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HomeMy WebLinkAbout#177 - 04 - 2012 - FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 177 Laboratory Name: Water and Sewer Authority of Cabarrus County Inspection Type: Commercial Maintenance Inspector Name(s): Chet Whiting Inspection Date: April 25, 2012 Date Report Completed: May 18, 2012 Date Forwarded to Reviewer: May 18, 2012 Reviewed by: Jason Smith Date Review Completed: May 29, 2012 Cover Letter to use: _ Insp. Initial X Insp. Reg. _ Insp. No Finding _ Insp. CP _ Corrected Unit Supervisor: Gary Francies Date Received: 5/30/2012 Date Forwarded to Linda: 6/6/2012 Date Mailed: 1, b I 1 A Beverly Eaves Perdue Governor Division of Water Quality Charles Wakild, P. E. Director June 7, 2012 177 Mr. Tim Furr Water and Sewer Authority of Cabarrus County 6400 Breezy Lane Concord, NC 28025 Dee Freeman Secretary Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Furr: Enclosed is a report for the inspection performed on April 25, 2012 by Chet Whiting, Gary Francies. Jason Smith and Nick Jones. 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 of receipt, please supply this office with a written item for item description of how these finding(s) were corrected. 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. 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 us at 828-296-4677. Sincerely, Gary Francies Certification Unit Supervisor Laboratory Section Enclosure cc: Chet Whiting Master File DENR DWO Laboratory Section NC Wastewater/Groundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location: 4405 Reedy Creek Road. Raleigh, North Carolina 27607-6445 Phone: 919-733.3908 \ FAX: 919-733-6241 Internet: www.dwglab.org Nahoully One NorthCarolna An Equal Opportunity \ Affirmative Action Employer On -Site Inspection Report LABORATORY NAME: Water and Sewer Authority of Cabarrus County NPDES Permit #: NCO036296 (Rocky River WWTP) and NCO081621 (Muddy Creek WWTP) ADDRESS: 6400 Breezy Lane Concord, NC 28025 CERTIFICATE M 177 DATE OF INSPECTION: April 25, 2012 TYPE OF INSPECTION: Commercial Maintenance AUDITOR(S): Chet Whiting, Gary Francies, Jason Smith, Nick Jones LOCAL PERSON(S) CONTACTED: Tim Furr I. INTRODUCTION: This laboratory was inspected to verify its compliance with the requirements of 15A NCAC 2H .0800 for the analysis of environmental samples. II. GENERAL COMMENTS: It was evident from the inspection that the laboratory tries to stay abreast of changing requirements and implements new procedures as they arise. Examples include the implementation of matrix spiking procedures and the updated Total Suspended Solids (TSS) weight gain requirement. In addition, the laboratory has implemented quality control (QC) procedures that exceed laboratory certification requirements, such as the analysis of blind quarterly QC samples for most parameters. The laboratory is reminded that any time changes are made to laboratory operations; the laboratory must update the Quality Assurance (QA)/Standard Operating Procedures (SOP) document(s). Any changes made in response to the Findings, Recommendations or Comments listed in this report must be 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 approved practice and regulatory requirements. In some instances, the laboratory may need to create a SOP to document how new functions or policy will be implemented. Findings A, B, C, D, E, F, G, H and J are new policies that have been implemented by our program since the last inspection Ill. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation Recommendation: Some instrument maintenance is documented on a sticker posted on the instrument. It is recommended that this information be documented in a log book for retention. Documentation of instrument maintenance is not currently a requirement; however, it is good laboratory practice and can provide valuable supporting documentation for troubleshooting and/or training purposes. Page 2 #177 Water and Sewer Authority of Cabarrus County Recommendation: Preservation checks for Total Residual Chlorine (i.e., Ammonia Nitrogen, Fecal Coliform, and BOD [prescreen]) are documented as <0.025 mg/L. The aliquot of sample tested for the presence of total residual chlorine does not have to be a quantitative analysis performed on the spectrophotometer. it is recommended that this be documented as presence or absence. Comment: The autoclave log did not document the items autoclaved (e.g., Total Phosphorus sample numbers for digestion, buffered sterile dilution water, fecal filtration units, etc.) The North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supporting records shall be maintained as evidence that these practices are being effectively carried out. Demonstration of acceptable corrective action (i.e., revised autoclave log sheets with a column to document the materials sterilized during each use) was received by email on 4/26/12. No further response is necessary for this finding. Comment: It was recommended that use of the internal thermometer be documented. This information was on the submitted revised autoclave log sheet. A. Finding: Data that does not meet all quality control requirements is not qualified on the Discharge Monitoring Report (DMR). Requirement: When quality control (QC) failures occur, the laboratory must attempt to determine the source of the problem and must apply corrective action. Part of the corrective action is notification to the end user. If data qualifiers are used to qualify samples not meeting QC requirements, the data may not be useable for the intended purposes. It is the responsibility of the laboratory to provide the client or end -user of the data with sufficient information to determine the usability of the qualified data. Ref: Quality Assurance Policies for Field Laboratories. Comment: Where applicable, a notation must be made on the Discharge Monitoring Report (DMR) form, in the comment section, when any required sample quality control does not meet specified criteria and another sample cannot be obtained. Comment: One instance, in the data reviewed, was observed where a quality control failure was not qualified on the data or DMR (Total Phosphorus, Matrix Spike failure on 5/4/11). Recommendation: Having a visual cue can be helpful in preventing the above -cited omission. It is recommended that the Matrix Spike acceptance criterion be recorded on the benchsheet. B. Finding: The preparation of Proficiency Testing (PT) samples is not documented. Requirement: 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. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. C. Finding: The laboratory's Standard Operating Procedure (SOP) does not address the preparation, analysis and documentation of PT samples. Requirement: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supporting records shall be maintained as evidence that these practices are being effectively carried out. Page 3 #177 Water and Sewer Authority of Cabarrus County The quality control document shall be available for inspection by the State Laboratory. Ref: 15A NCAC 2H .0805 (a) (7). D. Finding: The preparation of standards and reagents is not documented in such a way as to provide traceability from preparation to analysis. Requirement: Documentation of solution preparation must include the analyst's initials, date of preparation, the volume or weight of standard(s) used the solvent and final volume of the solution. This information as well as the vendor and/or manufacturer, lot number, and expiration date must be retained for primary standards, chemicals, reagents, and materials used for a period of five years. Consumable materials such as pH buffers, lots of pre -made standards and/or media, solids and bacteria filters, etc. are included in this requirement. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. Comment: The laboratory has an effective system documenting traceability of chemical receipt and primary stock standards prepared in the laboratory, however preparation of secondary standards is not (e.g. curve standards check standards prepared from stock standards) are not documented. General Laboratory E. Finding: The laboratory is analyzing additional quality control (i.e., purchased known value sample) with PT samples. Requirement: Laboratories shall conduct proficiency tests in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the PT 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 and preparatory techniques such as digestions, distillations and extractions. They shall not be analyzed with additional duality control or replicated beyond what is routine for environmental sample analysis. Results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine environmental samples. The same quality control acceptance criteria must also be used. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. F. Finding: A calibration blank and/or calibration verification standard (mid -range) are not analyzed at the end of the sample group and/or after every tenth sample for colorimetric, ion electrode or metals analyses. Requirement: The calibration blank and calibration verification standard (mid -range) must be analyzed initially (i.e., prior to sample analysis), after every tenth sample and at the end of each sample group to check for carry over and calibration drift. If either fall outside established quality control acceptance criteria, corrective action must be taken (e.g., repeating sample determinations since the last acceptable calibration verification, repeating the initial calibration, etc.). Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy based upon Standard Methods, 20th Edition, 1020 B. (10) (c), 3020 B. (2) (b), and 4020 B. (2). Metals — Standard Methods, 18th Edition, 3111 B Metals — Standard Methods, 18th Edition, 3113B Recommendation: The temperature of some cells in the hot block digester is not checked. It is recommended that the laboratory rotate temperature checks so that all cells are tested. In addition it is recommended that standards (including Q.C), blanks and samples be rotated through cells. Page 4 #177 Water and Sewer Authority of Cabarrus County C. Finding: The laboratory is analyzing only post digestion spikes and they are not identified as such. Requirement: Post Digestion Spikes (PDS) are used for some analyses (e.g., metals) to assess the ability of a method to successfully recover target analytes from an actual sample matrix after the digestion process has been performed. The PDS results are used with Matrix Spike (MS) results to evaluate matrix interferences. The MS and PDS should be prepared from the same environmental sample. A PDS is not to be analyzed in place of a MS. Post Digestion Spikes must be reported as post -digested and must not be misrepresented as pre-digested spikes. (Exception: TCLP and SPLP samples are always spiked post digestion.) Ref: Matrix Spiking Policy and Technical Assistance Document. Ammonia Nitrogen — Standard Methods, 18th Edition, 4500 NH3 F H. Finding: After the addition of the 10 N NaOH, the pH is not verified and documented to be greater than 11. Requirement: Add a sufficient volume of 10N NaOH solution to raise pH above 11. Ref: Standard Methods, 18th Edition, 4500 NH3 D. (4) (b). Requirement: Supporting records shall be maintained as evidence that these practices are being effectively carried out. Ref: 15A NCAC 2H .0805 (a) (7). I. Finding: Standard recovery results are not calculated. Requirement: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supporting records shall be maintained as evidence that these practices are being effectively carried out. Ref: 15A NCAC 2H .0805 (a)(7). Requirement: Any time quality control results indicate an analytical problem, the problem must be resolved and any samples involved must be rerun if the holding time has not expired. Ref: 15A NCAC 2H .0805 (a) (7) (F). J. Funding: The Ammonia Nitrogen Standard Operating Procedure (SOP) has not been updated to include matrix spiking procedures. Requirement: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supporting records shall be maintained as evidence that these practices are being effectively carried out. Ref: 15A NCAC 2H .0805 (a) (7). Fecal Coliform (Membrane Filter) — Standard Methods, 18th Edition, 9222 D Recommendation: It is recommend that the laboratory consider an alternate method for evaluating fecal coliform duplicates that reflects a more realistic assessment. Standard Methods, 21st Edition, 9020 B (8) (b) (1 — 5) uses a statistical approach to evaluate fecal duplicates. Another option could be a two tiered system, one for results with less than 20 fecal colonies based on raw colony counts, and another criterion for results with 20-60 colonies based upon a Relative Percent Difference calculation. Recommendation: The laboratory is measuring the 100 ml sample volumes using the graduation on the filter funnel. It is recommended that the laboratory use a graduated cylinder that has been sterilized. Page 5 #177 Water and Sewer Authority of Cabarrus County Total Suspended Solids - Standard Methods, 181h Edition, 2540 C Recommendation: The laboratory is folding Total Suspended Solids (TSS) filters and putting them in Gooch crucibles for drying. This also necessitates the filter being handled with gloves. There is a concern that material may flake off or.that the filter may otherwise be compromised. It is recommended that the laboratory switch to aluminum weighing dishes or some other method that allows the filters to be dried flat. Finding: Units of measure were not documented on the benchsheets Requirement: All laboratories must use printed laboratory bench worksheets that include a space to enter the signature or initials of the analyst, date of analyses, sample identification, volume of sample analyzed, value from the measurement system, factor and final value to be reported and each item must be recorded each time samples are analyzed. Ref: 15A NCAC 2H .0805 (a) (7) (H). IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing field testing records and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Quality. Data were reviewed for Rocky River WWTP (NPDES permit #NC0036296) for March and May, 2012. No transcription errors were detected. The facility appears to be doing a good job of accurately transcribing data. V. CONCLUSIONS: Correcting the above -cited findings and implementing the recommendations will help this lab to produce quality data and meet certification requirements. The inspector would like to thank the staff for its assistance during the inspection and data review process. Please respond to all findings. Report prepared by: Chet Whiting Date: May 18, 2012 Report reviewed by: Jason Smith Date: May 29, 2012