Chapter 4 - The Regulatory World


The Santa Clara County Hazardous Materials Storage Ordinance (HMSO)requires that Stanford obtain a permit for any facility in which hazardous materials are stored. This requirement applies to all storage facilities

In order to receive a permit for a particular facility, Stanford must submit a plan for monitoring the stored materials to detect releases. This plan must provide for regular testing and inspection. Stanford must also carry out regular maintenance, repair, or replacement of its storage facilities.

[Requires aboveground and underground tanks to be permitted]

The HMSO also requires aboveground and underground tanks to be permitted. EH&S should be contacted before installing or removing an aboveground or underground tank, so that proper permits can be obtained from the County Toxic Substances Control Division.

In addition, Stanford must provide appropriate emergency equipment and post emergency procedures where hazardous materials are stored.

[Imposes extensive inventory reporting requirements]

Through the HMSO, Santa Clara County imposes extensive inventory reporting requirements on Stanford's laboratories. Article 5 of the HMSO requires Stanford to submit a Hazardous Materials Inventory Statement(HMIS) as part of the Hazardous Materials Management Plan for each building containing hazardous materials. Each facility containing an aggregate of hazardous materials--including hazardous waste--in excess of 500 lb.. in weight for solids, 55 gallons for liquids, or 200 cubic feet at standard temperature and pressure for compressed gases must submit an HMIS for each hazardous material in that facility. The HMIS must list: general chemical names; common/trade names; major constituents for mixtures; manufacturers; United Nations or North America shipping numbers, if available; hazard class or classes;Material Safety Data Sheets (MSDSs); aggregate quantity ranges; and carcinogen identification forms. The HMIS is a matter of public record,except when trade secrets are jeopardized.

[Imposes noncompliance penalties]

Failure to submit an adequate HMIS to the County exposes the University and the individual researchers to criminal and civil penalties. Any"person, firm, or corporation who intentionally or negligently" violates a provision of the HMSO may be fined up to $500 per day for each violation. EH&S submits HMISs annually on behalf of Stanford's 2500 laboratories.

Also, SARA Title III (The "Community Right-to-Know Act") Sections 311 and 312 require certain facilities to submit chemical inventory information. Section 311 contains specific requirements for a facility that must prepare or have available Material Safety Data Sheets for the OSHA Hazard Communication Standard. These facilities must submit these MSDSs or a categorized list of the hazardous chemicals to the Local/State Emergency Planning Commissions, and the local fire department. This and the state version of these requirements, called the Hazardous Materials Release Response Law, are also addressed centrally when labs and shops submit their chemical inventories to the EH&S Chemical Inventory Group.

What Is A "Facility"?
For the purposes of the HMSO, a facility is a freestanding building that has been permitted for occupancy under the Uniform Building Code and the Uniform Fire Code. Therefore storage rooms inside buildings and storage sheds attached to buildings are not considered separate facilities under the HMSO.

Your HMSO Responsibilities
HMSO requirements are met through no single office or program at EH&S. Your compliance responsibilities are covered in the section "The HazMatSafety System at Stanford." Please refer to this section with questions on how to comply with HMSO provisions.


[Will be fully in effect by September 1993]

Santa Clara County has adopted a Model Ordinance for Toxic Gas Regulation. The purpose of this ordinance is to prevent, control, and respond to potentially dangerous conditions and to protect the public from acute exposure to toxic gas due to an accidental release. Additional provisions will be in force by September 1993, and buildings under planning must now comply with the ordinance's specifications and standards. In the interim, EH&S and the University Safety Partners will be developing department- and building-specific compliance plans.

[Applies to most gases]

The ordinance applies to any material: (1) for which EPA has established a Level of Concern (LOC); (2) which is shipped in compressed gas cylinders; and (3) which acts as a gas upon release at normal temperature and pressure or is used or handled as a gas whether or not in strict accordance with the definition of a compressed gas as defined by the Uniform Fire Code (UFC). Each regulated gas is classified as Class I, II, or III based on its Material Hazard Index (MHI). The MHI is calculated according to the LOC and the physical and chemical characteristics for a given gas. A regulated gas which exceeds its maximum threshold quantity will be classified one level higher than otherwise determined.

[Imposes extensive permitting and safety system requirements]

The ordinance requires that each "person, firm or corporation" obtain a permit to "store, dispense, use or handle" any regulated gas. General requirements concerning seismic protection, security, leak testing, separation of incompatibles, protective plugs/caps, emergency drills, fire extinguishing systems, and annual maintenance apply to all regulated gases. These requirements, however, do not apply to gases whose quantity in a single vessel does not exceed specified exempt amounts or which have an MHI less than 4,900. The ordinance also requires specific control mechanisms and procedures for each of the three classes of gases. The requirements are cumulative the hazard class increases. Thus, use of a Class I gas (which is the most hazardous class of the three) requires Class III and Class II controls in addition to specified Class I controls.

[Supplements UFC and UBC (1991) requirements]

The Model Ordinance for Toxic Gas Regulation and the Hazardous Materials Storage Ordinance are designed to supplement UFC and Uniform Building Code (UBC), 1988 editions, as adopted by the State of California. The UFC is organized into articles. You can find specific requirements regarding the storage of hazardous chemicals (solids and liquids at Article 80, and gases at Article 74). These requirements include the following: (1) the kind of piping, valves, and fittings that should be used; (2) the kinds of warning signs required; (3) the kind of shock padding and shelf storage necessary to protect the stored chemicals from seismic damage; and (4) the kind of storage cabinets that should be used. In the event of conflicting or overlapping provisions within the codes and the county ordinances, the more stringent requirement will prevail.

The 1991 edition of the UFC significantly modifies Article 80 to add specific fire hazards relating to hazardous materials, including both chemicals and radioactive materials. When storing such materials, Stanford must comply with the article's requirements as amended and adopted by Santa Clara County. Those portions of campus that are within the jurisdiction of the City of Palo Alto, rather than within the un incorporated areas of Santa Clara County, must comply with the amendments to the 1991 Uniform Fire Code as recently adopted by the City.

Your Toxic Gas Ordinance Responsibilities
* All toxic gas cylinders that are no longer needed should be returned to the vendor or disposed of properly (see the section on cylinder handling and disposal procedures).

* All processes involving toxic gases need to have their cylinders sized under TGO based on process flow rates and flow times.

Example: 5% F2 used in an Eximer Laser using a flow volume of 100 standard cubic centimeters (Scm3) of gas with a source time of 20 minutes per run at 2 runs per day and 5 days of use per week can be sized accordingly:

100 Scm3 x 20 min. x 2 runs x 5 days x 4.33 weeks = 86.6 liters gas used in 1 month = 3 ft3 per month

Multiply this quantity by the frequency (in months) with which the cylinder is changed to get its regulated size under the Toxic Gas Ordinance (e.g., 3 ft3 x 3 months = 9 ft3 cylinder size).

* Cylinders should be changed no more than once a month and no less than once a year due to the possibility of an accident occurring during change over or deterioration of the cylinder.

* To the extent possible, size experiments involving toxic gases so that they use exempt amounts.

* All toxic gas cylinders need to be purchased with restrictive flow orifices in them-supplied by the manufacturer.

* Call the EH&S Chemical Safety Program (723-0593) for procedures on properly changing and returning toxic gas cylinders to vendors, and determining engineering control requirements. By September 1993, same-day delivery and pickup of toxic gases to and from a centralized storage facility is planned--allowing users to avoid toxic gas storage in their labs.


[Intended to reduce risks of hazardous materials release]

To obtain a permit to store hazardous materials, Santa Clara County requires that Stanford submit a Hazardous Materials Management Plan(HMMP) for each storage facility. The purpose of this plan is to reduce the risk of a stored hazardous materials release and to aid in the emergency response to such releases. One element in the HMMP must be a description of the storage facility, including a detailed floor plan. This floor plan must indicate all hazardous materials, including wastes, and the hazard class and the quantity range for each such class, aggregated within each storage facility.

[EH&S coordinates overall HMMP responsibilities]

The HMMP must also include a description of the methods used to ensure separation and protection of stored hazardous materials from factors which may cause fire or explosion, or production of a flammable, toxic, or poisonous gas, or deterioration of the primary or secondary containment. Stanford must also describe its monitoring methods, emergency procedures, maintenance schedules, and record-keeping forms in the HMMP. Finally, the HMMP should include a completed Hazardous Materials Inventory Statement. EH&S handles Stanford's overall HMMP responsibilities, based on the cooperation of labs and shops with inventory and storage requirements.

Your HMMP responsibilities

* Follow EH&S's procedures for maintaining and updating chemical inventories

* Maintain secondary containment and segregation of chemicals.

* Use EH&S' Laboratory Safety Self-Survey Form to monitor safe hazardous materials storage and use. Call 725-1470 for copies of this form.

* Call EH&S' Chemical Safety Program (723-0593) with any other questions regarding your HMMP responsibilities.


[Applies to buildings containing acutely hazardous materials]

In 1986 the California Legislature adopted AB 3777 (La Follette), to regulate chemicals for which an on-site fire or other release is most likely to produce a toxic cloud that could have severe off-site health or environmental effects. AB 3777 created a new set of regulated chemicals called Acutely Hazardous Materials (AHM's) (Hazard Code 62 in the Chemical Safety Database). Local implementation is provided by the Santa Clara County Environmental Health Department, subject to limited oversight by the state Office of Emergency Services (OES).

[Specifies Threshold planning quantities (TPQ's) for acutely hazardous materials]

Any "business," including Stanford University, where the maximum quantity of an AHM in a building ever exceeds specified threshold quantities must register as an AHM handler. EH&S coordinates this registration based on chemical inventories provided by individual lab sand shops. These thresholds are the lower of the federal "threshold planning quantities (TPQ's)" established by EPA under SARA Title III, or the reporting thresholds set by state law. TPQ's range from 1 pound to 10,000 pounds, while the state thresholds are 55 gallons for liquids, 200 cubic feet for compressed gases (measured at standard temperature and pressure) and 500 pounds for solids. Local administering agencies may set lower reporting thresholds or add additional chemicals to the program. Currently, there are 360 AHM's listed in the regulation.

[If required by the County, Stanford's RMPP would specify risk-reducing changes in equipment, operations, maintenance]

Santa Clara County may require Stanford to prepare a Risk Management and Prevention Program (RMPP) for one or more on-site AHM's. RMPP's involve engineering and operational reviews of AHM handling systems, evaluations of the off-site consequences of likely AHM accidents, and the implementation of on-site improvements to reduce to likelihood and severity of and AHM accidents.

[Release of AHM's must be reported]

Releases of AHM's must be reported to local administering agencies. In addition, EPA has established for each AHM a reportable quantity (RQ) under Superfund, such that any unauthorized release of an amount exceeding the RQ also triggers immediate release reporting requirements.

A Note on RMPP's
EH&S currently registers buildings containing acutely hazardous materials with Santa Clara County, fulfilling much of the intent of an RMPP through other reports. Only after an RMPP is mandated by the County would lab or building occupants have to modify their hazardous materials management procedures. EH&S is providing this information for your reference.


[Requires posting of warning signs regarding carcinogens and reproductive hazards]

In 1986, the people of California passed an initiative called Proposition 65, or the Safe Drinking Water and Toxic Enforcement Act, that requires informing the public at large about environmental (occupational and non-occupational) exposures to chemicals above specific risk levels. Prop 65 requires the posting of warning signs in or near areas that contain any of the cancer-causing agents or reproductive toxins that are known to the state to cause cancer or reproductive toxicity. You may have noticed warning signs posted on gasoline pumps, outside convenience food stores, and in doorways to chemical laboratories. These warnings all fulfill Prop 65 warning requirements.

[Prop 65 substances are listed on copies of Life Safety Box inventories--don't tamper with the Life Safety Box contents]

This substance list is already quite large and will continue to grow. To find out whether your lab contains Prop 65-regulated substances, get a copy of your lab's Life Safety Box (LSB) inventory from your building/department/school safety coordinator. Any Prop 65 materials will appear on the inventory designated by a hazard code of 65 or 66.LSBs also have Prop 65 stickers affixed to them if a lab contains these materials.

[The Chemical Safety Database will say whether a chemical is a Prop 65 substance]

If you want to know whether a specific chemical is a Prop 65 substance, access the Chem Safety Database on Forsythe via Prism or Folio. Prop 65 substances will be so indicated in their hazard classifications. If your lab or building acquires Prop 65 substances for the first time, ask your building/department/School safety coordinator for an orange/yellow, EH&S-approved, Prop 65 warning sign. If these people do not have any more signs, call EH&S Communications (725-1470) for more copies. This label should be posted prominently on or immediately outside the door to your lab.

[Post warning labels prominently]

Verbal warnings should also be given to students and employees who occasionally enter a lab or office area containing Prop 65 carcinogens or reproductive toxins. Warning signs (see sample, left) should be posted to inform building occupants and visitors if a potential for exposure exists. The wording for such signs (as specified by the regulations) is the following:

For Carcinogens:


For Reproductive Toxins:


Prop 65 Actions
Materials regulated under Prop 65 are listed under hazard codes 65 and 66 in the chemical safety database. EH&S recommends the following specific actions:

* Post any area where these materials are used (signs are available from EH&S)

* Consult with your building/department/School safety coordinator to be sure that all Prop 65 warning signs have been posted properly

* To find out whether a substance is on the Prop 65 hazards list, access the Chem Safety Database on Forsythe via Prism. Just type "Prism sel Chem Safety" at the ">" prompt (having logged on to Forsythe) and follow the instructions given.

* Limit, where practical, public access in areas where Prop 65- regulated materials are regularly used

* Talk to lab workers and building occupants about these requirements and the meaning of the signs

* Request that EH&S Chem Waste Program (723-5075) dispose of any unwanted materials in your lab


CAL/OSHA currently regulates twenty-six chemicals as carcinogens and has very stringent requirements for their use (see box, next page). The use of thirteen of these chemicals (marked in bold) requires special programs regardless of exposure levels. The requirements for the remaining thirteen chemicals depend upon the level of exposure-commonly known as their permissible exposure levels (PEL's), or action levels. These requirements include training, use of personal protective equipment, standard operating procedures, labeling, emergency measures, posting, and, in some cases, medical surveillance and exposure monitoring. Most of these requirements may already be addressed in many labs throughout the University.

[Designated areas must be established for the use of listed carcinogens]

A specific area must be designated for use of any of the carcinogens marked in bold (see box) and for those others where exposure may be above the permissible exposure or action level. This designated area maybe an entire lab, or a device such as a fume hood or a glove box. CAL/OSHA requires that if any of the twenty-six carcinogens are used, they must be registered by quantity, name, and location. EH&S submits this registration annually based upon the information contained in chemical inventories.

[Spills, leaks, or possible exposures must be reported to EH&S]

Any spill, leak, or possible exposure involving these listed carcinogens must be reported to EH&S immediately. In turn, EH&S may need to report to CAL/OSHA, as CAL/OSHA has a twenty-four hour reporting requirement for certain exposures. Failure to report in the appropriate time frame could lead to a serious citation and fine.

CAL/OSHA Regulated Substances

Without PEL's/AL's With PEL's/AL's
4-Nitrodiphenol Inorganic Arsenic
Alpha-Naphthylamine 1,2-Dibromo-3-Chloropropane
Methyl Chloromethyl Ether Vinyl Chloride
3,3'-Dichlorobenzindine(and salts) Formaldehyde
Bis-Chloromethyl Ether Benzene
Beta-Naphthylamine Ethylene Oxide
Benzidine Acrylonitrile
4-Aminodiphenyl 4,4'-Methylene bis (2-chloroaniline)
Ethyleneimine Lead
Beta-Propiolactone Ethylene Dibromide (EDB)
2-Acetylaminofluorene Cotton Dust
4-Dimethylaminoazobenzene Asbestos

Coke Oven Emissions

Contact EH&S at 725-1474 for more information about carcinogen use.

NOTE: PEL's are Permissible Exposure Levels AL's are Action Levels


The Federal Occupational Safety and Health Administration (OSHA) has published new regulations to protect workers from potential exposures to HIV (the AIDS virus), Hepatitis B virus, and other bloodborne pathogens.

[Federal Standard became effective March 16, 1992]

The federal rule, which OSHA estimates will protect 5.6 million workers and prevent more than 200 deaths and 9,200 bloodborne infections annually, went into effect on March 6, 1992. Because California has its own OSHA-approved occupational health and safety plan, it must adopt a comparable standard for occupational exposure to bloodborne pathogens and other potentially infectious materials.

[Applies to employees and students who might come into contact with blood or other infectious materials]

The bloodborne pathogens rule applies to all employees who could be "reasonably anticipated" to come into "bodily contact with blood and other potentially infectious materials" as a result of performing their jobs. Although the majority of people affected by the standard will be health care workers, the University will have to include other employees who risk occupational exposures such as researchers, bio waste technicians, and some housekeeping staff. While OSHA regulations cover only employees, Stanford extends the same safeguards to students.

[Requires the establishment of a written Exposure Control Plan]

The rule requires that employers establish a written Exposure ControlPlan that identifies the tasks and procedures where occupational exposure to bloodborne pathogens is likely to occur, and specifies a schedule for the means of implementation for other provisions of the standard. Other provisions include:

* Following Universal Precautions (covering personnel practices and environmental controls).

* Implementing engineering and work practice controls.

* Providing training.

* Providing Hepatitis B vaccinations. Individuals will need to attend the training course before they can receive their Hepatitis B vaccinations. Those who decline the vaccination series must attend the course and sign a declination statement.

* Ensuring medical follow-up for workers who have an exposure incident, such as a needle stick.

* Providing personal protective equipment (mandatory use by employees of specified personal protective equipment).

* Recordkeeping.

* Communicating hazard information.

* Housekeeping.

For more information, contact the Biosafety Officer at 725-1473 or consult the Stanford Biosafety Manual.


Universal Precautions apply to blood, body fluids, and all human tissues. Body fluids include: semen, vaginal secretions, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid; feces, urine, sputum, nasal secretions, saliva, tears, and vomitus.


Universal Precautions are designed to supplement important routine infection control, such as handwashing.

1. Hands and other skin surfaces that are contaminated with blood or body fluids must be immediately and thoroughly washed.

2. Gloves must be changed and hands must be washed between patient contacts involving blood or body fluids.

3. Hands must be washed between patient contacts not involving blood or body fluids.

Use of Protective Barriers

Protective barriers will be worn to prevent exposure to blood or body fluids during procedures where splashing or aerosolization may occur. Individual departments/units will specify the type of protective barrier(s) to be used during any specific procedure, according to the type of exposure anticipated. Barriers such as gloves, gowns, plastic aprons, masks, protective eyewear or face shields may be required. These policies will be reviewed by the Infection Control Committee.


Gloves will be worn during phlebotomy, finger or heel sticks, when starting or manipulating intravascular lines, or during any procedure involving a potential exposure to blood. Gloves will be worn in situations where exposure to body fluids may occur.

1. Use sterile gloves for procedures involving contact with normally sterile areas of the body.

2. Use examination gloves for procedures involving contact with mucous membranes and for other patient care.

3. Change gloves between patient contacts.

4. Do not wash or disinfect surgical or exam gloves for reuse, as this may cause deterioration.

5. Use general-purpose utility gloves (e.g., rubber household gloves) for housecleaning chores and for instrument cleaning and decontamination procedures. Utility gloves may be decontaminated and reused, but should be discarded if peeling, cracked, torn, or damaged.

Preventing Penetrating Injuries
Gloves should reduce the incidence of contamination of the hands, but they cannot prevent penetrating injuries due to needles or other sharp

1. Do not recap needles by hand; do not remove used needles from disposable syringes by hand; and do not bend, break, or otherwise manipulate used needles by hand.

2. Place used disposable syringes, needles, scalpel blades, and other sharp items in red puncture-resistant containers for disposal. Containers should be located at the bedside or as close to the use area as practical.

3. Take care, both during and after procedures, to prevent injuries from needles, scalpels, or other sharp instruments or devices.


[Recognizes hazards and procedures unique to the laboratory setting by establishing performance rather than substance-based standards]

Prompted by the regulated community's concern about the unique characteristics of the laboratory workplace, the federal Occupational Safety and Health Administration (OSHA) issued a Laboratory Standard in January, 1990. The standard is designed to protect laboratory workers through a comprehensive approach tailored to the individual laboratory. The standard's new regulations are significant because they replace most existing substance-specific standards with a performance standard designed to avoid over-exposures. The standard exempts research and clinical labs from CAL/OSHA requirements intended for an industrial setting, but instead imposes regulations more appropriate to labs. For laboratories, the standard supersedes existing federal and state OSHA requirements, except that 1) Permissible Exposure Limits still apply and 2) even in the laboratory, chemical uses that are not on a laboratory scale are still regulated under existing regulations. Typically, "laboratory scale" means small quantities of chemicals that can be manipulated by one person and that are not part of a production process.

[Requires Stanford to generate a comprehensive Chemical Hygiene Plan that protects employees and students' health around chemical hazards]

Stanford has developed and made available to employees a written Chemical Hygiene Plan. Copies are maintained at EH&S and are available upon request by calling 723-0448. A poster summarizing Plan elements has been distributed to many labs and is also available from EH&S. The Plan is a corner piece of the performance standard and is intended to be reviewed annually and updated as necessary. The purpose of the Plan is to set forth procedures that will protect employees' health around hazardous chemicals and conform to the requirements specified in the regulations.

[The Plan must also cover various control measures such as employee training and medical examinations]

The Plan also covers control measures, equipment performance measures, employee training, prior approval criteria for hazardous procedures, medical examinations, appointment of a Chemical Hygiene Officer, and extra protection measures for particularly hazardous substances, including provisions for designated areas, containment, waste removal, and decontamination. OSHA provides specific guidance for Chemical Hygiene Plan provisions through non-mandatory recommendations extracted from the National Research Council's Prudent Practices for Handling Hazardous Chemicals in Laboratories.

[The Plan requires the implementation or written Standard Operating Procedures (SOPs)]

Standard Operating Procedures (SOPs) are required by the Plan. SOP's are documents that provide descriptions of standard methods or operations used in the lab (or other University workplaces) and how these should be performed. SOPs should be clear and concise so that they may be easily understood. They should be clearly stated and realistic in scope. SOPs should be developed for all routine, repetitive, and unique operations
as well as for non-routine events, such as spills.

[Faculty and/or lab directors are ultimately responsible for maintaining SOPs in their areas]

In labs, faculty or lab directors are ultimately responsible for SOPs for their areas. However, they can delegate the responsibility for writing to another individual in the lab who is knowledgeable about the equipment or process for which the SOP is being written. The SOP can be used as a training tool. All employees and students working in the lab should read any SOPs associated with their particular area of responsibility and should document that the SOPs are understood. Documentation could be a signed statement that the SOP has been read and understood. CAL/OSHA does not have specific guidelines or requirements for Standard Operating Procedures. To assist PI's and shop/lab supervisors in drafting the SOP's, EH&S has developed a standard format outlining recommended elements (see box, next page). In most cases the existing written methods used in labs can be modified according to the SOP format provided to satisfy this requirement.

[Expands existing medical surveillance and training requirements]

When there is a potential exposure resulting from a spill or accident, Stanford must provide initial and periodic exposure monitoring, information and training, and medical examinations for its laboratory workers. The Laboratory Standard training requirements are similar to the federal Hazard Communication Standard training requirements (see above), but include a few additional requirements. For example, training must include details of the Chemical Hygiene Plan and the location and availability of known reference material regarding safe handling of chemicals in the laboratory, including Material Safety Data Sheets.

[Expands existing MSDS requirements to include chemicals developed in labs]

Also, Stanford must determine whether chemical substances developed in its laboratories are hazardous and must prepare Material Safety Data Sheets as required by the Hazard Communication Standard for those chemicals it produces for a user outside of the laboratory. Stanford must also ensure that material safety data sheets from chemical suppliers are readily accessible to employees.

[Requires proper respiratory equipment for lab workers]

OSHA's Laboratory Standard also requires Stanford to provide proper respiratory equipment for its laboratory workers and to maintain accurate records regarding its compliance with the standard.

[Impacts lab supervisors, principal investigators, and safety committees beyond their existing communication responsibilities]

The Chemical Hygiene Plan requirement impacts laboratory supervisors and departmental safety committees beyond their existing Hazard Communication responsibilities. EH&S has minimized this impact by producing many elements of the Chemical Hygiene Plan centrally. But certain features of the Plan must be handled at the level of the department or, in some cases, of the lab, such as SOPs noted above.

Managing OSHA's Laboratory Standard
Complying with this new Standard requires a team effort between EH&S and safety groups at the department and laboratory level. The following list tells how safety contacts can minimize the added work load that this
Standard entails.

* When safety representatives receive EH&S' generic Chemical Hygiene Plan, they should read through the sections on Standard Operating Procedures (SOPs), Information and Training, Prior Approval Mechanisms, and Additional Protections. They should note any and all deficiencies in terms of specific laboratory hazards.

* Meet with building or departmental safety committee representative and formulate a plan for customizing EH&S' generic Plan to meet specific needs.

* If it makes sense to coordinate this process cross-departmentally within your School, involve your University Safety Partner.

* If significant administrative problems arise, contact your School's University Safety Partner.

* If significant concerns with the content of your Chemical Hygiene Plan arise, contact EH&S' Chemical Safety Program at 723-0593.

Standard Operating Procedures Format ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This 10-step guide can be used to create SOP's in your work area.

1. Process

List the process or type of process that involves the use of hazardous chemicals in this laboratory. This process may be described in general terms, such as "extraction" and "distillation" or in more detailed terms such as "spectrophotometer analysis of cholester extraction." If processes do not apply to your laboratory, then proceed to element 2b.

2. Hazardous Chemicals/Class of Hazardous Chemicals

a. For each process, list the hazardous chemicals and the expected by-products produced, or

b. List the class of chemicals.

3. Personal Protective Equipment

Discuss the personal protective equipment and hygiene practices used with each process, class of chemicals, or individual chemical.

* Personal protective equipment includes gloves, coats/garments, eyeglasses, goggles, face shields, and air purifying respirators. Include the type of gloves needed for each phase of the process. If laboratory coats, eye protection, or respirators are required, indicate when and why.

* If you think that your process may require respirator use, contact EH&S for assistance.

4. Engineering/Ventilation Controls

Describe engineering controls designed to reduce employee exposures to hazardous chemicals, such as ventilation devices, aerosol suppression devices, and safety features on equipment.

5. Special Handling Procedures and Storage Requirements

* Describe storage requirements for hazardous chemicals in your laboratory.

* Include restricted access plans, ventilation systems used, special containment devices, etc.

* Describe safe methods of transporting chemicals, such as double containment.

6. Spill and Accident Procedures

Indicate how accidental releases should be handled and by whom.

7. Waste Disposal

Describe waste disposal procedures for these chemicals (See Ch.4)


8. Approval Required

Discuss the circumstances under which a particular laboratory operation, procedure, or activity will require prior approval from the department before implementation.

9. Decontamination

Discuss decontamination procedures for equipment and glassware.

* Include controlled areas (e.g., glove boxes, restricted access hoods, perchloric acid fume hoods, or designated portions of the laboratory) in your discussion.

10. Designated Area

Indicate the designated area for your laboratory. A designated area must be considered for work with Cal/OSHA regulated carcinogens. The entire laboratory, fume hood, or a portion of the laboratory may be considered as a designated area. Used with permission of the Office of Environmental Health and Safety, University of California at San Diego, 1992.




Department of _____________________________________________

Standard Operating Procedures for: ________________________


Prepared by: ______________________________________________

Location of Procedures: _____________ Building: ___________

Rooms: ____________________________________________________


1. Process

2. Hazardous chemicals/Class of Hazardous Chemicals

3. Personal Protective Equipment

4. Engineering/Ventilation Controls.

5. Special Handling Procedures and Storage Requirements

6. Spill and Accident Procedures

7. Waste Disposal For Particularly Hazardous Substances

8. Approval Required

9. Decontamination

10. Designated Area





The Uniform Fire Code (UFC) is a model code, setting construction standards for buildings and related fixtures and equipment, in order to prevent or mitigate hazards of fire and explosions. The UFC is prepared by the Western Fire Chiefs Association for the ten western states they cover, including California. The UFC is amended annually and fully republished every three years. Local fire jurisdictions typically adopt the UFC, including local additions or deletions. Palo Alto and Santa Clara County have most recently adopted the 1991 UFC. The UFC defines a number of classes of hazardous materials, based on their physical, chemical or health hazards, and prescribes construction and handling standards tailored to each hazard class.


The U.S. Department of Transportation (DOT) regulates the transport of "hazardous materials" under authority of the Hazardous Materials Transportation Act (HMTA) and Title 49 of the Code of Federal Regulations (CFR). "Hazardous materials" generally are those that might create "an unreasonable risk to health and safety or property when transported in commerce." Under HMTA, DOT has defined a number of classes of hazardous materials, and prescribed appropriate labeling, packaging, employee protection, transport, and emergency response provisions. New training requirements for hazardous materials transporter, such as Central Stores, were recently promulgated in 49 CFR.