance of Ethylene Oxide Concentrations Below Detection

4.2 Alternate Compliance Date


PART 5.0 MONITORING AND RECORDS

5.1 Notification

5.2 Reporting

5.3 Source Testing



RULE 903

AIRBORNE ETHYLENE OXIDE CONTROL MEASURE

FOR STERILIZERS AND AERATORS

PART 1 GENERAL

1.1 Purpose
The purpose of this rule is to reduce ethylene oxide emissions to the atmosphere.
1.2 Applicability
Any person who owns or operates a sterilizer or an aerator must comply with this regulation.
1.3 Exemption, Small User
The requirements set forth in Part 3.0 - Standards do not apply to any facility which treats materials in a sterilizer and which uses a total of 25 pounds or less of ethylene oxide per calendar year.
1.4 Exemption, Emergency
The District Hearing Board may grant an emergency variance from Items (a) and (c) in Table 1 of Part 3.0-Standards, to a person who owns or operates an acute care facility if response to a local medical emergency requires increased operation of a sterilizer or aerator such that the requirements cannot be met. The demonstrated need for such increased operation shall constitute "good cause" pursuant to Health and Safety Code Section 42359.5. The emergency variance shall be granted in accordance with this part and any applicable District rule regarding the issuance of emergency variances for such occurrences, including the requirement that the emergency variance shall not remain in effect longer than 30 days. However, the emergency variance shall be granted only for the period of time during which increased operation of a sterilizer or aerator is necessary to respond to the local medical emergency.

PART 2 DEFINITIONS

2.1 Acute Care Facility
Any facility currently licensed by the California Department of Health Services as a general acute care hospital (as defined in Title 22, CCR, Section 70005), or any military hospital.
2.2 Aeration
The process during which residual ethylene oxide dissipates, whether under forced air flow, natural or mechanically assisted convection, or other means, from previously sterilized materials after the sterilizer cycle is complete.
2.3 Aeration-only Facility
A facility which performs aeration on materials which have been sterilized with ethylene oxide at another facility.
2.4 Aerator
Any equipment or space in which materials previously sterilized with ethylene oxide are placed or remain for the purpose of aeration. An aerator is not any equipment or space in which materials that have previously undergone ethylene oxide sterilization and aeration can be handled, stored, and transported in the same manner as similar materials that have not been sterilized with ethylene oxide.
2.5 Aerator Exhaust Stream
All ethylene oxide-contaminated air which is emitted from an aerator.
2.6 Back-draft Valve Exhaust Stream
The air stream which results from collection of ethylene oxide-contaminated air which may be removed from the sterilizer through a back-draft valve or rear chamber exhaust system during unloading of the sterilized materials.
2.7 Control Device
An article, machine, equipment, or contrivance which reduces the amount of ethylene oxide between its inlet and outlet and which is sized, installed, operated, and maintained according to good engineering practices, as determined by the District.
2.8

Control Efficiency

The ethylene oxide (EtO) mass or concentration reduction efficiency of a control device, as measured with ARB Test Method 431 (Title 17, CCR, Section 94143) according to the source testing requirements herein, and expressed as a percentage calculated across the control device as follows:

2.9 Date of Compliance
The time from District adoption of regulations enacting this control measure until a facility must be in compliance with specific requirements of this rule.
2.10 District
The Northern Sierra Air Quality Management District.
2.11 Ethylene Oxide (EtO)
A substance identified as a toxic air contaminant by the Air Resources Board in 17 CCR, Section 93000.
2.12 Facility
Any entity or entities that own or operate a sterilizer or aerator, are owned or operated by the same person or persons, and are located on the same parcel or contiguous parcels.
2.13 Facility-Wide Pounds of Ethylene Oxide Used Per Year
The total pounds of ethylene oxide used in all of the sterilizers at the facility during a one-year period.
2.14

Leak Free

That state which exists when the concentration of sterilant gas measured 1 cm away from any portion of the exhaust system of a sterilizer or aerator, during conditions of maximum sterilant gas mass flow, is less than:

  1. 30 ppm for sterilant gas composed of 12% ethylene oxide and 88% chlorofluorocarbon-12, by weight, and
  2. 10 ppm for other compositions of sterilant gas, as determined by ARB Test Method 21 (Title 17,CCR, Section 94124) using a portable flame ionization detector, or a non-dispersive infrared analyzer, calibrated with methane, or an acceptable alternative method or analytical instrument approved by the District. A chlorofluorocarbon-12 specific audible detector using a metal oxide semiconductor sensor shall be considered an acceptable alternative for exhaust systems carrying a sterilant gas mixture of ethylene oxide and chlorofluorocarbon-12.
2.15 Local Medical Emergency
An unexpected occurrence in the area served by the acute care facility resulting in a sudden increase in the amount of medical treatments which require a significant increase in the operation of a sterilizer or aerator.
2.16 Sterilant Gas
Ethylene oxide or any combination of ethylene oxide and (an)other gas(es) used in a sterilizer.
2.17 Sterilizer
Any equipment in which ethylene oxide is used as a biocide to destroy bacteria, viruses, fungi, and other unwanted organisms on materials. Equipment in which ethylene oxide is used to fumigate foodstuffs is considered a sterilizer.
2.18 Sterilizer Cycle
The process which begins when ethylene oxide is introduced into the sterilizer, includes the initial purge or evacuation after sterilization and subsequent air washes, and ends after evacuation of the final air wash.
2.19 Sterilizer Door Hood Exhaust Stream
The air stream which results from collection of fugitive ethylene oxide emissions, by means of an existing hood over the sterilizer door, during the time that the sterilizer door is open after the sterilizer cycle has been completed.
2.20 Sterilizer Exhaust Stream
All ethylene oxide-contaminated air which is intentionally removed from the sterilizer during the sterilizer cycle.
2.21 Sterilizer Exhaust Vacuum Pump
A device used to evacuate the sterilant gas during the sterilizer cycle, including any associated heat exchanger. A sterilizer exhaust vacuum pump is not a device used solely to evacuate a sterilizer prior to the introduction of ethylene oxide.

PART 3 STANDARDS

3.1 General Requirements

No person shall operate a sterilizer or aerator after the applicable date shown in column (d), Table 1, unless all of the following requirements are satisfied:

  1. There is no discharge of sterilizer exhaust vacuum pump working fluid to wastewater streams, and
  2. The exhaust systems including, but not limited to, any piping, ducting, fittings, valves, or flanges, through which ethylene oxide-contaminated air is conveyed from the sterilizer and aerator to the outlet of the control device are leak-free, and
  3. All of the control requirements shown in Table 1 below for the applicable control category are met; and
  4. For facilities using more than 600 pounds of ethylene oxide per year, the back-draft valve is ducted to the control device used to control the sterilizer exhaust stream or the aerator exhaust stream; and
  5. For facilities using more than 5,000 pounds of ethylene oxide per year, the sterilizer door hood exhaust stream is ducted to the control device used to control the aerator exhaust stream.

Table 1

Control and Compliance Requirements

CONTROL CATEGORY   REQUIREMENTS    

Facility-wide Pounds of Ethylene Oxide Used per Year

Exhaust Streams to be Controlled

Exhaust Streams to be Tested

Control Efficiency (%)

Date of Compliance (months)

Less than or equal to 25

None

None

None

None

More than 25 and less than or equal to 600

Sterilizer

Sterilizer

99.0

24

More than 600 and less than or equal to 5,000

Sterilizer

Aerator

Back-draft Valve

Sterilizer

Aerator

99.9

95.0

N/A *

18

More than 5,000

Sterilizer

Aerator

Sterilizer Door Hood

Back-draft Valve

Sterilizer

Aerator

99.9

99.0

N/A *

N/A *

12

Aeration-Only Facilities

Aerator

Aerator

95.0

18

         
* Not Applicable        

PART 4 ADMINISTRATIVE REQUIREMENTS

The facility shall be in compliance with all provisions specified in Part 3.0, Standards, no later than the date specified in column (d) of Table 1.

4.1 Compliance of Ethylene Oxide Concentrations Below Detection

For the purpose of determining compliance with the control efficiency requirement shown in column (c) of Table 1, Part 3.0, if a reduction in the amount of ethylene oxide across the control device is demonstrated, but the control efficiency cannot be affirmatively demonstrated because the concentration of ethylene oxide measured in the outlet of the control device is below 0.2 parts per million ethylene oxide, the facility shall be considered to be in compliance with this requirement.

4.2 Alternate Compliance Date

The owner or operator of any facility which uses more than 600 pounds of ethylene oxide per year may choose this alternate compliance option which addresses the date for compliance with the requirements of section C. If this compliance option is chosen, the owner or operator shall:

  1. Within 3 months of the date of District adoption of regulations enacting this control measure, comply with the requirements shown in subparts 3.1 A and 3.1 B and demonstrate a control efficiency of 99.9% for the sterilizer exhaust stream, in accordance with the source testing requirements set forth in Part 5.3; and
  2. Within 6 months of the date of District adoption of regulations enacting this control measure, submit to the District a plan to discontinue operation of all sterilizers and aerators or comply with the District requirements to submit a plan to comply with the requirements of Subparts 3.1 C, 3.1 D; and 3.1 E, and
  3. Within 18 months of the date of District adoption of regulations enacting this control measure, do one of the following:
    1. Demonstrate to the satisfaction of the District that operation of all sterilizers and aerators at the facility has been permanently discontinued; or
    2. Demonstrate compliance with the requirements of Subparts 3.1 C, 3.1 D and 3.1 E, in accordance with the source testing provisions set forth in Part 5.3.

PART 5 MONITORING AND RECORDS

5.1 Notification

Any person subject to this regulation must provide the District with the following information, in writing, within 30 days of the date of District adoption:

  1. The name(s) of the owner and operator of the facility, and
  2. The location of the facility, and
  3. The number of sterilizers and aerators at the facility, and
  4. An estimate of the total pounds of ethylene oxide and sterilant gas used by the facility, in all sterilizers, during the previous calendar year, as determined by a method approved by the District.

The District may exempt a source from this requirement if the District maintains current equivalent information on the source.

5.2 Reporting

Any person who owns or operates a sterilizer shall furnish a written report to the District annually on the date specified by the District, or, at the District's discretion, shall maintain such a report and make it available to the District upon request. This report shall include one of the following, as determined by the District:

  1. The number of sterilizer cycles and the pounds of ethylene oxide used per cycle for each sterilizer during the reporting period, as determined by a method approved by the District; or
  2. The total pounds of sterilant gas and the total pounds of ethylene oxide purchased, used, and returned in the previous calendar year, as determined by a method approved by the District.

5.3 Source Testing

Source testing shall be conducted according to ARB Test Method 431 (Title 17, CCR, Section 94143) and the method evaluations cited therein or an acceptable source test method approved by the Executive Officer of the Air Resources Board. Specific requirements for application are given below:

  1. The test on a control device for a sterilizer exhaust stream shall be run with a typical load, as approved by the District, in the sterilizer.
  2. The test on a control device for an aerator exhaust stream shall be run with a typical load, as approved by the District, in the aerator.
  3. The inlet and outlet of the control device shall be sampled simultaneously during testing to measure the control efficiency.
  4. The efficiency of each control device shall be determined under conditions of maximum ethylene oxide mass flow to the device, under normal operating conditions. To measure the control efficiency of the control device on the sterilizer exhaust stream, sampling shall be done during the entire duration of the first sterilizer evacuation after ethylene oxide has been introduced. To measure the control efficiency of the control device on an aerator exhaust stream with a constant air flow, sampling shall be done during a period of at least 60 minutes, starting 15 minutes after aeration begins. To measure the control efficiency of the control device on an aerator exhaust stream with a non-constant air flow, sampling shall be done during the entire duration of the first aerator evacuation after aeration begins.
  5. There shall be no dilution of the air stream between the inlet and outlet test points during testing.