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HomeMy WebLinkAbout#5670_2021_0625_TS_FINAL August 12, 2021 5670 Mr. Jamie McLaurin Town of Pittsboro WWTP P.O. Box 759 Pittsboro, NC 27312 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. McLaurin: Enclosed is a report for the inspection performed on June 25, 2021 by Tonja Springer. I apologize for the delay in getting this report to you. 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 must continue to carry out the requirements set forth in 15A NCAC 2H .0800. A copy of the laboratory’s Certified 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: Tonja Springer, Todd Crawford, Lab #5670 On-Site Inspection Report LABORATORY NAME: Town of Pittsboro WWTP NPDES PERMIT #: NC0020354 ADDRESS: 485 Small Street Pittsboro, NC 27312 CERTIFICATE #: 5670 DATE OF INSPECTION: June 25, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR: Tonja Springer LOCAL PERSON CONTACTED: Jamie McLaurin 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 25, 2021, June 7, 2021, June 14, 2021 and June 25, 2021. Staff were forthcoming and seemed eager to adopt necessary changes. 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 Environmental Conservation Laboratories, Inc. (ENCO) - Cary (#591). The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedure (SOP) documents in advance of the inspection. These documents were reviewed and editorial and substantive revision requirements and recommendations were made by this program outside of this formal report process. Although subsequent revisions were not requested to be sub mitted, they must be completed by January 2022. 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 Page 2 #5670 Town of Pittsboro WWTP 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 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: 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 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) (L). B. Finding: The laboratory benchsheet is lacking required documentation: the method reference and instrument identification. 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; 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) (A) and (C). C. Finding: The laboratory benchsheet is lacking required documentation: meter calibration time. 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: Meter calibration and meter calibration time(s). Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO) and NC WW/GW LC Approved Pr ocedure for the Analysis of pH. Comment: This Finding applies to DO and pH. D. 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 Page 3 #5670 Town of Pittsboro WWTP mmHg], and salinity). Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: Only Temperature is documented. The other calibration variables that are on the meter’s display after the calibration will need to be documented. These variables may have been programmed in the meter initially. Comment: Per NC WW/GW LC Branch policy, facilities may use a default value of zero ppt for Salinity when calibrating the DO meter unless it is known or suspected that the Salinity value of the samples being analyzed is > 9 ppt. In those situations, actual Salinity values must be used. Regardless of which value is used, it must be documented. E. Finding: Documentation of the compliance temperature-measuring device calibration verification does not include the serial number of the National Institute of Standards and Technology (NIST) traceable temperature-measuring device that was used in the comparison. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: All compliance temperature-measuring devices without a valid NIST certificate must be checked initially and every 12 months against an NIST traceable temperature-measuring device and the process documented. Documentation must include the serial number of the device being checked. The serial number, stated accuracy and expiration date of the NIST traceable temperature-measuring device used in the comparison must also be documented. Verification data must be kept on file and be available for inspection for 5 years. (NOTE: Vendors or other Certified laboratories may provide assistance in meeting this requirement. When a vendor or other Certified laboratory provides this assistance, they must provide a copy of their NIST Certificate or the serial number, accuracy and calibration expiration date.) Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: The laboratory retains the NIST certificate, however the temperature comparison documentation does not include the serial number of the NIST traceable temperature-measuring device to provide traceability to the certificate. Proficiency Testing F. 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 Page 4 #5670 Town of Pittsboro WWTP documents PT Sample results on the PT vendor preparation instructions with the date and PT result. Reporting G. Finding: Values for pH were reported that exceed the method specified accuracy of 0.1 units. Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents the limit of accuracy under normal conditions, especially for measurement of water and poorly buffered solutions. For this reason, report pH values to the nearest 0.1 pH unit. Ref: Standard Methods, 4500 H+ B-2011. (6). Comment: Compliance samples are reported on the Discharge Monitoring Report (DMR) to two decimal places (i.e., 0.01 pH units). Comment: Per PT Vendor instructions, the PT Sample results should be reported to two decimal places. H. Finding: Data qualifiers from the contract 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). Requirement: Sample results reported below the lowest reporting concentration, if required by the data receiver, shall be qualified as an estimated value. Ref: 15A NCAC 02H .0805 (e) (4). Comment: The contract laboratory is reporting results that are below the ranges of the calibration curves. The qualifiers reported from the contract laboratory with the data do not indicate the values are estimated. Comment: See the table in the Paper Trail Investigation section. Recommendation: It is recommend that the Town of Pittsboro request the contract laboratory to not report values that are below the concentration of the lowest standard in the associated calibration curve. Recommendation: 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. 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. I. Finding: The annual temperature-measuring device check procedure is not performed correctly. Page 5 #5670 Town of Pittsboro WWTP Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against a National Institute of Standards and Technology (NIST) traceable temperature- measuring device and record all four readings. The readings from both devices must agree within 0.5 °C. Ref: NC WWGW LC Approved Procedure for the Analysis of Temperature. Please submit an updated temperature verification bracketing the range of compliance samples analyzed with the report reply. Comment: The laboratory is performing the temperature-measuring check each analysis day at one temperature. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., labo ratory benchsheets, logbooks, etc.) and contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for Town of Pittsboro WWTP (NPDES permit # NC0020354) for November 2020, December 2020 and January 2021. The following errors were noted. Sample Collection Date Parameter Location Contract Lab Report Qualifier 11/12/2020 11/17/2020 11/19/2020 11/25/2020 Ammonia Effluent J: “The reported value is between the laboratory method detection limit (MDL) and the laboratory method reporting limit (MRL), adjusted for actual sample preparation data and moisture content, where applicable.” 12/8/2020 1/7/2021 Copper Effluent J: “The reported value is between the laboratory method detection limit (MDL) and the laboratory method reporting limit (MRL), adjusted for actual sample preparation data and moisture content, where applicable.” 11/9/2020 11/23/2020 Nickel Effluent J: “The reported value is between the laboratory method detection limit (MDL) and the laboratory method reporting limit (MRL), adjusted for actual sample preparation data and moisture content, where applicable.” 11/23/2020 Total Phosphorus Effluent B: “The analyte was detected in the associated method blank.” V. CONCLUSIONS: Correcting the above-cited Findings and implementing the Recommendations 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 Page 6 #5670 Town of Pittsboro WWTP 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: June 29, 2021 Report reviewed by: Tom Halvosa Date: July 2, 2021 Certificate Number:5670 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:Town of Pittsboro WWTP Address:485 Small Street Pittsboro, NC 27312- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment: 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 DISSOLVED OXYGEN Hach 10360-2011, Rev. 1.2 (LDO) (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.