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HomeMy WebLinkAbout#5375_2021_0325_TLH_FINAL April 21, 2021 5375 Mr. Thomas Sawyer South Camden Water & Sewer District 103 Water Plant Rd. Camden, NC 27921 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection D ear Mr. Sawyer: Enclosed is a report for the inspection performed on March 25, 2021 by Thomas Halvosa. Where Finding(s) are cited in this report, a response is required. Within thirty days, pl ease 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 must continue to carry out the requirements set forth in 15A NCAC 2H .0800. A co py of the la boratory’s Ce rtifie d Parameter 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, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Thomas Halvosa, Todd Crawford, File #5375 On-Site Inspection Report LABORATORY NAME: South Camden Water & Sewer District NPDES PERMIT #: NC0086681 ADDRESS: 103 Water Plant Rd. Camden, NC 27921 CERTIFICATE #: 5375 DATE OF INSPECTION: March 25, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR: Tom Halvosa LOCAL PERSON(S) CONTACTED: Tommy Sawyer, Brady Partian 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 facility is neat and well organized and has all the equipment necessary to perform the analyses. The staff were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2021 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 Environment 1, Inc. (Certification #10) and Environmental Conservation Laboratories, Inc. – Cary (Certification #591). The Approved Procedure document for the analysis of the facility’s currently certified Field Par ameter was provided at the time of the inspection. The laboratory submitted their Standard Operating Procedure (SOP) document in advance of the inspection. This document was reviewed and deemed acceptable. 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 2 #5375 South Camden Water & Sewer District 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 SOPs for the proper use of the word “should”. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: The laboratory benchsheet for pH is lacking required documentation: the method or Standard Operating Procedure, laboratory identification and units of measure. 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 Standard Operating Procedure, laboratory identification, the proper units of measure. 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), (B) and (L). Comment: The units of measure for pH in the calibration section of the benchsheet must be documented and reported as specified in the permit (S.U.). B. Finding: Error corrections are not properly performed. Cited previously on December 30, 2009. 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: The December 2019 pH benchsheet had an incorrect error correction for the pH value of the S1 sample site. The “3” in the 7.38 S.U. result was written over the previous result. C. Finding: The laboratory is not documenting traceability information for purchased materials, reagents and standards. 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 t his requirement. Ref: NC WW/GW LC Policy. Page 3 #5375 South Camden Water & Sewer District Comment: The laboratory was provided with an example receipt log to use for documenting traceability information for purchased materials, reagents and standards. Proficiency Testing D. Finding: The laboratory is n ot 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: Profi ciency 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. Reporting E. Finding: The laboratory does not report results of all tests on the characteristics of the effluent when duplicat e sample analyses are performed. Requirement: The results of all tests on the characteristics of the effluent, including but not limited to NPDES permit monitoring requirements, shall be reported on the monthly report forms. Ref: 15A NCAC 2B .0506 (b) (3) (J). Comment: The laboratory is performing duplicate analysis of pH samples and only reports the first measurement. The following convention must be followed when deciding which value to report in the daily cell: - Any value in violation of permit limits must be reported in the daily cell. If multiple samples yielded noncompliant results, the most extreme noncompliant value must be reported in the daily cell. - If all values taken during the day were compliant with the permit limits, the value closest to the bounds of the limit range (high or low) must be reported in the daily cell. - The other value not reported in the daily cell must be reported in the comment section. Recommendation: It is recommended that the laboratory no longer analyze duplicates for pH. 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 South Camden Water & Sewer District (NPDES permit # NC0086681) for February 2020, July 2020 and February 2021. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data. Page 4 #5375 South Camden Water & Sewer District V. CONCLUSIONS: We are concerned with the Finding that w as cited previously and not corrected. Laboratory Decertification Ref: 15A NCAC 02H .0807 (a) (1), (13) and (14): A laboratory may be decertified for any or all parameters for up to one year for any or all of the following infractions: (1) Failing to main tain the facilities, or records, personnel, equipment, or quality control program as set forth in these Rules; or (13) Failing to respond to requests for information by the date due; or (14) Failing to comply with any other terms, conditions, or requirements of this Section or of Laboratory certification. Correcting the above-cited Findings and implementing the Recommendation 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 a nd include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Tom Halvosa Date: April 1, 2021 Report reviewed by: Jason Smith Date: April 5, 2021 Certificate Number:5375 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:South Camden Water & Sewer District Address:103 Water Plant Rd. Camden, NC 27921 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:12/14/2018 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 pH SM 4500 H+B-2011 (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.