DISEASE PREVENTION AND CONTROL PROJECT

Public Disclosure Authorized

Public Disclosure Authorized

THE NEW VANADZOR MEDICAL CENTER

ENVIRONMENTAL IMPACT ASSESSMENT REPORT

AND Public Disclosure Authorized ENVIRONMENTAL MANAGEMENT PLAN

Public Disclosure Authorized

Yerevan, November 2013

List of Acronyms

AEN - Armenia Electric Network ANC - Ante-Natal Care AOC - Armenia Oncology Center BOD - Biological Oxygen Demand CJSC - Closed Joint Stock Company CHD - Coronary Heart Deceases EIA - Environmental Impact Assessment EMF - Environmental Management Framework EMP - Environmental Management Plan HPIU- Health Project Implementation Unit MAC - Maximum Admissible Concentration MC - Medical Center MCH - Maternal and Child Health MPE - Maximum Permissible Emission MPD - Maximum Permissible Discharge MNP - Ministry of Nature Protection MoH - Ministry of Health NCD - Non-communicable Deceases DPC - Disease Prevention and Control PAD - Project Appraisal Document PHC - Primary Health Care RA - Republic of Armenia SNCO - State Non Commercial Organization VOC - Volatile Organic Compound WB - World Bank

Table of Contents

EXECUTIVE SUMMARY ...... 1 1. INTRODUCTION ...... 6 2. METHODOLOGY ...... 6 3. LEGAL AND ADMINISTRATIVE FRAMEWORK ...... 7 3.1. National Legislation ...... 7 3.2. Licenses and permits to be obtained by the project proponent and by works contractor to carry out project activities ...... 9 3.3. World Bank Safeguard Policies ...... 10 3.4. Administrative Framework ...... 10 5. TECHNICAL STANDARDS AND REGULATIONS...... 11 6. PHYSICAL AND NATURAL ENVIRONMENT ...... 12 6.1. Geographic location ...... 12 6.2. Hydro-geological conditions ...... 12 6.3. Seismic condition and tectonics ...... 13 6.4. Climate ...... 13 6.5. landscape and soils ...... 13 6.6. Flora ...... 14 6.7. Fauna ...... 14 6.8. Specially protected natural areas ...... 14 7. TECHNICAL DESCRIPTION OF WORKS ...... 15 8. SENSITIVE RECEPTORS ...... 17 8.1 Ambient Air ...... 17 8.2. Water Resources ...... 17 8.3 Land Resources ...... 18 8.4 Social Environment ...... 18 8.5 Cultural Resources ...... 18 9. SOCIAL AND ECONOMIC ENVIRONMENT ...... 18 10. EXPECTED ENVIRONMENTAL AND SOCIAL IMPACTS ...... 20 10.1 Construction phase ...... 21 10.2 Operation phase ...... 23 11. IMPACT MITIGATION ...... 25 11.1. Construction Phase ...... 25 11.2. Operation Phase ...... 26 12. ENVIRONMENTAL MANAGEMENT PLAN ...... 27 12.1 Responsibilities and Institutional Arrangements ...... 27 12.2 Responsibilities of Construction Contractor ...... 27 12.3 Monitoring of EMP implementation ...... 27

13. STAKEHOLDER CONSULTATION ...... 27 ANNEX I. List of References ...... 28 ANNEX II. Environmental Management Plan (EMP) ...... 30 Environmental Monitoring Plan ...... 34 ANNEX III. Minutes of Public Consultation Meeting ...... 38 ANNEX IV. Location and Ownership of Land Plots Allocated for Vanadzor MC ...... 44 ANNEX V. Agreement for the Disposal of Construction Waste ...... 48 ...... 48 ANNEX VI. Calculation of Volumes of Emissions, Water Use, and Water Discharge ...... 49 ANNEX VII. Classification of MC Wastes ...... 54

EXECUTIVE SUMMARY

Introduction

Armenia faced enormous difficulties after the collapse of the Soviet Union. It led to the crisis in the provision of public services, including health care system. Main issues accumulated in the health sector of Armenia since independence were considered to be the following: low access and use of health services; under-funded healthcare system with poorly and inequitably used resources; high out-of-pocket informal payments; low perceived quality of care, especially in regions; excess capacity of physical infrastructure of hospitals and polyclinics; and geographic mal-distribution of health workforce between Yerevan and the regions of the country. The reform process, initiated in the mid-1990s, aimed at enhancing efficiency and ensuring accessibility and quality of essential health services, particularly for vulnerable groups.

The first WB-supported Armenia Health Finance and Primary Health Care Development Project was implemented in the years of 1997-2003 and significantly contributed to the success of the country health reforms and developments. A two-phase Adaptable Lending Program (APL) for the health systems modernization followed afterwards to support the reform of the health sector in Armenia in the three main areas: (i) development of primary health care, (ii) hospital optimization and modernization, (iii) and strengthening of the government institutional capacities. The first phase of the Health System Modernization Project (HSMP)was implemented in 2004-2010. The second phase started in 2007 and is scheduled to complete in December 2014.

Later, the Government of Armenia (GoA) applied for the WB loan to increase the effectiveness of prevention and treatment of non-communicable deceases, in particular Coronary Heart Deceases (CHD), oncologic illnesses, and diabetes mellitus. The new WB-financed Disease Prevention and Control (DPC) Project commenced in 2013 and is scheduled to complete in December 2019.

The DPC Project Development Objective is to improve (i) Maternal and Child Health (MCH) services and the prevention, early detection, and management of selected non-communicable diseases at the Primary Health Care (PHC) level; and (ii) the efficiency and quality of selected hospitals in Armenia. One of the targets selected for the Project intervention is the Lori Marz (province) hospital network. In particular, the project will finance civil works; provision of medical equipment, furniture and supplies; training and other TA for the improvement of Vanadzor Medical Center (MC).

Technical and Environmental Standards and Regulations The national legislation of Armenia includes a law on the Environmental Impact Assessment (EIA) . It does not establish categories of activities by the associated environmental and social risks, but provides description of activities that are subject to the EIA, and the State ecological examination. A project is cleared for implementation upon issuance of a positive conclusion of the ecological expert review. Construction of premises for Vanadzor MC is subject to the EIA procedure. Also, Armenia is a party to the Aarhus Convention on Access to Information, Public Participation in Decision Making, and Access to Justice in Environmental Matters. Disclosure of the EIA report and other environmental information related to the Project preparation and implementation is regulated by both – EIA law and the guiding principles of the Aarhus convention.

1

Following World Bank guidelines, the NDPC Project triggered OP/BP 4.01 Environmental Assessment, was classified as environmental Category B, and an Environmental Management Framework (EMF) was prepared to guide further environmental work required for the preparation and implementation of individual investments.

Environmental Screening

Based on the nature and scope of physical works required for the construction of a Vanadzor MC, as well as the general types of impacts expected from such kind of construction, this investment is classified as environmental Category B and requires EIA. Screening of the Vanadzor sub-project was conducted based on the OP/BP 4.01, and the Environmental Management Framework(EMF) prepared for the DPC Project.

Public Participation

According to the national legislation, as well as the WB requirements on the disclosure of information, the present draft EIA report will be disclosed in-country in Armenian and English languages by posting it on the web page of the Ministry of Health. A public consultation meeting will be held in the town of Vanadzor to discuss the draft EIA report with the locally affected people. The EIA report will be re-disclosed after incorporation of the received feedback, and attachment of minutes of the consultation meeting.

Sensitive Environmental Receptors and Potential Impacts

The new building of Vanadzor MC will be located at Nzhdeh Str. 2/42, next to the existing hospital No.1. The allocated land plot is 3.172 ha. It is State-owned and is currently not in any formal or informal use. There are several dilapidated buildings of the former military hospital on this plot. Other than the hospital No.1, there is a military base in the neighbouring area, while some land is staying idle. The selected location is convenient, because it is well accessible by public transport and at the same time it is close to the green zone surrounding the town. The plot is easily connectible to the water supply and sewage networks, power supply grid, and gas supply system of the Vanadzor municipality.

Environmental and Social sensitivities related to the construction and operation of the Vanadzor MC include: vegetative cover and topsoil of the allocated plot, a wider area of landscape which may get polluted with construction soil and/or may degrade as a result of borrowing for construction materials, soil and ground water that may get polluted with operational spills of fuel and runoff from the construction site, air that may be polluted locally with exhausts and dust from the construction site, and population of the Vanadzor city district within which the MC will be located.

Project Alternatives

At an early stage of planning optimization of the Lori marz health care system, two main options were considered for improving infrastructure and management of Vanadzor health case facilities. Given that Vanadzor MC CJSC had been established through a merger of the existing Vanadzor hospitals No.1 and No.2, one option was to upgrade the old buildings used by these two hospitals, while the second option was to construct a new building to house the MC. Feasibility study for the new construction was carried out in October 2011. Outcomes of this study justified new construction due to excessively high estimated costs of capital reconstruction of the existing two buildings that are located in the seismically active area of Lori Marz and carry significant structural damages. Cost of the new construction was estimated to be some 1,148,000 USD less

than works required for fundamental reconstruction of the two existing buildings. Therefore, a decision was made to provide new premises for the Vanadzor MC. Environmental footprint of this new construction is not going to be considerably stronger as compared to the option of reconstruction, because the plot allocated for the new construction is not a green field and carries dilapidated buildings of a former military base.

Environmental Impact Assessment Methodology

The present EIA covers the entire scope of the sub-project, including construction and operation of the Vanadzor MC. The EIA process included the desk top work to review project documents and scientific literature, as well as the field work required for verification of the available baseline data, collection of missing information, and meetings with the local stakeholders. The background information was compiled on the biophysical environment around the sub-project site, on the land tenure and land use of the allocated plot and its adjacent area, and the photo material was also compiled. Based on the background material, sensitive environmental receptors were identified and potential environmental and social impacts were defined for the construction and operation phases. Estimated costs were calculated for several discrete and most important mitigation measures for the inclusion into the bill of quantities for the upcoming civil works. A detailed EMP was developed by listing specific activities that carry various environmental and social risks, and measures prescribed for their mitigation. Indicators for quantitative or qualitative measurement of the effectiveness of mitigation measures were selected and used for the development of an Environmental Monitoring Plan.

Environmental and Social Baseline

Vanadzor is the third largest city of Armenia and the capital of the Lori Marz. It is located in the northern part of the country, around 128 km north from the capital city of Yerevan. As of the 2012 estimate, the city had a population of 104,921, down from 148,876 reported at the 1979 official census. Unemployment in the Vanadzor municipality is quite high and seasonal migration is characteristic of the city. At a height of 1425 meters above sea level, Vanadzor is located in the valley of Pambak River, on the point where the rivers of Tandzut and Vanadzor join the Pambak River. Vanadzor lies within a picturesque natural setting, however crumbled Soviet-era chemical factories dominate much of the valley below the city.

Expected Impacts and Mitigation

The expected environmental and social risks associated with the construction of the Vanadzor MC are moderate and can be effectively mitigated.

Impacts of the construction phase:

• Air pollution from the operation of the construction vehicles and machinery; • Nuisance to local population from the dust, noise and vibration generated at the construction site; • Disruption of local traffic due to movement of construction vehicles and machinery; • Land degradation and erosion as a result of damaged vegetative cover and borrowing; • Land and water pollution with runoff and spillages from the construction site; • Landscape degradation and pollution due to improper disposal of access material and construction waste; • Generation of hazardous waste (asbestos) from the demolition of premises of the former military hospital and possible encounter of more types of hazardous waste, not visible

and known upfront; • Traumatism and long term health damage among construction workers due to poor application of health and safety standards.

Mitigation measures of the construction phase:

• Keep construction vehicles and machinery in adequate technical condition; • Organize fueling, washing, and other servicing construction vehicles and machinery at service centers or in the designated locations of the construction site which can contain operational and accidental spillages of oils and lubricants, and do not allow direct water discharge to the natural water bodies; • Operate vehicles and machinery within working hours and shutting engines when idle; • Move vehicles and machinery along the existing or designated access roads to avoid excessive damage of natural vegetation; • Keep subsoil and topsoil separately and using them for backfilling and reinstatement of the construction site; • Pile construction materials and waste within the construction site and periodically disposing them into formally designated locations; • Avoid opening of new quarries to the extent possible. Disallow unlicensed extraction of material Stabilize and reinstate used sections of quarries to avoid erosion and severe degradation of landscape; • Make special arrangements for the safe removal and disposal of asbestos containing fragments of the existing dilapidated buildings; Instruct contractor’s personnel on the course of action if potentially hazardous substances are encountered in the course of demolition and excavation works; • Provide workers with adequate personal safety gear and insure its proper use; ensure that personnel operating complex construction machinery is trained and licensed.

Impacts of the operation phase:

• Accumulation of excessive amounts of waste on-site due to failure of its timely removal; • Open air burning or illegal dumping of waste resulting in the pollution of soil and water as well as in risks of spreading disease to local communities. • Public health and environmental damage caused by improper handling of medical waste; • Operation of the boiler house; • Damage to the MC building and deterioration of area around it due to leaking water/sewer pipes, and/or dis-functional drainage of storm water.

Mitigation measures of the operation phase:

• Collect household waste in regular plastic binds and regularly dispose of at the municipal landfill. Make and maintain proper arrangements for out-transportation of waste with specialized covered scavenger trucks. • Strictly disallow burning of any type of waste in open air at or around the MC site. • Collect medical waste separately in special containers and regularly hand it over for disposal to a specially licensed entity. • Accumulate chemically active liquids separately from other liquid waste and hand it over for deactivation and disposal to a specially licensed entity.

• Establish and consistently apply an organized system of the boiler house servicing and maintenance, including periodic checks of the technical condition of appliances and monitoring of emissions. • Undertake regular checking of communications inside and around the MC building to timely identify and fix any leakages that may occur. Arrange and maintain effective drainage system for the collection and discharge of storm water to avoid water damage to the building and waterlogging of the MC area.

Institutional Arrangements for Managing Environmental Impacts

Overall responsibility for managing environmental and social impacts of construction works at Vanadzor MC rests with the NDPC Project implementing entity, which is the Ministry of Health (MoH) of the RA. The Ministry will exercise environmental and social monitoring of works through the Health Projects Implementation Unit (HPIU) under it. HPIU is mandated to monitor implementation of the EMP by works contractor and to report on the outcomes of monitoring to the Ministry and to the WB. Once operational, the MC premises will be managed by the MC Directorate. Environmental compliance of the Center’s operation will be enforced by the Lori regional unit of the RA State Environmental Inspectorate.

Environmental Management Plan

The EMP is developed for the construction and operation of the MC’s premises in order to mitigate negative environmental and social impacts. EMP includes information on the risks arising at various stages of construction and operation activities, the sectors affected by the risks, as well as the list of mitigation measures, including parties responsible for their application, enforcement and monitoring. EMP will be included in the bidding documents for the construction of the MC and will become an integral part of the civil works contract.

1. INTRODUCTION

Armenia faced enormous difficulties after the collapse of the Soviet Union. It led to the crisis in the provision of public services, including health care system. Main issues accumulated in the health sector of Armenia since independence were considered to be the following: low access and use of health services; under-funded healthcare system with poorly and inequitably used resources; high out-of-pocket informal payments; low perceived quality of care, especially in regions; excess capacity of physical infrastructure of hospitals and polyclinics; and geographic mal-distribution of health workforce between Yerevan and the regions of the country. The reform process, initiated in the mid-1990s, aimed at enhancing efficiency and ensuring accessibility and quality of essential health services, particularly for vulnerable groups.

The first WB-supported Armenia Health Finance and Primary Health Care Development Project was implemented in the years of 1997-2003 and significantly contributed to the success of the country health reforms and developments. A two-phase Adaptable Lending Program (APL) for the health systems modernization followed afterwards to support the reform of the health sector in Armenia in the three main areas: (i) development of primary health care, (ii) hospital optimization and modernization, (iii) and strengthening of the government institutional capacities. The first phase of the Health System Modernization Project (HSMP) was implemented in 2004-2010. The second phase started in 2007 and is scheduled to complete in December 2014.

Later, the Government of Armenia (GoA) applied for the WB loan to increase the effectiveness of prevention and treatment of non-communicable deceases, in particular Coronary Heart Deceases (CHD), oncologic illnesses, and diabetes mellitus. The new WB-financed Disease Prevention and Control (DPC) Project commenced in 2013 and is scheduled to complete in December 2019.

The NDPC Project Development Objective is to improve (i) Maternal and Child Health (MCH) services and the prevention, early detection, and management of selected non-communicable diseases at the Primary Health Care (PHC) level; and (ii) the efficiency and quality of selected hospitals in Armenia. One of the targets selected for the Project intervention is the Lori Marz (province) hospital network. In particular, the project will finance civil works; provision of medical equipment, furniture and supplies; training and other TA for the improvement of Vanadzor Medical Center (MC).

2. METHODOLOGY

The present EIA was carried out according to the Terms of Reference agreed upon with its main financier - WB, and covered the entire scope of the Project, including construction phase and operation of the MC. The EIA process included desk work to review project documents and scientific literature, as well as field work aimed at verification of the available data, collection of missing information, and meetings with the Project stakeholders. The background information was compiled on the biophysical environment around the Project site, on the land tenure and land use of the allocated plot and its adjacent area, on the existence on the known or potentially present elements of historical and cultural heritage in the vicinity of the Project site, and the status of the allocated site was documented by creating of photo material.

Based on the background material, sensitive environmental receptors were identified and potential environmental and social impacts of the Project were defined for the construction and 6 operation phases. Estimated costs were calculated for several discrete and most important mitigation measures for the inclusion into the bill of quantities for the upcoming civil works. A detailed Environmental Management Plan (EMP) was developed listing specific activities carrying environmental and social risks and measures prescribed for their mitigation. Indicators for quantitative or qualitative measurement of the effectiveness of mitigation measures were selected and used for the development of an Environmental Monitoring Plan.

3. LEGAL AND ADMINISTRATIVE FRAMEWORK

3.1. National Legislation

The 10th Article of the Constitution of the Republic of Armenia (adopted in 1995 and amended in 2005) states the State responsibility for environmental protection, reproduction, and wise use of natural resources. Since 1991 more than 25 codes and laws as well as numerous by-laws and regulations have been adopted to protect the environment.

Land Code (2001) The Land Code defines the main directives for management use of the state lands, included those allocated for various purposes, such as agriculture, urban construction, industry and mining, energy production, transmission and communication lines, transport and other purposes. The Code defines the lands under the specially protected areas as well as other reserved lands. It also establishes the measures aimed to the lands protection, as well as the rights of state bodies, local authorities and citizens towards the land.

Water Code (2002) The main purpose of the Water Code is to provide the legal basis for the protection of the country’s water resources, the satisfaction of water needs of citizens and economic sectors through effective management of water resources, and safeguarding the protection of water resources for future generations. The Water Code addresses the following key issues: responsibilities of state/local authorities and public, development of the National Water Policy (2005) and National Water Program (2006), water cadastre and monitoring system, public access to the relevant information, water use and water system use permitting systems, trans-boundary water resources use, water quality standards, hydraulic structures operation safety issues, protection of water resources and state supervision.

Mining Code (2011) The code defines principles and rules of mining in the RA, the relations related to preservation and use of the deposits, conditions and requirements of efficient use, complex use and preservation of deposits, security of mining and protecting the environment from its negative impacts, as well as protection of rights of the state, citizens and users of deposits. According to the Code, natural deposits areas under the exclusive ownership of the state. They may be given out for use for a certain period of time, and cannot be privatized. The law also determines conditions, requirements and peculiarities of the natural resources and deposits. It also establishes payment principles, compensation, monitoring, and limitation for mining activities.

Law on Environmental Impact Assessment (1995) The Law on Environmental Impact Assessment (EIA), passed in 1995, provides legal basis for implementation and introduction of State expertise of planned activities and concept frameworks as well as presents the standard steps of the EIA process. The Law establishes general legal, economic, and organizational principles for conducting mandatory State EIA of various types of projects and concepts of sectoral development. Construction of the Vanadzor MC premises falls

under the category of activities requiring EIA and requires the Government’s positive conclusion on its outcomes.

Law on Ensuring Sanitary-epidemiological Security of the RA Population (1992) The Law “On Ensuring Sanitary-Epidemiological Security of the RA Population” was adopted in 1992, which sets legal, economic and institutional bases for ensured sanitary and epidemiological safety of the population, as well as other guaranties provided for by the State to exclude influence of adverse and hazardous factors on human organism and ensure favorable conditions for vital capacity of the present and future generations.

Law on Atmospheric Air Protection (1994) The objective of the Law is to provide the cleanness of the atmospheric air, elimination and prevention of the negative impact on the atmospheric air, as well as regulation of public relations in this field. The Law defines norms of permissible amount of concentrations and physical negative impact as well as norms of permissible pollution from movable and unmovable sources.

Law on Medical Care and Services to the Population (1996) The Law on Medical Care and Services to the Population establishes the legal, economic ad financial guidelines for medical care and service delivery, which ensures the realization of people’s constitutional right to preserve their health.

Law on the Protection and Use of Fixed Cultural and Historic Monuments and Historic Environment (1998) This Law provides the legal and policy basis for the protection and use of such monuments in Armenia and regulates the relations between protection and use activities. Article 15 of the Law describes procedures for, among other things, the discovery and state registration of monuments, the assessment of protection zones around them, and the creation of historic-cultural reserves. Article 22 requires the approval of the authorized body (Department of Historic and Cultural Monuments Preservation) before land can be allocated for construction, agricultural and other types of activities in areas containing monuments.

Law on Environmental and Nature Use Charges (1998) This Law regulates calculation of payments for various types of nature protection and nature utilization activities (hereinafter payments), the order of their processing, liability in case of violation of the law, and other relations.

Law on Rates of Nature Protection Payments (2006) This Law sets rates for nature protection payments and the mechanism of their calculation. The law specifies the rates of the payments for emission of harmful substances to the air from the cars, tracks used and owned by RA individuals and legal entities. Higher rates are set for Yerevan and specially protected areas. The law defines the rates of the payments for emission of harmful substances and combinations to the water basin.

Law on Flora (1999) The law defines RA state policy in the field of maintenance, protection, usage and regeneration of flora. The law defines objectives of flora examination, state monitoring, state inventory, requirements and approaches of red book preparation on flora, conditions, peculiarities, limitations of allocation of flora objects for purposeful usage, basis of termination of the right to use, provisions on flora maintenance, and economic encouragement of usage and implementation of supervision.

Law on Fauna (2000) The law defines RA state policy in the field of maintenance, protection, usage and regeneration of fauna. The law defines the objectives of survey of the fauna, state monitoring, state inventory, requirements and approaches of red book preparation on fauna, conditions, peculiarities, limitations of allocation of fauna objects for purposeful usage, basis of termination of the right to use, provisions on fauna maintenance, and economic encouragement of usage and implementation of supervision.

Law on Wastes (2004) The law regulates legal and economic relations connected to the collection, transfer, maintenance, development, reduction of volumes, prevention of negative impact on human health and environment. The law defines objects of waste usage, the main principles and directions of state policy, the principles of state standardization, inventory, and introduction of statistical data, the implementation of their requirements and mechanisms, the principles of wastes processing, the requirements for presenting wastes for the state monitoring, activities to decrease the amount of the wastes, including nature utilization payments, as well as the compensation for the damages caused to the human health and environment by the legal entities and individuals, using the wastes, as well as requirements for state monitoring and legal violations.

Law on Environmental Oversight (2005) This Law regulates the issues of organization and enforcement of oversight over the implementation of environmental legislation of the Republic of Armenia, and defines the legal and economic bases underlying the specifics of oversight, the relevant procedures, conditions and relations, as well as environmental oversight in the Republic of Armenia.

Law on Specially Protected Natural Areas (2006) This Law defines legal basis and relations of state policy for development, restoration, maintenance, reproduction and use of natural complex and separate objects, as well as ecosystems of specially protected natural areas of the Republic. According to the law, specially protected natural areas are divided into four categories, National parks, State Reserves, Natural museums and the forth category is divided into three separate types: areas of international, republican and local importance.

Law on Compensation Rates for Damage Caused as a Result of Environmental infringements to flora and fauna (2005) This Law defines the rates of damage compensation caused as a result of environmental infringements to flora and fauna, as well as the calculation and collection procedure of these tariffs.

3.2. Licenses and permits to be obtained by the project proponent and by works contractor to carry out project activities

• Civil license in the area of the capital construction, including development of documents for urban development, engineering research and expertise to be held by the design company. • Civil license in the area of capital construction to be held by the construction company providing works. • Positive conclusions for construction of Vanadzor MC issued by State Environmental Expertise SNCO of the Ministry of Nature Protection. Such conclusion is required in accordance with the Law on Environmental Impact Assessment.

• Agreements from the Vanadzor municipality for disposal of excavated materials and construction wastes in the approved dump sites shall be obtained by Construction Contractors prior to transportation and disposal of construction concrete rubbles, debris and spoils as well as excessive excavation materials in such dump sites; • Permit for water supply and waste water discharge for Vanadzor MC issued by the Ministry of Nature Protection (MNP). • Technical passports for medical wastes approved by the MNP. Technical passports should be developed by Vanadzor MC.

3.3. World Bank Safeguard Policies

The World Bank OP/BP 4.01 Environmental Assessment is considered to be an umbrella policy for the WB's environmental safeguard policies. These policies are critical for ensuring that potentially adverse environmental and social consequences are identified, minimized, and properly mitigated. The HPIU carried out screening of Vanadzor CM subproject and confirmed that alike NDPC Project in general, this subproject triggers only OP/BP 4.01, falls under Category B, and requires an EIA.

Construction of Vanadzor MC is subject to EIA procedure according to the national legislation too. The main differences between the OP/BP 4.01 and the RA Law on Environmental Impact Assessment are that (i) “EIA” by definition of the national law is a process of examining project documentation and undertaking is expert review by the Government Agency – State Environmental Expertise SNCO, while the conventional international understanding of this term is a study of potential impacts of a proposed project by the project proponent, which has to be submitted for clearance to an authorized entity. Also, the national legislation does not call for the preparation of an EMP, while OP/BP 4.01 clearly sets forth such requirement.

3.4. Administrative Framework

This section reviews the roles of government agencies that may have involvement in the Vanadzor MC sub-project, primarily, but not exclusively, from an environment perspective.

Ministry of Nature Protection The MNP is responsible for the protection, sustainable use, and regeneration of natural resources as well as the improvement of the environment in the Republic of Armenia. In those areas, the MNP’s authority includes overseeing national policy development, developing environmental standards and guidelines, and enforcement. The MNP also undertakes several functions through the following key detached divisions and subordinate bodies:

▪ Water Resources Management Agency WRMA is the key institution responsible for the water resources management: development of National Water Policy and National Water Plan; classification of water resources by their purpose usage; participation in water standards development and supervise their application, issue water use permits, etc.

▪ State Environmental Expertise SNCO conducts environmental assessments and issues conclusions.

▪ State Environmental Inspectorate includes 11 Regional Environmental Inspectorates and oversees the implementation of legislative and regulatory standards in natural resources protection, use and regeneration. It also conducts environmental inspections at worksites for control of environmental measures and valid permits.

▪ Environmental Impact Monitoring Centre collects water quality data from 131 sampling points.

Ministry of Energy and Natural Resources The Ministry of Energy and Natural Resources (MoE) is a state body of executive authority, which elaborates and implements the policies of the GoA in the energy and natural resources management sector.

Ministry of Healthcare The Ministry of Healthcare (MoH) is a state body of executive authority, which elaborates and implements the policies of the Republic of Armenia Government in the healthcare sector. The MoH implements the functions related to development and organization of implementation of healthcare management policy and state projects, development and approval and sanitary norms and rules, drafting as well as oversight over implementation of laws and regulations related to healthcare sector. The MoH is designated by the Government as the implementing entity for the WB-financed NDPC Project. The Ministry is supported by the Health Projects Implementation Unit (HPIU). The HPIU will be responsible for managing Vanadzor MC sub-project, including its environmental compliance.

4. ENVIRONMENTAL AND SOCIAL SCREENING NDPC Project carries investment components in support to provision of premises for medical facilities and therefore triggers OP/BP 4.01 Environmental Assessment. According to this policy, the NDPC Project is classified as the environmental Category B. Construction of Vanadzor MC carries medium environmental and social risks which can be effectively mitigated. Due to the above, Vanadzor MC subproject falls under environmental Category B.

Land plot selected for the construction of the Vanadzor MC is located in densely developed urban settings and encountering any unknown cultural property in the course of their construction is unlikely. OP/BP 4.11 Physical Cultural Heritage is not triggered.

The subproject does not trigger OP/BP 4.12 Involuntary Resettlement, because its implementation will not require any land take or cause physical relocation. Land plot allocated for the construction of new buildings for the Vanadzor MC is State-owned and is not under any type of informal land use.

In summary, the Vanadzor MC subproject falls under the safe environmental category as the NDPC Project as a whole, and does not trigger any additional safeguard policy not triggered by the NDPC Project. Therefore, construction of the Vanadzor MC is eligible for financing from the proceeds of the NDPC Project.

5. TECHNICAL STANDARDS AND REGULATIONS

The national technical standards and regulations applicable to the construction of Vanadzor MC are as follows:

- The RA Health Minister’s N 138 order as of May 6, 2002 on approving N2 – III – 11.3 sanitary norms on Noise at Workplaces, Public and Residential Buildings, and Residential Construction Areas.

- The RA Health Minister’s N 01-N order as of January 25, 2010, on Approving Sanitary Rules and Norms of Soil Quality Hygiene Requirements N 2.1.7.003-10.

- The RA Health Minister’s N 533-N order as of May 17, 2006, on Approving HN N 2.2.4-009- 06 Vibration Hygiene Norms at Workplaces, Residential and Public Buildings.

- The RA Government Decision N 750-N as of May 29, 2006 on Establishment of Technical Regulations for Requirements on Re-cultivation and for Classification of Disturbed Lands Which Are Subject to Re-cultivation.

6. PHYSICAL AND NATURAL ENVIRONMENT

6.1.Geographic location

Vanadzor is stretched to Pambak sub-area of Gugarkarea, Debed-Aghstev sub-province, province of Northern mountains of heterogeneous baseand intermountain concavities. It lies on the southern slopes of Bazoum mountain chain, on the left bank of catchments basin of Pambak River. Bazoum mountain chain represents the most north-western edge of Small Caucasus system of mountains of heterogeneous base, which runs from west to east, from Karchakh mountain pass to the gorge of Gayladzor, 66km in length and in the confluence of Pambak and Dzoraget rivers. The mountain chain has an average height of 2,800m, and the highest peak is Urasar mountain peak at a height of 2,992m. The mountain peak has limited fragmentation. The slopes of the mountain chain grow steep across the town of Vanadzor.

6.2.Hydro-geological conditions

Pambak River is the main stream of Debed River that runs into Kura River basin and its upstream. The riverbed is the spring at the intersection of Shirak and Pambak mountain chains at a height of 2,100m on the western slope of Djadjur. The Pambak River basin occupies 1,370 sq. kmarea, 80km in length, with average slope of 13 degrees, surrounded by Bazoum mountain chains in the north and Pambak mountain chains in the south. Getahovit is an expanded gorge which turns into a deep canyon on the outfall where it intersects with Dzoraget and from where the river Debed runs. The outfall marks 870m height above sea level. The river is mainly fed from a mix of snow and rainfall – 62.5% of water supply, and the remaining 37.5% come from underground waters; the main flow is observed in springtime, while floods happen in summer. Chichkhan River is one of the major streams of Pambak River and it intersects with Tandzut River and Vanadzor, a stream of Tandzout, near Vanadzor city.

The monitoring of environmental pollution of RA is implemented by the Ministry of Nature Protection of RA “Environmental impact monitoring centre” (“Eco-monitoring”) SNCO. According to “Eco-monitoring” Newsletter 2012 on “Environmental ecological monitoring results in the Republic of Armenia”, In May 2013 in the upper part of Vanadzor town of Pambak River and in October in the lower area of the town deficiency of oxygen regime was observed, the content of dissolved oxygen was respectively 5.13 mg/cu demand 5.69mg/cu dm.

In the lower land of Vanadzor town high pollution levels of ammonium and chromium were

observed in Pambak river, average annual concentrations have exceeded the acceptable border norms by 11.6 and 10.8 times respectively. In the upper land of Vanadzor town and in the area of Marts River high pollution levels of aluminium were observed; average annual concentrations have exceeded the acceptable border norms by 11.3-19.4 times.

Test samples taken from Pambak river show that acceptable levelsof average annual concentration of nitrites are 1.2-6.3 times exceeded. In the upper and lower areas of Vanadzor town, acceptable level of zinc is exceeded by 1.1 times, and the level of selenium - exceeded by 1.3- 1.4 times.

6.3.Seismic condition and tectonics

From a tectonic point of view the region of Vanadzor has rather complex geological structure which is explained by its positioning: situated in the north-west of Small Caucasus meganticlinorium, Sevan-Amasia tectonic zones, i.e. in Cimerel foliation zone of Kapan- Gogaran.

Sevan-Amasia tectonic zone is described by intensive foliation, which, in some areas is equally steep and semicircle with complex ascents and descents. In the above mentioned region, the likelihood of severe earthquake is at 8-9 magnitude scale with 0.5g maximum level of horizontal intensity (according to the information of the National Seismic Protection Service).

6.4. Climate

The climate in the region is considered to be moderate with relatively moist humid climate type all year-round: In January the average temperature ranges from -2-4, and during July-August 18- 20 degrees are observed, quantity of annual precipitations is 600-700mm, with maximum rainfall in spring and at the beginning of summer. In winter, mainly starting from the first half of December, a firm snow cover is formed 5-20cm capacity. The average wind speed reaches 3- 4m/second, and in the mining area the winds mainly blow from north-east to south-west.

6.5. landscape and soils

In the territory of Vanadzor and its neighbouring area mainly grey forest, brown forest lands, regular black soil, grassland and steppe as well as mountain meadows are found, while to the north mother rock desertification is common. The mine territory itself is commonly characterized by grey forest lands with weak, unsaturated, stepped, poor capacity, clay sand, mostly lightly weather-beaten lands. In the northern part of the mine, in lowlands grey forest lands gradually transform into brown forest lands characterized by washed, stepped, poor capacity, clay sand, and in most cases these lands have average level deflation.

The land cover of the area is diverse and is characterized by altitudinal zones. Brown forest lands of mountain forest zone is characterized by brown and dark-brown colour, rather high humus content (10-14%), which rapidly decreases with depth. The quantity of humic and fulvic acids in humic substances is almost equal.

These types of lands have mainly clay-sand mechanical composition. Absorption volume is high and Ca is dominant in absorbed cations. Reaction is neutral or weak basic. They are characterized by favourable physical and water physical properties and well expressed texture. Brown forest lands in the area are presented in the form of washed sub-types. Chemical composition of individual genetic horizons in the black soil of the area, in particular, in

terms of silicium, aluminium, iron, potassium content, no major differences were observed, and those are equally distributed within soil profile.

Soil solution reaction is mainly neutral (pH is close to 7). Absorbing complex is rich mainly with Ca and Mg. They are rich with general nitrogen (0.15-0.35%), phosphoric acid (0.15-0.26%) and potassium (1-2%). In river-valley-terrace featuring lands genetic horizons are weak. They have simple layer texture, big capacity and light mechanical composition (sand, clay sand). Humus content ranges from 1.5-2 up to 4-6%. Soil solution reaction is mainly neutral or weak basic. Absorption volume is not big (15-25m equiv. in 100g soil), calcium is dominant in the composition of absorbed cations.

6.6.Flora

The flora of Bazoum mountain chain has more than 1,033 species of vascular plants that belong to 436 generation/sorts and 98 families. Vegetation types of the region are forests and steppe species. In valleys, forest vegetation cover represents dominant beach and oak tree species, while in the valleyshrub-bunchgrass grassland are common. In the rocky falls bushes of rose-hip, thorn-bush are common among forest plants such as beech, oak, ash-tree, lime-tree, maple tree, fennel. Common tree species are wild pear, apple tree, nut tree, plump tree and to south-east - thin forests of Carpinusorientalis, Juniperus L. are found.

Vegetation existing in the site allocated for the construction of Vanadzor MC comprises of an artificial plantation of some coniferous and broadleaf tress that will be protection during construction works to the extent permitted by the design. No impact on natural vegetation is expected outside the boundaries of the construction site.

6.7.Fauna

Forest and steppe types are dominant in fauna. Mammals such as roe, brown bear, wild boar, wolf, fox, marten, rodents are rather common in the region. The forest is rich in bird species such as Bearded Reedlings, there are Finches, Bullfinches, and such predatory birds as Owls, Eurasian Eagle-Owls, Buzzards.

Works at the site allocated for the construction of Vanadzor MC, which has been fenced and used by a military hospital for decades, will not have any impact on wildlife, other then possible slight noise disturbance for the limited period of construction works.

6.8.Specially protected natural areas

Vanadzor is situated at a 9 km distance from the Gyulagarak State pine sanctuary on the northern slopes of Bazoum mountain chain, and at 12.6km distance from Margahovit, and respectively, at a 17.0 km distance from Caucasian flame tree sanctuaries on the northern slopes of Pambak mountain chain, while the distance from Dilijan National park is 19 km.

The 8-19 km distance from the mentioned state reserves, as well as the calculated parameters of construction and hospital operation allow us to conclude that the reserve will not be subjected to any impact which can be defined or measured.

7. TECHNICAL DESCRIPTION OF WORKS

The new building of the Vanadzor MC will be of 11,000 square meters and will consist of the following departments: • Reception Room and Emergency Department; • Department of Diagnostics and Day care unit; • 190-bed capacity in patient service, including General and Pediatric Surgery, Obstetrics and Gynecology, ICU, General Therapeutics, Pediatric, Oncology and Hemodialysis Departments; • Ancillary services including centralized sterilization, laundry, engineering and logistics services, etc.

Governmental Decree N 699-N was issued on April 24, 2011, according to which optimization of Vanadzor health care system shall include merging Vanadzor Hospital N2 and Vanadzor Hospital N1 named after L. Areshyan. As a result the new Vanadzor MC CJSC was founded. In addition, in accordance to the 4th point of the mentioned Decree the Government of the RA assigned the Minister of Health to start negotiations with World Bank for allocation of funds for construction of a new Vanadzor MC. Feasibility study for this new construction was carried out in October 26, 2011. Outcomes of this study justified new construction due to excessively high estimated costs of capital reconstruction of the existing two buildings which carry structural damages unacceptable in the seismically active area of Lori marz. Costs of the new construction were estimated to be some 1,148,000 USD less than works required for fundamental reconstruction of the two existing buildings. The new Vanadzor MC will provide all kinds of hospital and polyclinic services on one equally accessible location for the entire population of the Lori marz. The implementation of this plan will result in vacation of the Vanadzor Hospital No. 2 (except the Tuberculosis department block) and of the Vanadzor Hospital No. 1. The sub- buildings will be vacated and transferred to the Department of State Property Management by the GoA.

The Vanadzor MC will be constructed in the southern part of Vanadzor city, in the territory of the former military hospital. The area planned for construction occupies 29,900 square meters. The relief of the territory is basically smooth, with not high, artificial elevations, with general inclination to the northeast. The medical service in the MC will be carried out in the main building, where general and therapeutics, resuscitation, oncology, pediatric departments will be operating. The MC administration will operate in the same building as well. Simultaneously up to 190 patients may get full-time/inpatient permanent treatment in the MC.

As a part of the design works, there have been drilled 19 boreholes, and only in one there has been found water. Water has been found in the depth of 22.5 meters. There are no physico- geological phenomena having negative influence on resistance of the bases of the designed buildings. According to II-6.02-2006 of the Building Standards of the RA, the area allocated for the construction is situated in the 3rd seismic zone (a=0.4g). The seismic conditions of the area were examined on January 2013 by “Geotest” LLC. As per the presented findings the expected maximum horizontal accelerations of the soils and the values of the periods of the self- oscillations of the soils are located within permissible intervals, which will enable to estimate the soil conditions of the area as of second category in accordance with the seismic properties.

The estimated volume of the extracted soil will be totally 8,775m, the 4,200 m3 of which will be transferred to the designated waste point (landfill). The rest volume- 4575 m3 will be used for back filling and landscaping. Heating and hot water supply of the MC will be provided through the boiler-house. It is planned to install 3 hot water boilers of dual – gas/oil type. Natural gas is assigned to use as basic fuel, and solar oil – as reserve. Natural gas will be supplied from the

nearest medium pressure gas pipeline of “ArmRusgasprom” CJSC. Heating value of natural gas has been assumed 8,000 kcal/nm3.The rated gas consumption of one boiler will be116m3/h, the three ones together - 348m3/h.

Reserve fuel will be used only during emergency gas shut-off. Maximum consumption is accounted for 4 days. 20m3 reserve capacity is assigned for solar oil. Heating value of solar oil has been assumed 10,000 kcal/kg, and the calculated consumption rate -311kg/h.

Release of exhaust gases will be fulfilled through a pipe 20 m in height and 630 mm in diameter. The maximum volume of exhaust gases will make up 90300nm3/h; and the speed - 8 m/s. The design of the boiler-house has undergone an ecological examination in MNP and received positive conclusion.

Soil back filling under the grounds and external supply lines

Excavated soil will be used for backfilling. It shall be piled in the radial area of coverage of three cranes to be deployed at the construction site. Soil will be transported to the filling points by cranes. Mini excavators will be used for loading soil into the crane buckets.

Back filling by 50sm soft soil layer on the pipes installed on the trenches will be undertaken using manual labor, while other backfilling will be done with a bulldozer, by any kind of soil.

Works on seismic resistance of the buildings

Seismic resistance of the building will be ensured by installing of special earthquake resistance steel laminated rubber bearings.260 seismic isolation steel laminated rubber bearings will be installed in the main building.

Supply of energy and materials for construction period Table 7.1 № Name Unit of Measurement Total 1 Water l/s 1.0 2 Electric power kVA 490.0 3 Pressed air Kg/dm2 10 4 Vapor (steam) kg/h 675 5 Fuel T 210 6 Oxygen CBM 4400.0

The average of the workers for construction period accounted for 65. The number of the employees of different classes has been determined by the average number of the workers: Engineers 6 people Office workers/ 4 people Other workers 2 people

The total of the construction workers is 77 people.

External water supply

The external water supply will be carried out by "Armenian Water Sewerage Company" (AWSC) CJSC Vanadzor networks. Currently AWSC carries out its activities through 3 regional branches: North West, Center West, South, 17 sectors and 16 subsectors. The Company jointly

with its subdivisions provides technical operation, exploitation, and maintenance of water supply and wastewater systems of 37 towns, including Vanadzor (North West), and 280 rural communities in Republic of Armenia. The Company’s 100 percent shares belong to the state (State Committee of Water Economy of Republic of Armenia Ministry of Territorial Administration). Water supply and wastewater inter-communal networks are the property of the communities External Sewerage The hospital wastewater is disposed by gravity method. Connection to the external sewage network will be made with polyethylene non-pressure D = 150 mm pipes. Where there are network nodes on the changing locations of horizontal and vertical declivity it is planned to have observatory pits. All waste water generated at the MC will be discharged to the Vanadzor municipal sewage system through a single collector pipe.

Power supply

Electricity will be supplied to the MC by AEN (Armenia Electric Networks) Closed Joint Stock Company (CJSC), and for that purpose an electrical substation is designed. AEN is engaged in regulated distribution and sales of electric energy. Overall spread of its grid is 36 thousand km. The company has an exclusive license for distribution of electric energy within the RA.

8. SENSITIVE RECEPTORS

8.1 Ambient Air

In Soviet times the town of Vanadzor had a developed industry which was significantly polluting air. However, in the last few years the industrial production dropped dramatically and so has the level of emissions. At present, automobile exhausts are the only main contributor to the air pollution in Vanadzor.

Air pollution is characterized by background concentrations level of various pollutants. The air pollution control of residential areas on the territory of the RA is implemented by Environmental Impact Monitoring Center SNPO of the MNP by the means of observation stations located in the settlements. Permanent observation stations are located only in Yerevan, Vanadzor, Ararat and Hrazdan cities.

Based on the data of 2011 obtained from 24 observation stations installed in the town, the average annual concentrations of sulfur dioxide and nitrogen dioxide are found to be under the permitted ceilings.

8.2.Water Resources

Pambak River is the largest hydrographic unit in the vicinity of Vanadzor. The river basin comprises 1.370 square kilometers. It is surrounded by Bazum mountain range in the north and Pambak mountain range in the south. The river valley is a vast ravine, changing into a deep canyon at the river mouth.

Table 6.1.Characteristics of the Pambak River flow Flow Flow rate, Annual flow, Height of flow Flow River module, m3/sec million.m3 layer, mm coefficient l/sec km2 Pambak 8.96 283 8.37 264 0.42

River pollution is monitored by the Environmental Impact Monitoring Center of the MNP. High pollution with ammonium ion has been observed in Pambak River downstream of Vanadzor town. The average annual concentration exceeded the permitted limit by 10.4 times. In the upper section of Pambak River the average annual concentration of manganese also exceeds maximum permitted limit by 2.6 times, while in the bottom part of Vanadzor town the concentration of nitrite ion exceeds the norm by 3.7 times and concentration of chrome exceeds the norm by 3.0 times. Contents of the other pollutants are found to be within the permitted limits.

Though the Pambak river is located in the lower area than the Vanadzor MC, it will not be affected, because it is located 1.8 km away. Tandzout and Vanadzor rivers are located in the higher area and will not be affected.

8.3 Land Resources

Land plot allocated for the construction of Vanadzor MC is located in the highly transformed urban settings. Their vegetative cover is represented by grass, shrubs, and artificially planted trees, the part of which will have to be removed to allow construction of the Vanadzor MC. The land plot allocated for the construction of the Vanadzdor MC was previously used by the military hospital.

8.4 Social Environment

Land plot allocated for the construction of Vanadzor MC is located within the residential area, the existing hospital N1 and the military base.There are no schools and kindergardens nearby. The location and connectivity of the site are highly convenient for potential users of their services and will amplify social benefits of the provision of these new premises.

Staff and patients of the Vanadzor MC will be under immediate direct health impacts from the design of the buidlings and from the materials used for their construction and finishing, as well as from the operation of some medical devices, and management of the medical waste.

8.5 Cultural Resources

There are no known and registered physical cultural resources located in the vicinity of the land plots allocated for the construction of Vanadzor MC. Though due to the need of earth excavation works, encountering of change finds cannot be entirely excluded.

9. SOCIAL AND ECONOMIC ENVIRONMENT

Vanadzor city is the Lori Marz center located in the Northern part of the RoA, in the valley situated between Pambak and Bazoum mountain ranges. Vanadzor is 125 km away from the capital city of Yerevan. The community received a status of a city in 1924; formerly was known as Gharakilisa, and later was renamed to Kirovakan, and ultimately in 1992 was again renamed to Vanadzor. In terms of population, Vanadzor is the third largest community in Armenia after Yerevan and Gyumri. The size of the local population changed as follows: 494 inhabitants in 1831; 2,017 – in 1873; 3,917 – in 1897; 8,640 – in 1926; 17,607 – in 1939; 49,423 – in 1959, and 148,876 – in 1980. As of 2012, the number of Vanadzor population was 104,921. However, according to the national census carried out in October 2011, the number of permanent population of the town has significantly decreased during the last decade reaching 85,700 as of

January 1, 2013. The ethnic composition of the city population is diverse: Russian, Ukrainian, Yezidi, Georgian, Greek and other national minorities live in Vanadzor. Population data by gender and age is presented in the below Table 7.1.

Vanadzor is located at an altitude of 1,353 m above the sea level, and the city territory occupies 2,599.3 hectares. The climate is mild, temperate; the level of humidity is moderate. Winters are comparatively warm, with consistent snow cover, and summers are warm. The average annual level of atmospheric precipitation is 650 mm. Waters of Pambak, Tandzout and Vanadzor Rivers are utilized for irrigation purposes and as potable water. The city is rich with underground water reserves. There are forest resources to the south of the city, while in the adjacent territories there are reserves of natural construction materials, such as basalt, tuff, gypsum, clay, construction sand, which have industrial importance. There are a number of cultural artefacts in the city and the adjacent territories. In addition, there is a botanical garden in Vanadzor.

The territory of Vanadzor city is one of the most ancient dwelling locations in the Armenian uplands. Part of the city population has moved in from Yerevan province in the 19th century.

Table 9.1. Numbers of permanent population of Vanadzor by gender and age, as of January 1, 2011.1 Of which Age groups Total Male Female 0-4 years 5,769 2,922 2,847 5-6 years 1,278 641 637 7-10 years 4,116 2,067 2,049 11-14 years 5,105 2,402 2,703 15-17 years 2,218 1,143 1,075 18-22 years 8,174 4,116 4,058 23-45 years 31,432 15,691 15,741 46-64 years 21,609 10,157 11,452 65 and more years 13,334 4,979 8,355 Total 93,035 44,118 48,917 Source: RA Ministry of Territorial Administration

Despite the existence of labour migration, nevertheless, the labour market suffers imbalances: as of January 1, 2011, the number of employed population was 28,608, while the number of officially registered unemployed only was 5,045, of which, 3,292 were women. The structure of employed population by types of economic activities is presented below.

Table 9.2. Employment status of the population by the types of economic activity The number of N Type of activity employed, persons 1. Agriculture, hunting and forestry 3,556 2. Fishery and fish farming 58 3. Mining of minerals 64 4. Processing industry, includingprocessing of 2,625 agricultural produce 5. Production and distribution of electricity 198

1 According to the database of the RA Ministry of Territorial Administration

6. Construction 2,755 7. Sales and repair of cars and appliances 2,839 8. Agricultural services 128 9. Hotels and restaurants 2,753 10. Transport and communication 1,867 11. Local self-governance 1,314 12. Education sector 3,035 13. Health sector 1,150 14. Public utilities, social and individual services 3,656 15. Financial services 2,610 16. State administration bodies 4,608 Source: RA Ministry of Territorial Administration

In the past, Vanadzor was known as a highly developed industrial city. The local economy grew especially fast since 1940s. During those years new branches of the economy started to expand; major enterprises involved in the production of machinery, chemical industry, textile and food industries were built and commenced operation. The role of the city in the country’s economy was especially important in terms of production of various types of chemical goods and materials, including artificial fibre, nitric acid, calcium carbide, melamine and other. Later a severe economic decline was observed. In 1996, a production of machinery and equipment for the development of precious stones was established in the city. As of farming practices, the local population is primarily engaged in growing wheat, legumes and potato. Those engaged in animal breeding produce milk, meat, wool, eggs, and honey.

The population utilize health care services provided by health care institutions operating in Vanadzor city as well as the ambulatory of the nearest Gugark community. The health care system operating in Vanadzor city includes two hospitals which were merged in one Vanadzor MC, five policlinics, and two specialized medical centres/clinics.

In the course of 2011 and 2012, morbidity registered in health care institutions of Vanadzor and Gugark communities indicates the existence of serious problems in the health care sector in Lori marz, though in 2012 certain decrease in morbidity was registered.

Table 9.3.Distribution of morbidity by age groups 2011 2012 Adults 40,515 39,784 Children (0-14 years) 16,095 16,327 Children (15-17 years) 3,061 2,959 Total 59,671 59,070

However, it is alarming that morbidity is not only quite high among children aged 0-14 but, also, in 2012 it made 101.0% of the 2012 data.

10. EXPECTED ENVIRONMENTAL AND SOCIAL IMPACTS

The expected impact of the planned activities on the environment is presented in two stages: in the course of the implementation of construction works and operation/maintenance.

10.1 Construction phase

The main environmental and social risks are identified to be: • Air pollution during drilling and loading operations, and exploitation of construction equipment engines; • Land degradation and erosion as a result of damaging vegetative cover; • Nuisance to local communities from dust and noise during construction equipment operation and motor vehicles works; • Local traffic disruption due to movement of construction vehicles and machinery; • Unsafe disposal of access material and construction waste; • Soil and ground water pollution with operational spillages of fuel and the runoff; • Unsafe extraction of construction materials.

Impact on the air

Emissions of hazardous materials originate during construction works when drilling of foundations, land mass loading, unloading and transportation takes place, as well as a result of construction equipment diesel engines combustion of fuel, laying of asphalt, bitumen works and welding. a) dust emissions during drilling-loading works During the drilling-loading works inorganic dust emissions are generated, mainly during drilling with excavator, removal of the priming ground, and loading of dump trucks. b) Diesel fuel combustion products/results The technical means envisaged for construction provision use diesel for fuel. During the combustion of diesel fuel nitrogen, carbon and sulfur oxides, as well as solid particles (soot) are being generated.

Calculations of emissions of the above mentioned substances during short-term g/sec and the entire construction period are presented in Annex VII. Emissions generated during construction are of localized and temporary nature and quickly disperse. Therefore, as illustrated through calculations, the expected surface concentrations of pollutants at the construction phase are significantly lower compared to the maximum permitted values established for residential areas.

Impact of Water Use

During construction works the water will mainly be used for watering the construction site, cleaning the pipes, and household needs of the contractor’s staff and personnel.

Water use for watering of a construction site is classified as irredeemable water use and is counted as a loss. Water used for testing and disinfecting pipes is collected in a special tanker, and after neutralizing it with hypochlorite sodium, this water can be used for watering the construction site.

To meet household water consumption needs of personnel, the construction company will make accommodations equipped with bathroom and food court spaces in the town of Vanadzor. The water balance of the construction period is presented in the Table 10.1.

Table 10.1. Water usage, m3/annually Water discharge, Purposes of water usage m3/annually Circulating Total Drinking Technical Outflow Irredeemable volumes, quality quality utilization and m3/day loss Dust catching (watering 576.0 576.0 - - 576.0 - of platforms) Testing of pipes and 12.0 12.0 - - 12.0 - disinfection Drinking and household 879.4 879.4 - 866.2 13.2 - needs Subtotal 1467.4 1467.4 - 866.2 601.2 -

Surface water pollution is not expected from the construction works, as the closest surface water body is about 2 km away from the construction site. Ground water pollution may result from regular operational spills or accidental spill of fuel and lubricants in case servicing of construction vehicles and machinery is undertaken on-site. Unregulated washing of vehicles at the construction site may also result in ground water pollution.

Impact on Soil – waste, borrowing

The new building of Vanadzor MC will be located at Nzhdeh Str. 2/42, next to the existing hospital No. 1. The allocated land plot is 3.172 ha. It is State-owned and is currently not in any formal or informal use. According to Vanadzor city Community Chief`s decrees N394-A dated April 4, 2012, “Vanadzor MC” received free user right for 3.172 hectares land plot. The mentioned right has been registered on May 24, 2012 by State Committee of the Real Property Cadastre of the Lori marz. Address is 2/42 Njdeh Street, Vanadzor, Marz of Lori, RA. There are several dilapidated buildings of the former military hospital on this plot. Other than the hospital No. 1, there is a military base in the neighboring area, while some land is staying idle.

It is planned to organize a construction site for the construction of the Vanadzor MC and (taking into account the previous experience of construction activities conducted by PIU, for example Gyumri MC install a concrete mixer.

Currently, in the area of the planned Medical Center there are a number of semi-collapsed constructions and debris remained from the collapsed constructions (see Pictures No 1 - 4). Before the launch of construction works, the litter gathered in the area must be transported by the contractor to the dump allocated by the municipality. The debris occurring in the process must also be periodically transported to the dump. The location of a dump and transportation schedule is agreed with Vanadzor municipality (see Annex 4).

There are 34trees in the area (mainly poplar and coniferous species), that have been planted by the former exploiters of the area. The 22 trees will be cut, as they are located in the areas of envisaged constructions and roads. Some trees located in the marginal parts of the land plot will be retained. The planting of greenery in the unoccupied parts of the area is envisaged, including planting of trees.

In the course of construction works the outer layer of land in some parts of the site is withdrawn and it could cause phenomena of further erosion.

In total 3960.0 m3 of vegetated soil is removed and is stored in up to 50 meters away from the removed area and is later used for improving and landscaping purposes of the site.

As a result of construction works construction waste is generated, which may result in accumulation of garbage and pollution of the outer layer of the soil.

The total excavated soil mass will make 8775.0 m3, 4575.0 m3 of which will be used as backfilling. The surplus land mass of 4200.0 m3, as well as the construction waste will be removed to the mentioned dump provided by Vanadzor municipality.

Noise generation

The technical machines used in the process of construction works generate additional noise.The specific parameters of noise generated by the technical means are presented in Table 10.2.

Table 10.2. Name of technical Number of Absolute (tech. passport) Permissible level of means simultaneously parameter of noise, dBA noise at the operating workplace, machine dBA Excavator 2 99 - 102 85 Bulldozer 1 102 - 104 85 Hoisting crane 1 77 - 84 85 Dumper 1 82 – 87 85

Taking into account the distance of the residential districts from the construction site, the noise of the mentioned above technical means will not create an exceeding normative source for residential and public buildings.

10.2 Operation phase

The main environmental risks: - improper operation of boiler house - organic, chemical and household waste generation

Impact on the air quality

The MC’s heating system operation results in generation of hazardous substances from the combustion of fossil fuel that are being emitted into the atmosphere, thus impacting the environment.

Characteristics of emission sources and nitrogen oxide (calculated as nitrogen dioxide, see annexes) emissions according to fuel type are presented in Table 10.3.

Table 10.3. Fuel type Name of Emissions, g/sec Emissions, t/yearly pollutant Natural gas Nitrogen dioxide 0.024 0.45 Diesel fuel Nitrogen dioxide 0.16 -

The estimations of hazardous substances emitted and dispersed into the atmosphere realized during the boiler-house operation showed, that the expected surface based concentrations are in the range of permissible norms.

Data on maximum allowable level of pollution in case of natural gas and diesel fuel operation are shown at the below Table 10.4.

Table 10.4. Fuel type Pollutant type Maximum allowable Maximum pollution concentration (MAC) (portion of MAC) (absolute units, mg/m3) Natural gas Nitrogen dioxide 0.00196 0.023 Diesel fuel Nitrogen dioxide 0.013 0.155

Water use

Economic water supply of the drinking water of the Medical Center will be carried out from the urban water supply network (spring water sources). The water use volumes are not comparable with Vanadzor water consumption and cannot break the water balance.

The water supply internal network is circuit-shaped. The hot water is supplied from the boiler- house, which will be located at the Medical Center’s area.

To ensure the fire safety of the area a ground fire-fighting hydrant is to be installed. The water supply and water discharge calculations are provided in the annexes. Below in the table 8.7. are the results of these calculations.

Water discharge

The sewage waters of the Medical Center arise as a result of household water usage and works of laboratories. All the sewage waters are accumulated in one sewage pipe and connected with Vanadzor municipal sewage system (AWSC).

Water balance Table 10.5. Water consumption, m3/year Discharge, m3/year Water user Total Drinking Service Discharge Water losses water water Staff 349.44 349.44 - 342.45 6.99 Patients 13870 13870 - 13592.6 277.4 Cooking 3678.24 3678.24 - 3604.68 73.56 Laboratories 821.6 821.6 - 805.2 16.4 Laundries 1368.0 1368.0 - 1340.6 27.4 Cleaning floors 3613.5 3613.5 - - 3613.5 Total 23700.78 23700.78 - 19685.53 4015.25

Waste

Clinical wastes, X-ray films development solutions and waste of domestic nature (see the annexes) are generated at the MC.

The surgical (clothes, bandages, paper containers and cardboard boxes) and organic wastes can be combined and send to thermal neutralization to the relevant organizations (“Ecologia V.K.H” LLC, contract N103 dated 23/12/2011).

In particular, there are a few companies in the republic that possess a waste processing license and positive environmental expertise assessment that carry out clinical waste collection and burning.

Neutralization of X-ray films developing solutions are also implemented by organizations that have received a positive assessment of environmental expertise and a waste processing license. Wastes of domestic nature will be transported to municipal landfill on the basis of a contract with Vanadzor city garbage disposal company.

11. IMPACT MITIGATION

Below presented a generic set of mitigation measures, proposed for the construction and operation phases of the Vanadzor MC Project.

11.1. Construction Phase

Emissions, noise and vibration originate during construction works when drilling foundations, loading/unloading/transporting materials, operating construction equipment and vehicles, etc. For minimizing these negative impacts: - keep construction equipment and machinery in an adequate technical condition; - avoid idling of engines; - do not use sub-standard fuel.

Excessive and unmanaged water use at the construction sites may result in waterlogging of the site, runoff from the site, pollution of the ground water with oil and lubricants. For minimizing these negative impacts: - do not allow leakages from the construction sites; - any vehicle washing done on-site should be in a designated location with mechanism to prevent oil from seeping into ground.

In case of encountering any unidentified objects and/or substances beneath the soil: - immediately take all construction activities on hold and contact national authorities responsible of handling emergency situations(Ministry of Emergency Situations); - do not resume works until having received formal permission from the above authorities.

Clearing of the site allocated for the construction of Vanadzor MC will require demolition of several dilapidated construction formerly used as the military hospital premises. These buildings are roofed with asbestos-containing material and are likely to carry asbestos containing pipes inside as well as to have some internal parts covered with lead containing paints. To avoid health hazards of workers and environmental pollution with hazardous waste: - ensure proper use of personal protective gear by all workers and personnel exposed to hazardous materials; - avoid unnecessary fragmentation of asbestos containing parts of the buildings while demounting and sprinkle them in advance; - keep asbestos containing construction waste in separate and especially isolated location of the work site and timely remove it to the formally designated disposal site (Vanadzor New Constructed Landfill) using covered vehicles.

Non-toxic construction waste, including excess excavated material, may hinder works and pollute environment if mismanaged. In order to minimize negative impacts from generated construction waste: - organize temporary on-site storage of waste in especially designated locations and timely remove it to the location of permanent disposal; - use covered vehicles for waste transportation; - timely obtain written permission from municipal authorities for permanent disposal of waste and ensure that all waste is disposed exclusively in such formally designated locations.

Accidents leading to health damage and even casualties may occur in the course of construction. To minimize risk of negative health impact and accidents: - constructors should be properly insured (Insurance of construction workers); - ensure that workers and any visitors are provided and use personal protective gear; - insure that workers receive worksite safety training, - insure that workers operating large equipment are properly trained and licensed - ensure that construction equipment are inspected and licensed - ensure that construction equipment is used strictly following its operation instructions; - keep first aid medical kits and fire-fighting equipment on site.

Construction works, especially operation of machinery, may cause nuisance to nearby residents caused with noise, dust, and vibration. Construction may cause nuisance to the patients and personnel of the Vanadzor hospital and to the staff of the research laboratory. To minimize this impact: - keep construction equipment and machinery in an adequate technical condition; - avoid idling of engines; - water work sites in the course of dusty works or in case of especially hot and dry weather conditions; - disallow on-site activities beyond the working hours.

11.2. Operation Phase

Operation of hot water supply and heating systems, as well as running of emergency back-up systems of power generation, emit to the ambient air. In order to minimize negative impacts of emission: - install and operate high quality and energy efficient cooling/heating units; - provide adequate insulation of buildings to decrease energy consumption; - keep boiler and other equipment in good working condition to avoid excessive fuel use and emissions.

Operation of the MC will generate variety of wastes, including medical, household, liquid, and hazardous wastes. Waste management system must include: - waste separation (medical, household, hazardous); - provision of adequate containers for separated collection of waste, provide safe on-site waste storage facilities, and convenient access to such facilities by waste transportation vehicles; - contractual arrangements with specialized companies licensed for the removal, deactivation, and disposal of medical and hazardous waste(the list of specialized licensed companies is available at MNP); - arrangement for the connection to the municipal waste water collection system and provide adequate maintenance to ensure flawless operation of internal sewerage.

Smooth operation of the MC will require regular good maintenance of the internal communications and the yard area, including regular check-up of water and sewage pipes to avoid leakage; periodic cleaning of storm water drainage passages to avoid water damage to the building and waterlogging of the yard; timely clean-up of snow deposited on the roof and in the yard to avoid damage and leaking of the roof and nuisance to the staff and visitors of the MC.

12. ENVIRONMENTAL MANAGEMENT PLAN

The EMP, attached to the present EIA report as Annex II ,was developed for the Vanadzor MC subproject to mitigate the negative environmental and social impacts at the construction and operation phases. EMP includes information on the risks arising on different stages of the activities, the sectors affected by the risks, as well as the list of envisaged measures, implementers, responsible people and State or community control intended to reduce each affect of the impact.

12.1 Responsibilities and Institutional Arrangements

HPIU is responsible for the implementation of the EMP including obligation of qualitative and timely implementation of all mitigation measures, supervision on implementation, documentation of the results of the supervision about cases such as environmental problems connected with implementation of environmental activities and manual principles for contractors.

12.2 Responsibilities of Construction Contractor

HPIU shall obtain Construction Permit associated to construction activities. If any additional licenses, permits, consents required (e.g. inert material etc.) construction company shall obtain such license, permits, and consents within its capacity (including conclusion of the ecological expertise).

12.3Monitoring of EMP implementation

HPIU carries overall responsibility for the implementation of EMP and for organizing environmental monitoring of works. Environmental monitoring of works shall be undertaken according to the Environmental Monitoring Plan attached to the present EIA report and the outcomes of monitoring will be documented in monthly environmental supervision reports. A template of environmental monitoring checklist to be used during field work is provided in Annex III to this EIA report.

13. STAKEHOLDER CONSULTATION

According to the Aarhus Convention, the requirements of WB and the RA Law on Environmental Impact Assessment, the public consultation on the present draft EIA report will be held in the town of Vanadzor, after which the EIA report will be finalized and the minutes of the consultation meeting will be attached to it as Annex IV.

ANNEX I. List of References

1. Convention on Access to Information, Public Participation in Decision-Making and Access to Justice in Environmental Matters (1998); available online at: www.unece.org 2. Convention on Environmental Impact Assessment in a Transboundary Context (1991); available online at: www.unece.org 3. The World Bank Operational Manual. OP 4.01 4. Biodiversity of Armenia, http://www.nature-ic.am/biodiv/index%20eng.html 5. Climate Change Information Centre of Armenia, http://www.nature.am/ 6. Construction norms and regulations volume II-L.9-70 Hospitals & Polyclinics; 7. Construction norms and regulations 2.08.02-89 Public buildings; 8. Decree # 1911- N dated 02.11.06 of the Government of RA on “Optimization of the Marz Health Care Systems. 9. Environmental Impact Monitoring Centre of the Ministry of Nature Protection of the Republic of Armenia, Report on Surface Water State for 2012, Yerevan, 2013 (in Armenian) 10. Encyclopedia Soviet Armenia, Yerevan, Armenia, 1987 11. Environmental Research and ManagementCenter of the AmericanUniversity of Armenia, http://enrin.grida.no/htmls/armenia/soe_armenia/english/ermcaua/ermc.htm 12. Fourth national Report to the Convention on Biological Diversity, Ministry of Nature Protection of the Republic of Armenia, Yerevan, 2009 13. Khandjyan N., Specially protected areas of Armenia, RA Ministry of Nature Protection, Yerevan, Armenia, 2004 14. RA Governmental Regulation on assessment of impact on atmosphere caused by economic activities, 25 January 2005, N91-N 15. National Atlas of Armenia, Yerevan, Armenia, 2007 16. Set of methodologies for calculation of pollutants emission into atmospheric air by different enterprises, Goskomgidromet, Leningrad, Russia, 1986 17. SNIP 1.02.01-85: Instruction on content, order of development, agreement and approval of design-tender documentation for construction of enterprises, buildings and structures. 18. SNIP 2.04.02-84: Water supply, External pipelines and structures 19. State of the Environment Report for Armenia, Year 2000, http://enrin.grida.no/htmls/armenia/soe2000/eng/ 20. Temporary methodological guideline on calculation of emissions of non-organized sources in construction industry, USSR Minpromstroy, Moscow, Russia, 1984

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21. The Results of 2001 Census of the Republic of Armenia (Figures of the Republic of Armenia); State Committee on the Organization and Conduction of the RA Census 2001, National Statistical Service on the Republic of Armenia, 2003 22. Water Quality and Quantity Stations in Armenia, Armhydromet Agency, www.meteo.am 23. ПКТИ of Lithuania SSR Ministry of Local Industry “Package of uniform program for calculation of air pollution ” (PUPAPC) “Raduga”, 1990 24. EMEP/EEA Air Pollutant Emission Inventory Guide book, 2009 25. IFC. Environmental, Health and Safety (EHS) Guidelines 26. IPCC Guidelines for National GreenhouseGas Inventories, 2006 27. STATISTICAL YEARBOOK OF ARMENIA. 2012. www.armstat.am 28. Marzes of the Republic of Armenia and YerevanSity in Figures, 2012

ANNEX II. Environmental Management Plan (EMP) Activity Potential Impact Mitigation Measure Indicator of Mitigation Cost of Responsibility Mitigation for Mitigation Construction Phase Provision of Delivery of substandard Purchase of construction materials from Delivery of standard quality None Construction construction materials materials which may cause the licensed providers construction materials carrying contractor risks to the safety of relevant certificates of origin structure and to health of people Transportation of - Pollution due to poor - Adequate technical condition of - Vehicles and machinery found in No specific extra Construction construction materials technical condition of vehicles and machinery decent technical condition during cost: common contractor and waste vehicles and movement of inspections responsibility of Movement of uncovered truckloads - Confinement and protection of truck - No uncovered truck loads found works contractor construction machinery - Nuisance to local loads with lining during inspections residents from noise and - Respect of the established hours and - No activity ongoing out of working dust routes of transportation hours which may be disturbing for nearby population - No complaints from nearby residents Operation of - Pollution of environment - Adequate technical condition of - Vehicles and machinery found in No specific extra Construction construction equipment with emissions and construction equipment decent technical condition during cost: common contractor on site leakages - no excessive exhaust inspections responsibility of - Nuisance for nearby - no fuel and lubricant leakage - No heavy vehicles and machinery works contractor population - Observation of working hours found operational out of the established hours - No complaints from nearby population Maintenance of - Pollution of ground water - Cars and construction equipment - No direct entry of runoff from car- No specific extra Construction construction equipment and soil with oil products washed outside the construction site or wash to water bodies cost: common Contractor due to operation of on maximum distance from the river - No spillages of fuel and lubricants responsibility of equipment - Refueling or lubrication of construction found on the ground within and works contractor - Damage in case of fire equipment and outside the construction nearby the construction site site or at the predetermined point. - Presence of basic fire extinguishing - Technical order at the equipment means on site maintenance point solid impenetrable floor or adsorbent cover enough area

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and impenetrable barriers around fuel containers - Provision of work site with basic fire extinguishing means Earth works - Loss of vegetation due to - Topsoil removal and temporary storage - Excess material disposed at the 1500 USD Construction ground piling and at a separate place at the beginning of agreed upon safe permanent storage Contractor minimization of pollution works (to dispose to landfill in case of sites with no threat of erosion and no of surface water reservoirs pollution and for re-cultivation of the blocking of waterways with particles land) - No remnants of excess material at - Pollution with probably - Temporary storage of excavated soil at the construction site upon completion contaminated soil of determined places of works surface and ground waters - Backfilling of the excavated ground as - No damage to chance finds if needed and disposal of the excess mass encountered to the places, approved in writing. Borrowing for - Slopes erosion and - Purchase of inert materials from the - Construction contractor (if mining) 600 USD Construction construction material landscape damage existing suppliers, or an external provider of inert Contractor - River banks erosion, - Obtaining of the license for production materials able to present relevant pollution of water flow of inert materials and strict compliance license for mining upon inspection with weighted particles, with the license - Mining activity of construction and disturbance of aquatic - Terrace working on quarries, backfill contractor (if being undertaken) life on the worked areas and harmonization found technically sound and with the landscape compliant with the license conditions - Working out of gravel outside water flow, arrangement with separating ridges and without putting equipment into water flow Generation of - Pollution of soil, surface - Temporary storage of construction - Construction waste found at the No specific extra Vanadzor construction waste water and ground water, waste in especially allocated areas; work site piled up in designated cost: common Municipality - Accidents at construction - Timely disposal of wastes to the locations responsibility of site due to scattered formally designated locations - No excessive amount of works contractor Construction fragments of construction - Hand-over of larger amounts of construction waste stored on site contractor materials and debris, hazardous wastes to the companies - Documents present on the handover - Deterioration of esthetic having license for decontamination and of larger amounts of hazardous waste appearance of construction placement of hazardous materials. to companies licensed for its disposal site and its surroundings

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Production of household Pollution of soil and water - Placement of waste collection - Waste collection containers found No specific extra Vanadzor waste with domestic waste containers at the construction site and at the construction site cost: common Municipality construction base (if any) - No pollution of the construction site responsibility of - Agreement with Vanadzor with household waste works contractor Construction Municipality on regular disposal of contractor domestic wastes Production of liquid - Flooding of the - Arrangement and maintenance of - Toilets provided at the construction No specific extra Construction wastes construction site and toilets in compliance with sanitation site and found in good sanitary cost: common contractor complication of activities norms at the construction site and condition responsibility of - Pollution of surface and construction base (if any) - No water logging of construction works contractor ground waters - Arrangement and regular cleaning of site drainage system for storm water collection and drain - Arrangement of sedimentation pond for water used for domestic and machinery washing and cleaning purposes Operation of asphalt- - Population disturbance - Obtaining of emission permit by the - Construction contractor holding 500 USD Construction concrete plant near the construction site construction contractor and strict permit for operating asphalt-concrete contractor - Atmospheric air and compliance with it plant and found compliant with its surface water pollution - Selection of a place for the plant that conditions provides minimal disturbance of - Adequate placement of a plant, population with noise, dust and exhaust which is least harmful for the - Arrangement of sedimentation pond for environment and disturbing for waste water from the plant population - Presence of sedimentation pool for a plant runoff. - No complaints from nearby residents Construction site re- Loss of aesthetical value of - Dismantlement of construction base (if - No remnants of a work camp left 4500 USD Construction cultivation and the landscape due to any) and temporary access roads to the behind after demobilization of Contractor landscaping construction of the site (if any) and asphalt-concrete plant contractor Medical Center and harmonization of the areas with the - Temporary access roads landscape harmonized with landscape and - Final cleaning of the construction site enabling conditions provided for and permanent access roads and natural regeneration of vegetation landscaping-greening of the area - Construction site landscaped and greened 32

Labor safety Traumatism and accidents - Provision of construction workers with - Construction workers found No specific extra Construction at work site working clothes and PPE wearing uniform clothes and cost: common Contractor - Strict compliance with the rules of adequate protective gear during responsibility of construction equipment operation and inspections works contractor usage of PPE - No violations of equipment operation and use instructions registered during inspections Operation Phase Generation of - Pollution of MC building - Waste separation and on-site storage in Good sanitary conditions in and To be included MC household, medical, and and its surrounding area adequate containers around MC in the MC administration, hazardous waste - Possible spread of - Arrangements in place for timely operation and Vanadzor infection removal of household waste by maintenance Municipality municipal service provider budget -Arrangements in place for hand over of medical waste and hazardous waste to respectively licenses companies Emergency cut-offs in Disruption of the hospital - Back-up arrangements in place for Smooth operation of the MC To be included MC the utility service operation causing nuisance ensuring permanent supply of electric in the MC administration provision (electric to the staff and patients power, hot water and healing to the operation and power, water, gas) and Medical Center maintenance fire incidence - Fire emergency preparedness of the budget hospital staff and existence of water stock for fire-fighting Improper operation of - Air pollution Periodic checks of devices and regular Smooth operation of the heating To be included MC boiler house - Possible poisoning of maintenance system in the MC administration personnel and patients operation and maintenance budget Water damage to the - Leakage of water and/or - Periodic check-up of pipes and other - No water damage to the building To be included MC building from leaking sewage pipes internal communications - Clean yard area around MC in the MC administration pipes, storm water, and - Improper operation of - Timely cleaning of snow deposits on operation and melting snow storm water drainage the roof and in the yard maintenance system budget

Total cost of mitigation measures (without maintenance charges) is USD 7,100 33

Environmental Monitoring Plan

Where When Why Who What How is the parameter is to be is the parameter to is the parameter to will monitor the Activity parameter is to be monitored? is the parameter to monitored? be monitored? be monitored? parameter? be monitored?

Construction phase Provision of construction Purchase of construction In the provider’s office Verification of During conclusion Provide technical HPIU materials materials from the licensed or warehouse documents of supply contracts order of facility and provider its safety for human health Transportation of Technical condition of vehicles - Construction site Inspection of roads Undeclared - Limit pollution of HPIU, construction materials and and machinery - Routs of transportation adjacent to the inspections during soil and air from Inspection Police waste Confinement and protection of of construction materials construction object work hours and emissions; Movement of construction truck loads with lining and wastes in the direction of beyond Limit nuisance to machinery Respect of the established the movement rout local hours and routes of - Communities from transportation noise and vibration; - Minimize traffic disruption. Maintenance of construction - Washing of cars and Construction site and Inspection of During operation of - Avoid pollution of HPIU equipment construction equipment outside construction base activities equipment water and soil with the construction site or on adjacent to it (if any) oil products due to maximum distance from the operation of river equipment - Refueling or lubrication of - Timely localize and construction equipment and decrease expected outside the construction site or damage in case of at the predetermined arranged fire point. - Technical order of the construction equipment maintenance point

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Earth works - Topsoil removal and Construction site Inspection of During earth works - Limit loss of HPIU temporary storage at a separate activities vegetation due to place at the beginning of works ground piling and (to dispose to landfill in case of minimization of pollution and for re-cultivation pollution of surface of the land if it is good) water reservoirs with - Temporary storage of particles excavated soil at determined - Limit pollution with and allowed places in contaminated soil of compliance with ground piling surface and ground parameters. waters - Backfilling of the excavated material as needed and disposal of the excess mass to the places, approved in writing. - Immediate termination of activities in case of unexpected archaeological findings and providing of full information to the Agency of cultural heritage

Extraction of inert material - Purchase of inert materials Quarries of inert Inspection of During excavation - Limit slope erosion HPIU from the existing suppliers, if materials documents and reclamation at and landscape Ministry of there is such opportunity Inspection of quarries damage Nature Protection - Obtaining of the license for activities Generation of construction Temporary storage of Construction site; Inspection of Periodically during Prevent pollution of HPIU waste construction waste in Waste disposal site activities construction and soil, surface water Vanadzor especially allocated areas; upon its completion and ground water, municipality - timely disposal of wastes to Avoid accidents at the formally designated the construction site locations due to scattered fragments of construction materials and debris

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Production of domestic - Placement of waste collection Construction site and Visual observation Total period of Prevent pollution of Construction wastes containers at the construction construction base (if construction soil and water with Contractor site and construction base (if any) domestic waste Vanadzor any) Municipality - Agreement with Vanadzor Municipality on regular disposal of domestic wastes Production of liquid wastes - Arrangement and Construction site and Visual observation Total period of - Prevent flooding of Construction maintenance of toilets in construction base (if construction construction site and Contractor compliance with sanitation any) In case of waste disruption of works Vanadzor norms at the construction site precipitations due to water logging Municipality and construction base (if any) - Reduce pollution of - Arrangement and regular surface and ground cleaning of drainage system for waters rain water collection and drain - Arrangement of sedimentation pond for water used for domestic and machinery washing purposes Operation of asphalt- - Obtaining of emission permit Construction site and Inspection of Total period of - Limit population Construction concrete plant (concrete- by the construction contractor construction base (if documents plant operation disturbance near the Contractor mixer) and strict compliance with it any) Inspection of construction site - Selection of a place for the activities - Limit atmospheric plant that provides minimal air and surface water disturbance of population with pollution noise, dust and exhaust - Arrangement of sedimentation pond for waste water from the plant

Construction site re- - Dismantlement of Construction site, Inspection of Final period of Reduce loss of Construction cultivation and landscaping construction base (if any) and construction base and activities construction aesthetical value of Contractor temporary access roads to the temporary access roads the area Vanadzor site (if any) and asphalt- (if any) Municipality concrete plant and harmonization of the areas with the landscape 36

- Final cleaning of the construction site and permanent access roads and landscaping-greening of the area

Workers’ health and safety - Provision of constructors with Construction site Inspection of Total period of Reduce probability Construction working clothes and PPE activities works of traumas and Contractor - Strict compliance with the accidents to Ministry of rules of construction equipment constructors healthcare operation and usage of PPE

Operation Phase Emergency situations at the - Existence of back-up MC premises Inspection Total period of Smooth operation of Management of Medical Center arrangements for sustaining operation of the the Medical Center, VanadzorMC electric power supply, water Medical Center safety of its staff and supply, and heating in case of patients Ministry of external emergency cut-offs Emergency - Water stocked for fire- Situations fighting Operation of boiler-house Flue gases MC premises Inspection of Weekly Operation budget Management of temperature and Vanadzor MC color of exhaust gases Waste water management MC area MC premises Inspection of pipes Monthly Operation budget Management of Vanadzor MC

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ANNEX III. Minutes of Public Consultation Meeting

The Minutes of the Public Hearing on Vanadzor MC Construction EIA & EMP Protocole

List of participants: Menua Brutyan Head of “Lori marz inhabitants Association” NGO Lusine Vardanyan Head of Health Department of Lori Marz government Gohar Petrosyan Secretary of “ Lusastgh” NGO Anahit Karapetyan “Fortuna TV1”- journalist Lia Nerkararyan “Loru marz” magazine- journalist Marine Maghakyan “Healthy lifestyle” NGO Khoren Vardanyan Member of Vanadzor city community local Parliament Arthur Hambaryan Member of council of the elders of Vanadzor City Vahagn Davitakyan Member of council of the elders of Vanadzor City Artyom Grigoryan Member of council of the elders of Vanadzor City Arthur Ohanyan Member of council of the elders of Vanadzor City Karen Paravyan Member of council of the elders of Vanadzor City Gayane Kalantaryan Member of council of the elders of Vanadzor City Armine Sargsyan Vanadzor City resident Varsik Petrosyan Vanadzor City resident Ruzanna Voskanyan Vanadzor City resident Arpine Poghosyan Vanadzor City resident, economist

Vanadzor MC Margaryan Mher Director of Vanadzor MC Artak Yedoyan Deputy Director of Vanadzor MC Gohar Galstyan Deputy Director of Vanadzor MC Vahagn Mkrtchyan Head of Pathology Department Samvel Sahakyan Head of Emergency services Narine Kalashyan Head of Oncology Department Anahit Darbinyan Head of Laboratory –Diagnostic Department Arpine Hambaryan Head of Pediatric Department Gagik Ghambaryan Surgeon

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Naira Danyelyan Accountant Kristine Akmailyan IT specialist Vahandukht Grigoryan Statistician

HPIU Davit Melik-Nubaryan Hospital network optimization component coordinator Naira Kalantaryan Hospital network optimization specialist

Summary The Minutes of the Public Hearings on Environmental issues of the new Vanadzor Medical Center construction took place on November 19, 2013 in Vanadzor city of Lori marz. The public hearings were held in Vanadzor MC, with participation of HPIU hospital system optimization component coordinator and component specialist, director of Vanadzor MC and MC staff members, representatives of Lori Marz government Health and Social Protection Department, Representatives of NGOs, Members of Council of the Elders of Vanadzor City, mass media, activists from the region, citizens.

The Vanadzor MC Director Mher Margaryan welcomed the participants and asked HPIU coordinator Davit Melik-Nubaryan to present the information about current activities on Vanadzor new MC modernization.

The HPIU coordinator presented the activities in the scope of "Disease prevention and Control" Project planned to be implemented in Vanadzor city. He described in details the infrastructures of the new Vanadzor MC, the location of the departments and the new services envisaged. But the most important information was about the measures on mitigation of environmental risks during the construction and maintenance of the Vanadzor MC. He told that all needed measures should be undertaken to minimize the environmental risks, paying attention especially on perfect management of the medical and construction waste and the prevention of pollution of the water drainage system of Vanadzor City, which is very important.

Several questions were raised by the participants.

The Head of “Lori marz inhabitants Association” NGO Menua Brurtyan told that the environmental safeguard measures presented in the report of the local consultant are very important and complete, but the implementation of these measures needs strong control.

The deputy Director of the Vanadzor MC Artak Yedoyan asked about the duration of the Project. The coordinator answered that the construction activities should be completed in two years.

As new modern equipment will be provided for the Vanadzor MC, the journalist from the "Fortuna" TV asked if trainings of the specialists are planned in the scope of the project.

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The coordinator answered that trainings are planned, as it is very important for perfect maintenance of the new equipment. The selection of the specialists for the future trainings is still under discussion, if the local specialists would be trained or some of the needed specialists will be invited from Yerevan. He also added that new medical services, such as invasive cardiology and angiography, would be implemented in Vanadzor MC. Lori marz would be the third of Armenian marzes to have such kind of tertiary medical services. The MC would be provided also with modern CT scanner and Ultrasound equipment. These measures would decrease the patients’ flow to Yerevan.

The citizens of Vanadzor city asked if the hospital mortuary will be renovated in the scope of the Project. The Coordinator answered that the reconstruction of the mortuary is not planned under this Project. The members of council of the elders of Vanadzor City asked to include the mortuary renovation activities in the Project activities list if possible.

Another question was about the hemodialysis service. The Coordinator answered that the hemodialysis service would be modernized and equipped with contemporary equipment as well. The department would be located on the first floor of hospital, with separate entry. The staff of the Vanadzor MC was interested if reduction of staff is planned in the new MC. The Coordinator answered that no reduction of medical staff is planned.

The head of Oncology services of the MC asked if Mammography equipment will be provided for the MC. She explained that the statistical data are very disturbing, cancer morbidity rate in Vanadzor city is the highest in the RA, almost 40% greater than the rates in other regions. The mortality rate from oncology diseases is also higher than in other marzes.

The coordinator answered that currently provision of mammography equipment is not envisaged in the equipment list planned for the Vanadzor MC, but the list is not final and some changes are available. What about the oncology diseases statistics, it is very important that a new chemotherapeutic department, equipped with modern equipment is planned in the structure of new MC.

The members of council of the elders of Vanadzor City were concerned about the costs of the new services. The Coordinator answered that the costs can’t be higher than the average costs in the RA, because Vanadzor MC is not a private institution.

The deputy director Artak Yedoyan added that the artificial decreasing of costs can harm the medical staff causing decreasing of salaries and this is a real corruption risk.

The members of council of the elders of Vanadzor City were concerned also about involving the local population in the construction activities. The Coordinator answered that all the measures would be undertaken to involve the local people in the construction works, the initial calculations show that almost 120 people can be engaged.

Menua Brutyan Head of “Lori marz inhabitants Association” NGO was interested in what stage the activities on modernization of Vanadzor MC are. The Coordinator answered that the architectural design activities are completed and the tender for

40 selection of Constructor Company will be announced soon. The process of opening of bidding documents will be available online on HPIU web page. At the end of the meeting, the Coordinator thanked the participants for active participation and interesting discussion.

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ANNEX IV. Location and Ownership of Land Plots Allocated for Vanadzor MC

Plan of the land plot and the proposed building

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View of the allocated land plot from space (Google map)

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Vanadzor MC – According to Vanadzor city Community Chief’s decrees N 394-A and N 347-A dated April 4, 2012, “Vanadzor MC” CJSC received free user right for 3.172 hectares land plot. The mentioned right has been registered on May 24, 2012 by the State Committee of the Real Property Cadastre of the Lori marz. Address is 2/42 Njdeh street, Vanadzor, marz of Lori, RA.

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Photos of the siteallocated for Vanadzor MC building, dated September 2013: a fenced area carrying dilapidated premises of the former military hospital

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ANNEX V. Agreement for the Disposal of Construction Waste

From: S. Darbinyan, Head of Vanadzor Municipality To: N. Zuloyan, Director of HPIU

In Vanadzor city, the location designated for the disposal of construction waste is the Taron 4 district, 8 km away from the town.

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ANNEX VI. Calculation of Volumes of Emissions, Water Use, and Water Discharge

1. Emissions 1.1 Impact at the construction phase a) Dust emissions during drilling-loading operations Q1 = (P1 x P2 x P3 x P4 x P5 x G x 106 x B x P6) / 3600 t/hour (formula 1), where P1 - faction share of the dust in priming, 0.05 P2 - 0-50 micron size particles share in the spread of dust aerosol, 0.03 P3 - coefficient, which takes into account the average wind speed at the construction equipment work area, 1.0 P4 - coefficient, which takes into account the content of moisture in the substance, 0.6 P5 - coefficient, which takes into account the size of the substance , 0.2 P6 - coefficient, which takes into account the site conditions, 1.0 B - coefficient, which takes into account the height of material unloading , 0.5 G – amount of reprocessed priming, taking into account the priming, vegetated soil and dismantled asphalt: 8775m3 or 23692.5 t. Soil construction works will be carried out in 22 months: 22 months x 22 days / month x 8 hours / day = 3872 hours/construction. 23692.5 t : 3872 hours = 6.1 tons / hour. 6 Q1 = (0.05 x 0.03 x 1.0 x 0.6 x 0.2 x 6.1 x 10 x 0.5 x 1.0)/3600 = 0.15g/sec. Total emissions after soil works completion will make: 0.15 g/sec. x 3872 hours x 3600 seconds/hour: 1000000 g/t = 2.09 t/construction. b) Diesel fuel combustion outcomes Diesel related fuel emissions are calculated on the basis of "Determination of hazardous substances amounts emitted from auto transportation into the atmosphere” methodical instruction. According to the mentioned methodology the specific emissions of heavy auto transportation and mechanical equipment are presented below in Table 1.

Table 1.Specific emissions (g/kg fuel) Fuel Type Name of substance NOx CH VOC CO N2O CO2 PM Diesel fuel 42.3 0.243 8.16 36.4 0.122 3138 4.3

Taking into account that newly purchased equipment will be used, age-related parameters of park are not applied.

In total 5 pieces of technical units will be used in the process of construction works), which operate on diesel fuel. Diesel fuel consumption during construction works (22 months) will make: 48.4 t, the daily average 0.1 t/day.

Table 2.Total emissions Vehicles type Pollutants Emission factor Emissions, Emissions, g/kg g/sec. t/construction CO 87.14 0.3 4.2 NOx 42.3 0.147 2.04 Trucks, excavators, VOC 8.16 0.03 0.39 bulldozers PM 4.3 0.015 0.2

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Nitrogen oxides and hydrocarbons are combined in transportation emissions, taking into account the rapid transformation of nitrogen oxide into the atmosphere, as well as the commonness of hydrocarbons and VOC characteristics.

Sulfuric anhydride

Sulfuric anhydride (SO2) emissions are calculated based on the approach that the entire sulfur contained in fuel fully turns into SO2. In this case CORINAIR inventory system formula is applied: ESO2=2Σksb, where ks- the average content of sulfur in the fuel: 0,002t/y b- is the fuel consumption: 48.4t/constr. SO2 = 2 x 48.4 x 0.002 = 0.19 t/constr. or 0,014g/sec.

Summarizes of the calculations results according to the types of activities and separate substances/materials are described below in Table 3.

Table 3. № Name of pollutant Emissions, g/sec Emissions, t/construction

1. Inorganic dust 0.15 2.09

2. Carbon oxide 0.3 4.2

3. Nitrogen oxides 0.147 2.04

4. VOC 0.03 0.39

5. PM 0.015 0.2

6. Sulfur oxides 0.014 0.19

1.2. Impacts at the operational phase

Calculated emissions of hazardous substances

ECOMAX boiler stations are certified in accordance with EN 257 and EN676 European Union standards that provide low level of hazardous substances emissions (Low NOx). In accordance with ECOMAX technical passports in the process of two types of boiler stations’ operation only nitrogen oxides emissions arise, which specific emissions can be ≤ 97 mg/kW hour in case of natural gas and ≤ 180 mg/kW hour for liquid fuel operations. The maximum thermal demand of the Medical Center makes 3236.4 kW hour.

Emission estimates for natural gas The nitrogen oxide emissions in case of maximum demand will make: GNO2 = 97 mg/kW x 3236.4 kW= 313930.8 mg or 87.2 g/h (0.024 g/sec.) The annual emissions are calculated using the annual maximum thermal demand. The annual emissions of nitrogen dioxide generated as a result of boiler-house operation are calculated according to the required quantity of natural gas. 9 GNO2 = 501120 x 9.2 x 97: 10 = 0.45 t/year. 50

Emission estimates for diesel fuel

During emergency disconnections of natural gas the burners are automatically switched on to diesel fuel supply system. The nitrogen oxide emissions in case of maximum demand will make: 180 mg/kW x 3236 kW = 582 g/h (0.16 g/sec.) The annual emissions are not calculated as the diesel fuel is only used during natural gas emergency disconnections, which may not have long-term nature.

2. Water use and water discharge calculations 2.1 Impacts at the construction phase Water use Construction platforms Taking into account that at the same time the construction works are carried out in one part of construction area, which calculated surface makes about 2600 m2, the watering calculation was carried out for that size of the area. M1 = S1 x K1 x T, where 2 S1 – surface of watered area 800 m , 2 3 K1 - 1 m daily watering norm, 0,003 m ; T – construction period by days, during which watering is to be carried out, 240 3 3 M1 = 800 x 0.003 x 240 = 576.0 m / construction or 2.4 m /day

Communal-domestic use water demand calculation for administrative employees and workers (including drivers)

The water consumption of employees and workers (including drivers) for drinking and domestic needs is calculated as follows: Wcubic t = (n x N x + n1 x N1) T1,where n - number of engineer technical employees: 12 people N- engineer technical personnel water consumption normative: 0,016 m3day/person T1 - number of working days: 484 days n1- number of workers (including drivers): 65 people 3 N1 - workers water consumption normative: 0,025 m day/person

3 Wcubic t = (12 x 0.016 + 65 x 0.025) x 484 = 879.4 m /construction Average daily 1.817 m3/day

Testing of water pipes and washing with chlorine water will make: 12.0 m3

The total water use during the construction phase will make:

576.0 + 879.4 + 12.0 = 1467.4 m3/construction or 4.22 m3/day

Water discharge Water volume used for watering and pipes washing is classified to irredeemable water use and losses. The wastewaters volumes originating due to drinking water use make:

Wwater discharge = Wcubic t– (Wcubic t x K), where 51

K – coefficient of losses, 0.015 3 3 Wwater discharge = 879.4– 879.4 x 0.015 = 866.2 m /constr. hour, or 1.8 m /day.

2.2. Impacts at the operation phase

Water use

Drinking and domestic water consumption demand for service and medical personnel

Wcubic t = n x N x T1, where n – number of administrative and service personnel: 84 people N–water consumption normative: 0.016 m3 day/person T1- number of working days: 260 days 3 3 Wcubic t = 84 x 0.016 x 260 = 349.44 m /year or 1.344 m /day

Calculation of laboratories water demand

Chemical and biological laboratories are envisaged to be built. L = (k1 x n1 + k2 x n2)x T, where 3 k1 – normative of chemical laboratory water consumption: 0.48 m /day n1 – number of laboratory employees: 4 people 3 k2 – normative of biological laboratory water consumption: 0.31 m /day n2 – number of laboratories: 1 person T – number of working days: 260 days L = (0.48 x 4 + 0.31 x 4) x 260 = 821.6 m3/year or 3.16 m3/day

Calculation of kitchen (cafeteria)water consumption demand

Wcubic = 0.016 x (N1 x T1 x m1 + N1 x T1 x m1) 0.016 – normative of water consumption for preparing one kind of meal N1 – maximum number of patients: 190 T1 – number of calendar working days: 365 m1 – daily comsumption of a meal for one client: 3 N2- medical personnel: 100 T2 – number of calendar working days: 260 m2 – daily comsumption of a meal for one client: 1 3 Wcubic = 0.016 x (190 x 3 x 365 + 84x 1 x 260) = 3678.24 m /year

Calculation of hospital beds water consumption demand

Wb.= 0.2 x N x T 0.2 – normative of water consumption for one hospital bed N – number of hospital beds: 190 T – number of calendar working days: 365 3 3 Wb. = 0.2 x 190 x 365 = 13870.0 m /year or 38m /day.

Calculation of laundry house water consumption demand

Number of dry linen: 8 kg/month water use norm: 0,075 m3 of water/kg number of working days (months): 12 months 52 number of hospital beds: 190 The laundry house water use will be: 8 x 0.075 x 12x 190 = 1368.0 m 3/year or 3.75 m3/day.

Calculation of water consumption demand for wet cleaning of floors

W pcs. = 0.0005 x S x k x T S - surface area of floors: 9900 m2 k - the number of floors washed in a single day: 2 T - the number of working days during the year: 365 3 W pcs. = 0.0005 x 9900 x 2 x 365 = 3613.5 m /year Average daily: 9.9 m3/day.

Water discharge

The water use for washing floors and irrigation is classified to irredeemable water usage. The drinking, domestic, cafeteria, laundry house and laboratories used water discharge utilized by service and medical personnel and patients is calculated by the following formula:

WΣ = WΣ - AWL where AWL is the average water loss (in percentage -2%) 3 AWLl = WΣ x 0.02 = (349.44 + 821.6 + 3678.24 + 13870.0 + 1368) x 0.02 = 401.75 m /year 3 W w.d. Σ. = 20087.28–401.75 = 19685.53m /year. Average daily: 53.9 m 3/day. Total water use will make: • 2370078 m3/year. • The daily average, 64.9 m3/day; Total wastewater outflow will be: • 19685.53m 3/year. • The average daily53.9 m3/day.

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ANNEX VII. Classification of MC Wastes

In accordance with “List of production and consumption wastes originating at the territory of the RA” the following wastes can originate at the MC (the last number of classifier distinguishes the waste’s level/class of danger).

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List of wastes generated at Medical center

Codes Name of wastes Aggregate status and Origin physical form 97010100 01 05 3 Medical waste risky for human health (infectious) Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 97010200 01 05 3 Disinfection waste Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 97010400 01 05 3 Medical waste, which are risky in terms of injuries or Solid Health care (wide profile, specialized hospitals, maternity infections hospitals, polyclinics) 97010800 13 05 3 Used single-use syringes Finished goods that have Health care (wide profile, specialized hospitals, maternity lost their properties hospitals, polyclinics) 9701030 01 05 4 Human body and internal organs Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 9701050 01 99 4 Sharp objects (lancet, scalpel) Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 9701060 01 05 4 Medical waste formed due to health care services Solid Health care (wide profile, specialized hospitals, maternity provision (diagnostics, prevention, treatment and child hospitals, polyclinics) delivery) 9701070 01 05 4 Broken or used medical needles Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics) 9701080 13 00 4 Medical devices and instruments that do not meet certain Finished goods that have Health care (wide profile, specialized hospitals, maternity requirements, for example, thermometers, diagnostic lost their properties hospitals, polyclinics) instruments, syringes 9701090 01 05 4 Other wastes which collection and destruction is carried Solid Health care (wide profile, specialized hospitals, maternity out in accordance with specific requirements, in order to hospitals, polyclinics) prevent the spread of infections 9701190 01 00 4 Other wastes which collection and destruction is not Solid Health care (wide profile, specialized hospitals, maternity carried out in accordance with specific requirements in hospitals, polyclinics) order to prevent the appearance of infections 9701390 01 00 4 Other medical waste for protection of human health Solid Health care (wide profile, specialized hospitals, maternity hospitals, polyclinics)

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