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HomeMy WebLinkAbout#5049_2020_0227_JMS_FINALLaboratory Cert. #: 5049 Laboratory Name: Catawba County Schools Inspection Type: Field Municipal Maintenance Inspector Name(s): Jason Smith Inspection Date: February 27, 2020 Date Forwarded for Initial March 16, 2020 Review: Initial Review by: Michael Cumbus Date Initial Review March 17, 2020 Completed: ❑ Insp. Initial ® Insp. Reg Cover Letter to use: ❑Insp. No Finding ❑Corrected ❑Insp. CP ❑Insp. Reg. Delay (to use: rt click, properties, chock) Unit Supervisor/Chemist ll: Todd Crawford Date Received: 3/18/2020 Date Forwarded to Admin.: 3/24/2020 Date Mailed: � —J Special Mailing Instructions: CLOY COOPER Governor MICHAEL S. REGAN Secretary S. DANIEL SMITH Director 5049 Mr. Morgan Williams Catawba County Schools P.O. Box 1010 Newton, NC 28658 NORTH CAROLINA Environmental Quality March 25, 2020 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Williams: Enclosed is a report for the inspection performed on February 27, 2020 by Jason Smith. Where Finding(s) are cited in this report, a response is required. Within thirty days of receipt, 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 wish to obtain an electronic copy of this report by email or if you have questions or need additional information, please contact me at (919) 733-3908 Ext. 259. Sincerely, Todd Crawford Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Jason Smith, Dana Satterwhite North Carolina Department of Environmental Quality I Division of Water Resources 4405 Reedy Creek Road 1 1623 Mail Service Center I Raleigh, North Carolina 27699-1623 NORTH CAROLINA DWd M.1rW-to 919,733,3908 LABORATORY NAME: NPDES PERMIT : ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION AUDITOR(S): LOCAL PERSON(S) CONTACTED: I. INTRODUCTION: Catawba County Schools N00051608, N00029297, NCO086304 and NCO074233 2500 N. College Ave Newton, NC 28658 5049 February 27, 2020 Field Municipal Maintenance Jason Smith David McCorkle 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 environmental samples. II. GENERAL COMMENTS: The laboratory is responsible for facilities at four county schools and the inspection was performed at Blackburn Elementary School. Staff were forthcoming and seemed eager to adopt necessary changes. All required Proficiency Testing (PT) Samples for the 2020 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, 2020. The laboratory is reminded that Standard Operating Procedure (SOP) documents are required to be implemented by July 1, 2020. SOP templates may be found on the NC WW/GW LC website here: https://deg.nc,gov/about/divisions/water-resources/water-resources-data/water-sciences- home-page/laboratory-certification-branch/technical-assistance-policies Additionally, a documented training program for current and future analysts must be implemented by August 1, 2020. These requirements and the SOP templates posted on the NC WW/GW LC website were discussed during the inspection. Any time changes are made to laboratory procedures, the laboratory must update the SOP document(s) and inform relevant staff. In some instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. Page 2 #5049 Catawba County Schools The laboratory is also reminded that SOPs 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". Contracted analyses are performed by Water Tech Labs, Inc. (Certification # 50). A. Finding: Error corrections are not 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: Overwriting and the use of correction fluid were observed. E. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure. 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. 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). C. Finding: The laboratory benchsheet is lacking required documentation: the 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. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (B). Comment: Each facility has its own benchsheet which identifies the school where the facility is located. However, this is the only identification on the benchsheet and does not identify the lab performing the analyses as "Catawba County Schools". D. Finding: The laboratory benchsheet is lacking required documentation: the 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 instrument identification. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (C). E. Finding: The sample collector and/or analyst is not clearly identified on the benchsheet. Page 3 #5049 Catawba County Schools Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the sample collector; the signature or initials of the analyst. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (D) and (E). Comment: The sample collector/analyst initials the benchsheet in an unlabeled section outside of the table. Documentation must clearly identify the person(s) responsible for both sample collection and analysis. F. Finding: The laboratory benchsheet is lacking required documentation: sample identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: sample identification. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (1). Comment: Each facility has its own benchsheet which identifies the school where the facility is located. However, the benchsheet does not indicate that the samples are effluent samples. G. Finding: The laboratory benchsheet is lacking required documentation: the proper 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. Ref: 15A NCAC 02H .0805 (g) (2) (Q. Comment: The units of measure are not documented on the calibration logs for Dissolved Oxygen (DO), Total Residual Chlorine (TRC) and pH. The units of measure are documented on the benchsheet, but TRC is incorrectly listed as "pg/10" and needs to be corrected to "pg/L". H. Finding: The laboratory benchsheet is lacking required documentation: NPDES permit number. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Facility name, sample site (ID or location), and permit number. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO), NC WW/GW LC Approved Procedure for the Analysis of pH, NC WW/GW LC Approved Procedure for the Analysis of Temperature and NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 CI G-2011). I. Finding: Documentation of the calibration variables for the DO meter does not include all pertinent data. 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). Page 4 #5049 Catawba County Schools J. Finding: The results of the Total Residual Chlorine (TRC) gel -type standard analyses are not being accurately documented. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Value obtained for the Daily Check Standard(s) and percent recovery. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The analyst analyzes the gel -type standard on the low level program but documents a decimal in the result that is not displayed on the instrument. For example, during the inspection, the analyst analyzed the gel standard and the meter read 162 pg/L and stated that he would record the value as 1.62 pg/L. The analyst stated that this is how he has always documented it and agreed that it is incorrect and that it would be correctly documented without the decimal place. K. Finding: The laboratory is not analyzing a Post -analysis Calibration Verification Standard when performing analyses at multiple sample sites in a single day. Requirement: When performing analyses at multiple sample sites in a single day, a Post - analysis Calibration Verification Standard must be analyzed after the last sample. It is recommended that a mid -day calibration verification be performed when samples are analyzed over an extended period of time. The value obtained for the Post -analysis Calibration Verification Standard must read within ±10% of the true value of the Post - analysis Calibration Verification Standard for standards >_50 pg/L and within ±25% of its true value for standards <50 pg/L. If the obtained value is outside of the acceptance limits, corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). pH — Standard Methods, 4500 H+ B-2011 (Aqueous) L. Finding: The laboratory is not analyzing a post -analysis check standard buffer when performing analyses at multiple sample sites in a single day. Requirement: When performing analyses at multiple sample sites, a post -analysis calibration verification using the check standard buffer must be analyzed at the end of the run. It is recommended that a mid -day check standard buffer be analyzed when samples are analyzed over an extended period of time. The post -analysis check standard buffer(s) must read within ±0.1 S.U. or corrective actions must be taken. If recalibration is necessary, all samples analyzed since the last acceptable calibration verification must be reanalyzed, if possible. If samples cannot be reanalyzed, the data must be qualified. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Dissolved Ongen — Standard Methods, 4500 O G-2011 (Aqueous) pH — Standard Methods, 4500 H+ B-2011 (Aqueous) M. Finding: Samples are not being stirred during analysis for pH and DO. Requirement: Samples shall be gently stirred during measurement. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Page 5 #5049 Catawba County Schools Requirement: Establish equilibrium between electrodes and sample by stirring sample to insure homogeneity; stir gently to minimize carbon dioxide entrainment. Ref: Standard Methods, 4500 H+ B-2011 (4) (b). Requirement: Movement of water across the membrane (for membrane electrode technologies) is important for accurate readings. Some probes come with stirrers for this purpose. Measurements should be taken while the stirrer is in use or by swirling the DO probe in the sample flow. Preferably, insert the probe into flowing conditions. If analyzed in a container, stir gently with the probe or add a stir bar. Do not put the probe on the sides or the bottom of the container. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Requirement: Provide sufficient sample flow across membrane surface to overcome erratic response (see Figure 4500-0:4 for a typical example of the effect of stirring). Ref: Standard Methods, 4500 O G-2011 (3) (b). Proficiency Testing N. Finding: Additional QC beyond what is routine for Compliance Samples is being analyzed with PT Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each parameter method on the laboratory's CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, distillations and extractions) and the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Comment: The laboratory analyzes a known QC sample from the PT vendor with PT Samples. Comment: Corrective -action standards, that are provided with the true values in a sealed envelope, are not considered PT Samples and do not meet the PT requirements outlined in 15A NCAC 02H .0800. In general, laboratories must not analyze standards with known concentrations along with PT Samples with unknown concentrations, as this is not the routine testing protocol for Compliance Samples. This is not to say that they cannot be used for troubleshooting purposes before analyzing a remedial PT Sample. This would be considered part of the corrective action plan. 0. Finding: The laboratory is not documenting the preparation of 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 Page 6 #5049 Catawba County Schools 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. Comment: Dating and initialing the instruction sheet for each prepared PT Sample (i.e., TRC) would satisfy the documentation requirement. P. Finding: Values less than the established reporting limit are being reported on the DMR. Requirement: For all calibration options, the range of standard concentrations must bracket the permitted discharge limit concentration, the range of sample concentrations to be analyzed and anticipated PT Sample concentrations. One of the standards must have a concentration less than the permitted Daily Maximum Limit. The lower reporting limit concentration is equal to the lowest standard concentration. Sample concentrations that are less than the lower reporting limit must be reported as a less -than value. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The laboratory has established a lower reporting limit of 25 pg/L. Samples with concentrations less than that must be reported as < 25 pg/L on the DMR. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for Bandys High School (NPDES permit # NC0051608), Fred T. Foard High School (NPDES permit # NC0029297), Mill Creek Middle School (NPDES permit # NC0086304) and Blackburn Elementary School (NPDES permit # NC0074233) for August, September and October 2019. The following errors were noted: Date Parameter Location Value on Benchsheet Value on DMR 9/5/19 Temperature Fred T. h Foard High 21.8 °C 21.3 °C School Effluent 9/27/19 Temperature Bandys High School 21.3 °C No Value Effluent Reported 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 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 7 #5049 Catawba County Schools includerespond to all Findings and supporting documentation, implementation ?nd steps taken . prevent - for each corrective action. Report prepared by: Jason Smith Date: March 16, 2020 Report reviewed by: Michael Cumbus Date: March 17, 2020 \ 2 \ Lo : m b » $ 2 ui ) § � E - \ E� \ CL § ; 16 k § E \ IL § | k = § { \ \ § \ � \ \ � y .. .. . . ..$ . . . ) m 0 2 a s / \ a)00 \ z ) \ \ 75 k ® G \ / R \ d ) w \ \ \ ( ) z u / g ) x § \ ± _ \ ) § / f \ \ @& o E o / P m \ 't \ ƒ � ) J \ o § } 2 \ U) § § j ƒ £