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HomeMy WebLinkAbout#5440_2018_0124_AO_FINALTo be attached to all inspection reports in-house only. Laboratory Cert. #: 5440 Laboratory Name: Halifax County Schools Inspection Type: Field Municipal Maintenance Inspector Name(s): Anna Ostendorff Inspection Date: January 24, 2018 Date Forwarded for Initial January 31, 2018 Review: Initial Review by: Tonja Springer Date Initial Review February 5, 2018 Completed: ❑ Insp. Initial ® Insp. Reg Cover Letter to use: ❑Insp. No Finding ❑Corrected ❑Insp. CP ❑Insp. Reg. Delay (to use: rt c(ick, properties, check) Unit Supervisor/Chemist III: Beth Swanson Date Received: February 5, 2018 Date Forwarded to Admin.: February 20, 2018 Date Mailed: February 20, 2018 Special Mailing Instructions: Also submit a digital copy of the final report to Bryan Pierce directly February 20, 2018 5440 Mr. M. Bryan Pierce Halifax County Schools P.O. Box 373 Halifax, NC 27839 ROY COOPER MICHAEL S. REGAN Sec , filar v LINDA CULPEPPER 1111crinr 1 wccfor Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Pierce: Enclosed is a report for the inspection performed on January 24, 2018 by Anna Ostendorff. 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, Beth Swanson Technical Assistance and Compliance Specialist Division of Water Resources Attachment cc: Dana Satterwhite, Anna Ostendorff Water Sciences Section NC Wastewater/Groundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location:44d5 Reedy Creek Road, Raleigh, North Carolina 27607 Phone: 919-733-39081 FAX: 919-733-6241 Internet: htt01deu.nc.gov(about/division s/water-resources/water-resources-data/water-sciences-home.page(laborate ry-certification- bra nch LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): Halifax County Schools NCO038610 6915 Highway 301 North Halifax, NC 27839 5440 January 24, 2018 Field Municipal Maintenance Anna Ostendorff LOCAL PERSON(S) CONTACTED: Bryan Pierce 1. 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. Staff were forthcoming and proactive in adopting the necessary changes. The inspector would like to commend the laboratory for promptly revising and submitting the benchsheet and required documentation prior to the completion of this report. Laboratories have up to 30 days after receiving the inspection report to submit corrective actions and documentation, but Mr. Pierce began corrective actions immediately after the inspection. All required Proficiency Testing (PT) Samples have been analyzed for the 2017 PT Calendar Year and the graded results were 100% acceptable. Requirements that reference 15A NCAC 2H .0805 (g) (1), stating "Data pertinent to each analysis must be maintained for five years. Certified Data must consist of date collected, time collected, sample site, sample collector, and sample analysis time. The field benchsheets must provide a space for the signature or initials of the analyst and proper units of measure for all analyses", are intended to be a requirement to document all pertinent information for historical reconstruction of data. It is not intended to imply that existing records are not adequately maintained unless the Finding speaks directly to that. Contracted analyses are performed by Environment 1, Inc. (Certification # 10). Quality Assurance Policies for Field Laboratories and Approved Procedure documents for the analysis of the facility's currently certified Field Parameters were provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: All original records are not being maintained for five years. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Comment: Original records are defined as the first place the data are documented. The analyst was recording values from the instrument calibration on a scrap piece of paper, then transferring the values to a digital calibration log. The scrap piece of paper was then discarded. Original records must be retained to verify accurate transcription of data. B. Finding: The laboratory does not have a system of traceability for purchased materials and reagents. Requirement: 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. This information must be retained for chemicals, reagents, standards and consumables used for a period of five years. Consumable materials such as pH buffers and lots of pre -made standards are included in this requirement. Ref: Quality Assurance Policies for Field Laboratories. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Comment: Use of the Lab Supply log provided by the inspector during the audit would satisfy this requirement. C. Finding: The thermometer calibration verification documentation did not include the stated accuracy or the expiration date of the National Institute of Standards and Technology (NIST) traceable temperature -measuring device that was used in the comparison. This is considered pertinent data. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). 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. D. Finding: The calibration documentation for Dissolved Oxygen does not include all applicable information. This is considered pertinent data. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Requirement: Calibration documentation must include the following, where applicable to the instrument used and the type of calibration performed: elevation. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. Comment: The Dissolved Oxygen meter is calibrated using temperature and elevation. The elevation is programmed into the meter and stored for future use. This information must be documented. E. Finding: The laboratory benchsheet was lacking pertinent data: Instrument identification. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Instrument identification. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen, NC WW/GW LC Approved Procedure for the Analysis of pH, NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: The instrument identification must be documented on both the calibration log and the benchsheet for traceability. Recommendation: It is recommended that the instrument serial number be used to fulfil this requirement. F. Finding: The laboratory benchsheet was lacking pertinent data: Method reference. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Method reference. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen, NC WW/GW LC Approved Procedure for the Analysis of pH, NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: This is a new requirement implemented with the revised Approved Procedure documents completed in December 2017 and January 2018. Proficiency Testing G. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. Requirement: All PT Samples are to be analyzed and the results reported in a manner consistent with the routine analysis and reporting requirements of Compliance Samples. Laboratories must document any exceptions. 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, May 31, 2017, Revision 2.0. Comment: The analysis of PT Samples is designed to evaluate the entire process used to routinely report Compliance Sample results; therefore, PT Samples must be analyzed and the process documented in the same manner as Compliance Samples. Dissolved Oxygen — Standard Methods, 4500 O G-2011 (Aqueous) H. Finding: The laboratory is not performing a post -analysis calibration verification when analyses are performed at multiple sample sites. Requirement: When performing analyses at multiple sample sites, a post -analysis calibration verification must be performed at the end of the run, regardless of meter type. It is recommended that a mid -day calibration verification be performed when samples are analyzed over an extended period of time, The calculated DO value must verify the meter reading within ±0.5 mg/L. If the meter verification does not read within ±0.5 mg/L of the theoretical DO, corrective action must be taken. Alternatively, if the meter is calibrated at each sample site prior to analysis, a post -analysis calibration verification is not required. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. Comment: This is a new requirement effective December 2017. pH — Standard Methods, 4500 H+ B-2011 (Aqueous) I. Finding: The laboratory is not analyzing a check standard buffer after calibration and prior to sample analysis. Requirement: Instruments are to be calibrated according to the manufacturer's calibration procedure prior to analysis of samples each day compliance monitoring is performed. Calibration must include at least two buffers. The meter calibration must be verified with a third standard buffer solution (i.e., check buffer) prior to sample analysis. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: All check standard buffers must read within ±0.1 S.U. to be acceptable. If the meter verification does not read within ±0.1 S.U., corrective actions must be taken before any samples are analyzed. Possible corrective actions may be found in the NC WW/GW LC Approved Procedure for the Analysis of pH document provided at the time of the inspection. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to electronic Discharge Monitoring Reports (eDMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for Pittman Elementary School WWTP (NPDES permit # NC0038610) for April, August and October 2017. The following error was noted: Date Parameter Location Value on Value on eDMR Benchsheet 4/26/2017 Dissolved Oxygen Effluent 6.1 mg/L 6.9 mg/L It was also noted that the laboratory has been reporting all non -detect values from the Contract Laboratory as numerical values. As an example, for the data reviewed from April 2017, the following errors were noted: Date Parameter Location Contract Lab Data Value on eDMR 4/12/2017 BOD Effluent <2.0 mg/L 1 mg/L 4/12/2017 Fecal Coliform Effluent <1 CFU/100mL 0 CFU/100mL 4/12/2017 Total Suspended Residue Effluent <2.5 mg/L 2 mg/L 4/26/2017 BOD Effluent <2.0 mg/L 1 mg/L Values of results which are less than a detectable limit are reported in the daily cells of the eDMR using the "less than" symbol (<) and the detectable limit used during the testing. For monthly calculations, the eDMR automatically calculates the arithmetic mean of a "less than" value as "zero" and the geometric mean (as for Fecal Coliform) of a "less than" value as "one". To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether amended eDMRs 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 respond to all Findings and include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Anna Ostendorff Date: January 29, 2018 Report reviewed by: Tonja Springer Date: February 5, 2018 C N E a `m W .o W E Z m p N L) j O J U �F 0 ._ U N N U w w 0 N w w W a 0 _w lL F a w U N O O L U U) T C O U N as S N � CD o aqi D Q. O Q Q � _ Q O N N w O O O = j m V ' N 0. Q w W