PWS Spill Prevention Plan Update.docx

Records Management

Title

Spill Prevention, Countermeasures and Control (SPCC) Plan Update

Eastern Colorado Health Care System (ECHCS), Aurora CO

Background

Oil Pollution Prevention Regulations promulgated under the Clean Water Act, and later amended by the Oil Pollution Act of 1990, require facilities to prepare and implement a plan to prevent any discharge of oil into navigable waters or adjoining shorelines of the United States. This is the Spill Prevention Control and Countermeasures (SPCC) plan. The State of Colorado has regulatory authority over oil storage and distribution systems, and SPCC requirements from the US Environmental Protection Agency (USEPA). Because of the quantity of oil stored at the ECHCS, and the installation’s proximity to a receiving water body, the medical center is subject to SPCC requirements under 40 CFR 112. The ECHCS currently has an SPCC Plan with an Oil Spill Contingency Plan (OSCP) appendix to fulfill the regulatory requirements identified above. Mandatory technical updates are needed from a third-party registered professional engineering firm located within the State of Colorado to ensure timely in-person reporting to the State of Colorado’s Department of Oil and Public Safety if required.

Scope

The contractor shall update the current Spill Prevention Control and Countermeasure Plan (SPCC) Plan and Oil Spill Control Plan (OSCP) appendix. These provide guidance to ECHCS personnel on site specific procedures for the handling of petroleum products and petroleum/oil spills. The updated plan shall include site analysis/evaluation, preventative measures, above ground storage tank inspections, prevention training, spill prevention, control, and countermeasures requirements, and the development of written procedures. These include, but are not limited to, piping layout after completion of repairs; leak monitoring panel update; adding further oil containing equipment to the AST list and adjusting calculations.

Specific Tasks

The contractor shall furnish all materials, equipment, supplies, personnel, transportation, and all other resources necessary to modify the existing SPCC Plan and OSCP Appendix, perform a comprehensive field investigation/evaluation (in conjunction with ECHCS personnel), and provide an updated SPCC Plan in accordance with the EPA required format. The contractor shall update the existing SPCC Plan and OSCP and submit it to ECHCS for comment.

Task 1 – Compliance Requirements

The contractor shall be responsible for identifying the applicable federal, state, local, and Department of Veterans Affairs (VA) laws and regulations and apply the procedures and protocols as required.

Subtask 1 - Public Laws and Statutes: The Contractor shall comply with the issue or version (including all changes and amendments) of federal, state and local environmental statutes and regulations in effect of date of issuance of this delivery order, including, the applicable portions of the documents cited in the basic contract. The plans shall meet the following requirements:

- 40 CFR 109, Criteria for State, Local, and Regional Oil Removal Contingency Plans

- 40 CFR 110, Discharge of Oil

- 40 CFR 112, Oil Pollution Prevention

- 40 CFR 117, RQs for Hazardous Substances

- 40 CFR 125, Criteria and Standards for Best Management Practices

- 40 CFR 280, Technical Standards and Corrective Action Requirements for Owners and Operators of Underground Storage Tanks

- 40 CFR 300, Oil and Hazardous Substance Pollution Contingency Plan

· 44 CFR 302, Emergency Operations Plan Requirements

· 49 CFR 171-178, HAZMAT Regulations

· State of Colorado Department of Oil and Public Safety Regulations

Subtask 2 - The contractor shall perform an in-depth review of the existing ECHCS SPCC Plan and OSCP. The contractor shall field verify the information contained in these plans and gather additional information as needed to accurately update these plans. The contractor shall provide, within the updated plan, a detailed inventory of storage, handling, and transfer facilities that could possibly produce a significant spill of oil, including photographs and site drawings.

TASK 2 - Deliverables: Draft and Final SPCC Plan with an OSCP Appendix

1. The contractor shall prepare a draft updated plan and submit it to the ECHCS point of contact (POC) 45 days after completion of the site survey at the Denver VAMC. The final plan shall incorporate ECHCS comments and be submitted within 5 work-days after receipt of comments.

2. The contractor shall submit two (2) hard copies and (2) digital copies of the final SPCC Plan and OSCP appendix specified above. The digital version of the document shall be supplied by the contractor on contractor-supplied CD-ROMs. Electronic copies shall be submitted in both a “pdf-type” file and “Microsoft Word compatible file”. The final submittal shall also include contractor developed and/or updated ECHCS installation site maps supporting the SPCC Plan and OSCP. The maps shall be delivered in hard copy and on contractor supplied CD-ROM(s) and compatible with the current version of AutoCAD.

Period of Performance

This work is expected to be completed within 60 days from start to finish which is inclusive of all revisions from comment resolutions. Period of performance: June 27, 2026, to August 27, 2026.

Place of Performance

Rocky Mountain Regional VA Medical Center 1700 North Wheeling Street Aurora CO 80045

POC/COR

Performance Work Statement (PWS) – FY26 Spill Prevention

C-10

Performance Objective

Performance Standard

Acceptable Quality Level (AQL)

Method of Surveillance

Compliance Review & Plan Update Updated SPCC & OSCP incorporating interim changes; must meet 40 CFR 109/110/112/117/280/300 and Colorado Oil & Public Safety regulations.

100% Compliance

Document review against PWS and regulatory checklist.

Schedule Compliance Draft due within 45 days after site survey; final due within 5 days of Government comments.

Weekly status checks & milestone tracking.

Deliverables Quality

Final deliverables must be 95% defect-free.

95% Compliance

Technical review of draft and final deliverables.

100% Compliance Monitoring of records & information security compliance.

Monitoring of records & information security compliance.

Quality Assurance Surveillance Plan (QASP) – Spill Prevention

RECORDS MANAGEMENT

1. Contractor shall comply with all applicable records management laws, and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act, (44 U.S.C. chs, 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974, (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transportation, or state of completion.

2. In accordance with 36 CFR 1222.32, all data created for government use and delivered to, or falling under the legal control of, the government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA)(5 U.S.C. 552), as amended, and the Privacy Act of 1974 (U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

3. In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

4. Eastern Colorado Health Care System (ECHCS) and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of ECHCS or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage, or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to ECHCS. The agency must report promptly to NARA in accordance with 36 CFR 1230.

5. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the contract. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to ECHCS control or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the Contract. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

6. The Contractor is required to obtain the Contracting Officer’s approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating co, contracts. The Contractor (and any sub-contractor) is required to abide by Government and ECHCS guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

7. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contractor and in accordance with ECHCS policy.

8. The Contractor shall not create or maintain any records containing any non-public ECHCS information that are not specifically tied to or authorized by the contract.

9. The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

10. ECHCS owns the rights to all data and records produced as part of the contract. All deliverables under the contract are property of the U.S. Government for which ECHCS shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

11. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take VHA provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

FLOWDOWN OF REQUIREMENTS TO SUBCONTRACTORS

1. The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this contract, and require written subcontractor acknowledgement of same.

2. Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.

INFORMATION SECURITY

1. GENERAL

Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

a. A contractor/subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

b. All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

c. Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of Veterans Affairs does not have a Memorandum of Agreement with Defense Security Service (DSS). Verification of a Security Clearance must be processed through the Special Security Officer located in the Planning and National Security Service within the Office of Operations, Security, and Preparedness.

d. Custom software development and outsourced operations must be located in the U.S. to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the contractor/subcontractor must state where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor.

e. The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor’s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

3. VA INFORMATION CUSTODIAL LANGUAGE

a. Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data

- General, FAR 52.227-14(d) (1).

b. VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor’s information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct on site inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements.

c. Prior to termination or completion of this contract, contractor/subcontractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

d. The contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract.

e. The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed.

f. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold

4. LIQUIDATED DAMAGES FOR DATA BREACH

c. Each risk analysis shall address all relevant information concerning the data breach, including the following:

(1) Nature of the event (loss, theft, unauthorized access);

(2) Description of the event, including:

(a) Date of occurrence;

(b) Data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code;

(3) Number of individuals affected or potentially affected;

(4) Names of individuals or groups affected or potentially affected;

(5) Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text;

(6) Amount of time the data has been out of VA control;

(7) The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons);

(8) Known misuses of data containing sensitive personal information, if any;

(9) Assessment of the potential harm to the affected individuals;

(10) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate; and

(11) Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised.

d. Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $ 42.00 per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following:

(1) Notification;

(2) One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports;

(3) Data breach analysis;

(4) Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution;

(5) One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and

(6) Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs.

5. SECURITY CONTROLS COMPLIANCE TESTING

On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-day’s notice, at the request of the government, the contractor must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time.

6. TRAINING

a. All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:

(1) Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems;

(2) Successfully complete the VA Cyber Security Awareness and Rules of Behavior training and annually complete required security training;

(3) Successfully complete the appropriate VA privacy training and annually complete required privacy training; and

(4) Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access [to be defined by the VA program official and provided to the contracting officer for inclusion in the solicitation document – e.g., any role-based information security training required in accordance with NIST Special Publication 800-16, Information Technology Security Training Requirements.]

b. The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required.

c. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.