HomeMy WebLinkAbout#5213_2016_0407_BS_FINALTo be attached to all inspection reports in-house only.
Laboratory Cert. #:
Laboratory Name:
Inspection Type:
Inspector Name(s):
Inspection Date:
Date Report Completed:
Date Forwarded to Reviewer:
Reviewed by:
Date Review Completed:
Cover Letter to use:
Unit Supervisor/Chemist III:
Date Received:
Date Forwarded to Admin:
Date Mailed:
Cc: Wes Bell
5213
NC DOT — Division of Highways
Field Maintenance
Beth Swanson, Gary Francies
4/7/2016
4/18/2016
4/18/2016
Anna Ostendorff
4/18/2016
❑ Insp. Initial ❑ Insp. Reg.
❑ Insp. No Finding ❑ Insp. CP
® Corrected ❑ Insp. Reg. Delay
Gary Francies
4/29/2016
5/17/2016
5/17/2016
Water 17esources
ENVIRONMENTAL QUALITY
May 17, 2016
5213
Ms. Michelle Anderson
NC DOT — Division of Highways
PO Box 250
N. Wilkesboro, NC 28659
PAT MCCRORY
DONALD R. VAN DER VAART
S. JAY ZIMMERMAN
SUBJECT: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Maintenance Inspection
Dear Ms. Anderson:
Enclosed is a report for the inspection performed on April 7, 2016 by Beth Swanson and myself. Since
the Finding(s) cited during the inspection were all corrected prior to the completion of the enclosed
report, a response is not required. The staff is commended for taking the initiative in correcting the
Findings in such a timely manner. For Certification maintenance, your laboratory must continue to carry
out the requirements set forth in 15A NCAC 2H .0800.
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 (828) 296-4677.
Sincerely,
Gary Francies, Technical Assistance/Compliance Specialist
Division of Water Resources
Attachment
cc: Beth Swanson
master file
LABORATORY NAME:
NPDES PERMIT :
ADDRESS:
CERTIFICATE #:
DATE OF INSPECTION:
TYPE OF INSPECTION:
AUDITOR(S):
LOCAL PERSON(S) CONTACTED:
INTRODUCTION:
NC DOT — Division of Highways
NC0029190, NC0028607 and NC0028614
PO Box 250
N. Wilkesboro, NC 28659
5213
April 7, 2016
Field Maintenance
Beth Swanson and Gary Francies
Michelle Anderson
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.
GENERAL COMMENTS:
This Certification applies to the NC Welcome Center on 1-77 (NPDES #NC0029190), the Yadkin I-
77 rest area (NPDES #NC0028614) and the Iredell 1-77 rest area (NPDES #NC0028607). Only
the meters and data for NPDES #NC0029190 were reviewed during this inspection. All facilities
are Certified for the same parameters and use the same benchsheets. The temperature sensor
verifications and Total Residual Chlorine (TRC) calibration curve verifications for the meters at all
facilities were received by email on April 8, 2016 and observed to be acceptable.
All required Proficiency Testing (PT) samples for the 2016 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, 2016.
Contracted analyses are performed by Pace Analytical Services, Inc. - Huntersville (Certification
#12). Temperature sensor verifications and meter curve verifications are performed by Statesville
Analytical, Inc. (Certification #440). The meters and PT samples are also taken to Statesville
Analytical, Inc. and PT analysis is performed there by the DOT staff.
Current Quality Assurance Policies for Field Laboratories and Approved Procedure documents for
the analysis of the facility's currently certified methods were provided at the time of the inspection.
FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
Comment: The facilities were not retaining original records for upstream and downstream data.
The North Carolina Administrative Code, 15A NCAC 2H .0805 (g) (1) states: Data pertinent to
each analysis must be maintained for five years. Notification of acceptable corrective action (i.e., a
statement that the analysts at each facility are retaining the original record for upstream and
Page 2
#5213 NC DOT — Division of Highways
downstream data and that a note was posted at each facility as a reminder with an
implementation date of April 12, 2016) was received by email on April 15, 2016. No further
response is necessary for this Finding.
Comment: The facilities had no documentation of traceability. The Quality Assurance Policies for
Field Laboratories document states: 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 as well as the vendor and/or
manufacturer, lot number, and expiration date 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. Notification of acceptable
corrective action (i.e., a statement that a copy of the receipt log supplied by the auditor that has all
required traceability information was posted at the three NPDES facilities and implemented on
April 13, 2016) was received by email on April 15, 2016. No further response is necessary for
this Finding.
Comment: Error corrections were not performed properly. There were instances of write overs,
no initials or dates, and use of Wite-Out®. The Quality Assurance Policies for Field Laboratories
document states: All documentation errors must 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. Write the correction adjacent to the error. The correction
must be initialed by the responsible individual and the date of change documented. All data and
log entries must be written in indelible ink. Pencil entries are not acceptable. Notification of
acceptable corrective action (i.e., a statement that all analysts were counseled on the proper
method of error correction and that a reminder notice was posted at all facilities with an
implementation date of April 13, 2016) was received by email on April 15, 2016. No further
response is necessary for this Finding.
Proficiency Testing
Comment: The laboratory was not documenting PT sample analyses in the same manner as
environmental samples. The Proficiency Testing Requirements document states: All PT sample
analyses must be recorded in the daily analysis records as for any environmental sample. This
serves as the permanent laboratory record. Notification of acceptable corrective action (i.e., a
statement that the benchsheet will be brought to Statesville Analytical, Inc. and used to record the
PT results beginning with the 2016 PT study) was received by email on April 15, 2016. No further
response is necessary for this Finding.
Comment: The preparation of PT samples was not being documented. The Proficiency Testing
Requirements document states: PT samples received as ampules must be diluted according to
the PT provider's instructions. The preparation of PT samples must be documented in a
traceable log or other traceable format. The diluted PT sample becomes a routine
environmental sample and is added to a routine sample batch for analysis. Notification of
acceptable corrective action (i.e., a statement that beginning with the 2016 PT study, the
instruction sheet for the Total Residual Chlorine sample will be initialed, dated and retained)
was received by email on April 15, 2016. No further response is necessary for this Finding.
Page 3
#5213 NC DOT — Division of Highways
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous)
Comment: The time collected was not clearly stated on the benchsheet. There were columns
labeled both "Time Collected" and "Sample Analysis Time" with only Sample Analysis Time
completed and no notes stating that collection and analysis time were the same. The North
Carolina Administrative Code, 15A NCAC 2H .0805 (g) (1) states: Certified Data must consist of
date collected, time collected, sample site, sample collector, and sample analysis time.
Notification of acceptable corrective action (i.e., a copy of the benchsheet for pH and Dissolved
Oxygen (DO) that has been updated to include one column labeled "Time collected/analyzed"
and a statement that it will be implemented on May 1, 2016) was received by email on April 15,
2016. No further response is necessary for this Finding.
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous)
Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous)
Temperature — Standard Methods, 2550 B-2000 (Aqueous)
Comment: The benchsheets were lacking pertinent data: Instrument identification. The Approved
Procedure for the Analysis of pH, the Approved Procedure for the Analysis of Dissolved Oxygen,
the Approved Procedure for the Analysis of Total Residual Chlorine and the Approved Procedure
for the Analysis of Temperature documents state: The following must be documented in indelible
ink whenever sample analysis is performed: Instrument Identification. Notification of acceptable
corrective action (i.e., copies of all benchsheets updated with the instrument identification and a
column to indicate when that meter was used for Temperature data and a statement they will be
implemented on May 1, 2016) was received by email on April 15, 2016. No further response is
necessary for this Finding.
Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous)
Comment: The benchsheet was lacking pertinent data: Meter calibration. The meter calibration
time was recorded on the benchsheet, but not a record of the mg/L reading from the meter
following calibration. The Approved Procedure for the Analysis of Dissolved Oxygen document
states: The following must be documented in indelible ink whenever sample analysis is performed:
Meter calibration. Notification of acceptable corrective action (i.e., a copy of the updated
benchsheet with a column where the analysts have a space to record the mg/L meter reading
directly after calibration and a statement it will be implemented on May 1, 2016) was received by
email in April 15, 2016. No further response is necessary for this Finding.
Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous)
Comment: A reagent blank was not analyzed when preparing and analyzing the annual PT
sample. The Approved Procedure for the Analysis of Total Residual Chlorine document states:
Each day that prepared standards are analyzed a reagent blank must be analyzed to determine
if method analytes or other interferences are present in the laboratory environment, the reagents
or the apparatus. Although the Approved Procedure does not explicitly state that a reagent blank
is required when preparing and analyzing the PT sample, it is the intent that this also applies to
the PT as a Quality Control element that is prepared with reagent water. A reagent blank is made
from the same laboratory water source used to make quality control and/or calibration standards
with DPD. The concentration of reagent blanks must not exceed 50% of the reporting limit (i.e.,
the lowest calibration or calibration verification standard concentration), unless otherwise specified
by the reference method or corrective action must be taken. Notification of acceptable corrective
action (i.e., a statement that beginning with the 2016 PT study, a reagent blank will be analyzed
Page 4
#5213 NC DOT — Division of Highways
and documented to be no greater than 7 lag/L) was received by email on April 15, 2016. No
further response is necessary for this Finding.
Comment: Values less than the established reporting limit were being reported on the Discharge
Monitoring Report (DMR). The lowest calibration standard concentration currently verified is 15
lag/L. The Approved Procedure for the Analysis of Total Residual Chlorine document states: The
concentrations of the calibration standards must bracket the concentrations of the samples
analyzed. One of the standards must have a concentration equal to or below the lower reporting
concentration for Total Residual Chlorine. The lower reporting limit must be less than or equal to
the permit limit. Notification of acceptable corrective action (i.e., a statement that any sample
result below 15 lag/L will be reported on the DMR as <15 lag/L beginning with the March 2016
DMR) was received by email on April 18, 2016. No further response is necessary for this
Finding.
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
Comment: Values were reported that exceed the method specified accuracy of 0.1 units.
Standard Methods, 4500 H+ B-2000, (6) states: 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. Notification of acceptable
corrective action (i.e., a statement that pH results would be reported to 0.1 units beginning with
the March 2016 DMR) was received by e-mail on April 18, 2016. No further response is
necessary for this Finding.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks,
etc.) and contract lab .reports to DMRs submitted to the North Carolina Division of Water
Resources. Data were reviewed for NPDES permit #NC0029190 for October and December
2015.
The analyst does not include the < symbol for contract data that have non -detect results. The
value reported on the DMR is the reporting limit applicable to the data for that parameter. This
applies to all three Certified NPDES facilities.
On the October DMR, the facility reported the NO3 + NO2 result (68.4 mg/L) instead of the Total
Nitrogen result (68.9 mg/L) from the contract lab. This is a quarterly sample, so we were unable to
find another set of data and verify whether this was a one-time error or the normal procedure. The
error was pointed out to the analyst and she stated she will be more aware of reporting results for
the proper parameter in the future.
In order to avoid questions of legality, it is recommended that you contact the appropriate
Regional Office for guidance as to whether an amended DMR will be required. A copy of this
report will be made available to the Regional Office.
V. CONCLUSIONS:
All Findings noted during the inspection were adequately addressed prior to the completion of this
report. The inspector would like to thank the staff for its assistance during the inspection and data
review process. No response is required.
Report prepared by: Beth Swanson Date: April 18, 2016
Report reviewed by: Anna Ostendorff Date: April 19, 2016