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HomeMy WebLinkAbout#5350_2021_0419_TS_FINAL INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5350 Laboratory Name: Town of Troy WWTP Date Mailed: Special Mailing Instructions: May 14, 2021 5350 Mr. Bryan Bowles Town of Troy WWTP 315 N. Main Street Troy, NC 27371- Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Bowles: Enclosed is a report for the inspection performed on April 19, 2021 by Tonja Springer. Where Finding(s) are cited in this report, a response is required. Within thirty days , please supply this office with a written item for item description of how these Finding(s) were corrected. Please describe the steps taken to prevent recurrence and include an implementation date for each corrective action. If the Finding(s) cited in the enclosed report are not corrected, enforcement actions may be recommended. For Certification maintenance, your laboratory mu st continue to carry out the requirements set forth in 15A NCAC 2H .0800. A copy of the laboratory’s Certified Paramete r List at the time of the audit is attached. This list will reflect any changes made during the audit. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you have questions or need additional information, please contact me at (919) 733-3908 Ext. 259. Sincerely, Be th Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Tonja Springer, Todd Crawford, File #5350 On-Site Inspection Report LABORATORY NAME: Town of Troy WWTP NPDES PERMIT #: NC0028916 ADDRESS: 650 Glenn Rd. Troy, NC 27371 CERTIFICATE #: 5350 DATE OF INSPECTION: April 19, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Bryan Bowles 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 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The inspection was performed remotely due to the coronavirus pandemic. The laboratory submitted the requested documentation and pictures of their reagents and instruments electronically on March 3, 2021 and April 9, 2021. Contract lab reports were submitted to our office by mail on April 19, 2021. Staff was f orthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2021 PT Calendar Year have not yet been analyzed. The laboratory is reminded that results must be received by this office directly from the vendor by September 30, 2021. Contracted analyses are performed by Meritech, Inc. (Certification #165). The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in advance of the inspection. These documents were reviewed. Although subsequent revisions were not requested to be submitted, they must be completed November 2021. The laboratory is reminded that any time changes are made to laboratory procedures, the laboratory must update the QA/SOP document(s) and inform relevant staff. Any changes made in response to the pre-audit review or to Findings, Recommendations or Comments listed in this report must be incorporated to insure the method is being performed as stated, references to methods are accurate, and the QA and/or SOP document(s) is in agreement with each approved practice, test, analysis, measurement, monitoring procedure or regulatory requirement being used in the laboratory. In some Page 3 #5350 Town of Troy WWTP instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. The laboratory is also reminded that SOPs are required to be reviewed at least every two years and are intended to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOP s for the proper use of the word “should”. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: The laboratory incorrectly documented traceability information of purchased reagents. Requirement: 15A NCAC 02H .0805 (a)(7)(K) and (g)(7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: Date received, Date Opened (in use), Vendor, Lot Number, and Expiration Date (where specified). A system (e.g., traceable identifiers) must be in place that links standard/reagent preparation information to analytical batches in which the solutions are used. Documentation of solution preparation must include the analyst’s initials, date of preparation, the volume or weight of standard(s) used, the solvent and final volume of the solution. This information as well as the vendor and/or manufacturer, lot number, and expiration date must be retained for primary standards, chemicals, reagents, and materials used for a period of five years. Consumable materials such as pH buffers, lots of pre-made standards and/or media, solids and bacteria filters, etc. are included in this requirement. Ref: NC WW/GW LC Policy. Comment: The laboratory incorrectly wrote the lot number for the pH 7.0 buffer as the lot number for the pH 10.0 buffer and the lot number for pH 10 as the lot number for the pH 7 .0 buffer on the Consumables Traceability Log. The Lot number for pH 7.0 buffer should be Lot #OGC930 instead of Lot #OGC851 and the pH 10.0 buffer should be Lot #OGC851 instead of Lot # OGC930. Recommendation: It is recommended that the laboratory establish a periodic peer review of traceability do cumentation. B. Finding: Error corrections are not always properly performed. Requirement: All documentation errors shall be corrected by drawing a single line through the error so that the original entry remains legible. Entries shall not be obliterated by erasures or markings. Wite-Out®, correction tape, or similar products designed to obliterate documentation are not to be used; instead the correction shall be written adjacent to the error. The correction shall be initialed by the responsible individual and the date of change documented. Ref: 15A NCAC 02H .0805 (g) (1). Comment: Corrections are initialed but not dated. On the following days corrections were initialed but not dated: November 15, 2020, December 15, 2020 and January 6, 2021. C. Finding: The laboratory benchsheets do not fully reference the approved methods. Page 4 #5350 Town of Troy WWTP Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of the method or Standar d Operating Procedure. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (A). Comment: The reference methods did not include the approval year. Comment: This Finding applies to DO, pH and Temperature. Comment: The methods for which the lab is certified are: • DO – SM 4500 O G-2011 • pH – SM 4500 H+ B-2011 • Temperature – SM 2550 B -2010 D. Finding: The laboratory benchsheet is lacking required documentation: the instrument identification and laboratory identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the laboratory identification; the instrument identification. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (B) & (C). Comment: This F inding applies to DO, pH and Temperature. E. Finding: The DO laboratory benchsheet is lacking required documentation: meter calibration time. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Meter calibration and/or verification date and time(s) Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). F. Finding: Documentation of the calibration variables for the DO meter does not include all pertinent data. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Calibration variables (temperature, elevation or barometric pressure [in mmHg], and salinity). Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: The meter has an internal barometer that automatically senses the barometric pressure. The salinity has been programmed into the meter. The salinity value may be added to the benchsheet as a blanket statement. Comment: The laboratory is using the One Touch Calibration and documenting the % saturation and temperature. The other calibration variables, barometric pressure and salinity, that are on the meter’s display after the calibration will need to be documented. Proficiency Testing Page 5 #5350 Town of Troy WWTP G. Finding: The laboratory is not documenting the preparation of TRC PT Samples. Requirement: PT Samples received as ampules are diluted according to the Accredited PT Sample Provider’s instructions. It is important to remember to document the preparation of PT Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a routine Compliance Sample and is added to a routine sample batch for analysis. No documentation is needed for whole volume PT Samples which require no preparation, however the instructions must be maintained. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Commen t: The vendor instructions are retained for 5 years but are not dated and initialed. The vendor instructions can be dated and initialed to meet this requirement. H. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. Requirement: All PT Sample analyses must be recorded in the daily analysis records as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT Samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all parameter methods. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 4.0. Comment: The PT Sample results are not documented in an analysis record in enough detail to demonstrate that all calibration and QC requirements are met. The laboratory only documents PT Sample result s on the PT vendor form with no additional information. Reporting I. Finding: Data qualifiers from the cont ract laboratory reports are not being transferred to the DMR. Requirement: Reported data associated with quality control failures, improper sample collection, holding time exceedances, or improper preservation shall be qualified as such. Ref: 15A NCAC 02H .0805 (e) (5). Comment: This was noted for an Influent BOD sample collected on December 10, 2020. Sample results reported by the contract lab included a qualifier “G7 Less than 1 mg/L DO remained for all dilutions set. The reported value is an estimated greater than value and is calculated for the dilution using the least amount of sample”. Temperature – Standard Methods, 2550 B -2010 (Aqueous) Recommendation: It is recommended that Temperature results be reported on the DMR in whole numbers, as stated in the “Precision in Discharge Monitoring Reports” document issued by the Division of Water Resources. Page 6 #5350 Town of Troy WWTP Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) Comment: The true value of the Total Re sidual Chlorine (TRC) daily calibration check standard is documented on the benchsheet as 189 µg/L with an acceptance range of 171 - 209 µg/L. Based on the daily calibration check standard verification that was submitted, the true value is 190 µg/L with an acceptance range of 172 - 210 µg/L. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., labo ratory benchsheets, logbooks, etc.) and contract lab oratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for Town of Troy WWTP (NPDES permit # NC0028916) for November and December 2020 and January 2021. The following errors were noted: Date Parameter Location Value on Benchsheet Value on DMR 11/10/2020 Fecal Coliform Effluent * 10 colonies/100 mL 24 colonies/100 mL 11/12/2020 Fecal Coliform Effluent *24 colonies/100 mL 10 colonies/100 mL 1/6/2021 TSS Effluent 6 mg/L 7 mg/L *Contract Laboratory data Contract laboratory results for Copper (32 mg/L), Conductivity (1,022 µmhos/cm) and Cyanide (26 mg/L) wer e reported on the DMR for November 10, 2020 instead of November 9, 2020. Contract laboratory results for Conductivity (1,100 µmhos/cm) were reported on the DMR for November 11, 2020 instead of November 10, 2020. Contract laboratory result for Conductivity (988 µmhos/cm) was reported on the DMR for November 13, 2020 instead of November 12, 2020. To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether an amended DMR(s) will be required. A copy of this report will be made available to the Regional Office. V. CONCLUSIONS: Correcting the above-cited Findings and implementing the Recommendation(s) will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for their assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Tonja Springer Date: April 29, 2021 Report reviewed by: Tom Halvosa Date: May 4, 2021 Certificate Number:5350 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:Town of Troy WWTP Address:650 Glenn Rd. Troy, NC 27371- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:8/13/2019 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) DISSOLVED OXYGEN SM 4500 O G-2011 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) TEMPERATURE SM 2550 B-2010 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.