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
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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
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