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Memorandum

From: Carey A. Johnston, P.E.

USEPA/OW/OST

ph: (202) 566 1014

johnston.carey@epa.gov

To: Public Record for the 2006 Effluent Guidelines Program Plan

EPA Docket Number OW-2004-0032 (www.epa.gov/edockets/)

Date: August 4, 2005

Re: Industry Sectors Being Evaluated under Proposed “Health Services Industry” Category

Overview

EPA establishes technology-based national regulations, termed "categorical pretreatment 

standards," for categories of industry discharging pollutants to Publicly Owned Treatment Works 

(POTWs) that may pass through, interfere with or are otherwise incompatible with POTW 

operations. CWA section 307(b). Generally, categorical pretreatment standards are designed such 

that wastewaters from direct and indirect industrial dischargers are subject to similar levels of 

treatment. EPA has promulgated such pretreatment standards for 35 industrial categories.

EPA is reviewing various indirect discharging industries without categorical pretreatment 

standards to determine whether their discharges were causing pass through or interference, in 

order to determine whether categorical pretreatment standards are necessary for other industrial 

categories.

As discussed in the 2005 Annual Screening-Level Analysis (see DCN-02173), stakeholder 

comments and pollutant discharge information have helped EPA identify industrial sectors for 

this review. In particular, EPA has looked more closely at sectors that are comprised entirely or 

nearly entirely of indirect dischargers, and is grouping them into the following seven industrial 

categories: Food Service Establishments; Industrial Laundries; Photoprocessing; Printing and 

Publishing; Independent and Stand Alone Laboratories; Industrial Container and Drum Cleaning; 

and Health Services Industry. 

EPA is including within the Health Services Industry the following activities: 

Independent and Stand Alone Medical and Dental Laboratories, Offices and Clinics of Doctors of 

Medicine, Offices and Clinics of Dentists, Nursing and Personal Care Facilities, Veterinary Care 

Services, and Hospitals and Clinics. This memorandum describes the rationale for this grouping 

by examining the type of operations performed, pollutants and wastewaters generated, and 

available pollution prevention and treatment options for each industry sector. At the end of this 
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memorandum is further information about Independent and Stand Alone Medical and Dental 

Laboratories (Attachment 1), Offices and Clinics of Dentists (Attachment 2), and Hospitals and 

Clinics (Attachment 3).

Type of Operations Performed

All six industry sectors are grouped under the two digit SIC code 80, “Health Services,” 

and the two digit NAICS code 62, “Health Care and Social Assistance.” The Census Bureau 

defines the Health Care and Social Assistance industrial sector as:

The Health Care and Social Assistance sector comprises establishments providing health 

care and social assistance for individuals. The sector includes both health care and social 

assistance because it is sometimes difficult to distinguish between the boundaries of these two 

activities. The industries in this sector are arranged on a continuum starting with those 

establishments providing medical care exclusively, continuing with those providing health care 

and social assistance, and finally finishing with those providing only social assistance. The 

services provided by establishments in this sector are delivered by trained professionals. All 

industries in the sector share this commonality of process, namely, labor inputs of health 

practitioners or social workers with the requisite expertise. Many of the industries in the sector 

are defined based on the educational degree held by the practitioners included in the industry.

Excluded from this sector are aerobic classes in Subsector 713, Amusement, Gambling 

and Recreation Industries and nonmedical diet and weight reducing centers in Subsector 812, 

Personal and Laundry Services. Although these can be viewed as health services, these services 

are not typically delivered by health practitioners.1

As described in this definition, all six industry sectors identified by stakeholders require 

services to be delivered by trained professionals for the purpose of providing health care and 

social assistance for individuals. These entities may be free standing and perhaps privately owned 

or may be part of a hospital or health system. These services can include diagnostic, preventative, 

cosmetic, and curative health services and may include the following seventeen operations, not 

all of which generate wastewater:

• Administrative Activities and Services;

• Support Services;

• Facilities Management, Maintenance, and Plant Operations;

• Laboratory Services;

• Diagnostic Services;

• Surgical Services;

 1

U.S. Census Bureau. 2002 NAICS Definitions. Available online at: 

http://www.census.gov/epcd/naics02/def/NDEF62.HTM#N62.
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• Inpatient Care Services;

• Critical Care Services;

• Emergency Care Services;

• Respiratory Care Services;

• Dialysis;

• Physical Therapy/Occupational Therapy;

• Outpatient Services (Nonsurgical);

• Oncology/Cancer Care Services;

• Dentistry;

• Animal Research and Testing;

• Clinical Research; and

• Construction and Renovation.2

These seventeen operations are defined in more detail in the following document, 

“Profile of the Healthcare Industry," EPA/310-R-05-002, February 2005. 

Pollutants and Wastewaters Generated

The healthcare industry provides a variety of services to support the healthcare needs of a 

community or individuals. Many of the activities in healthcare result in waste outputs and air or 

water pollution. In order to understand which activities generate polluting waste outputs, it is 

necessary to look at various functions within healthcare, and understand the products and 

supplies used and the resulting wastes. 

Healthcare is vastly different from the many industries that have a defined ‘product line,’ 

a finite number of input materials and defined and consistent ‘waste outputs.’ There are 

thousands of procedures, tests, processes, and activities, which encompass as many materials. 

The hazardous component in healthcare waste tends to be made up of small amounts of many 

different wastes, emanating from many different departments. Due to the decentralized nature of 

service delivery in healthcare, there can be various departments with different functions all 

generating various amounts of hazardous waste.

In addition to the wide variety of the operations within this sector is the fact that 

comparatively little information exists on the pollutant discharges from the six industrial sectors 

identified by stakeholders. This is due to the fact that most facilities in this proposed grouping are 

indirect dischargers (i.e., no discharge data collected by PCS) and few facilities in this category 

are TRI reporters (only federal facilities in the healthcare industry are required to report pollutant 

 2

U.S. EPA. Profile of the Healthcare Industry. Available online at: 

http://www.epa.gov/compliance/resources/publications/assistance/sectors/notebooks/health.pdf. EPA/310-R-05-002. 

February 2005.
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release and other waste management information to TRI).3

 3

Ibid, Page 52.
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However, currently available data suggest some common pollutants in wastewaters from 

these six industrial sectors. These pollutants include metals (e.g., silver and mercury), inorganic 

compounds (e.g., barium), organics (e.g., phenols, acetone, solvents), pharmaceutical (including 

antibiotics, genotoxins, antineoplastics, hormones, and other organic wastewater contaminants), 

biological agents (e.g., pathogens, viruses), and other chemical (e.g., cleaning agents, solvents). 

Source of some of these pollutants include: (1) photoprocessing (e.g., silver);4 (2) improper 

disposal of mercury containing equipment or disposal of dental mercury amalgam (e.g., 

mercury); (3) sewage disposal of spent or unused drugs (e.g., pharmaceuticals, endocrine 

disrupting chemicals);5,6 and diagnostic testing (e.g., barium). Many more examples are given in 

the Profile of the Healthcare Industry.

Photograph and X-ray processing is carried out in dental clinics, hospitals, and 

photo-processing laboratories. Silver-based photographic materials consist of solid crystals of 

silver chloride or silver bromide suspended in gelatin and coated on a film or paper support. The 

processing of photographic films and papers may vary somewhat, but generally consists of the 

following three steps: (1) Development of the image, in which metallic silver is formed in the 

image areas; (2) Removal of some or all of the silver, in which silver is converted to crystals of 

silver bromide or silver chloride and then removed as a soluble silver-thiosulfate complex in a fix 

solution; and (3) Stabilizing the image by rinsing residual thiosulfate and silver-thiosulfate 

complexes out of the emulsion layers with water, or, in the case of washless processing, with a 

stabilizer solution instead of water.7

bromide, chromium, cyanide, iron, selenium, and zinc.

Silver is the primary contaminant of concern in photo 

processing wastewater. Discharges may also contain elevated concentrations of ammonia,

 4

U.S. Department of Defense. Handbook Nondomestic Wastewater Control and Pretreatment Design 

Criteria. MIL-HDBK-1005/17. Available online at: http://www.afcesa.af.mil/ces/cesc/wastewater/1005_17.PDF. 

October 30, 1998.

5

Giger, Walter, Alfredo C. Alder, Eva M. Golet, Hans-Peter E. Kohler, Christa S. McArdell, Eva Molnar, 

Hansrudolf Siegrist, and Marc J.-F. Suter. Occurrence and Fate of Antibiotics as Trace Contaminants in 

Wastewaters, Sewage Sludges, and Surface Waters. Chimia 57 (2003) 485–491 © Schweizerische Chemische 

Gesellschaft. ISSN 0009–4293. Available online at: at http://www.sach.ch/doc/chimia/sept03/giger.pdf.

6

Endocrine Disrupting Chemicals (EDCs) and Pharmaceuticals and Personal Care Products (PPCPs) in 

Reclaimed Water in Australia. Australian Water Conservation and Reuse Research Program. Available online at: 

www.clw.csiro.au/priorities/urban/awcrrp/stage1files/AWCRRP_1H_Final_27Apr2004.pdf. January 2004.

7

U.S. Department of Defense. Handbook Nondomestic Wastewater Control and Pretreatment Design 

Criteria. MIL-HDBK-1005/17. Available online at: http://www.afcesa.af.mil/ces/cesc/wastewater/1005_17.PDF. 

October 30, 1998.
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Dentistry services, including oral surgery, periodontics, and oral healthcare, are provided 

in a wide range of settings from individual private practices to dental surgery centers that are free 

standing or located within large teaching and research hospitals. It is estimated that dental 

facilities in the United States used 40 metric tons of mercury in 1997, which may be placed in 

teeth, recycled, discharged into wastewater, or disposed of as waste.8 About 50 percent of dental 

amalgam is mercury. A study by the Association of Metropolitan Sewerage Agencies found that 

dental offices are the largest source of mercury to POTWs, contributing more than 35 percent of 

mercury influent to the POTWs studied.9 Other studies have estimated the contributions to be as 

high as 80 percent.10 Other wastes from dentistry include X-ray wastes (developer chemicals, 

silver discharges, lead shields), high-level disinfectants, chemical sterilizers, nitrous oxide, and 

biohazardous wastes, especially sharps.

Two data sources for the Hospitals and Clinics industrial sector include the EPA 

document titled Preliminary Data Summary for the Hospital Point Source Category, EPA 

440-1-89-060-n, September 1989,11 and the U.S. Department of Defense document titled, 

Handbook Nondomestic Wastewater Control and Pretreatment Design Criteria, 

MIL-HDBK-1005/17, October 1998.12 These documents state that hospital wastewater is 

primarily domestic in nature. Although some additional pollutants are added to the wastewater 

(e.g., solvents, metals, and chemical products), they are generally treated at the point of 

generation or mixed with other wastewaters and diluted prior to discharge. As a result, effluent 

concentrations for hospitals are very similar to domestic wastewater without the need for a 

centralized on-site wastewater treatment system. These documents did not, however, address the 

concern of pharmaceuticals or endocrine disrupting chemicals in wastewater.

Available Pollution Prevention and Treatment Options

There are a variety of resources on pollution prevention, wastewater treatment, and water 

conservation available to the six industrial sectors in the proposed grouping. There are 

similarities in the potential pollution prevention, wastewater treatment, and water conservation 

 8

Stone, Mark E., DDS. “The Effect of Amalgam Separators on Mercury Loadings to Wastewater Treatment 

Plants,” CDA Journal, Vol. 32, No.7, July 2004.

9

Association of Metropolitan Sewerage Agencies. Mercury Source Control & Pollution Prevention 

Program Evaluation: Final Report. March 2002 (Amended July 2002).

10Stone, 2004.

11U.S. EPA Office of Water Regulations and Standards. Preliminary Data Summary for the Hospitals 

Point Source Category. EPA 440/1-89/060-n. September 1989.

12U.S. Department of Defense. Handbook Nondomestic Wastewater Control and Pretreatment Design 

Criteria. MIL-HDBK-1005/17. Available online at: http://www.afcesa.af.mil/ces/cesc/wastewater/1005_17.PDF. 

October 30, 1998.
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across the six industrial sectors. For example, some the options available to the proposed Health 

Services Industry category revolve around pollution prevention and treatment at the unit 

operation as opposed to a centralized on-site wastewater treatment system. The following 

documents a number of these examples.

• Resources are presented on the Hospitals for a Healthy Environment web page 

(http://www.h2e-online.org) for water conservation fact sheets.

• The document titled “Water Conservation Checklist: Hospitals/Medical Facilities; Every 

Drop Counts!” published by the North Carolina Department of Environment and Natural 

Resources Division of Pollution Prevention and Environmental Assistance contains a list 

of water use areas throughout a hospital and ways to reduce water consumption in each of 

those areas. This document can be found at: http://www.p2pays.org/ref/23/22006.pdf.

Based on this document water use in hospitals can be reduced considerably as shown in 

the following table:

Types of Water Uses Average Water Use (% of total) Potential Savings (% of total)

Cooling 53 32

Domestic 24 10

Cleaning 10 9

Kitchen 5 --

Process 4 --

Other 4 --

TOTALS 100% 51%

139,214 gpd 71,000 gpd

Source: ICI Conservation in the Tri-County Area of the Southwest Florida Water Management District 

(SWFWMD). SWFWMD. Available online at: 

http://www.swfwmd.state.fl.us/conservation.waterwork/checkhospital.htm. Accessed August 10, 2005. 

November 1997.

• The New Hampshire Department of Environmental Services developed an environmental 

fact sheet titled “Water Efficiency Practices for Health Care Facilities” which also 

presents practices by water use area. This document can be found at: 

http://www.des.state.nh.us/factsheets/ws/ws-26-14.htm.

• Southwest Florida Water Management District (SWFWMD) also has a similar factsheet 

titled “Water Conservation @ Work: Hospitals.” This document can be found at: 

http://www.swfwmd.state.fl.us/watercon/waterwork/checkhospital.htm. 
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• Healthcare Purchasing News has developed a Self Study Series to evaluate 

environmentally preferable products. One item in this series discusses microfiber mops 

which use less water than conventional cotton mops. The article discusses the economic, 

environmental, employee, and patient benefits of using microfiber mops. This document 

can be found at: http://198.151.15.185/pubs/ShouldYouMicrofiber.pdf.

• The University of Wisconsin Cooperative Extension developed a hospital waste reduction 

checklist which includes strategies for reducing wastewater discharges. These strategies 

include substitution of less toxic materials, procedures for moving or cleaning sewer 

lines, traps, or sumps, and chemical storage and disposal options. This document can be 

found at: http://www.uwex.edu/shwec/Pubs/pdf/425-9602.pdf.

• The Medical Academic and Scientific Community Organization prepared a pretreatment 

manual for use by hospitals to help solve a sewer discharge compliance problem. The 

manual outlines the elements of typical source reduction programs and a wastewater 

pretreatment strategy. This document can be found at: 

http://www.masco.org/mercury/pretreatment/index.html. 

• EPA’s Small Business Ombudsman developed a fact sheet for walk-in urgent care 

facilities and smaller hospitals. The fact sheet explains some of the best management 

practices (BMPs) related to toxic chemicals or hazardous materials used as part of the 

diagnostic, treatment, and cleaning processes used in these smaller facilities. This 

document can be found at: 

http://www.smallbiz-enviroweb.org/html/pdf/BMP_HealthCare-4.pdf.13

• EPA Regions 1 and 2 have on-going programs to provide information to help healthcare 

facilities reduce environmental impacts of their operations and improve their 

understanding of and compliance with environmental regulations. The EPA programs 

also help facilities realize the cost savings and environmental benefits that can be attained 

through improvements in recycling, energy efficiency and water conservation. More 

information can be found at: http://www.epa.gov/region1/healthcare/ and 

http://www.epa.gov/region2/healthcare/.

With respect to controlling mercury discharges, healthcare facilities contain mercury in 

some medical equipment (e.g. pressure gauges, thermometers), laboratory reagents, and common 

facility items (e.g., fluorescent lights, thermostats, cleaning supplies). Some hospitals approached 

the problem of mercury use within their facilities by following some basic steps, including:

 13North Carolina Department of Environment and Natural Resources. Environmental Best Management 

Practices for Small Businesses. October 2004. Available online at: 

http://www.smallbiz-enviroweb.org/html/pdf/BMP_HealthCare-4.pdf.
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• Conducting inventories to identify sources of mercury within their facilities;

• Making recommendations to existing hazardous waste and safety committees and the 

administration for reducing or eliminating these sources;

• Instituting immediate steps for mercury reduction; and,

• Devising long-term goals for the virtual elimination of mercury from their facilities. 

An example of this approach was documented at two major Detroit hospitals that instituted 

mercury pollution prevention plans. Wastewater sampling was conducted to evaluated their 

performance. Before the mercury pollution prevention program, mercury measures at these sites were 

in the range of 0.28 ppb to 0.96 ppb. After the program was instituted, these figures dropped to 0.09 

ppb to 0.15 ppb.14

Recently, EPA modified Resource Conservation and Recovery Act (RCRA) hazardous waste 

regulations to allow the healthcare facilities and other facilities that generate spent mercury-containing 

equipment to send this spent equipment to a central consolidation point 

(http://www.epa.gov/epaoswer/hazwaste/recycle/electron/crt.htm). EPA is now managing spent 

mercury-containing equipment under the universal waste program 

(http://www.epa.gov/epaoswer/hazwaste/id/univwast.htm). This regulatory change is expected to 

increase the number of these articles, items and devices collected (including healthcare mercurycontaining equipment such as thermometers and sphygmomanometers), but more importantly, to 

increase the amount of mercury being diverted from the non-hazardous waste stream (e.g., discharges 

to POTWs) into the hazardous waste stream because it will allow generators, especially those that 

generate this waste sporadically, to send it to a central consolidation point. Before this regulatory 

change, these materials could not be consolidated by an entity unless it had a RCRA permit. Under 

the universal waste program, a handler of universal waste can send the universal waste to another 

handler, where it can be consolidated into a larger shipment for transport to a destination facility. 

Therefore, spent mercury-containing equipment will be easier to send to recycling and proper 

disposal, making it less likely that it will be sent for improper disposal.

With respect to photoprocessing, EPA’s Preliminary Data Summary for the 

Photoprocessing Industry, 199715

 14Williams, Guy. Mercury Pollution Prevention in Healthcare. Available online at: 

http://www.newmoa.org/prevention/topichub/22/Mercury_Pollution_Prevention_in_Healthcare_NWF.htm. 1997.

, identified control and treatment technologies that are available 

to photoprocessing operations in the health services category. These include source reduction, 

water reduction, and silver recovery technologies. The following table, which is reproduced 

from the 1997 PDS, provides a comparison of various silver recovery and management systems. 

15U.S. EPA Office of Water. Second Preliminary Technical Assessment of the Best Available Technology, 

Best Demonstrated Technology and Pretreatment Technology for the Printing and Publishing Point Source 

Category. Docket OW-2003-0074. December 1997.
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According to the PDS, silver recovery is almost always practiced to some extent. The most 

common methods are metallic replacement and electrolytic recovery.
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Silver Recovery Technologies

Technology Advantages Disadvantages

Metallic Replacement Can achieve 99% recovery;

Can be used for all silver rich 

solutions;

Low capital and operating and 

maintenance costs;

Simple operation

Must be replaced on schedule;

Tendency to channel and cause 

concentrated silver discharge; 

efficiency diminishes with use;

High smelting and refining costs;

effluent not suitable for re-use

Electrolytic Recovery Can achieve 90% recovery;

No additional chemicals released; fix 

solution can be recycled;

Moderate capital costs

Low refining costs

Cannot achieve 5 mg/L;

Not suitable for silver-poor solutions

Precipitation Can attain 0.1 mg/L

Little maintenance

Low to moderate capital costs

High smelting and refining costs;

complex operation;

operation costs vary from moderate to 

high;

treated solution not suitable for reuse

Evaporation/Distillation Can reduce wastes up to 90%

Virtually zero overflow of silver

High energy requirements;

Moderate to high capital cost

Reverse Osmosis Efficiently recovers silver from dilute 

silver wastestreams;

Reduces effluent volume significantly;

No water treatment chemicals required;

Purified water is recyclable

Capital and O&M Costs vary 

significantly;

Frequent maintenance of membranes 

and pumps;

works best with dilute solutions

Virtually all discharging photoprocessors discharge indirectly to POTWs. Many POTWs 

have stringent silver limits in their NPDES permits or need to reduce metals concentrations in 

biosolids. POTWs have identified photographic facilities as a whole as a major source of silver. 

In an attempt to provide photoprocessing facilities and POTWs with a cost-effective alternative 

to numeric limits and monitoring, in 1997, AMSA, the Silver Council and two industry groups 

for the Photographic industry developed a “Code of Management Practices for Silver 

Dischargers” (Silver CMP)16

 16Association of Metropolitan Sewerage Agency (AMSA) and the Silver Council. Code of Management 

Practices for Silver Dischargers. Available online at: 

http://www.p2pays.org/ref/02/2003/11-17/features/digital_2003.html. Accessed January 25, 2004.

. The Silver CMP provides recommendations on control 

technologies and management practices for controlling silver discharges to POTWs, and 

encourages pollution prevention technologies such as water conservation. The recommended 

practices are defined by a minimum recovery of silver from silver-rich processing solutions (e.g. 

90%, 95%, and 99%). The minimum recovery and recommended practices vary with the size of 

the photoprocessor, defined by flow volume of silver-rich solution and wash water. Four 
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POTWs documented loadings reductions of 20% to 52% over historical baselines after CMP 

implementation.

Technology exists to remove dental mercury amalgam discharges. EPA’s Environmental 

Technology Verification program demonstrated mercury removals for an amalgam separator at 

99.6%-99.9%.17

Finally, common techniques available for all six industrial sectors for reducing or 

eliminating pollutant discharges from laboratory wastewaters include the following:18

• Substitute chemicals with less toxic alternatives.

• Use the minimum amount of chemical required.

• Label all chemical containers properly.

• Store glassware and breakable containers on textured rubber mats.

• Order chemicals in plastic-coated bottles.

• Transport solvent bottles in protective holders.

• Keep doors of chemical storage cabinet latched.

• Equip chemical storage shelves with barriers one-fifth the height of the tallest container.

• Keep all counter-top chemicals in a tray or within bermed areas.

• Never store chemical bottles and containers in sinks.

• Surround sinks and counter tops with a protective lip.

• Plug all floor drains.

• Protect safety shower drain from chemical spills with temporary plugs or sumps.

• Maintain adequate and readily available supply of spill cleanup materials.

• Check chemical disposal guidelines and POTW acceptance criteria prior to discharging to 

a drain.

• Keep work areas clean and well organized to help prevent accidents.

• Use drip pans and splash guards where spills frequently occur.

 17U.S. EPA. “Environmental Technology Verification Report: Removal of Mercury from Dental Office 

Wastewater”. Available online at: http://www.epa.gov/etv/pdfs/vrvs/09_vr_drna.pdf. NSF 

02/01/EPAWQPC-SWP. September 2002.

18Anastas, P. T.; Warner, J. C. Green Chemistry: Theory and Practice, Oxford University Press: New York, 

1998, Cited at: www.chemistry.org/portal/a/c/s/1/acsdisplay.html?DOC=greenchemistryinstitute\gc_principles.html.
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Attachment 1: 

Independent and Stand Alone Medical and Dental Laboratories Memorandum
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Memorandum

From: Carey Johnston

USEPA/OW/OST

ph: (202) 566 1014

johnston.carey@epa.gov

To: Public Record for the 2006 Effluent Guidelines Program Plan

EPA Docket Number OW-2004-0032 (www.epa.gov/edockets/)

Date: August 11, 2005

Re: Independent and Stand Alone Medical and Dental Laboratories

Activities at medical and dental laboratories differ from those of other types of standalone 

laboratories. These operations are only covered by 40 CFR Part 460, Hospitals Point Source 

Category, if they are located at a directly-discharging hospital with greater than 1,000 beds.

Industry Profile

Medical and dental laboratories include SIC codes 8071 and 8072. The 1987 SIC Code 

Manual defines these SIC codes as follows:

• 8071: Establishments primarily engaged in providing professional analytic or diagnostic 

services to the medical profession or to the patient as prescribed by a physician. 

Laboratories engaged in the manufacture of medical or pharmaceutical products are 

classified in Manufacturing. Laboratories engaged in commercial medical research are 

classified in Industry 8731, and those engaged in noncommercial medical research are 

classified in Industry 8733.

• 8072: Establishments primarily engaged in making dentures, artificial teeth, and 

orthodontic appliances to order for the dental profession. The manufacture of teeth other 

than to order is classified in Manufacturing. Establishments providing dental x-ray 

laboratory services are classified in Industry 8071.

SIC Code 8071 includes medical laboratories that test blood and other tissue samples for 

pathogens, viruses, and chemicals such as HIV, blood sugar, and drugs. Two prominent 

laboratories include Quest Diagnostics and American Medical Laboratories. SIC Code 8072 

includes labs that manufacture crowns, bridges, dentures, veneers, orthodontic appliances and 

other dental prosthetics.

Table 1-1 shows Census data for medical and dental laboratories. No stand-alone 
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medical or dental laboratories reported to TRI in 2000. Table 1-2 shows that only three medical 

laboratories have data available in the 2000 PCS, and all three are minor dischargers. Almost all 

facilities discharge indirectly: only three of the approximately 18,000 stand-alone medical and 

dental laboratories discharge directly. No dental laboratories have data available in 2000 PCS.

Table 1-1. Census Data

SIC Code NAICS Code

Number of 

Facilities in 

1997

Number of 

Facilities in 

2002

8071: Medical laboratories 621511: Medical laboratories 4,655 5,513

621512: Diagnostic imaging centers 4,421 5,577

8072: Dental laboratories 339116: Dental laboratories 7,609 7,089

Table 1-2. TRI Facility Counts

SIC 

Code

Number of Facilities Reporting to 2000 TRI Number of Facilities 

Reporting to PCS in 2000 

Direct (Minors) -Only Indirect-Only Both No Discharge 

Reported

8071 0 0 0 0 3

8072 0 0 0 0 0

Wastewater Characteristics

Wastewater Quantity

Table 1-3 presents the information available for the three medical laboratories in the 2000 

PCS database.

Table 1-3. Wastewater Flows in PCS

SIC NPID Flow (MGY)

8071 ME0001635 5.22

8071 MT0028487 69.0

8071* WV0105112* 28.8*

*This NPID belongs to a U.S. Fish and Wildlife Service office in West 

Virginia. The SIC code designation is most likely an error.

At this time, EPA did not locate other data sources for wastewater quantity for these types 
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of laboratories.

Raw and Treated Wastewater Quality

Table 1-4 lists the facilities in the 2000 PCS database. The U.S. Fish and Wildlife 

Service office in West Virginia SIC code designation is most likely an error.

Table 1-4. List of Facilities in PCSLoads2000 (All Minors)

SIC Name Major/Minor City State TWPE

8071 Mount Desert Island Biological Minor Bar Harbor Maine 21.2

8071 Rocky Mountain Laboratories Minor Hamilton Montana 1.86

8071 U.S. Fish & Wildlife Service Minor Shepherdstown West Virginia 0

Casting molds of dental or medical prosthetics generates wastewater with plaster solids, 

and therefore greater TSS, in wastewater. EPA does not believe that amalgam or any other 

mercury-containing materials are used in dental laboratory processes (Galsky). OECA’s 2004 

Healthcare Sector Notebook1 notes that molding casts, prosthetics, and other medical lab items 

may use Cerrobend®, a ductile, formable metal that includes lead. 

Photograph and X-ray processing is carried out in dental clinics, hospitals, and 

photo-processing laboratories. Silver-based photographic materials consist of solid crystals of 

silver chloride or silver bromide suspended in gelatin and coated on a film or paper support. The 

processing of photographic films and papers may vary somewhat, but generally consists of the 

following three steps: (1) Development of the image, in which metallic silver is formed in the 

image areas; (2) Removal of some or all of the silver, in which silver is converted to crystals of 

silver bromide or silver chloride and then removed as a soluble silver-thiosulfate complex in a fix 

solution; and (3) Stabilizing the image by rinsing residual thiosulfate and silver-thiosulfate 

complexes out of the emulsion layers with water, or, in the case of washless processing, with a 

stabilizer solution instead of water.2

bromide, chromium, cyanide, iron, selenium, and zinc. At this time, EPA did not locate any other 

data sources on raw or treated wastewater quality.

 Silver is the primary contaminant of concern in photo 

processing wastewater. Discharges may also contain elevated concentrations of ammonia,

On-Site Wastewater Treatment/Pretreatment

 1

U.S. EPA Office of Enforcement and Compliance Assurance. Profile of the Healthcare Industry. 

February 2005. Available online at: 

http://www.epa.gov/Compliance/resources/publications/assistance/sectors/notebooks/health.pdf.

2

U.S. Department of Defense. 1998. Handbook Nondomestic Wastewater Control and Pretreatment 

Design Criteria. MIL-HDBK-1005/17. Available online at: 

http://www.afcesa.af.mil/ces/cesc/wastewater/1005_17.PDF. Accessed October 30, 1998.
Παγε 17 οφ 4

From OECA’s 2004 Healthcare Sector Notebook, in rooms where casts are fitted and/or 

plaster molds are made, plaster recovery systems may be used. A phone conversation with a 

dental laboratory confirmed the use of plaster recovery systems (Galsky). Silver recovery is one 

method of pollution prevention for photoprocessing wastewaters. More details on this and other 

technologies are documented in the Photoprocessing profile. Common techniques at reducing or 

eliminating pollutant discharges from laboratory wastewaters are also detailed in the Independent 

and Standalone Laboratories profile.

References

1. National Association of Dental Laboratories web page. Available at 

http://www.nadl.org/. As accessed on October 22, 2004.

2. Phone conversation from Ellie Codding, EPA, to Mr. Larry Galsky, CDT, of Galsky 

Dental Laboratories. Dental Laboratory Processing. November 2, 2004.

3. U.S. EPA Office of Enforcement and Compliance. Profile of the Healthcare Industry. 

EPA/310-R-04-001. February 2005. Available online at: 

http://www.epa.gov/Compliance/resources/publications/assistance/sectors/notebooks/heal

th.pdf.

4. Valuations Resources.com web site on Medical Laboratories. Available online at 

http://www.valuationresources.com/Reports/SIC8071MedicalLaboratories.htm. 

Accessed October 22, 2004.
Attachment 2:

Offices and Clinics of Dentists Memorandum
Παγε 19 οφ 2

Memorandum

From: Carey Johnston

USEPA/OW/OST

ph: (202) 566 1014

johnston.carey@epa.gov

To: Public Record for the 2006 Effluent Guidelines Program Plan

EPA Docket Number OW-2004-0032 (www.epa.gov/edockets/)

Date: August 11, 2005

Re: Offices and Clinics of Dentists

Industry Profile

Dental facilities include facilities in SIC Code 8021, Offices and Clinics of Dentists. The 1987 SIC Code Manual 

defines SIC Code 8021 as follows:

• This industry comprises establishments of health practitioners having the degree of D.M.D. (Doctor of dental 

medicine), D.D.S. (Doctor of dental surgery), or D.D.Sc. (Doctor of dental science) primarily engaged in the 

independent practice of general or specialized dentistry or dental surgery. These practitioners operate private or 

group practices in their own offices (e.g., centers, clinics) or in the facilities of others, such as hospitals or HMO 

medical centers. They can provide either comprehensive preventive, cosmetic, or emergency care, or specialize in a 

single field of dentistry.

Table 1-1. Census Data

SIC Code NAICS Code Number of Facilities in 1997

8021 : Offices and Clinics of Dentists 6212: Offices of Dentists 114,178

Table 1-2 shows the facility counts available from TRI and PCS.

Table 1-2. Facility Counts

SIC Code

Number of Facilities Reporting to 2000 TRI Number of 

Facilities 

Reporting to PCS 

(Minors)

Direct-Only Indirect-Only Both No Water 

Discharge Reported

8021 0 0 0 0 2
Παγε 20 οφ 2

Wastewater Characteristics

Wastewater Quantity

Table 1-3 summarizes the wastewater flow data available in the 2000 PCS database. No 

facilities reported to the 2000 TRI.

Table 1-3. Wastewater Flow Data from PCSLoads2000

SIC NPDES ID Flow, MGY

8021 FL0033154 0.120

8021 MD0053155 1.43

Raw and Treated Wastewater Quality

Almost all dental facilities discharge to POTWs. Of the 114,178 facilities in the 1997 

Census, only 2 appear in the PCS database, both of which are minor discharges. Table 1-4 lists 

the facilities noted as SIC Code 8021 in the 2000 PCS database. By name, both appear to be 

treatment plants, not dental facilities.

Table 1-4. List of Facilities in PCSLoads2000

SIC Name City NPID Major/Mi

nor

8021 Oak Lane Building Sewage Treatment 

Plant

Jacksonville FL0033154 Minor

8021 Thunderbird Motel WWTP Newburg MD0053155 Minor

On-Site Wastewater Treatment/Pretreatment

Dental facility pretreatment usually includes:

• Silver recovery for X-ray wastes and

• Simple drain traps in patient chair-side sinks to recover solid particles of amalgam and 

other tissue.
Attachment 3:

Hospitals and Clinics Memorandum
Παγε 22 οφ 16

Memorandum

From: Carey Johnston

USEPA/OW/OST

ph: (202) 566 1014

johnston.carey@epa.gov

To: Public Record for the 2006 Effluent Guidelines Program Plan

EPA Docket Number OW-2004-0032 (www.epa.gov/edockets/)

Date: August 11, 2005

Re: Hospitals and Clinics

Introduction

40 CFR Part 460, promulgated in 1976, applies to effluent discharges to surface water 

from hospitals with greater than 1,000 occupied beds. In 1989, EPA published a Preliminary 

Data Summary (PDS) for the Hospitals Point Source Category1

. EPA’s Office of Enforcement 

and Compliance Assistance (OECA) developed a Healthcare Sector Notebook in February 20052

. 

Industry Profile

Hospitals include facilities in SIC codes 8062, General Medical and Surgical Hospitals, 

8069, Specialty Hospitals, Except Psychiatric (children's hospitals), and 8063, Psychiatric 

Hospitals. The 1987 SIC Code Manual defines these SIC codes as follows: 

• 8062 General Medical and Surgical Hospitals - Establishments primarily engaged in 

providing general medical and surgical services and other hospital services. Specialty 

hospitals are classified in Industries 8063 and 8069. This SIC code includes only General 

Medical and Surgical Hospitals

 1

U.S. EPA Office of Water Regulations and Standards. Preliminary Data Summary for the Hospitals 

Point Source Category. EPA 440/1-89/060-n. September 1989.

2

U.S. EPA Office of Enforcement and Compliance Assurance. Profile of the Healthcare Industry. 

EPA/310-R-04-001. Available online at: 

http://www.epa.gov/Compliance/resources/publications/assistance/sectors/notebooks/health.html. February 2005.

• 8063 Psychiatric Hospitals - Establishments primarily engaged in providing diagnostic 

medical services and inpatient treatment for the mentally ill. Establishments, known as 

hospitals, primarily engaged in providing health care for the mentally retarded are 
Παγε 23 οφ 16

classified in Industry 8051. This SIC code includes: Mental hospitals, except for the 

mentally retarded and Psychiatric hospitals.

• 8069 Specialty Hospitals, Except Psychiatric - Establishments primarily engaged in 

providing diagnostic services, treatment, and other hospital services for specialized 

categories of patients, except mental. Psychiatric hospitals are classified in Industry 8063. 

This SIC code includes: Alcoholism rehabilitation hospitals; Cancer hospitals; 

Children's hospitals; Chronic disease hospitals; Drug addiction rehabilitation hospitals; 

Eye, ear, nose, and throat hospitals: in-patient; Hospitals, specialty: except psychiatric; 

Maternity hospitals; Orthopedic hospitals; Rehabilitation hospitals: drug addiction and 

alcoholism; and Tuberculosis and other respiratory illness hospitals.

Table 1-1. Census Data

SIC Code NAICS Code

Number of 

Facilities in 

1997

Number of 

Facilities in 

2002

8062: General Medical and 

Surgical Hospitals

622110: General Medical and 

Surgical Hospitals 

5,487 5,404

8063: Psychiatric Hospitals 622210: Psychiatric and Substance 

Abuse Hospitals

801 605

8069: Other Specialty 622310: Specialty (Except Psychiatric 

and Substance Abuse) Hospitals

397 316

Total 6,685 6,325

EPA’s 1989 PDS states that, using 1985 data, 97 percent of the hospitals are indirect 

dischargers. This was an increase from 1975, when 92 percent of hospitals were indirect 

dischargers.

Table 1-2 shows the facility counts available from the 2000 TRI and PCS databases. 

Using 2002 U.S. Census and 2000 PCS data, 34 of 6,325 hospitals are direct dischargers, and 

99.5 percent of hospitals are indirect dischargers. Note: hospitals are exempt from TRI 

reporting unless they are federal facilities.

Table 1-2. 2000 TRI and PCS Facility Counts

SIC 

Code

Number of Facilities Reporting to 2000 TRI Number of Facilities 

Reporting to PCS 2000

Direct Indirect Both No Discharge Reported Direct (Major/Minor)

8062 0 0 0 1 2 20

8063 0 0 1 0 1 7
Παγε 24 οφ 16

8069 0 0 0 0 0 4

Total 0 0 1 1 3 31

Wastewater Characteristics

Wastewater Quantity

EPA located wastewater volume data from the 1989 PDS, textbooks, TRI, and PCS. 

Table 1-3 summarizes the wastewater flow data from the PDS and textbooks.

Table 1-3. Typical Wastewater Flow Rates from Hospitals

Type of Establishment Wastewater Flow Range

(gal/day per unit) Unit Textbook Source

Hospital 242 Bed 1989 PDS*

Hospital, medical 125 - 240 Bed Metcalf & Eddy

Hospital, mental 75 - 140 Bed

Hospital 150 - 250+ Person Standard Handbook of 

Environmental Engineering

*The 1989 PDS cites 1976 data from the American Hospital Association (AHA), that approximately 242 gallons of 

wastewater are generated per bed per day at hospitals. The PDS also states that, “based on the latest information, 

this figure has not changed.” 

From the Center for Medicare and Medicaid Services (CMS) web site3

, the number of 

hospital beds in 2000 was 983,628. Using the data in Table 3, hospitals discharge an estimated 

120 to 240 MGD of wastewater, or 43,800 to 87,600 MGY.

Based on a survey of 26 Florida hospitals, conducted by the Southwest Florida Water 

Management District (SWFWMD)4

, hospitals use an average of 139,214 gallons per day (GPD) 

of water. Table 1-4 shows the types of water use.

Table 1-4. Types of Hospital Water Use

Types of Water Uses Average Water Use

 3

Centers for Medicare and Medicaid Services Web Page. Available online at: 

http://www.cms.hhs.gov/charts/healthcaresystem/chapter2.asp. Accessed October 22, 2004.

4

Southwest Florida Water Management District. November 1997. Water Conservation Facts @ Work: 

Hospitals. Available online at: http://www.swfmd.state.fl.us/watercon/waterwork/checkhospital.htm. Accessed 

August 10, 2005.
Παγε 25 οφ 16

(% of total)

Cooling 53

Domestic 24

Cleaning 10

Kitchen 5

Process 4

Other 4

TOTALS 100%

139,214 gpd

Source: Southwest Florida Water Management District. November 1997. Water Conservation 

Facts @ Work: Hospitals.

Table 1-5 summarizes the 2000 PCS data available for flow.

Table 1-5. 2000 PCS Data Available for Flow

SIC 

Code Flow, MGY

8062 Max 3,150

Min 0.27

Median 18.7

8063 Max 12,300

Min 0.34

Median 24.8

8069 Max 15.8

Min 2.77

Median 12.9

Raw Wastewater Quality

Hospital wastewater is expected to contain normal sanitary wastewater contaminants

plus cleaning agents, germicides, acids, and chemicals associated with laboratory and health care 

services. The various medical industry wastewaters include wastewaters from clinical 

laboratories, research laboratories, medical waste incinerators equipped with fume scrubbers, 

vehicle maintenance facilities, and hospital laundries. Silver may be present in the combined 
Παγε 26 οφ 16

hospital wastewater as a result of X-ray processing,5 This unit operation is described in more 

detail in the Independent and Stand-alone Medical and Dental Laboratories and 

Photoprocessing profiles. Wastewater produced by hospitals and by hospital-related industries 

originates from many sources.

The 1989 PDS states that EPA sampled four hospitals to better characterize the contents 

of hospital wastewater, and determine if hospitals should be selected for further study. Criteria 

for selection for further study included the presence of unexpected chemicals or chemical

concentrations above wastewater treatability levels. Analysis included over 400 toxic and 

hazardous pollutants. Based on sampling results, neither criteria were met, although five 

pollutants were detected at levels higher than expected for non-industrial wastewater. These 

pollutants were silver, phenols, barium, acetone, and mercury.

Since the 1989 PDS, many studies world wide raise the question of the fate of 

pharmaceuticals, including antibiotics, genotoxins, and antineoplastics, in hospital and domestic 

wastewater. In 2003, the USGS6 published a study of 139 streams, which they tested for 

pharmaceuticals, hormones, and other organic wastewater contaminants (OWCs). At least one 

OWC was detected in 80% of the streams sampled, with 82 of the 95 analyzed OWCs 

determined in this study detected in at least one sample. The antibiotics erythromycin and 

lincomycin were two of the most commonly detected OWCs. In addition to antibiotics there 

may be other pharmaceuticals and personal care products in the untreated effluent including 

potential endocrine disrupting chemicals.7,8 Although antibiotics are excreted in urine from 

households, hospital toilet waste has a greater likelihood of containing antibiotics.

 5

U.S. Department of Defense. 1998. Handbook Nondomestic Wastewater Control and Pretreatment 

Design Criteria. MIL-HDBK-1005/17. Available online at: 

http://www.afcesa.af.mil/ces/cesc/wastewater/1005_17.PDF. Accessed October 30, 1998.

6

Barnes, Kimberlee K., Dana W. Kolpin, Michael T. Meyer, E. Michael Thurman, Edward T. Furlong, 

Steven D. Zaugg, and Larry B. Barber. Water-Quality Data for Pharmaceuticals, Hormones, and Other Organic 

Wastewater Contaminants in U.S. Streams. U.S. Geological Survey. 1999-2000. Available online at: 

http://toxics.usgs.gov/pubs/OFR-02-94/. 

7

Giger, Walter, Alfredo C. Alder, Eva M. Golet, Hans-Peter E. Kohler, Christa S. McArdell, Eva Molnar, 

Hansrudolf Siegrist, and Marc J.-F. Suter. Occurrence and Fate of Antibiotics as Trace Contaminants in 

Wastewaters, Sewage Sludges, and Surface Waters. Chimia 57 (2003) 485–491 © Schweizerische Chemische 

Gesellschaft. ISSN 0009–4293. Accessible at http://www.sach.ch/doc/chimia/sept03/giger.pdf.

8

Australian Water Conservation and Reuse Research Program. Endocrine Disrupting Chemicals (EDCs) 

and Pharmaceuticals and Personal Care Products (PPCPs) in Reclaimed Water in Australia. Available online at:

http://www.clw.csiro.au/priorities/urban/awcrrp/stage1files/AWCRRP_1H_Final_27Apr2004.pdf. January 2004.
Παγε 27 οφ 16

Hospital may operate laundry facilities which typically process linens, gowns and lab 

coats that will contribute a certain amount of organic material, fats, oils and grease (FOG) and an 

alternating range of pH (alkaline detergent followed by an acidic sanitizer) to the wastestream. 

Depending upon the processes employed, the hospital laundry wastestream can have elevated 

temperatures and pH extremes and can contain starch, particulate (including lint), proteins (blood 

products), detergents, and oxidizers (bleach or other disinfectant). BOD and COD concentrations 

from laundry wastewater are usually in the normal range for domestic sewage. Some laundry 

chemicals (sodium hydroxide and bleach) are known to often have significant levels of mercury 

contamination. In addition, just one broken mercury thermometer can cause temporary high 

levels of mercury in the laundry wastewater. Hospital laundry wastewater flows can vary from a 

few hundred gallons per day to many thousands of gallons per day.9

Treated Wastewater Quality

Tables 1-6 and 1-7 show flow data available from the 2000 TRI and PCS. Tables 1-8, 

1-9, and 1-10 show the top pollutants reported to the 2000 TRI and PCS, based on TWPE and 

total pounds reported.

Table 1-6. Discharges Reported to TRIReleases2000 for One Facility*

SIC Code Discharge 

Status

Pounds to 

Stream TWPE

8063 D 750 365

8063 I 736 358

Note: Only one facility reported water discharges to the 2000 TRI.

Table 1-7. Discharges Reported to PCSLoads2000

SIC Pounds to 

Stream TWPE

8062 20,458 4.51 

8063 4,891 0.36 

Table 1-8. Top Pollutant from TRIReleases2000 Data*

SIC Code Chemical TWPE % of Total SIC 

TWPE Pounds % of Total SIC Pounds

 9

Medical Academic and Scientific Community Organization, Inc. End-of-pipe Subcommittee, Technology 

Identification Subgroup Report. Available online at: http://www.masco.org/mercury/techid/index.html, December 

1997.
Παγε 28 οφ 16

8063 Chlorine 724 1 

1,486 

1

*Note: Only one facility reported water discharges to the 2000 TRI.
Παγε 29 οφ 16

Table 1-9. Top Pollutants from PCSLoads2000 by TWPE

SIC Parameter TWPE % of Total SIC 

TWPE

8062 Chlorine, Total Residual 4.42 98%

Total for SIC Code 8062 4.51

8063 Nitrogen, Ammonia Total (As n) 0.14 38%

8063 Copper, Total (As Cu) 0.13 37%

8063 Zinc, Total (As Zn) 

0.053 

15%

8063 Nitrogen, Nitrate Total (As n) 0.034 10%

Total for SIC Code 8063 0.36 

Table 1-10. Top Pollutants from PCSLoads2000 by Pounds

SIC Parameter Pounds % of Total SIC Pounds

8062 Solids, Total Dissolved- 180 Deg.c 5,730.92 28%

8062 Oxygen Demand, Chem. (Low Level) (COD) 4,960.54 24%

8062 Solids, Total Dissolved 4,824.45 24%

8062 Solids, Total Suspended 3,081.54 15%

Total for SIC Code 8062 20,458.27 

8063 Solids, Total Suspended 1,083.09 22%

8063 Bod, 5-day (20 Deg. C) 639.36 13%

8063 Nitrogen, Nitrate Total (As N) 544.63 11%

8063 Oil & Grease Freon Extr-Grav Meth 114.85 2%

8063 Phosphorus, Total (As P) 94.92 2%

8063 Nitrogen, Ammonia Total (As N) 74.24 2%

Total for SIC Code 8063 4,891.19

Tables 1-11 and 1-12 list the facilities reporting to the 2000 TRI and PCS.

Table 1-11. List of Facilities in TRIReleases2000

SIC Facility Name City State Discharge 

Type TWPE

8062 U.S. VA Togus VA Med/Regional 

Office Center

Togus ME No Disch

8063 VA Hudson Valley Health Care System 

Castle Point 

Castle Point NY ??
Παγε 30 οφ 16

8063 VA Hudson Valley Health Care System 

Montrose Camp

Montrose NY Direct 365

8063 VA Hudson Valley Health Care System 

Montrose Camp

Montrose NY Indirect 358

Table -12. List of Facilities in PCSLoads2000

SIC Facility Name City TWPE NPID Major/

Minor

8062 Castaner General Hospital Lares 4.4 PR0025283 Major

8062 U.s.m.c. Development &Education Quantico 0.069 VA0002151 Major

8063 Marlboro Psychiatric Hosp Stp Marlboro 

0.36 

NJ0022586 Major

8062 Caritas Southwood Hospital Norfolk 0.364039 MA0102288 Minor

8062 Clara Maass Medical Center Belleville 6.72E-02 NJ0032280 Minor

8062 Diagnostic & Treatment Center Naguabo 194.5359 PR0023183 Minor

8062 Franciscan Medical Center Dayton OH0127019 Minor

8062 Gibson General Hospital Princeton IN0056626 Minor

8062 Harbor Hospital Center Baltimore 0 MD0064475 Minor

8062 Huron Memorial Hosp Bad Axe 7.916473 MI0037508 Minor

8062 Jefferson Co Medical Ctr Plt Louisville 1.912969 KY0053783 Minor

8062 Miami Valley Hospital Dayton OH0115762 Minor

8062 Montana Behavioral Health Inc. Butte 24.86648 MT0021431 Minor

8062 Morton Plant Health System Clearwater 5.862706 FL0168831 Minor

8062 Owensboro Mercy Health System Owensboro KY0100498 Minor

8062 Quality Health Service of Pr Ponce 327.0937 PR0025895 Minor

8062 Red Bird Mission Hospital Queendale 0.176617 KY0026000 Minor

8062 Ri Mhrh Facilities & Maint. Cranston 8.68E-02 RI0020176 Minor

8062 Rockford Memorial Hospital Rockford 0.572972 IL0073580 Minor

8062 Union Co Methodist Hospital Morganfield 2.90E-02 KY0022993 Minor

8062 Usvah - Ft Lyon (E) Fort Lyon 70.80236 CO0020249 Minor

8062 Veterans Administration Medica Togus 10.07631 ME0000736 Minor

8062 Zambarano Dr. U.E. Mem. Hosp. Wallum Lake 209.9387 RI0100129 Minor

8063 Brook Lane Psychiatric WWTP Hagerstown MD0053198 Minor

8063 Carrier Foundation STP Belle Mead 0.174901 NJ0023663 Minor

8063 Choate Mental Health&dev Ctr Anna 0.205647 IL0070033 Minor

8063 Greystone Park Psych Hospital Greystone Park 0.271731 NJ0026689 Minor

8063 Hastings Regional Center Hastings NE0125016 Minor
Παγε 31 οφ 16

SIC Facility Name City TWPE NPID Major/

Minor

8063 Logansport State Hospital Logansport 0 IN0038521 Minor

8063 Muscatatuck State Dev. Center Butlerville 0.111432 IN0038539 Minor

8069 McDowell Appalachian Reg Hosp McDowell 6.10E-02 KY0085791 Minor

8069 No Princeton Developmental Ctr Skillman 2.108294 NJ0022390 Minor

8069 Nursing & Personal Care Home Bruce 2.150472 MS0032051 Minor

8069 Woodward Resource Center Woodward IA0063916 Minor

On-Site Wastewater Treatment/Pretreatment

EPA’s 1989 PDS states that hospital wastewater is primarily domestic in nature. 

Although some additional pollutants are added to the wastewater (e.g., solvents, metals, and 

chemical products), they are generally treated at the point of generation or mixed with other 

wastewaters and diluted prior to discharge. As a result, effluent concentrations for hospitals are 

very similar to domestic wastewater without the need for a centralized on-site wastewater 

treatment system. The PDS did not address the concern of pharmaceuticals in wastewater, 

which is discussed in the Raw Wastewater Section of this report.

Pretreatment at hospitals may consist of the following technologies:

• Solvent recycling and reclamation (through distillation) for xylene and ethanol;

• Dilution or decay of radioactive materials;

• Silver recovery for X-ray wastes;

• Acid neutralization (through use of limestone) in the laboratories;

• Grease traps in the cafeteria and kitchen; and 

• Plaster recovery in the room where casts are fitted.

A majority of healthcare facilities discharge wastewater to POTWs. These facilities 

complete discharge monitoring reports (DMR) according to their state, tribal and local water discharge 

guidelines, but there is not a centralized data collection system for the information. 

Hospitals that discharge directly and have greater than 1,000 occupied beds are covered 

by 40 CFR Part 460. They generally have on-site biological treatment in addition to the 

pretreatment listed above. The most common type of biological treatment is the trickling filter. 

Other technologies in use include activated sludge and aerated lagoons.
Παγε 32 οφ 16

Multimedia Environmental Releases

Hospitals generate infectious (red bag or biohazard) waste, hazardous waste, solid waste, 

and volatile air emissions. OSHA and RCRA regulate the largest hospital waste stream: solid 

and hazardous waste. OECA’s Healthcare Sector Notebook10

 10U.S. EPA Office of Enforcement and Compliance Assurance. Profile of the Healthcare Industry. 

EPA/310-R-04-001. September 2004. Available online at: 

http://www.epa.gov/Compliance/resources/publications/assistance/sectors/notebooks/health.html.

provides detailed information on 

multimedia releases from hospitals.

Industry Trends and Trade Associations

The following is a summary of information on Economic Trends from OECA’s 

Healthcare Sector Notebook (Section 6.1).

Healthcare Expenditures as a Share of the Gross Domestic Product

According to the Centers for Medicare and Medicaid Services (CMS), the healthcare 

industry currently accounts for approximately 13 percent of the Gross Domestic Product (GDP) 

of the United States. By the year 2010, healthcare expenditures are expected to increase to 17 

percent of the GDP. As shown in Figure 1-1 below, the growth of spending has stabilized since 

1993 because medical prices averaged only a 2.9 percent annual growth between 1993 and 1999. 

This growth is relatively minimal compared to the 11.2 percent average annual growth between 

1980 and 1982, and the 6 percent average annual growth between 1982 and 1993. Another 

factor to consider in this stabilization is the growth in the complementary care industry (i.e., 

non-allopathic healthcare services), which was reported to be approximately 42 billion dollars in 

the mid 1990's.
Παγε 33 οφ 16

Figure 1-1: National Healthcare Expenditures as a Share of the GPD 

Source: June 2002 Centers for Medicare and Medicaid Services Report.

Healthcare Spending

In calendar year 2000, the United States spent $1.3 trillion on healthcare (NAICS code 

62). Most of this money was split between hospital care (32 percent) and physician and clinical 

services (22 percent). 

As shown in Figure 1-2 below, prescription drugs accounted for 9 percent of the total 

healthcare spending in 2000. According to the CMS, between 1990 and 2000, prescription drug 

spending increased by more than 3 percent while the amount of money spent at hospitals 

decreased by 4.8 percent. 

Figure 1-2: The Nation’s Health Dollar, CY 2000 

Source: June 2002 Centers for Medicare and Medicaid Services Report.
Παγε 34 οφ 16

Inpatient Care Versus Outpatient Care

The implementation of Medicare prospective payment systems and the increased 

enrollment into various managed care programs, has been a contributing factor in the decreased 

length of patient hospital stays since 1980. According to the CMS, in 1980, the average length 

of a hospital stay was between 7 and 8 days. In 1999, it was approximately 2 to 3 days. These 

factors, along with advances in technology and pharmaceuticals available to treat diseases, have 

also led to a decline in the number of inpatient hospital procedures. As shown in Figure 1-3 

below, inpatient care accounted for 87 percent of hospital procedures in 1980. In 2000, that 

number was down to 63 percent.

Figure 1-3: Community Hospital Expenditures: Inpatient and Outpatient Shares for All Payers 
Παγε 35 οφ 16

Source: June 2002 Centers for Medicare and Medicaid Services Report.

Pollution Prevention

In 1998, EPA entered into a MOU with the American Hospital Association which calls 

for: (1) virtually eliminating mercury-containing waste by 2005; (2) reducing the overall volume 

of all environmental releases by 33 percent by 2005 and by 50 percent by 2010; and (3) 

identifying hazardous substances for pollution prevention and waste reduction opportunities, 

including hazardous chemicals and persistent, bioaccumulative, and toxic pollutants. The H@E 

effort educates health care professionals about pollution prevention opportunities in hospitals and 

health care systems. Through activities, such as the development of best practices, model plans 

for total waste management, resource directories, and case studies, the project hopes to provide 

hospitals and health care systems with enhanced tools for minimizing the volumes of waste 

generated and the use of persistent, bioaccumulative, and toxic chemicals. Such reductions are 

beneficial to the environment and health of our communities. Furthermore, improved waste 

management practices will reduce the waste disposal costs incurred by the health care industry. 

For more information see the web site for Hospitals for a Healthy Environment (H2E) at 

http://www.h2e-online.org/ and http://www.hercenter.org/.

The web site for Sustainable Hospitals, http://www.sustainable hospitals.org/ provides 

technical support to the healthcare industry for selecting products and work practices that reduce 

occupational and environmental hazards, maintain quality patient care, and contain costs. This 

site focuses on mercury-free products and other pollution prevention opportunities.

The web site for the American Society for Healthcare Environmental Services (ASHES), 
Παγε 36 οφ 16

http://www.ashes.org/, provides information on environmental excellence and advances in 

healthcare environmental services, textile care professions and related disciplines. 

There are also a variety of resources on water conservation available to the healthcare 

industry. Many of these resources are presented on the Hospitals for a Healthy Environment 

web page for water conservation fact sheets (). Several of these resources are described below 

in additional detail:

• The document titled “Water Conservation Checklist: Hospitals/Medical Facilities; Every 

Drop Counts!” published by the North Carolina Department of Environment and Natural 

Resources Division of Pollution Prevention and Environmental Assistance contains a list 

of water use areas throughout a hospital and ways to reduce water consumption in each of 

those areas. This document can be found at: http://www.p2pays.org/ref/23/22006.pdf.

Based on this document water use in hospitals can be reduced considerably as 

shown in the following table (also discussed in Section 2):

Types of Water Uses Average Water Use (% of total) Potential Savings (% of total)

Cooling 53 32

Domestic 24 10

Cleaning 10 9

Kitchen 5 --

Process 4 --

Other 4 --

TOTALS 100% 51%

139,214 gpd 71,000 gpd

Source: ICI Conservation in the Tri-County Area of the Southwest Florida Water Management District 

(SWFWMD). SWFWMD, November 1997.

• The New Hampshire Department of Environmental Services developed an environmental 

fact sheet titled “Water Efficiency Practices for Health Care Facilities” which also 

presents practices by water use area. This document can be found at: 

http://www.des.state.nh.us/factsheets/ws/ws-26-14.htm 

• Southwest Florida Water Management District (SWFWMD) also has a similar factsheet 

titled “Water Conservation @ Work: Hospitals.” This document can be found at: 

http://www.swfwmd.state.fl.us/watercon/waterwork/checkhospital.htm. 

• Healthcare Purchasing News has developed a Self Study Series to evaluate 
Παγε 37 οφ 16

environmentally preferable products. One item in this series discusses microfiber mops 

which use less water than conventional cotton mops. The article discusses the economic, 

environmental, employee, and patient benefits of using microfiber mops. This document 

can be found at: http://198.151.15.185/pubs/ShouldYouMicrofiber.pdf

• The University of Wisconsin Cooperative Extension developed a hospital waste reduction 

checklist which includes strategies for reducing wastewater discharges. These strategies 

include substitution of less toxic materials, procedures for moving or cleaning sewer 

lines, traps, or sumps, and chemical storage and disposal options. This document can be 

found at: http://www.uwex.edu/shwec/Pubs/pdf/425-9602.pdf. 

• The Medical Academic and Scientific Community Organization prepared a pretreatment 

manual for use by hospitals to help solve a sewer discharge compliance problem. The 

manual outlines the elements of typical source reduction programs and a wastewater 

pretreatment strategy. This document can be found at: 

http://www.masco.org/mercury/pretreatment/index.html. 

• EPA’s Small Business Ombudsman developed a fact sheet for walk-in urgent care 

facilities and smaller hospitals. The fact sheet explains some of the best management 

practices (BMPs) related to toxic chemicals or hazardous materials used as part of the 

diagnostic, treatment, and cleaning processes used in these smaller facilities. This 

document can be found at: 

http://www.smallbiz-enviroweb.org/html/pdf/BMP_HealthCare-4.pdf. 

• EPA Regions 1 and 2 have on-going programs to provide information to help healthcare 

facilities reduce environmental impacts of their operations and improve their 

understanding of and compliance with environmental regulations. The EPA programs 

also help facilities realize the cost savings and environmental benefits that can be attained 

through improvements in recycling, energy efficiency and water conservation. More 

information can be found at: http://www.epa.gov/region1/healthcare/ and 

http://www.epa.gov/region2/healthcare/.

With respect to controlling mercury discharges, healthcare facilities contain mercury in 

some medical equipment (e.g. pressure gauges, thermometers), laboratory reagents, and common 

facility items (e.g., fluorescent lights, thermostats, cleaning supplies). Some hospitals approached 

the problem of mercury use within their facilities by following some basic steps, including:

• Conducting inventories to identify sources of mercury within their facilities;

• Making recommendations to existing hazardous waste and safety committees and the 

administration for reducing or eliminating these sources;

• Instituting immediate steps for mercury reduction; and,

• Devising long-term goals for the virtual elimination of mercury from their facilities. 
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An example of this approach was documented at two major Detroit hospitals that instituted 

mercury pollution prevention plans. Wastewater sampling was conducted to evaluated their 

performance. Before the mercury pollution prevention program, mercury measures at these sites 

were in the range of 0.28 ppb to 0.96 ppb. After the program was instituted, these figures 

dropped to 0.09 ppb to 0.15 ppb.11

References

2. Centers for Medicare and Medicaid Services Web Page. 

http://www.cms.hhs.gov/charts/healthcaresystem/chapter2.asp, accessed 10/22/04.

3. Hospitals for a Healthy Environment Web Page for Water Conservation Fact Sheets 

(http://www.h2e-online.org).

4. U.S. EPA Office of Water and Hazardous Materials. Development Document for Interim 

Final Effluent Limitations, Guidelines and Proposed New Source Performance Standards 

for the Hospital Point Source Category. EPA 440/1-76/060n. April 1976.

5. U.S. EPA Office of Enforcement and Compliance Assurance. Profile of the Healthcare 

Industry. EPA/310-R-04-001. February 2005.

6. U.S. EPA Office of Water Regulations and Standards. Preliminary Data Summary for 

the Hospitals Point Source Category. EPA 440/1-89/060-n. September 1989.

7. Barnes, Kimberlee K., Dana W. Kolpin, Michael T. Meyer, E. Michael Thurman, Edward 

T. Furlong, Steven D. Zaugg, and Larry B. Barber. Water-Quality Data for 

Pharmaceuticals, Hormones, and Other Organic Wastewater Contaminants in U.S. 

Streams, 1999-2000. U.S. Geological Survey. Available at 

http://toxics.usgs.gov/pubs/OFR-02-94/.

 11Williams, Guy, 1997. Mercury Pollution Prevention in Healthcare, 

http://www.newmoa.org/prevention/topichub/22/Mercury_Pollution_Prevention_in_Healthcare_NWF.htm.