Los Angeles City Fire Department CUPA Deficiency Progress Report - Update 6

Report Submitted: September 23,2013

Evaluation Date: July 18 - 21,2011

Evaluation Follow-Up Team:

Kareem Taylor, Cal/EPA Asha Arora, DTSC Ari Erman, DTSC Jack Harrah, Cal EMA Laura Fisher, SWRCB Sean Farrow, SWRCB

Corrected Deficiencies: 1,4, 5, 6, 12, 14, 16, 17, 19,20, 21, 22 Next Progress Report (Update 6) Due: September 23,2013

Please update the deficiencies below that remain outstanding.

Deficiency: The CUPA is not adequately implementing i t s fee accountability program, which is impacting the CUPA's ability t o administer the unified program (UP) in the City o f Los Angeles.

A combination of events and actions are collectively the cause of this situation. The CUPA's operations are deficient in the following areas:

Single fees collected and earmarked solely for UP-related activities are being inappropriately used to fund personnel and other related expenses for non-UP work activities. Cal/EPA and the SWRCB have discovered that a CUPA inspector has been reassigned from underground storage tank (UST) plan check activities to the fire department's non-UP related Regulation Four Unit that handles fire suppression and sprinkler systems. The inspector's position remains fully funded by the CUPA's single fee revenues.

Using the UP fee revenues t o fund work activities that are not part of the scope of the UP is not allowed by statute. Pursuant t o state law, the UP single fee revenues are required t o be used for the sole purpose of funding the necessary and reasonable costs incurred by the CUPA in their administration of the UP in the City of Los Angeles.

Page 1 of 59

Cal/EPA has discovered that the CUPA's fee accountability program is insufficient to acquire and maintain the necessary resources to regulate approximately 9500 businesses. The fee accountability program also fails to address the additional resources necessary for the aboveground petroleum storage tank (AST) program. Insufficient resource allocation has impacted the CUPA in the following ways:

o incomplete inspections o incomplete unified program consolidated forms (UPCF) o current business planslthree-year review certifications have not been

collected and properly reviewed o current chemical inventories/inventory certifications have not been collected

and properly reviewed o inaccurate Annual Summary Reports o inaccurate Semi-Annual UST Report 6

Corrective Actions: Effective immediately, CUPA single fees collected will no longer be used to fund any non-UP related personnel or activities.

By January 21,2012, the CUPA will ensure that UP funds used for non-UP activities are returned to Los Angeles City Fire Department's CUPA. The CUPA will submit, to CalIEPA, documentation of the UP funds return.

By January 21,2012, the CUPA will assess i t s resource needs based on the number of businesses it regulates and report its finding in the first progress report to CalIEPA.

By April 21, 2012, the CUPA will, in coordination with the Los Angeles City Council, develop a fee accountability program that will more adequately address the CUPA's resource needs.

The CUPA will submit requested documentation to Cal/EPA verifying progress toward acquiring additional resources along with quarterly progress reports.

By July 1, 2012, the CUPA will have begun following i t s new fee accountability program that more adequately addresses the CUPA's resource needs.

CUPA's 1'' Update (10-20-11): As a result of the recent audit findings, the Los Angeles Fire Department CUPA has elected to "detail" Inspector II, Gilbert Urrea to the Environmental Unit. This detail will assist with the work load assigned to the Environmental Unit Plan-check personnel and maintain compliance with the fee accountability program accepted by the City of Los Angeles. This temporary detail will provide the unit the greatest opportunity for success and provide a more efficient work flow for the regulated community.

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Cal/EPAJs lSt Response: The CUPAJs solution to move the inspector back to CUPA- related duties is acceptable. Please continue t o update Cal/EPA on the remaining elements of this deficiency.

CUPA's 2nd Update (2-28-12): CUPA continues process of analyzing necessary resources to perform all its functions adequately. CUPA's Inspection Unit is fully staffed. CUPA Manager's interviews were conducted in January, projected hiring in February 2012.

Cal/EPAJs 2nd Response: The CUPA's solution t o move the inspector back to CUPA- related duties partially corrects the deficiency in that it stops the misallocation of CUPA funds; however, the CUPA did not submit documentation showing that the misallocated funds had been returned to the UP. The CUPA will submit this documentation that was due January 21, 2012 immediately.

Also, the CUPA was to assess i t s resource needs by January 21,2012, but has not submitted its assessment in this update. Please submit the resource assessment t o Cal/EPA immediately.

CUPA's 3rd Update (4-27-12): CUPA fees collected were only used for CUPA activities for Fiscal Years 2009-2010 and 2010-2011. In fiscal year 2010-2011, CUPA actual revenues received were 88% of the projected revenue. Also, the actual revenues received were 84% of the forecasted CUPA cost. The shortfall in revenues was offset by the City's General Fund.

Inspector detailed out of the UP was a workload issue, and the salary was fully covered by the City's General Fund. Page 1, of Attachment A, shows the forecasted cost for administering the UP for fiscal year 2010-2011. Page 2, of attachment A, shows revenues collected for previously years and projected revenues for this fiscal year. For the current fiscal year, CUPA is projected to recover 98% of the UP cost from fees collected by the program's single fee.

At this point CUPA is evaluating i t s resources based on improved data collection and tracking as a result of the recent Annual Inventory Update Forms remitted t o CUPA. CUPA is working on a fee accountability program which will be completed by May 28, 2012.

CUPA's 3rd Update (5-28-12): A draft copy of Fee Accountability Program is attached (see Attachment I). Resources assessment is included as part o f the Fee Accountability Program. The assessment includes time allocation for staffing, total number of hours required for inspections, and number of inspectors needed.

CalIEPA's 3rd Response: The CUPA's explanation that the CUPA inspector assigned t o non-UP activities was funded by LA City's general fund in FY 2010/2011 is acceptable.

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The fee accountability document is acceptable with one exception. In the "Remittance of Surcharge" section, please revise the language so that it states "The CUPA shall transmit all collected state surcharge revenues to the Secretary quarterly, within 30 days of the end of each state fiscal quarter. With each surcharge transmittal the CUPA shall separately report the amount of surcharge revenues collected for: CUPA oversight, regulated USTs, (AST???) and the CalARP Program."

CUPA's 4th Update (12-15-12): Remittance o f Surcharge section of the Fee Accountability Program has been revised (See Attachment A).

Cal/EPA's 4th Response: Cal/EPA considers this deficiency corrected.

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Deficiency: In some cases, the CUPA is not following-up and/or documenting return t o compliance (RTC) for businesses cited for violations in notices t o comply, notices of violation (NOV) and inspection reports.

According to the fiscal year (FY) 2008/2009 "NOV tracking sheet," 46 out of 96 businesses that received a NOV have not RTC. According t o the "Violation Notices Tracking Sheet July 1 - December 31, 2010," none of the 94 businesses that received a NOV have RTC certifications.

Corrective Actions: Effective immediately, the CUPA will regularly document enforcement activities (enforcement letters, re-inspection reports, phone calls, RTC certifications) using Microsoft Excel until the CUPA's database is upgraded to Envision Connect.

By October 21, 2011, the CUPA will develop a l is t o f all businesses with ongoing violations and submit the l is t t o Cal/EPA.

The CUPA will submit requested documentation to CaljEPA verifying that follow-up actions are taking place along with quarterly progress reports.

By July 21, 2012, the CUPA will have followed-up with all the businesses on the list and provide requested documentation to Cal/EPA.

CUPA's 1'' Update (10-20-11): As a result of the recent Audit findings, the Los Angeles Fire Department CUPA has reviewed the Notice of Violation spread sheet (see attached) and identified the status of all NOV's written during the evaluated period. The computer program use to manage data records is configured t o NOT remove a facility from the lnspectors "to Do" list if there is an outstanding "Notice t o Correct". This program configuration has placed each non-compliant facility at the top of the Inspectors 2011 inspection responsibilities.

Cal/EPAJs 1'' Response: Does the notice of violation tracking excel spreadsheet represent all the businesses with ongoing violations? If not, please update the spreadsheet t o include all businesses with ongoing violations and submit along with the next progress report. Cal/EPA noticed that there were no 2011 NOVs listed on the spreadsheet; however, the sample pdf version contained all 2011 NOVs. Are both documents to be used together t o document RTC between July 2010 and July 2011? Please clarify. Please continue t o update Cal/EPA on the remaining elements of this deficiency.

CUPA's 2nd Update (2-28-12): CUPA has continued t o update enforcement activities for all program elements t o track RTC accurately.

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Cal/EPAPs 2nd Response: The CUPA did not answer Cal/EPAfs question posed in the first response. "Does the notice of violation tracking excel spreadsheet represent all the businesses with ongoing violations?" Please respond t o the question. Also, are the dates in the issue date column in the notice of violation spreadsheet the original inspection dates or does the column only represent the dates that NOVs were issued? Cal/EPA need to determine whether the NOV spreadsheet represents a l ist of all businesses with ongoing violations or is the spreadsheet limited t o inspections performed within a certain timeframe. The corrective action called for the CUPA t o develop a l is t of all businesses with ongoing violations by October 21, 2011. Cal/EPA is uncertain that the attached NOV spreadsheets from the first and the second update fulfills the corrective action. Please respond to the questions posed immediately.

CUPA's 3rd Update (4-27-12): Most current notice of violation tracking excel spreadsheet represents all businesses with ongoing violations. The date in the "date column" represents date o f inspection. NOVs are written on the day of inspection.

Cal/EPAJs 3rd Response: The CUPA answered Cal/EPAfs questions about the NOV spreadsheets. Please follow-up with all the facilities listed and document the follow-up actions on the spreadsheet.

CUPA's 4th Update (12-15-12): CUPA has reviewed the most updated spreadsheet and determined that, to-date, 23 of the 70 business issued NOVs, since January 1, 2012, have returned t o compliance. By February 15, 2013, CUPA will inspect the 47 facilities that did not RTC. Businesses with violations will be issued new NOVs. Follow up inspection will be done 30 days from the NOV, as per Inspection and Enforcement Plan; an enforcement action will be taken against businesses that do not RTC after the 30 days.

Cal/EPAPs 4th Response: Cal/EPA has four different NOV spreadsheets from the CUPA: "Copy of Julyl-Dec2010NOVTS" from update 1, "Copy of NOV Tracking Sheet 09-10, 2011" and "Copy of NOV Tracking Sheet 10 - 12,2011" from update 2, and a NOV spreadsheet for FY 2011/2012 from Update 3. Do you have updated MS Excel versions of the "Copy of Julyl-Dec2010NOVTS", "Copy of NOV Tracking Sheet 09-10, 201lU, and "Copy of NOV Tracking Sheet 10 - 12,2011" spreadsheets that have RTC dates or follow- up actions for each facility listed? If so, please submit the spreadsheets to Cal/EPA within two weeks of this response. Cal/EPA is concerned that the facilities with NOVs inspected in calendar years 2010 and 2011 may not have been followed-up with by the CUPA. The spreadsheets should demonstrate that the CUPA is following-up with noncompliant facilities by indicating either the date of RTC or that the CUPA performed appropriate enforcement actions in lieu of RTC. Appropriate enforcement actions include but are not limited to phone calls, enforcement letters, reinspections, formal enforcement (civil, criminal, AEO, citations, red tag). Please submit RTC documentation including the inspection reports for the following facilities from the NOV lists.

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Requested Facility RTC Documents:

1. Central Los Angeles Transfer, 1950 E Washington Blvd, inspected 9-27-11, RTC 2-21- 12

2. Grand Classic Oil Co., 7550 S Sepulveda Blvd., inspected 9-6-11, RTC 9-22-11 3. Centron Shell, 1317 E Washington Blvd., inspected 1-19-12, RTC 1-20-12 4. Jeds Mobil, 12450 Roscoe Blvd., inspected 5-22-12, RTC 5-22-12 5. Azez Chevron, 14204 S Figueroa St., inspected 5-22-12, RTC 5-22-12

CUPAJs sth Update: Updated spreadsheets were submitted on May 9,2013, copies of spreadsheets are attached (see Attachment A). Attachment B includes RTC documents requested.

Cal/EPAJs sth Response: This deficiency is still ongoing. The RTC documentation the CUPA submitted is satisfactory. Along with the next progress report, please submit the NOV tracking sheet that either shows that the CUPA followed-up with all of the facilities on the list or that the facilities RTC. The NOV tracking sheet should be the same as the one for update #5. The following facilities on the list st i l l require CUPA follow-up or RTC:

1. Sunbelt Rental, 18251 Napa St. 2. M.W.D Sunset, 2100 N. Soto St. 3. Sunset Garage, 610 N. Figueroa 4. Chevron 90477,4005 Eagle Rock 5. Raffi's Chevron, 4510 Cezanne Ave 6. Wilmington Arco, 1020 W. Anaheim

For Jed Mobil, according to the violation report dated 5-22-12, it appears that the red tag #I690 was tapered with in some fashion. Chapter 6.7 section 25299(e) states, "Any person who violates Section 25292.3 & liable for a civil penalty of not more than five thousand dollars ($5,000) for each underground storage tank for each day of violation." Did the CUPA pursue a civil penalty against Jed Mobil for tapering with a red tag?

CUPAJs 6th Update (9- 23,2013): Attachment A includes updated NOV Tracking Sheets. Jeb Mobile NOV, dated 5-22-12, was not written for tampering with red tag; but rather, the inspector cited CCR language indicating the penalties for tampering with the red tag (see Attachment B).

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Deficiency: The CUPA is not fully implementing i t s lnspection and Enforcement (I and E) Plan. In many cases, CUPA inspectors are not completing an inspection report after each inspection and leaving a copy with the facility operator. Cal/EPA, Cal EMA, and the SWRCB have observed that many facility files did not contain current inspection reports.

Corrective Actions: Effective immediately, the CUPA will document all inspections using an inspection report for each program element.

By October 21,2011, the CUPA will submit inspection report templates for the hazardous materials release response plan (HMRRP), AST, and UST programs to Cal/EPA.

By July 21, 2012, the CUPA will provide a l ist of facilities that were inspected during FY 2011/2012. Cal/EPA will review the l is t and will request copies of inspection reports from the l ist.

CUPAJs lSt Update (10-20-11): As a result o f the recent Audit findings, the Los Angeles Fire Department CUPA has developed and implemented inspection reports for the following CUPA elements; UST, HMRRP, UST File Review, and CalARP (see attached). The attached forms will serve as an immediate notification t o the regulated community o f compliance issues that are outstanding upon completion o f the regulatory inspection.

Cal/EPA's lSt Response: Please refer t o the SWRCB's response.

SWRCBJs lSt Response: Does the CUPA have an UST inspection checklist for single-walled UST's? On the submitted doubled-walled checklist, you mention monitoring plan approved, but when for emergency response, you only ask if it is current. Regulations do state that the emergency response plan and monitoring plan shall be approved by the local agency. The options listed (1-3) for pressurized systems should have a line leak detector for all options, not just option 3. When does the CUPA inspector determine SOC? The State Water Board considers this deficiency to be a work in progress.

CUPA's 2"d Update (2-28-12): CUPA uses single-walled or double-walled UST lnspection checklist as applicable. NOV's tracking sheets attached.

Cal/EPAJs 2nd Response: The CUPA submitted its HMRRP, UST, and CalARP inspection checklists. The HMRRP and CalARP (program 3) checklists are satisfactory. Please refer t o the SWRCB's comments about the UST inspection checklist. The APSA checklist has not been submitted t o date. Please submit the APSA inspection checklist immediately.

SWRCBJs Response: Has the CUPA changed its language on its UST inspection checklist in regards to the monitoring and response plan? Has the CUPA updated i t s inspection checklist t o include line leak detectors for all pressurized systems?

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When is Significant Operational Compliance (SOC) criteria determined? On the next progress report, please address the concerns. The SWRCB considers this deficiency t o be a work in progress.

CUPA's 3rd Update (4-27-12): A draft APSA checklist has been developed (see Attachment B). CUPA has implemented the use of a newlmodified inspection "Compliance Check Sheets" and "Notice of Violation forms (see Attachment B). "SOC" is determined at the end of the reporting period.

CalIEPA's 3rd Response: The CUPA submitted the requested checklists including a draft APSA checklist. Please refer t o SWRCB's response.

SWRCB's Response: SWRCB has reviewed the UST checklist. The CUPA has not developed a checklist that fully encompasses a complete UST inspection. By November 30, 2012, the CUPA will submit t o Cal/EPA a revised UST checklist that captures all aspects o f an UST inspection. Once reviewed by Cal/EPA, the CUPA will immediately implement its use. A couple of examples where the checklist is lacking detail is as follows:

o Line leak detectors o SOC determination o Paperwork- at the CUPA's office and facility

SWRCB is attaching LG 159 and i t s enclosure as an example of a complete UST inspection checklist.

For SOC determination, the CUPA states it is determined at the end of the reporting period. Effective immediately, the CUPA inspectors will determine SOC during the annual UST compliance inspection and note it on i t s UST inspection checklist. This will enable the CUPA t o accurately collect and report SOC information to SWRCB. SOC must be noted even if SOC violations are corrected at the conclusion of the inspection.

SWRCB considers this deficiency to be a work in progress.

CUPA's 4th Update (12-15-12): Checklist has been revised (see Attachment B). Inspectors will make SOC determination during the annual UST compliance inspection and denote it on the UST Compliance Checklist.

CalIEPA's 4th ~ e s ~ o n s e : Cal/EPA requests that the CUPA provide completed inspection reports (all program elements) for the following facilities from the FY 201112012 NOV list:

Requested facilities:

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1. Marina Car Wash, 2305 Lincoln Blvd. inspected 7-14-11 and 9-1-11 2. American Auto Service, 11232 Vanowen St. UN 5, inspected 9-20-11 3. Xtra Fuel, 484 E Imperial HWY, inspected 9-26-11 and 10-13-11 4. Skipower Plating works Inc., 7131 N Vineland Ave, inspected 11-4-11 5. Azez Chevron, 14204 S Figueroa St., inspected 5-22-12 6. Regal Cleaners, 10631 W Pico Blvd, inspected 5-8-12 7. Central Metal Inc., 2203 S Alameda St., inspected 1-30-12 8. AAMCO Transmissions, 8535 Venice Blvd., inspected 10-17-11

Please refer to SWRCB's and OSFMfs responses.

a SWRCB's Response: SWRCB considers the UST inspection checklist a work in progress.

CUPA Action Items:

o Identify which items cover release detection and release prevention criteria.

o Add line integrity testing as a requirement for emergency generators with pressurized piping.

SWRCB Comments:

o SWRCB has reviewed the submitted UST inspection checklist. The CUPA has captured the line leak detectors in the pressurized line systems section. However, since line leak detectors are generally not found on emergency generators, line integrity testing is performed on systems which use pressure to deliver fuel t o day tanks and this is missing from your inspection checklist option.

o On page 2 in the additional requirements section, the CUPA cites 2637 in regards to contractor training and appropriate licensing. SWRCB could not find the citation the CUPA is referring to.

o SWRCB has requested that inspectors determine SOC compliance during the inspection and the CUPA has added this t o its checklist. Unfortunately during its review, SWRCB cannot determine easily what items capture release detection and release prevention criteria. The CUPA may want t o identify these items for i t s inspectors.

o Under the UST System Inspection section, the checklist has dispenser containment is present (if applicable) as criteria. There should be no

Page 10 of 59

dispenser in California where under dispenser containment is missing in accordance with T.23, Section 2666(e). The CUPA may want to remove the "if applicable" from the requirements.

OSFM's Response: Please see APSA checklist with OSFMJs comments.

CUPA's 5th Update (5-20-13): Inspection reports and/or NOV are included (See Attachment C). Revised draft copies of UST and APSA checklists are included (See Attachment D).

Cal/EPAPs 5th Response: The CUPA submitted inspection reports and/or NOVs for the facilities requested by Cal/EPA. The "issue date" in the FY 2011/2012 NOV list did not necessarily correlate with a routine inspection date so the CUPA did not provide completed inspection reports (all program elements) for all of the facilities requested in Cal/EPAJs 4th response. Cal/EPA needs to verify that the CUPA is using the templates it submitted to Cal/EPA in a previous progress report; therefore, Cal/EPA is requesting that the CUPA submit the most current and completed inspection reports (all applicable program elements) for the following facilities that submitted UP documentation in CERS:

1. Valley-Toledo Inc., 12975 Bradley Ave. Sylmar. Programs - BP, HWG, TP, CalARP, APSA

2. Valvoline Instant Oil Change, 1701 Pacific Coast Hwy Lomita. Programs - BP, HWG, APSA

3. RTDD CHEVRON MART, 11951 W Olympic Blvd. Los Angeles. 4. Equinix Operating Co, Inc. (LA2), 818 West Seventh Street Los Angeles. Programs

- BPI UST, CalARP

SWRCB Response: The CUPA has made progress towards correcting this deficiency. The only recommendation is in regards to ELD. On the SW UST checklist the CUPA mentions ELD and the correct H&SC citation. However, the DW UST checklist does not capture ELD. H&SC 25292.5 addresses the DW tank systems. In any event, SWRCB finds the checklist t o be acceptable.

OSFM's Response: Regarding the CUPAJs APSA inspection checklist, the CUPA has made some changes per my recommendations on March 25,2013, but not all. See the attached checklist with my current edits. Again, the CUPA needs t o keep in mind that if this checklist is insufficient for those more complex APSA facilities, then the CUPA may use USEPAJs onshore facilities checklist (excludes oil drilling, production and workover facilities) which may be found at http://www.epa.gov/emergencies/content/spcc/spccguidance.htm. Please incorporate the changes as suggested.

Page 11 of 59

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An evaluation of the number of inspections conducted for the last three fiscal years indicates that LA County PA meets the mandated triennial inspection frequency. There are currently no RCRA LQG or TP facilities that are over four years overdue.

There are currently 11 RCRA LQG facilities and 22 TP facilities that have not been inspected in the last three years. As stated above, the PA has implemented a plan to ensure that RCRA LQG and TP facilities that have not been inspected for more than 3 years are given priority. By July 21, 2012 there will be no RCRA LQG and TP facilities that have not been inspected in the past three years.

From the State reports:

LA City

3 year frequency average for RCRA is 32% and TP is 33.3%. During the first 2 '/1 months of FY 2011-12, we have completed 21 RCRA inspections and 17 TP inspections.

FISCAL YEAR 2010-11

2009-10

2008-09

CalIEPA's lSt Response: Please refer t o the DTSC's response.

DTSC's lSt Response: It is encouraging t o see CUPAs efforts in correcting this deficiency. Please submit a quarterly progress report t o Cal/EPA to provide an update on the number of RCRA LQG and TP facilities inspected.

RCRA Facilities 111

120

119

CUPA's 2nd Update (2-28-12): The Table above has been updated to reflect the 29 RCRA and 3 1 TP inspections conducted from July 1, 2011 to January 24, 2012. At the current rate of RCRA and TP facility inspections, we are on schedule t o meet the target date of July 21,2012.

CalIEPA's 2nd Response: The table's inspection percentages are encouraging. Has the PA verified that all RCRA LQG and TP facilities have been inspected within 3 years?

RCRA Inspected 3 8 4 1

34

CUPAJs 3rd Update (4-27-12): The Table above has been updated to reflect the additional 14 RCRA and 19 TP inspections conducted from the January 25,2012 through April 26,2012. There are seven RCRA LQGs and eight TP facilities which have not been inspected within the past 3 years. The remaining facilities will be inspected by next week. We are on schedule t o meet the target date of July 21, 2012.

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Percent Inspected 34% 34%

29%

TP Facilities 161

164 177

TP Inspected 3 6

6 1 7 2

Percent Inspected

22% 37%

41%

Cal/EPAJs 3rd Response: Please refer t o DTSC's response.

DTSC Response: The CUPA is making good progress toward correcting this deficiency. Please inspect the remaining RCRA and TP facilities that have not been inspected within three years and submit a quarterly progress report t o Cal/EPA to provide an update on the number of RCRA LQG and TP facilities inspected.

CUPA's 4th Update (12-15-12):

LA County PA has completed all inspections that were noted as overdues during the CUPA audit. There are no remaining overdue RCRA-LQG or TP facilities that require inspections. This is supported by the statistics listed on the table below.

Cal/EPAJs 4th Response: Cal/EPA and DTSC consider this deficiency corrected.

Page 15 of 59

Fiscal Year

712012-11/2012 2011-2012 2010-2011 2009-2010 2008-2009

RCRA Facilities

106 106 111 120 119

Percent lnspected

25% 5 1% 34% 34% 29%

RCRA lnspected

13 5 5 38 4 1 34

TP Facilities

158 158 161 164 177

TP lnspected

12 67 36 6 1 7 2

Percent lnspected

8% 42% 22% 37% 41%

5. Deficiency: The CUPA1s PA has not fully developed and implemented the hazardous waste generator (HWG) and TP program. Based on the file review, it appears that administrative reviews of the TP notifications are not done accurately. In addition, technical reviews are not verified accurately during the inspections. The following are instances observed by DTSC where the TP program was not implemented accurately:

California Electroplating Inc. (Commerce Office) inspected on 7/28/08 shows cyanide and chrome treatment listed as one permit-by-rule (PBR) unit. (Cyanide and chrome treatment must be under separate units.) Barry Avenue Plating (Culver City Office) inspected on 6/21/11 shows cyanide and chrome treatment listed as one PBR unit. The Bumper Shop inspected on 10/21/09 shows both PBR and a conditionally exempt small quantity treatment unit (CESQT). (Facility with CESQT is not eligible t o treat waste in any other tier.) Stutzman Plating, Inc. (Culver City Office) inspected on 11/7/07 shows one PBR unit for evaporation of cyanide and other wastes. (Evaporation of cyanide waste is not eligible under PBR.) Highland Plating Company (Culver City Office) inspected on 10/23/09 shows cyanide and chrome treatment listed as one PBR unit. (Cyanide and chrome treatment must be under separate units.) Accurate Engineering (Sylmar Office) inspected on 2/5/08 and re-inspected on 6/5/08 shows an incomplete PBR notification and types of waste treated. (Notification needs to be corrected during administrative review and technical review during the inspections.) PPG Industries, doing business as Sierracin Corporation (Sylmar Office) and inspected on 2/9/10, shows that the TP notification l is ts evaporation for aqueous waste as "Special waste" under the CESW tier. (Waste was incorrectly listed as special waste.)

The PA did not demonstrate that its staff had been adequately trained in the TP program involving cyanide, chrome, and multiple units involving hazardous waste. In addition, the PA did not demonstrate that its staff was familiar with conducting administrative and technical reviews of the TP program (types of waste treated, treatment technologies, TP eligibility, one unit vs. two units).

Corrective Actions: By October 21, 2011, the CUPA, in coordination with their PA, will develop and implement a plan to fully develop and implement the HWG and TP program. In the plan, the PA will identify their corrective actions to be taken t o address the instances cited by DTSC under this deficiency.

By January 21, 2012, the CUPA will ensure that its PA follows-up with all facilities that treat aqueous waste containing cyanide, chrome, CEQST treatment facilities and corrects their treatment authorizations, as necessary.

Page 16 of 59

By January 21, 2012, the CUPA will ensure that i t s PA provides HWG and TP training t o i t s staff, which will include but not be limited to, basic HWG training, tiered permitting of cyanide and chrome and multiple units involving hazardous waste.

The CUPA will provide documentation of the trainings by January 21,2012.

CUPA's lSt Update (10-20-11): As a result o f the recent Audit findings, the Los Angeles Fire Department CUPA has reviewed and approved the response provided by the Los Angeles County PA (see attached). It is the intent of the Los Angeles Fire Department CUPA t o evaluate i t s oversight practices with the Los Angeles County (PA) and take a more active role in the inspection processes exercised for waste management.

LA County PA, West office staff conducted an inspection at Stutzman Plating, Inc. on 9/21/11 regarding its cyanide evaporation. The inspector verified that the cyanide waste stream is recycled and not evaporated. Therefore, this is not considered an unauthorized treatment.

To address the other issues on this deficiency, LA County PA will do the following: 1. Inspection Manager will provide instructions to all inspection staff clarifying the

following: a. All staff upon inspecting these sites shall issue notices to correct the

violation. b. Each cyanide and/or chrome treatment unit shall be submitted under

separate unit pages. c. CESQT generators may not hold other state or federal hazardous waste

permits or authorization for the facility, including other onsite permits. 2. The 2012 annual authorization letter for Tiered Permit/PBR shall include instructions

t o submit each unit on a separate unit page and sample to be provided to over 175 TP/PBR facilities. I f compliance not obtained, a referral t o Districts shall be made to provide strict enforcement.

3. Request TP/Cyanide training refresher from DTSC and document the training by January 21,2012.

CalIEPA's lSt Response: Please refer to the DTSC's response.

DTSC's lst Response: The action plan is acceptable with DTSC. In the next progress report, please provide the PA's corrective action documentation that addresses the instances that DTSC cited in this deficiency. DTSC has agreed to conduct the TP/Cyanide training on December 8, 2011 in Commerce.

CUPA's 2nd Update (2-28-12):

Page 17 of 59

The Annual Permit By Rule Renewal Notification letter has been revised to ensure that the owner/operator of a TP facility submits separate Unified Program Onsite Hazardous Waste Treatment Unit Forms for each treatment unit operating under Permit by Rule. A sample notification letter and treatment forms are attached.

Corrective actions for the instances cited by DTSC are indicated below. California Electroplating Inc. (Commerce Office) inspected on 7/28/08 shows cyanide and chrome treatment listed as one permit-by-rule (PBR) unit. (Cyanide and chrome treatment must be under separate units.) Business will be submitting updated renewal notification with each unit on a separate unit page by March 1,2012. Barry Avenue Plating (Culver City Office) inspected on 6/21/11 shows cyanide and chrome treatment listed as one PBR unit. Business will be submitting updated renewal notification with each unit on a separate unit page by March 1, 2012.

The Bumper Shop inspected on 10/21/09 shows both PBR and a conditionally exempt small quantity treatment unit (CESQT). (Facility with CESQT is not eligible to treat waste in any other tier.) Beginning in 2006, the business has only treated hazardous waste under PBR. All other tiers were inactivated in 2006.

Stutzman Plating, Inc. (Culver City Office) inspected on 11/7/07 shows one PBR unit for evaporation of cyanide and other wastes. (Evaporation of cyanide waste is not eligible under PBR.) Business does not treat cyanide waste: All rinse containing cyanide is returned to the plating tank.

Highland Plating Company (Culver City Office) inspected on 10/23/09 shows cyanide and chrome treatment listed as one PBR unit. (Cyanide and chrome treatment must be under separate units.) Business will be submitting updated renewal notification with each unit on a separate unit page by March 1, 2012. Accurate Engineering (Sylmar Office) inspected on 2/5/08 and re-inspected on 6/5/08 shows an incomplete PBR notification and types o f waste treated. (Notification needs t o be corrected during administrative review and technical review during the inspections.) Company has submitted proper notification and all tiers are now being reported properly. Documentation was submitted to Asha Arora (DTSC).

PPG Industries, doing business as Sierracin Corporation (Sylmar Office) and inspected on 2/9/10, shows that the TP notification lists evaporation for aqueous waste as "Special waste" under the CESW tier. (Waste was incorrectly listed as special waste.) Under direction of inspector, Sierracin Corporation conducted several hazardous waste determinations to appropriately report the correct tier. I t was determined that the CA tier is correct and the CESW tier that was inaccurately reported will not be

Page 18 of 59

regulated as the waste being sent t o the evaporation unit is not hazardous. We are waiting for the revised/signed paperwork from the facility prior t o inactivating any TP permits. Paperwork will be forwarded t o Asha Arora (DTSC) upon receipt.

Asha Arora of DTSC conducted the TP/Cyanide training for HHMD staff on December 8, 2011. The training was attended by 3 1 HHMD inspectors and included emphasis on thorough documentation of TP inspections.

Cal/EPAPs 2nd Response: The CUPA correction progress for this deficiency is satisfactory. Please continue provide updates for this deficiency.

DTSC's Response: This deficiency has been partially corrected. DTSC conducted the TP/Cyanide training on December 8, 2011 in Commerce. In the next progress report, please provide the PA's pending corrective action documentation that addresses the instances that DTSC cited in this deficiency.

CUPAJs 3rd Update (May 28,2012): The PA's pending corrective action documentations from previous update are now corrected with supporting documents attached t o this update. The businesses that were outstanding from previous update that are now in compliance are as follow:

California Electroplating Inc (Commerce Office) inspected on 7/28/08 showed cyanide and chrome treatment listed as one permit-by-rule (PBR) unit. (Cyanide and chrome treatment must be under separate units.) The business submitted an updated renewal notification with each treatment unit on a separate unit page. Please see attached "Onsite Hazardous Waste Treatment Notification." Barry Avenue Plating (Culver City Office) inspected on 6/21/11 showed cyanide and chrome treatment listed as one PBR unit. The business submitted an updated renewal notification with each treatment unit on a separate unit page. Please see attached "Onsite Hazardous Waste Treatment Notification." Highland Plating Company (Culver City Office) inspected on 10/23/09 showed cyanide and chrome treatment listed as one PBR unit. (Cyanide and chrome treatment must be under separate units.) The business submitted an updated renewal notification with each treatment unit on a separate unit page. Please see attached "Onsite Hazardous Waste Treatment Notification."

LA County PA has responded and submitted supporting documents t o show compliance on all the facilities indicated on the CUPA Audit Report (see Attachment J). From PA perspective, this deficiency has been corrected.

Page 19 o f 59

Cal/EPA1s 3rd Response: The CUPA has corrected this deficiency based on a review of the documents received in attachment J. Cal/EPA and DTSC consider this deficiency corrected.

Page 20 of 59

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Nevertheless, we welcome constructive criticism regarding individual performances and will continue to provide advanced technical inspection training to all staff. To that end, we will request that DTSC incorporate these subjects into the Training requested in conjunction with Deficiency # 5 by January 21, 2012.

Cal/EPA's lSt Response: Please refer to the DTSC's response.

DTSC's 1'' Response: DTSC has agreed to conduct this training on December 8, 2011 in Commerce.

CUPA's 2nd Update (2-28-12):

Asha Arora of DTSC conducted training on December 8, 2011 at our Division Headquarters. The training was attended by 31 technical staff and included basic generator requirements, permit-by-rule notifications, tank integrity assessments, waste analysis plans and treatment units. The thorough inspection and documentation of TP facilities was emphasized. In addition, Inspections Section supervisors will review submitted documentation to ensure hazardous waste generator oversight inspections are complete and properly documented.

Cal/EPAPs 2"d Response: Cal/EPA and DTSC consider this deficiency corrected.

Page 22 of 59

7. Deficiency: The CUPA is not inspecting all UST facilities annually.

The file review and CUPA database query conducted by the SWRCB indicated that there are several UST facilities that have not been inspected within the last 12 months.

Corrective Actions: By October 21, 2011, the CUPA will identify UST facilities that have not been inspected within the last 12 months and submit t o Cal/EPA a l is t of UST facilities that need t o be inspected.

By June 30,2012 and each subsequent year, the CUPA will have inspected every UST facility it regulates. Also, submit t o Cal/EPA a list of UST facilities that were inspected in FY 2011/2012.

CUPA's lSt Update (10-20-11): As a result of the recent audit findings, LA City Cupa's Action Plan is t o have the facilities that have not been inspected within the last 12 months, that are the most delinquent, appear at the top of the current years "TO DO List"

Cal/EPAJs lst Response: Please refer t o the SWRCB's response.

SWRCB lSt~esponse: The SWRCB considers this deficiency to be a work in progress. On the next progress report, please submit the "TO DO LIST."

CUPA's 2nd Update (2-28-12): Please see the attached "TO DO LIST" for all inspectors.

Cal/EPAPs tnd Response: The "TO DO LIST" provided does not specifically address the corrective action "identify UST facilities that have not been inspected within the last 12 months and submit t o Cal/EPA a list of UST facilities that need to be inspected." The list includes facilities from many program elements and there are no inspection dates showing when the facilities were last inspected. Please submit a l is t of UST facilities t o Cal/EPA identifies UST facilities that have not been inspected within the last 12 months. Include the most current inspection date for each facility listed.

SWRCB Response: After reviewing the submitted TO DO List, the SWB noticed that it is sorted by Fiscal Year and Inspector. How is the inspection process proceeding? The SWRCB considers this deficiency to be a work in progress.

CUPA's 3rd Update (4-27-2012): Currently there are 1,375 UST facilities in the UP. Total facilities inspected in the last 12 months are 941. List of facilities and inspection dates is included (see Attachment C). CUPA will divert all available inspectors in order t o inspect all UST facilities within the required 12 months period. CUPA will submit progress report in the next update.

Page 23 of 59

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CUPA's 6th Update (9- 23,2013): CUPA's FY 12/13 inspection summary and UST inspection trend for the fiscal year are include in Attachment E.

Page 25 of 59

8. Deficiency: The annual UST inspection is not always conducted in accordance with the requirements set forth in state law.

Upon questioning the CUPA, it was confirmed that i f the CUPA is not present to witness the annual UST monitoring certification (while access to the underground equipment is accessible); the inspector conducts a walk-through of the facility at another time. This walk-through inspection does not meet the inspection requirements. The CUPA is not always verifying that:

Sumps and under-dispenser containments are clean and dry;

Sensors are placed correctly; Sensors are of the correct type;

Tags have been applied to sensors; Secondary open for earliest possible alarm; and

Etc. to verify compliance.

Corrective Actions: By January 21, 2012, the CUPA will develop and submit to Cal/EPA an UST inspection policy to be included in the I and E Plan. This policy will outline how the CUPA will conduct UST inspections. The policy will describe various types of inspections including those when the inspector is not able to witness the annual UST monitoring certification.

By April 21,2012, the CUPA will make the necessary amendments to this policy, incorporate it into the CUPA's I and E Plan and begin to implement the policy.

By September 30,2012, the CUPA will conduct their FY 2011/2012 self audit and submit the narrative self audit report to Cal/EPA. The FY 2011/2012 self audit report will address the status of implementation and identify any necessary changes.

CUPA's 1'' Update (10-20-11): none

Cal/EPAJs lSt Response: The CUPA did not submit an update for this deficiency.

CUPAJs 2"d Update (2-28-12): CUPA has developed and included in the I & E Plan the UST Inspection Procedures.

Cal/EPAPs 2nd Response: The CUPA submitted LA County CUPA's I & E Plan, but not LA City CUPA's plan along with the first progress report. Cal/EPA has not received the CUPA's UST inspection policy requested in the corrective action. Please refer to the SWRCB's comments.

Page 26 of 59

SWRCB Response: Per the corrective actions, please submit t o Cal/EPA the newly created UST policy outlining how CUPA inspectors will conduct UST inspections. The SWRCB considers this deficiency to be a work in progress.

CUPAJs 3rd Update (4-27-12): CUPA revised Inspection and Enforcement Plan (see Attachment D)

Cal/EPA's 3rd Response: Please refer t o the SWRCB's response.

SWRCB Response: SWRCB has reviewed the submitted I & E Plan. The plan does not address the whole deficiency and the required corrective actions. By November 30, 2012, the CUPA will address the deficiency by submitting to Cal/EPA a revised I & E Plan. Once reviewed and approved by Cal/EPA, the CUPA will begin to implement its use immediately.

SWRCB considers this deficiency to be a work in progress.

CUPAJs 4th Update (12-15-12): CUPA is revising I & E Plan to address all deficiencies related t o UST inspection. Upon completion o f the Plan, CUPA will submit Plan to Cal/EPA.

Cal/EPAJs 4th Response: The SWRCB will contact the CUPA about whether the FY 2011/2012 self-audit is acceptable. Please refer to the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency to be a work in progress.

Action Plan: Once the newly revised I&E Plan is complete, please submit it t o Cal/EPA for review.

CUPAJs 5th Update (5-20-13): Revised I & E Plan is included (see Attachment F). Page 3 of the I & E Plan has been revised t o address Cal/EPA and SWRCB comments.

Cal/EPAJs 5th Response: Please refer t o the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency to be a work in progress. Other than being a little vague, the CUPA has captured what needs to occur if its inspectors are not able to witness an annual monitoring certification.

Action Plan/Questions: Have UST inspectors used the new format when they were not present during the annual monitoring certification? How did it work for them? SWRCB understands that these questions may be a little early t o answer. We also wanted the CUPA t o submits it self-audit and address how the implementation of the revised I&E Plan but this too may be a little t o early. On the next progress report, please take some time to answer our questions.

Page 27 of 59

CUPA's 6th Update (9- 23,2013): From the date the I&E was revised, to include the new format, there has been no need to utilize it; inspections were conducted during the annual monitoring certification.

Page 28 of 59

9. Deficiency: The CUPA is not preparing a compliance report for every UST inspection

File review indicates that an inspection report is not prepared for every UST inspection. Upon questioning the CUPA, it was confirmed that inspection reports are not prepared for facilities that are in compliance.

File review and CUPA database query indicate that not all CUPA inspectors use the same method for documenting and reporting violations. Some inspectors enter the data in Envision while some complete a checklist. Upon questioning the CUPA, this was confirmed.

The CUPA is not having a facility representative sign the inspection report indicating their review and receipt of the inspection report. In addition, the CUPA is not always mailing a compliance report t o the owner or operator after the inspection.

Corrective Actions: By January 21, 2012, the CUPA will develop a UST inspection policy t o be included in the I and E Plan that describes steps that will be taken to prepare compliance reports for every annual UST inspection.

By April 21, 2012, the CUPA will submit this policy to Cal/EPA for review.

By July 21,2012, the CUPA will incorporate and implement the UST inspection policy as described above.

By September 30,2012, the CUPA will conduct their FY 2011/2012 self audit and submit the narrative self audit report t o Cal/EPA. The FY 2011/2012 self audit report will address the status of implementation and identify any necessary changes.

CUPAJs 1'' Update (10-20-11): none

Cal/EPAJs lSt Response: The CUPA did not submit an update for this deficiency.

CUPAJs 2nd Update (2-28-12): Please see deficiency Number 8.

Cal/EPAPs 2nd Response: The CUPA submitted LA County CUPA's I & E Plan, but not LA City CUPA's plan along with the first progress report. Cal/EPA has not received the CUPA's UST inspection policy requested in the corrective action. Please refer t o the SWRCB's comments.

SWRCB Response: On the next progress report, please submit t o Cal/EPA, the newly created policy describing how inspectors are t o prepare compliance reports for every annual UST inspection. The SWRCB considers this deficiency to be a work in progress.

Page 29 of 59

CUPA's 3rd Update (4-27-12): UST inspection policy has been incorporated in the Enforcement and Inspection Plan (see Attachment D)

CalIEPA's 3rd Response: Please refer t o the SWRCB's response.

SWRCB Response: SWRCB has reviewed the submitted I & E Plan. Under the general inspection procedures, number 3 states, "Before leaving the facility, the inspector reviews the inspection results with the operator/manager. An inspection compliance report or notice of violation is prepared and given t o each business inspected."

The CUPA does not address when the compliance report is prepared and given t o each business. The question remains, when are inspectors preparing compliance reports? The plan only addresses reviewing inspection results with manager/operator before leaving the facility. The CUPA may want t o review Health and Safety Code, Chapter 6.7, Section 25288.

SWRCB considers this deficiency to be a work in progress.

CUPA's 4th Update (12-15-12): CUPA has revised general inspection procedures t o clarify that compliance reports are completed and given to each business prior t o leaving the facility (see Attachment D).

Cal/EPAPs 4th Response: The SWRCB will contact the CUPA about whether the FY 2011/2012 self-audit is acceptable. Please refer t o the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency to be half corrected.

CUPA's sth Update (5-20-13):

Cal/EPAJs 5th Response: Please refer t o the SWRCBJs response.

SWRCB Response: The CUPA did not submit a response. SWRCB considers this deficiency to be a work in progress. The purpose for the comment half corrected in response 4 was due to not receiving the CUPAs FY 2011/2012 self-audit. Just recently, SWRCB received the document and has reviewed it. SWRCB could not find any reference regarding the CUPAs policy on preparing compliance inspection reports as per the agreed upon corrective actions. Specifically, the corrective action stated, "The self-audit report will address the status of implementation and identify any necessary changes." The CUPA should be currently getting ready to write its self-audit for FY 2012/2013 and/or may have already completed it. On the next progress report, please submit the FY 2012/2013 self-audit t o Cal/EPA and address the policy as agreed upon.

Page 30 of 59

In addition, SWRCB has a few comments/recommendations regarding the submitted 2011/2012 self-audit. First, on page 7, the CUPA states inspecting USTs annually is a goal. Health and Safety Code section 25288 states every UST within a jurisdiction shall be inspected at least once every year. SWRCB recommends the CUPA change the wording. Also on page 7, you have a statement that contradicts your Consolidated Permit Plan. The self-audit states, "...permits will not be issued t o facilities that are not in compliance." This meets the UST Statutes and Regulations. Your Consolidated Permit Plan states, "the UST element of the Consolidated Permit shall not be issued t o facilities with Class I or Class II UST violations." As per the response in deficiency 10, the CUPA needs to revise i t s Consolidated Permit Plan.

CUPA's 6th Update (9- 23- 2013): The CUPA is in the process of completing the 2012/2013 self-audit and will submit the audit report upon its completion. For Consolidated Permit Plan please see update for deficiency 10.

Page 31 of 59

10. Deficiency: The CUPA issues the UST operating permit without verifying compliance.

The file review indicated that compliance is not verified prior to issuing an operating permit. Upon questioning the CUPA, it was confirmed that operating permits are issued based on payment of fees rather than compliance.

Corrective Actions: By January 21, 2012, the CUPA will develop and submit to Cal/EPA a policy to be included in their Consolidated Permit Program to ensure that a UST facility is in compliance before issuing the permit to operate.

By April 21, 2012, the CUPA will make the necessary amendments to this policy, incorporate it into the CUPA's Consolidated Permit Program and begin to implement the policy.

By September 30,2012, the CUPA will conduct their FY 2011/2012 self audit and submit the narrative self audit report to Cal/EPA. The FY 2011/2012 self audit report will address the status of implementation and identify any necessary changes.

CUPA's 1'' Update (10-20-11): none

CalIEPA's 15' Response: The CUPA did not submit an update for this deficiency.

CUPA's 2nd Update (2-28-12): Consolidated Permit Conditions require the permit holder to comply with applicable regulations in order to maintain the operating permit. Facilities are being inspected for compliance and violation of any condition may cause revocation of the Unified Program permit.

CaljEPA's 2nd Response: Cal/EPA has not received the CUPA's Consolidated Permit policy as requested in the corrective action. Please refer to the SWRCB's comments.

SWRCB Response: Per the corrective actions, please submit to Cal/EPA, the newly created policy addressing permit issuance. The SWRCB considers this deficiency to be a work in progress.

CUPA's 3rd Update (4-27-12): CUPA is working on adding a field of non-compliance in Envision for inspectors to mark. Envision will not issue permits for non-compliant facilities.

Cal/EPA's 3rd Response: Cal/EPA has not received the CUPA's Consolidated Permit policy as requested in the corrective action. Along with the next progress report, please submit a revised Consolidated Permit Program that includes a policy to ensure that a UST facility is in compliance before issuing the permit to operate. Please refer to the SWRCB's response.

Page 32 of 59

SWRCB Response: By November 30,2012, the CUPA will submit t o Cal/EPA, a copy of it Consolidated Permit policy. Once reviewed by Cal/EPA, the CUPA will immediately begin t o implement its use.

SWRCB considers this deficiency to be a work in progress.

CUPA's 4th Update (11-30-12): Copy of CUPAJs Consolidated Permit Plan is included (see Attachment E)

Cal/EPAJs 4th Response: The SWRCB will contact the CUPA about whether the FY 2011/2012 self-audit is acceptable. Please refer to the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency t o be a work in progress.

Action Plan: The CUPA shall update its Consolidated Permit Plan t o include permit renewal and the need t o be in compliance with UST regulations prior t o issuance.

SWRCB Comments: SWRCB has reviewed the submitted Consolidated Permit Plan and finds that it does not capture the requirement of needing t o be in compliance. The CUPA has the ability t o revoke an UST permit per the submitted plan, but it does not address compliance prior t o issuance.

CUPAJs sth Update (5-20-13): Page 3, of the Consolidated Permit Plan, has been revised t o address UST permit renewal (see Attachment G). The "Permit Issuance Status" field in Envision is utilized t o place permits on hold.

Cal/EPA's sth Response: Please refer t o the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency t o be a work in progress. We have reviewed the submitted plan and the CUPAs comments. The CUPA incorrectly states permit renewal issuance. Health and Safety Code, chapter 6.7, section 25285(b) states a local agency shall not issue or renew a permit to operate an underground storage tank if the local agency inspects the tank and determines that the tank does not comply with this chapter.

Action Plan: On the next progress report, please revise and submit t o Cal/EPA, a copy of the CUPAs Consolidated Permit Plan. In addition, please submit a screenshot of the CUPAs database showing the field in Envision that places a hold on permit issuance.

CUPA's 6th Update (9-23- 2013): UST Permit Renewal section (page 3) o f the Consolidated Permit Plan has been revised (see Attachment F). Attachment F also

Page 33 of 59

11. Deficiency: The CUPA is not approving the UST owner/operator submitted monitoring and response plans.

The file review indicates that the CUPA is not signing the approvaI/disapproval section, indicating that the plans/forms have been reviewed for completeness and accuracy. Upon questioning the CUPA, the failure to approve or disapprove these forms was confirmed.

Corrective Actions: By January 21, 2012, the CUPA will develop and submit to Cal/EPA a policy to be included in the I and E Plan that describes the CUPA approval process for UST owner/operator submitted monitoring and response plans.

By April 21, 2012, the CUPA will make the necessary amendments t o this policy, incorporate it into the CUPA's I and E Plan and begin to implement the policy.

By September 30,2012, the CUPA will conduct their FY 2011/2012 self audit and submit the narrative self audit report to Cal/EPA. The FY 2011/2012 self audit report will address the status of implementation and identify any necessary changes.

CUPA's lSt Update (10-20-11): none

Cal/EPAJs lSt Response: The CUPA did not submit an update for this deficiency.

CUPAJs 2nd Update (2-28-12): CUPA has implemented the review and approval process for UST Monitoring and Response Plans.

Cal/EPAJs 2"d Response: Cal/EPA has not received the CUPA's approval policy for submitted monitoring and response plans as requested in the corrective action. Please refer t o the SWRCB's comments.

SWRCB Response: Per the corrective actions, please submit t o Cal/EPA, the newly created policy describing how CUPA inspectors are to approve the submitted monitoring and response plans. The SWRCB considers this deficiency to be a work in progress.

CUPA's 3rd Update (4-27-12): CUPA Inspection and Enforcement Plan is attached (Attachment E)

Cal/EPA's 3rd Response: Cal/EPA has not received the CUPA's policy that describes the CUPA approval process for UST owner/operator submitted monitoring and response plans as requested in the corrective action. Please refer t o the SWRCB's response.

Page 35 of 59

SWRCB Response: SWRCB has reviewed the submitted I & E Plan and finds that the submitted plan does not address the deficiency. By November 30,2012, the CUPA will submit t o Cal/EPA a revised I & E Plan which addresses the deficiency.

The submitted screen shot of the Envision database needs some clarification. SWRCB does not see anything related to approving the submitted owner/operator monitoring and response plan.

For the next progress report, the CUPA will clarify the boards concerns and perform the following actions:

o Submit t o Cal/EPA a copy of an approved monitoring and response plan for 10 facilities, which were approved between 2-28-12 and 9-1-12.

o In addition to the submitted documents, the CUPA will submit t o Cal/EPA a screen shot from i t s database for each of the submitted documents showing that the database is being utilized as described by the CUPA.

SWRCB considers this deficiency to be a work in progress.

CUPAJs 4th Update (12-15-12): CUPA is revising I & E Plan to address all deficiencies related to UST inspection. Upon completion of the Plan, CUPA will submit Plan to Cal/EPA.

Cal/EPAJs 4th Response: The SWRCB will contact the CUPA about whether the FY 2011/2012 self-audit is acceptable. Please refer t o the SWRCBJs response.

SWRCB Response: SWRCB considers this deficiency to be a work in progress.

Action Plan: Once the newly revised I&E Plan is complete, please submit it to Cal/EPA for review.

CUPAJs 5th Update (5-20-13): Revised I&E Plan is included (see Attachment F).

Cal/EPAJs sth Response: Please refer to the SWRCBJs response.

SWRCB Response: SWRCB considers this deficiency t o be a work in progress. We have reviewed the submitted "Draft" I&E Plan and could not find any reference towards reviewing and approving submitted forms. The CUPA will identify in its plan, the approval process. The CUPA should think about its current process and how it will utilize CERS for this process.

Page 36 of 59

CUPA's 6th Update (9-23-2013): The Underground Storage Tank Facilities Inspections section of the I&E Plan has been updated to include monitoring and response plan approval (see Attachment G).

Page 37 of 59

Deficiency: The CUPA's UST files are not complete. All files reviewed were missing one or more of the following documents:

Financial responsibility; Plot plans; Secondary containment inspections; Tank and line integrity tests; Monitoring certifications; ELD certifications; Designated operator; Tank lining and recertification reports; UPCF A; and UPCF B.

Corrective Actions: Immediately, the CUPA will start t o collect and retain UST facility compliance documents for all facilities for the prescribed time frames.

By January 21, 2012, the CUPA will implement the use of a file review checklist. This file review checklist will be maintained in the UST facility file for 3 years; allowing for future verification that the deficiency has been corrected.

By July 21, 2012, the CUPA will report t o Cal/EPA on how the file review and checklist implementation has progressed.

CUPA's 1'' Update (10-20-11): As a result of the recent Audit findings, LA City Cupa has developed file review checklists for the following elements, Tank Facilities, Haz Mat Facilities and Cal ARP Facilities. (see attached)

Cal/EPA's 1'' Response: Please refer t o the SWRCB's response.

SWRCB lS t~esponse: With the development of the UST file review checklist, the CUPA i s well on i t s way toward correcting this deficiency. Please continue the use of the of the file review checklist. SWRCB considers this deficiency to be a work in progress.

CUPA's 2nd Update (2-28-12): CUPA continues using file review checklists t o collect and retain all required compliance documents.

Cal/EPAPs 2nd Response: Please continue to update Cal/EPA on the progress toward correcting this deficiency.

Page 38 of 59

SWRCB Response: The SWRCB considers this deficiency to be a work in progress. Per the corrective actions above, please update Cal/EPA and the SWRCB on how the use of the file review checklist is proceeding.

CUPAJs 3rd Update (5-28-12): Inspectors are required t o complete a file review checklist for all annual inspections performed.

Cal/EPAJs 3rd Response: Please refer to the SWRCB's response.

SWRCB Response: By November 30,2012, the CUPA will submit t o Cal/EPA, a copy of the CUPA's file review checklist for 10 facilities between the period of 5- 28-12 and 9-1-12 where CUPA inspectors have used i t s checklist t o verify that files are complete.

SWRCB considers this deficiency to be a work in progress.

CUPAJs 4th Update (12-15-12): Included are 10 Tank Compliance Checklists that includes file and system records review for the period between 5-28-12 and 9-1-12 (see Attachment F).

Cal/EPArs 4th Response: Please refer to the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency t o be a work in progress.

Action Plan: On the next progress report, submit t o Cal/EPA, a copy of the

CUP AS^^^^ review checklist for 10 facilities between the period of 5-28-12

and 9-1-12 where CUPA inspectors have used its checklist to verify that files are complete.

SWRCB Comments: SWRCB has reviewed the submitted documents and the conclusion of the review is that the CUPA did not submit a file review checklist. Instead, the CUPA submitted UST inspection checklists for 10 UST facilities.

Below is a snapshot o f the f i le review checklist that SWRCB approved for

use by the CUPA which was submitted in the first progress report.

Page 39 of 59

kos Angeles Fire Department Hazardous Materials Secrion

L\DERGROL\D STORaGE TA\X FIJ..E REYEW .LXD EQLlP'\IEW C H E W S T

Facilitv Same-

Address

FILE R . l E W : Rlght Slde 1. CLFA Pcm~i t current 2. Continuous rnonitoring~stcmcc~ification current 3. Linc lcak dctccror ccrtificationcurrcnt (if applicable) 1. S c c o n d q containment testing current (if applicablc) 5 . LPCF UST Facility Form on filc current 6. LTCF UST Tank Page 1 A 1 Form on filc current 7. Pmof of Financial Responsibility current 8. UST Monitoring Plan on filc currcnt 9. UST Plot Plan on filc cumnt(or refer to H?vBP) 10. UST Response Plan on file current 1 I . Dcsignatcd Opcraror Wotification on filc currcnt 12. Owncr'Opcrator A~rccmcnt on file current (ifapplicablc) 13. Rcquircd intcgritv testing current (if applicablc) 1.8, Enhanccd leak dctcction tcstingcumnt (ifapplicablc) Lcft Slde: Notice of Violations. Clcarcd. Notcs and E-mails

Date:

Specialist:

YEY1YO/?iA

CUPAJs 5th Update (5-20-13): Attachment H includes the 10 requested File Review Checklists.

Cal/EPAJs 5th Response: Cal/EPA and the SWRCB consider this deficiency corrected. Please refer t o the SWRCB1s response.

SWRCB Response: SWRCB considers this deficiency corrected. Please continue to utilize the checklist and maintain them in the facility file as required by the agreed upon corrective actions.

Page 40 of 59

13. Deficiency: The CUPA is not inspecting each HMRRP facility once every three years. The Annual Summary Reports for the past three FYs indicate that 110 percent of facilities have had routine inspections; however, out of the files reviewed by Cal EMA, 50 percent of the facilities reviewed were not inspected within the past three FYs.

Corrective Actions: By January 21,2012, the CUPA will determine the status of the HMRRP facility inspections and develop an action plan to ensure the HMRRP inspections are achieved. By February 1, 2012, the CUPA will begin inspecting at least one-third of its business plan facilities annually. Priority will be given t o the facilities that have not been inspected for the longest period of time.

By April 21, 2012, the CUPA will submit t o Cal/EPA the status of all HMRRP inspections. Along with each progress report, the CUPA will update Cal/EPA on the total number of business plan facilities and the number of business plan routine inspections conducted in the current fiscal year. Also, submit t o Cal/EPA 10 random business plan inspection reports from the facilities inspected within the current FY.

By July 21, 2012, the CUPA will have inspected at least one-third of its business plan facilities.

CUPA's 1'' Update (10-20-11): none

CalIEPA's 1'' Response: The CUPA did not submit an update for this deficiency. Please refer t o the Cal EMA's response.

Cal EMA's lSt~esponse: The CUPA has developed the LOS ANGELES COUNTY CERTIFIED UNIFIED PROGRAM AGENCY INSPECTION AND ENFORCEMENT PLAN, which identifies HMBP facilities, required inspection frequencies, prioritization of inspections and compliance alternatives with enforcement options. This deficiency remains in the process of being corrected. Cal EMA looks forward to following the CUPA's progress on inspections. Please continue to provide updates for the total number of HMBP facilities and the number of inspection of the HMBP facilities on the next progress report.

CUPA's 2nd Update (2-28-12): Total number of HMBP facilities: 7,365; number of routine HMBP inspections from July 1, 2011 through December 31, 2011: 1,066.

Cal/EPArs 2nd Response: The CUPA's progress toward correcting this deficiency is satisfactory. Please continue to update Cal/EPA on the progress toward correcting this deficiency. Please refer t o the Cal EMA's response.

Cal EMA's Response: The CUPA is making progress towards correction of this deficiency. Please continue to provide updates for the total number of HMBP

Page 4 1 of 59

facilities and the number of inspection of the HMBP facilities on the next progress report.

CUPA's 3rd Update (5-28-12): Between July 1,2011 and June 6, 2012, CUPA has inspected 1,528 HMRRP facilities. Ten business plan review reports are included (see Attachment L).

CalIEPA's 3rd Response: The CUPA must inspect 2338 out of 7086 BP facilities by July 21, 2012. The CUPA should have inspected at least another 810 BP facilities by July 21, 2012 to meet its goal. On the next progress report, please report the number of BP inspections performed for FY 2011/2012. Also, the CUPA will need to explain how the Fire /Life Safety Violation form (BP inspection report?) is used. How are violations and RTC denoted? Please refer t o the Cal EMA's response.

Cal EMA's Response: Attachment L is a number of various Fire /Life Safety Violation data sheets. Perhaps the file was not identified correctly or was not sent. Please either send or correctly identify which file the CUPA would like t o have reviewed.

CUPA's 4'h Update (12-15-12): CUPA inspected 1923 HMRRP facilities in fiscal year 2011/2012. Notices of Violations in Attachment L of CUPAJs 3rd update (5-28-12) identify violations by circling the violation. Corrected violations are initialed and dated on the NOV.

Cal/EPAts 4th Response: Out of 7589 HMRRP facilities, the CUPA inspected 1919 facilities or 25%. The CUPA did not inspect one-third of its HMRRP facilities in FY 2011/2012. This deficiency remains in progress o f being corrected. By July 1, 2013, please report the number of HMRRP facilities inspected in FY 2012/2013. Please refer t o the Cal EMA's response.

Cat EMA's Response: The CUPA is making progress toward the correction o f this deficiency. Please continue t o provide updates for the total number of HMBP facilities and the number of inspections of the HMBP facilities on the next progress report.

CUPAJs 5th Update (5-20-13): Of the 7,085 HMRRP facilities that CUPA regulates, 1,020 facilities were inspected, by April 30, 2013, for fiscal year 2012/2013.

CalIEPA's 5th Response: Please refer t o the Cal EMA's response.

Cal EMA's Response: The CUPA has reported that it has inspected 1020 HMRRP facilities out of 7085 by April 30, 2013. Extrapolating to the end of FY 2012-2013 gives an estimated 1224 inspections, which is about 52% of those needed to maintain the required three-year inspection frequency (about 2361 per annum).

Page 42 of 59

About 17% of the total HMRRP facilities were inspected in FY 12-13, less than the 25% reported for FY 11-12. It would appear that the CUPA is falling further behind in its business plan inspections. The CUPA is encouraged to step up its business plan inspections, to prevent falling even further behind. This deficiency is st i l l in progress.

CUPA's 6th Update (9- 23,2013): For Fiscal Year 2012-2013 the CUPA completed 1772 inspections. Attachment H shows the trend in the number of inspections completed. The trend shows significant increase in the number of inspections during the last quarter of the fiscal year, this is directly related to the increase in staffing.

Page 43 of 59

14. Deficiency: The CUPA is not adequately reviewing business plans to ensure completeness. Of the 20 files reviewed:

Nine lacked the Business Activities Page, One lacked the Hazardous Materials Inventory pages, Nine lacked the Annotated Site Map, and Seven had incomplete Emergency Response Plans (lacking the equipment inventory, notification procedures, or both).

Corrective Actions: By January 21, 2012, the CUPA will develop a business plan review process and checklist t o ensure that all business plans are complete and accurate.

By April 21, 2012, the CUPA will submit copies o f at least ten complete business plans and corresponding business plan review checklists for hazardous materials facilities.

By July 21, 2012, the CUPA will ensure that all business plans are complete and correct.

CUPA's lSt Update (10-20-11): Refer t o the attached business plan review checklist.

Cal/EPA's lSt Response: Please refer t o the Cal EMA's response.

Cal EMA's lst Response: The CUPA has developed a business plan review checklist t o ensure that all business plans are complete and accurate.

This deficiency remains in the process o f being corrected. Cal EMA looks forward to following the CUPA's progress on complete business plans. Please continue to provide updates for the total number of HMBP facilities and the number o f business plans that are complete and correct.

CUPA's 2nd Update (2-28-12): CUPA continues to follow i t s Business Plan review process.

Cal/EPAPs 2nd Response: The CUPA's progress toward correcting this deficiency is satisfactory. Please continue to update Cal/EPA on the progress toward correcting this deficiency. Please refer t o the Cal EMA's response.

Cal EMA's Response: This deficiency remains in the process of being corrected. Cal EMA looks forward to following the CUPA's progress on complete business plans. Please continue to provide updates for the total number of HMBP facilities and the number of business plans that are complete and correct.

Page 44 of 59

CUPAJs 3rd Update (5-28-12): Number of HMBP facilities is 7,086. Attachments M - 1 through M-3 include ten (10) completed inspection business plans and corresponding business plan review checklists.

Cal/EPAJs 3rd Response: The eight business plans submitted for this deficiency were satisfactory. Please submit two more. In the next progress report, please update Cal/EPA on the number of business plans that have been reviewed for completeness and accuracy in FY 2011/2012. How many businesses have the CUPA initiated enforcement actions against for not submitting business plans that are complete and correct in FY 2011/2012? Please refer t o the Cal EMA's response.

Cal EMAJs Response: The CUPA did submit eight, o f the ten, copies of complete business plans and corresponding business plan review checklists for hazardous materials facilities. The CUPA will need to

This deficiency remains in the process of being corrected. Cal EMA looks forward to following the CUPA's progress on complete business plans. Please continue to provide updates for the total number of HMBP facilities and the number of business plans that are complete and correct.

CUPAJs 4th Update (12-15-12): Copy of two completed business plans and corresponding business plan checklist are included (see Attachment G).

Cal/EPAJs 4th Response: Cal/EPA and CalEMA consider this deficiency corrected on April 2, 2013 based on the information received.

Page 45 of 59

15. Deficiency: The CUPA is not ensuring that HMRRP businesses submit either an updated hazardous materials inventory or a "no-change" to their inventory certification on an annual basis. During the file review, 95% of the files reviewed lacked a current inventory or "no-change" certification.

The CUPA has a "Business Plan Annual Renewal Certification" form that is not currently being used.

Corrective Actions: By November 21, 2011, the CUPA will submit an action plan outlining how it will ensure that HMRRP businesses annually submit either an annual certification o f "no-change" t o their inventory or an updated inventory by March 1''.

By January 21, 2012, the CUPA will develop a tracking method to determine who did or did not submit the information.

By April 21, 2012, the CUPA will submit copies o f 10 updated facility inventory forms and 20 completed and signed HMRRP facility annual "no-change" certifications t o Cal/EPA.

CUPA's lSt Update (10-20-11): none

Cal/EPA's 1'' Response: The CUPA did not submit an update for this deficiency. Please refer t o the Cal EMA's response.

Cal EMA's lSt ~esponse: The CUPA did not address this deficiency. Cal EMA looks forward to following the CUPA's progress on the "Business Plan Annual Renewal Certification" form. Please continue t o provide updates for the total number of HMBP facilities and the number of "Business Plan Annual Renewal Certification" forms that have been submitted.

CUPA's 2nd Update (2-28-12): In December CUPA mailed the Annual Inventory Update Form to all 9800 businesses with the March 1, 2012, due date. The responses are being reviewed and entered into Envision database as they are received.

Cal/EPAJs 2nd Response: The CUPA has not submitted an action plan on how it will ensure that HMRRP businesses annually submit either an annual certification of "no- change" to their inventory or an updated inventory by March 1''. Also, the CUPA has not submitted its tracking method to determine who did or did not submit the information. The submittal of business plan inspection reports is not a demonstration that inventory submittals are properly tracked. Please refer t o the Cal EMA's response.

Cal EMA's Response: Since the annual mailout has just occurred, please report progress with the next quarterly update.

Page 46 of 59

CUPA's 3rd Update (4-27-12): In December 2011, all businesses within the UP were mailed the Annual lnventory Update Form. A field was created in Envision to track received forms (see Attachment E). Upon receiving the forms, Envision is updated t o reflect the receipt of certification of "no change" or inventory update. A total o f 3043 facilities have submitted certificate of "no change" or inventory update. CUPA by January 1, 2013 will have electronic reporting in place which will provide more accurate tracking of submittals.

CUPA's 3rd Update (5-28-12): As of May 23, 2012, a total of 3,203 facilities had submitted either an annual certification of "no-change" to their inventory or an updated inventory. An excel printout generated from Envision data is attached (Attachment N) as a sample of the tracking sheet. Attachments 0-1 through 0-4 include 10 updated facility inventory forms and 20 completed and signed HMRRP facility annual "no- change" certifications.

Cal/EPA's 3rd Response: In the next progress report, please update Cal/EPA on the number of annual inventory certifications of "no-change" or updated inventories have the CUPA received in FY 2011/2012. How many businesses have the CUPA initiated enforcement actions against for not submitting either an annual certification of "no- change" to their inventory or an updated inventory in FY 2011/2012? Also, an action plan is needed. Please refer to the Cal EMA's response.

Cal EMA's Response: The CUPA has been working on updating the 2012 Annual Hazardous Materials Inventory (refer t o Attachment E (on previous email 4- 2012) and Attachment 0); however, the CUPA has not submitted an action plan outlining how it will ensure that HMRRP businesses annually submit either an annual certification of "no-change" to their inventory or an updated inventory. Cal EMA looks forward to following the CUPA's progress on their continuing annual 2012 inventory updates, as well as, the Action Plan for ongoing annual certifications.

CUPA's 4th Update (12-15-12): In fiscal year 2011/2012, 3,628 facilities either submitted an annual certification of "no change" or inventory update. CUPA is in the process of implementing electronic reporting in the first quarter of 2013. An action plan will be developed after the electronic reporting has been instituted and experience has been gained from i t s use.

Cal/EPAPs 4th Response: The CUPA collected either an annual certification of "no change" or inventory update from 3,628 or 48% of its 7589 HMRRP facilities. What is the status of the other 52%? Has the CUPA exercised appropriate enforcement against HMRRP facilities that have not submitted either an annual certification of "no change" or inventory update? Please refer t o the Cal EMA's response.

Page 47 of 59

Cal EMA's Response: The CUPA has still not identified an Action Plan other than the narrative in this progress report and has stated that the Action Plan is still in progress. CalEMA looks forward to following the CUPA's progress on their development of their Action Plan for ongoing annual inventory certifications.

CUPA's 5th Update (5-20-13): Action Plan is included (see Attachment I).

Cal/EPAJs 5th Response: The CUPA submitted an adequate action plan. The CUPA did not answer the questions that were posed in Cal/EPA1s response to the CUPA's 4th update. In the next progress report, please update Cal/EPA on the number of annual inventory certifications of "no-change" or updated inventories have the CUPA received in FY 2012/2013. How many businesses has the CUPA initiated appropriate enforcement actions against for not submitting either an annual certification of "no- change" to their inventory or an updated inventory in FY 2012/2013? Please refer t o the Cal EMA's response.

Cal EMA's Response: While a little sketchy in detail about how the CUPA is going t o detect that a business has not submitted i t s annual inventory electronically, the action plan submitted with the progress report is otherwise satisfactory.

CUPA's 6th Update (9- 23,2013): In Fiscal Year 2012-2013 the CUPA received 1510 annual inventory certification of "no-change" or updated inventories. CUPA did not take any enforcement action against facilities that did not submit the annual inventory certification of "no change".

Page 48 of 59

16. Deficiency: The CUPA is not ensuring that HMRRP businesses certify that they have reviewed their business plan, made necessary changes and submitted any business plan revisions to the CUPA at least once every three years.

The CUPA has a "Business Plan Annual Renewal Certification" form that includes a review certification area, but it is not used.

Corrective Actions: By November 21,2011, the CUPA will submit an action plan outlining how it will ensure that HMRRP businesses certify to the CUPA that they have reviewed the emergency plan and training program portions of their business plan, made necessary changes and submitted any changes to the CUPA at least once every three years.

By January 21,2012,, the CUPA will develop a tracking method to determine who did or did not submit the information.

By April 21, 2012, the CUPA will submit copies of 20 completed and signed three-year review certifications submitted by HMRRP businesses.

CUPA's 1'' Update (10-20-11): none

Cal/EPA's 1'' Response: The CUPA did not submit an update for this deficiency. Please refer to the Cal EMA's response.

Cal EMA's 1'' Response: The CUPA did not address this deficiency. Cal EMA looks forward to following the CUPA's progress on the "Business Plan Annual Renewal Certification" form. Please continue to provide updates for the total number of HMBP facilities and the number of "Business Plan Annual Renewal Certification" forms that have been submitted and that the facilities have reviewed their business plan, made necessary changes and submitted any business plan revisions to the CUPA at least once every three years.

CUPA's 2nd Update (2-28-12): Please see Deficiency # 15.

Cal/EPAPs 2nd Response: The CUPA has not submitted an action plan outlining how it will ensure that HMRRP businesses certify to the CUPA that they have reviewed the emergency plan and training program portions of their business plan, made necessary changes and submitted any changes to the CUPA at least once every three years. Also, the CUPA has not submitted its tracking method to determine who did or did not submit the information. The submittal of business plan inspection reports is not a demonstration that business plan reviews are properly tracked. Please refer to the Cal EMA's response.

Page 49 of 59

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17. Deficiency: The CUPA is not ensuring that HMRRP businesses submit a revised business plan within 30 days from when a substantial change or specified event occurs.

Business are required to submit a revised business plan when there is a 100 percent or more increase in the quantity of a previously disclosed hazardous material, any handling of a previously undisclosed hazardous material subject t o the inventory requirements, change of business address, change of business ownership, or change o f business name. Business are also required to submit a revised business plan whenever a substantial change in the handler's operations occurs that requires a modification of its business plan.

The CUPA inspectors make changes t o the business contact information and address on the "Business Information" form and changes to the facility's inventory on the "lnspection Responsibility" form during inspections, but do not require the business to submit revised UPCF forms with all of the required information.

Corrective Actions: By January 21, 2012, the CUPA will submit copies of five business plan facility inspection reports where it was found that changes needed to occur in the inventory or contact information. Also, submit copies of the updated business plan forms submitted that corrected the violations.

By July 21,2012, the CUPA will ensure that all HMRRP businesses use the UPCF or forms that store the same information as the UPCFs when changes are made.

CUPA's lSt Update (10-20-11): none

Cal/EPA's lSt Response: The CUPA did not submit an update for this deficiency. Please refer t o the Cal EMA's response.

Cal EMA's lSt~esponse: The CUPA did not address this deficiency. Cal EMA looks forward to reviewing five business plan facility inspection reports where it was found that changes needed t o occur in the inventory or contact information. Additionally, please submit copies of the updated business plan forms submitted that corrected the violations.

CUPA's 2"d Update (2-28-12): Please see attached HMBP Compliance lnspection Checklist/Fire Life Safety Violation form for five facilities.

Cal/EPAPs znd Response: The CUPA submitted business plan inspection reports that cited business plan violations, but the corrected and approved business plan submittals were not submitted. Along with the next progress report, please submit the corrected and approved business plans or enforcement documentation for the five business plan inspection reports submitted. Please refer t o the Cal EMA's response.

Page 5 1 o f 59

Cal EMA's Response: The inspection reports enclosed with the 2nd update demonstrate that the CUPA is commencing enforcement against those handlers with outdated business plans. With the next quarterly update, please summarize the number of violations of this requirement your inspectors have noted since your evaluation (July 2011), the number of returns t o compliance within 30 days, and a summary of further enforcement for those handlers still in violation after 30 days.

CUPA's 3rd Update (4-27-12): Attached are five (5) business plans that have inventory or contact information corrections and the Envision printouts showing updated information for the facilities (see Attachment H).

CUPA's 3rd Update (5-28-12): Notice of Violation Tracking Sheet is included in Attachment Q.

CalIEPA's 3rd Response: Cal/EPA and Cal EMA consider this deficiency corrected.

Cal EMA's Response: Cal EMA considers this deficiency corrected on June 1, 2012 based on information received with the 4-27-2012 update.

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18. Deficiency: The CUPA is not collecting, tracking or accurately reporting Significant Operational Compliance (SOC) information on a semi-annual basis.

The CUPA is not collecting SOC criteria during each UST compliance inspection; therefore, the CUPA is not able to comply with the required SOC reporting.

Corrective Actions: By October 21, 2011, the CUPA will have begun collecting SOC criteria during each UST compliance inspection.

By October 21, 2011, the CUPA will submit t o Cal/EPA a revision of i t s Notice of Violation Tracking spreadsheet. The revision will include columns to allow for the tracking o f SOC information.

By September 1,2012, the CUPA will submit t o Cal/EPA i t s Semi-Annual UST Report 6 (data from January to June of 2012) that includes accurate SOC information.

CUPA's lSt Update (10-20-11): As a result o f the recent Audit findings, LA City Cupa has modified the NOV tracking sheet t o include violation classifications and SOC RD/RP criteria (see attached)

Cal/EPA's 1'' Response: Cal/EPA appreciates the CUPA's progress in correcting this deficiency. The CUPA has created a mechanism for collecting and tracking SOC. Please continue to update Cal/EPA on the progress towards correcting this deficiency. Please refer t o the SWRCB's response.

SWRCB lSt ~esponse: The CUPA has satisfied the first corrective action. Please refer t o the SWRCB comments for deficiency # 3 regarding determining SOC. SWRCB considers this deficiency to be a work in progress.

CUPA's 2nd Update (2-28-12): See Deficiency #3.

Cal/EPAPs 2nd Response: The CUPA's tracking spreadsheet for SOC is satisfactory. Is the CUPA collecting SOC criteria during UST inspections as requested in the corrective action? Please provide documentation of this.

a SWRCB Response: The SWB considers this deficiency to be a work in progress.

CUPA's 3rd Update (4-27-12): Yes, CUPA is collecting SOC background information regarding classification, but does not require the inspector t o determine the SOC criteria while on site. The SOC determination is documented during the NOV tracking sheet update on the day of inspection.

Cal/EPA's 3rd Response: Please refer t o the SWRCB's response.

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SWRCB Response: Please see deficiency number three for comments.

SWRCB considers this deficiency to be a work in progress.

CUPA's 4th Update (12-15-12): SOC will be determined by inspector during inspection, a check box has been added to the UST Compliance Checklist. Please see CUPA's 4th update for deficiency number three.

Cal/EPA1s 4th Response: Please refer t o the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency to be a work in progress.

Action Plan: Please refer t o deficiency 3 for action plan and comments.

SWRCB Comments: SWRCB appreciates the CUPAs efforts towards correcting this deficiency.

CUPA's 5th Update (5-20-13): Please see CUPA's 5th update for deficiency number three.

Cal/EPA's sth Response: Please refer t o the SWRCB's response.

SWRCB Response: SWRCB considers this deficiency to be a work in progress.

Action Plan/Questions: How is the collection of SOC information during the CUPAs inspections going? Does the CUPA feel i t s process is adequate? Does the CUPA need to change how the information is collected? Please submit answers to Cal/EPA on the next progress report.

CUPA's 6th Update (9- 23,2013): The submitted UST Checklist was a draft copy. The CUPA will start utilizing the checklist in October and will report, on its adequacy in collecting SOC information, in December of 2013.

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19. Deficiency: The CUPA is not collecting, retaining, and managing information necessary to implement the UP. The following information is not being adequately collected, retained or managed:

Enforcement information is not regularly tracked in any database or on inspection reports. NOV's are stored in a binder maintained by the Los Angeles City Fire Department's legal section. When the Annual Summary Reports become due, the CUPA management reviews all of the NOV's created during the reporting FY and records the information in Microsoft Excel. This occurs once per FY. SOC information is not regularly tracked in any database or on inspection reports. Complete UPCF information is not always being collected. Cal/EPA, Cal EMA, and SWRCB have observed that HMRRP and UST forms information is either out-of- date or missing.

Corrective Actions: Immediately, the CUPA will regularly document enforcement activities using Microsoft Excel until the CUPA's database is upgraded to Envision Connect.

By October 21,2011, the CUPA will add a column in i t s NOV tracking sheet in order to record SOC. The CUPA will submit the NOV tracking sheet along with each progress report.

By October 21, 2012, the CUPA will have demonstrated that it is collecting, retaining, and managing information necessary to implement the UP by submitting requested enforcement, SOC and UPCF documentation to Cal/EPA.

CUPA's 1'' Update (10-20-11): As a result of the recent audit findings, the LA City CUPA has modified the NOV tracking sheet to include violation classifications and SOC RD/RP criteria (see attached). The LA City CUPA is s t i l l assessing an efficient process to assure completion of the UPCF information by the regulated community.

Cal/EPAts lSt Response: Cal/EPA appreciates the CUPA's progress in correcting this deficiency. The CUPA has created a mechanism for collecting and tracking SOC. Please submit another copy of the NOV tracking sheet with updated follow-up information along with the next progress report.

CUPAJs 2nd Update (2-28-12): NOV Tracking Sheets attached.

Cal/EPAJs 2nd Response: The NOV tracking spreadsheet tracks RTC dates, SOC, and violation classifications. It does not track enforcement activities such as AEOs, civil and criminal enforcement actions, SEPs, red tag, and the penalty amounts for enforcement actions. The CUPA may remedy this by adding a formal enforcement column and a

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penalty amount column t o the NOV spreadsheet. The CUPA may also start entering the information into Envision. If the latter is occurring, submit a screenshot of queried facilities that the CUPA performed formal enforcement actions against.

CUPAJs 3rd Update: Included is a copy of the Notice of Violation Tracking Sheet (see Attachment Q). Currently, CUPA uses the NOV as formal enforcement; i f compliance is not obtained within 30 then the violation is forwarded to the Legal Unit (F-290 Legal Request). Penalties are established and tracked by the Legal Unit and the City Attorney's office. CUPA is in the process of establishing an Administrative Enforcement Order, a copy of Board Report to establish the order is included (see Attachment R).

Cal/EPAJs 3rd Response: NOV's are considered informal enforcement per CCR, title 27, section 15110 (d) and should be tracked as such. The Legal Unit may track formal enforcement actions and penalty amounts on behalf of the CUPA, but the CUPA will need to be able to retrieve the information for summary reporting and ultimately for reporting the information into CERS. In the next progress report, include the record of the formal enforcement tracking (AEOs, civil and criminal enforcement actions, SEPs, red tag, and the penalty amounts) used by the Legal Unit.

CUPAJs 4th Update: The Legal Unit tracks all it cases through the "Legal Tracking System" a screen shot of the tracking system is included (see Attachment J).

Cal/EPAJs 4th Response: Cal/EPA considers this deficiency corrected.

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20. Deficiency: The CUPA is not reviewing its' I and E Plan annually and updating it as needed.

In addition, the I and E Plan is missing the HWG program element and should be updated to include that element. The CUPA's current plan only refers t o the PA's I and E Plan in regard to the HWG program; however, that plan is not readily available.

Corrective Actions: By October 21, 2011, the CUPA will review i t s entire I and E Plan and update it as needed.

By October 21, 2011, the CUPA, in coordination with their PA, will revise its' I and E Plan t o include the administration of the HWG program element.

CUPA's 1'' Update (10-20-11): As a result o f the recent audit findings, the LA City Cupa has reviewed and updated its' I and E Plan. (See attached)

CalIEPA's lSt Response: The CUPA's I and E plan has been updated. The CUPA has included LA County PA's I and E plan as an appendix item in i t s I and E plan. Cal/EPA considers this deficiency corrected.

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21. Deficiency: The CUPA did not adequately complete a FY 2009/2010 narrative self audit o f its activities.

The FY 2009/2010 narrative self audit reviewed by Cal/EPA did not differ much from the FY 2008/2009 narrative self audit. The only changes observed were the changes from "FY 2008/2009" t o "FY 2009/2010".

Corrective Actions: By September 30,2012, the CUPA will conduct their FY 2011/2012 self audit and submit the narrative self audit report t o Cal/EPA.

CUPA's 1'' Update (10-20-11): Refer t o attachment.

Cal/EPA's 1'' Response: The CUPA's FY 2010/2011 self audit is acceptable. Cal/EPA will review the FY 2011/2012 self audit upon submittal. This deficiency is s t i l l in progress.

CUPA's 2nd Update (2-28-12): CUPA will submit FY 2011/2012 Self-Audit in September 2012.

Cal/EPA1s 2nd Response: Cal/EPA will review the FY 2011/2012 Self Audit in September 2012.

CUPA's 3rd Update:

Cal/EPA's 3rd Response: Cal/EPA considers this deficiency corrected.

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Deficiency: The CUPA is not accurately reporting information on the Annual Inspection (Report 3) and Enforcement (Report 4) Summary Reports.

FY 2009/2010 - HWG and the AST program information is missing from Reports 3 and 4. Also, on Report 3 the percent of routine inspections with class 1 or 2 violations that RTC was reported as 100 percent for the HMRRP and California Accidental Release Response Plan (CalARP) facilities; however, on Report 4 no facilities with violations were reported for those program elements.

FY 2008/2009 - On Report 3 the percent of routine inspections with class 1 or 2 violations that returned to compliance was reported as 100 percent for the HMRRP and CalARP businesses; however, on Report 4 no facilities with violations were reported for those program elements. Also, on Report 4 the number of local and statutory Administrative Enforcement Orders (AEO) reported are identical for HWG businesses; however, the two types of AEOs come from two different authorities. Local AEO authority comes from local law, code, or ordinance. Statutory AEO authority comes from the state Health and Safety Code. FY 2007/2008 -The percentages of routine inspections with class 1 or 2 violations that returned to compliance was not reported for the HWG program element.

Corrective Actions: By September 30,2011, the CUPA will submit its FY 2010/2011 Annual Summary Reports that accurately depicts i t s inspection and enforcement activities.

CUPA's lSt Update (10-20-11): As a result of the recent audit findings, the LA City Cupa has submitted the quarterly and annual reports with the most accurate statistical data available. (See attached)

Cal/EPA's lSt Response: The CUPA's inspection and enforcement summary reports are acceptable. Cal/EPA considers this deficiency corrected. Please ensure that noncompliant facilities return to compliance in a timely manner. None of the facilities with class 1 or 2 violations return to compliance within 90 days according to the FY 2010/2011 summary reports.

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