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Home My WebLink About#5556_11_2014_final INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5556 Laboratory Name: Betsy-Jeff Penn 4H Center Inspection Type: Field Initial Inspector Name(s): Tonja Springer Inspection Date: 11/25/2014 Date Report Completed: 12/5/2014 Date Forwarded to Reviewer: 12/5/2014 Reviewed by: Beth Swanson Date Review Completed: December 8, 2014 Cover Letter to use: Insp. Initial Insp. Reg. Insp. No Finding Insp. CP Corrected Insp. Reg. Delay Unit Supervisor/Chemist III: Dana Satterwhite Date Received: 12/8/2014 Date Forwarded to Linda: 12/9/2014 Date Mailed: 12/10/2014 _____________________________________________________________________ On-Site Inspection Report LABORATORY NAME: Betsy-Jeff Penn 4H Center ADDRESS: 804 Cedar Lane Reidsville, NC 27320 NPDES PERMIT # NC0078271 CERTIFICATE #: 5556 DATE OF INSPECTION: November 25, 2014 TYPE OF INSPECTION: Field Initial AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Jeff Johnson I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A NCAC 2H .0800 for the analysis of environmental samples. II. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. Benchsheets are well designed, easy to follow and concise. Records are well organized and easy to retrieve. The laboratory has been proactive in keeping up with updates and changes required by this program. Contracted analyses are performed by Pace Analytical Services, Inc. - Eden (Certification #633) and PACE Analytical Services, Inc. Asheville (Certification #40) Current quality assurance policies for Field Laboratories and approved procedures for the analysis of the facility’s currently certified parameters were provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Quality Control Comment: Data from the contract lab reports that does not meet all quality control requirements is not qualified on the Discharge Monitoring Report (DMR). The Quality Assurance Policies for Field Laboratories states: When quality control (QC) failures occur, the laboratory must attempt to determine the source of the problem and must apply corrective action. Part of the corrective action is notification to the end user. If data qualifiers are used to qualify samples not meeting QC requirements, the data may not be useable for the intended purposes. It is the responsibility of the laboratory to provide the client or end-user of the data with sufficient information to determine the usability of the qualified data. Where applicable, a notation must be made on the Discharge Monitoring Report (DMR) form, in the comment section or on a separate sheet attached to the DMR form, when any required sample quality control does not meet specified criteria and another sample cannot be obtained. Notification of Page 2 #5556 Betsy-Jeff Penn 4H Center acceptable corrective action (i.e., a statement that qualifiers from the contract lab reports will be documented beginning with the December, 2014 DMR) was received by email on 12/3/2014. No further response is necessary for this finding. Comment: The laboratory needs to increase the documentation of purchased reagents. Lot Numbers were being documented. The Quality Assurance Policies for Field Laboratories states: All chemicals, reagents, standards and consumables used by the laboratory must have the following information documented: Date Received, Date Opened (in use), Vendor, Lot Number, and Expiration Date. Consumable materials such as pH buffers and lots of pre-made standards are included in this requirement. Demonstration of acceptable corrective action (i.e., an updated benchsheet with all traceability information) was received by email on 12/3/2014. No further response is necessary for this finding. Comment: The laboratory benchsheets for Temperature and pH were lacking pertinent data: Instrument identification. The NC WW/GW LC Approved Procedure for the Analysis of pH and NC WW/GW LC Approved Procedure for the Analysis of Temperature state: The following must be documented in indelible ink whenever sample analysis is performed: Instrument Identification. Demonstration of acceptable corrective action (i.e., an updated benchsheet with instrument identification) was received by email on 12/3/2014. No further response is necessary for this finding. Proficiency Testing Comment: The laboratory is not documenting Proficiency Testing (PT) sample analyses in the same manner as environmental samples. Results are documented on the vendor’s reporting form and submitted electronically. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2 document states: All PT sample analyses must be recorded in the daily analysis records as for any environmental sample. This serves as the permanent laboratory record. Notification of acceptable corrective action (i.e., a statement that PT samples will be documented on the benchsheet) was received by email on 12/3/2014. No further response is necessary for this finding. Temperature – Standard Methods, 2550 B-2000 Comment: The temperature correction factor (this was +0.1°C at the time of the inspection) for the pH meter is not being applied to the reported temperature reading. The NC WW/GW LC Approved Procedure for the Analysis of Temperature states: The following must be documented in indelible ink whenever sample analysis is performed. Document sample temperature measurements with any applicable temperature corrections applied. Demonstration of corrective action (i.e., an updated benchsheet with temperature correction applied) was received by email on 12/3/2014. No further response is necessary for this finding. Comment: The laboratory was reporting Temperature in tenth degree increments (e.g., 24.7°C), but will begin reporting in whole numbers in December, 2014. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for August, September and October, 2014. No transcription errors were detected. It appears the facility is doing a good job of accurately transcribing data. Page 3 #5556 Betsy-Jeff Penn 4H Center V. CONCLUSIONS: All findings noted during the inspection were adequately addressed prior to the completion of this report. The inspector would like to thank the staff for its assistance during the inspection and data review process. No response is required. Report prepared by: Tonja Springer Date: December 5, 2014 Report reviewed by: Beth Swanson Date: December 5, 2014