SHASTA COUNTY AIR QUALITY MANAGEMENT DISTRICT

RULE 3:20 - ETHYLENE OXIDE AIRBORNE TOXIC CONTROL MEASURE FOR STERILIZERS AND AERATORS
(Added 1/14/92) (Amended 12/23/92)

a. Definitions.

For the purposes of this section, the following definitions shall apply.

Acute care facility means 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.

Aeration is 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.

Aeration-only facility means a facility which performs aeration on materials which have been sterilized with ethylene oxide at another facility.

Aerator means 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.

Aerator exhaust stream means all ethylene oxide-contaminated air which is emitted from an aerator.

Back-draft valve exhaust stream is 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.

Control device means 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.

Control efficiency is 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:

EtO in - EtO out x 100 = % Control Efficiency

EtO in

   

Date of compliance means the time from District adoption of regulations enacting this control measure until a facility must be in compliance with specific requirements of this rule.

District means the local air pollution control District or air quality management District.

Ethylene oxide (EtO) is the substance identified as a toxic air contaminant by the Air Resources Board in 17 CCR, Section 93000.

Facility means any entity or entities which: 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.

Facility-wide pounds of ethylene oxide used per year is the total pounds of ethylene oxide used in all sterilizers at the facility during a one-year period.

Leak-free refers to 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:

30 ppm for sterilant gas composed of 12% ethylene oxide/88% chlorofluorocarbon-12 by weight, and


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 semi-conductor sensor shall be considered an acceptable alternative for exhaust systems carrying a sterilant gas mixture of ethylene oxide and chlorofluorocarbon-12.

Local medical emergency means 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.


Sterilant gas means ethylene oxide or any combination of ethylene oxide and (an)other gas(es) used in a sterilizer.


Sterilizer means 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 to be a sterilizer.


Sterilizer cycle means 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.


Sterilizer door hood exhaust stream is 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.


Sterilizer exhaust stream is all ethylene oxide-contaminated air which is intentionally removed from the sterilizer during the sterilizer cycle.


Sterilizer exhaust vacuum pump means 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.

b. Applicability

Any person who owns or operates a sterilizer or an aerator must comply with this regulation.

c. Notification

Any person subject to this regulation must provide the District with the following information, in writing, within thirty (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.

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


d. 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.

e. Requirements

No person shall operate a sterilizer or aerator after the applicable date shown in column (d), Table I, 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 the control requirements shown in Table I 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 I

Control and Compliance Requirements

Control Category Requirements

Facility-wide Pounds of EtO Used per Year (a)
Exhaust Streams
to be Controlled
(b)
Exhaust Streams
to be Tested
(c)
Control
Efficiency
(%)
(d)
Date of
Compliance
(months)

<25

None

None

None

None

>25 and <600

Sterilizer

Sterilizer

99.0

24

>600 and <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.

f. Exemptions

  1. The requirements set forth in subsection "e" above 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.
  2. The District hearing board may grant an emergency variance from items (a) and (c) in Table I of subsection "e", Requirements, 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 section and any applicable District rule regarding the issuance of emergency variances for such occurrences, including the requirement that 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.

g. Compliance

The facility shall be in compliance with all provisions specified in subsection "e", Requirements, no later than the date specified in column (d) of Table I.

  1. For the purpose of determining compliance with the control efficiency requirement shown in column (c) of Table I, subsection "e", 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 in compliance with this requirement.

h. Alternate Compliance Date.

The owner or operator of any facility that 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 subsection "e". If this compliance option is chosen, the owner or operator shall:

  1. Within three (3) months of the date of District adoption of regulations enacting this control measure, comply with the requirements shown in subsections "e"(1) and "e"(2) and demonstrate a control efficiency of 99.9% for the sterilizer exhaust stream, in accordance with the source testing requirements set forth in subsection "i"; and
  2. Within six (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 subsections "e"(3), "e"(4), and "e"(5),and
  3. Within eighteen (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 subsections "e"(3), "e"(4), and "e"(5), in accordance with the source testing provisions set forth in subsection "i", below.

i. 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 load 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 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 sixty (60) minutes, starting fifteen (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.