Executive Council

Authorizes Release:

Vice President for Administration and Finance

Responsible Area:

Facilities Services

Review Cycle:

Annually or as required

Last Review:

March 2021

Related Policies and Additional References:



The Refrigerant Management Plan provides guidance for developing policies and procedures necessary to meet the requirements of an effective refrigerant management program to ensure safer handling and storage of refrigerants and minimize the potential for negative environmental impact.


This document applies to operations and maintenance activities within St. Mary’s University Facilities that involve refrigerants. The Facilities Director is responsible for implementing the Refrigerant Management Plan and maintaining all records required per the Plan.

Applicable Documents

  • Refrigerant Management “Book”
  • Chiller Refrigerant Usage / Repair binders
  • Refrigerant Cylinder Log
  • Refrigerant Leak Report
  • Refrigerant Recovery Recycling & Reclaim
  • Equipment Refrigerant Usage Form
  • Intact Equipment Disposal Form


Refrigerants require special purchasing, storage, handling and disposal to minimize the introduction of refrigerant into the atmosphere. All maintenance technicians that handle refrigerant are certified by the Environmental Protection Agency (EPA). Records concerning purchases, use, service logs, and disposal of refrigerants are maintained in the Central Plant office. The following elements are required as part of the Refrigerant Management program:

  • Availability of recovery and recycling equipment in sufficient quantity to perform work within EPA regulations.
  • Responsibility for the care and maintenance of recovery and recycle equipment including recordkeeping.
  • Records to show performance and compliance to regulations and disposition of recovered or recycled refrigerant.
  • Refrigerant cylinders stored onsite will not be filled to more than 80% fluid capacity
  • Refrigerants shall not be mixed. A separate clean evacuated labeled vessel will be used for each refrigerant.
  • Equipment suspected of refrigerant leaks will be stopped and inspected with repairs made before resuming normal operation. (Equipment containing more than 50lbs must be identified and records kept of capacity and if it exceeds allowable leak rate).
  • Mgmt will be notified of any venting or inability to repair leaks immediately.
  • Refrigerants shall be recovered, reclaimed, or properly destroyed whenever removed from equipment
  • Before refrigerant is recovered, recycling or reclamation requirements shall be determined.
  • Equipment will meet or exceed applicable standards before being used.
  • Only approved containment vessels and equipment will be used. Dry nitrogen shall be used to break all vacuums created by the recovery process.
  • Use BMP (Best Manufacturing Practices) to avoid intentional venting of refrigerants into atmosphere (July 1992).
  • Disposal processes for contaminated CFC and HCFC, flushing and cleaning, used refrigerant quality policy, equipment service specifications.
  • Assessment to determine air permitting requirements.
  • If applicable create Halon (computer room fire extinguisher) and refrigerant bank policies.


  • The Facilities Director will assign a Refrigerant Manager that is responsible for the following:
  • Coordinate refrigerant purchases and maintain inventory of use records.
  • Gather and disseminate information on refrigerant technology, codes, and regulations
  • Develop and apply administrative controls.
  • Develop and implement this Refrigerant Plan.
  • Perform systems assessments and evaluate alternatives.
  • Plan for future refrigerant and equipment needs.
  • Develop a refrigerant management plan schedule.
  • Ensure regulatory compliance.
  • Ensure safe handling of refrigerants by all personnel.
  • Minimize risks associated with refrigerant handling (develop risk assessment and identify mitigations).
  • Procurement of equipment and services to comply with regulations, technical training, refrigerant transportation and disposal, safety equipment, and management of refrigeration equipment retrofit or replacement.

Record Keeping

All record keeping will be performed by the Refrigerant Manager and maintained in the Facilities Services Office per Facilities Record Retention Policy.

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