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INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 5131
Laboratory Name: Town of Warsaw
Inspection Type: Field Maintenance
Inspector Name(s): Todd Crawford
Inspection Date: March 20, 2014
Date Report Completed: April 7, 2014
Date Forwarded to Reviewer: April 7, 2014
Reviewed by: Jason Smith
Date Review Completed: April 10, 2014
Cover Letter to use: Insp. Initial Insp. Reg.
Insp. No Finding Insp. CP
Corrected
Unit Supervisor/Chemist III: Dana Satterwhite
Date Received: 4/11/2014
Date Forwarded to Linda: 4/24/2014
Date Mailed: 4/24/2014
_____________________________________________________________________
On-Site Inspection Report
LABORATORY NAME: Town of Warsaw
NPDES PERMIT #: NC0021903
ADDRESS: PO Box 464
Warsaw, NC 28398
CERTIFICATE #: 5131
DATE OF INSPECTION: March 20, 2014
TYPE OF INSPECTION: Field Maintenance
AUDITOR(S): Todd Crawford
LOCAL PERSON(S) CONTACTED: Greg Hughes and Angie Miller
I. 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 laboratory was clean and well organized. The facility has all the equipment necessary to perform the
analyses. Records were also well organized and quickly retrieved upon request.
Proficiency Testing (PT) samples for the 2014 proficiency testing calendar year have not yet been
analyzed. The laboratory is reminded that these results must be submitted to this office directly from the
vendor by September 30.
Current quality assurance policies for Field Laboratories and approved procedures for the analysis of
the facility’s currently certified parameters were provided at the time of the inspection.
Contracted analyses are performed by Vann Laboratories (Certification #22).
The requirements associated with Findings B, C, and D have been implemented by our program since
the last inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
Comment: Instrument identification for the meters used for Temperature, pH, Dissolved Oxygen and
Total Residual Chlorine was not documented on the benchsheet. The NC WW/GW LC Approved
Procedure for the Analysis of Temperature, NC WW/GW LC Approved Procedure for the Analysis of pH,
NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen and NC WW/GW LC
Approved Procedure for the Analysis of Total Residual Chlorine documents state: The following must be
documented in indelible ink whenever sample analysis is performed: Instrument identification. This
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#5131 Town of Warsaw
requirement is a new policy that has been implemented by our program since the last inspection.
Notification of acceptable corrective action (i.e., a statement that the revised benchsheet developed by
the inspector, which identifies all meters by model and serial number, would be used starting April 1,
2014) was received via email on April 1, 2014. No further response is necessary for this finding.
General
Comment: The laboratory needed to increase the documentation of purchased materials and reagents.
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. A system (e.g.,
traceable identifiers) must be in place that links standard/reagent preparation information to analytical
batches in which the solutions are used. 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 chemicals, reagents, standards and consumables used for a period of five years.
Consumable materials such as pH buffers, Total Residual Chlorine reagents and lots of pre-made
standards are included in this requirement. This requirement is a new policy that has been implemented
by our program since the last inspection. Demonstration of acceptable corrective action (i.e., a
traceability log sheet showing traceability information for all reagents currently in use) was received via
email on April 1, 2014. No further response is necessary for this finding.
A. Finding: Error corrections are not performed properly.
Requirement: 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. Ref: Quality Assurance Policies for Field
Laboratories.
Proficiency Testing
B. Finding: The laboratory is not analyzing Proficiency Testing (PT) samples in the same manner
as environmental 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 and any
other samples analyzed according to the requirements of 15A NCAC 2H .0800. Ref: Proficiency
Testing Requirements, February 20, 2012, Revision 1.2.
Comment: The laboratory’s common practice was to analyze a known standard along with the
PT sample as additional quality control. Environmental samples are not analyzed in this
manner.
C. 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.
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#5131 Town of Warsaw
Comment: Dating and initialing the instruction sheet for the preparation of the Total Residual
Chlorine PT would satisfy the documentation requirement.
D. Finding: The laboratory is not documenting Proficiency Testing (PT) sample analyses in the
same manner as environmental samples.
Requirement: All PT sample analyses must be recorded in the daily analysis records as for any
environmental sample. This serves as the permanent laboratory record. Ref: Proficiency
Testing Requirements, February 20, 2012, Revision 1.2.
Total Residual Chlorine – Standard Methods, 4500 Cl G-2000
Comment: It would be acceptable and more economical, in terms of cost and time, if the facility
switched from liquid reagents to DPD powder pillows. Use of the flow-thru cell could also be
discontinued.
Comment: The true value of the check standard was not documented on the benchsheet. The NC
WW/GW LC Approved Procedure for Analysis of Total Residual Chlorine document states: The
following must be documented in indelible ink whenever sample analysis is performed: True value of
the check standard. Notification of acceptable corrective action (i.e., a statement that the revised
benchsheet developed by the inspector, which shows the true value of the check standard, would be
used starting April 1, 2014) was received via email on April 1, 2014. No further response is necessary
for this finding.
Comment: The meter calibration time was not documented. The NC WW/GW LC Approved Procedure
for Analysis of Total Residual Chlorine documents state: The following must be documented in indelible
ink whenever sample analysis is performed: Meter calibration and meter calibration time(s). Notification
of acceptable corrective action (i.e., a statement that the revised benchsheet developed by the inspector,
which provides space for calibration time, would be used starting April 1, 2014) was received via email on
April 1, 2014. No further response is necessary for this finding.
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 Resources. Data were
reviewed for December, 2013, January and February, 2014. The following error was noted:
Date Parameter Location Value on Benchsheet Value on DMR
12/19/13 Dissolved Oxygen Effluent 11.5 mg/L 10.8 mg/L
In order to avoid questions of legality, it is recommended that you contact the appropriate Regional Office
for guidance as to whether an amended Discharge Monitoring Report will be required. A copy of this
report will be made available to the Regional Office.
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V. CONCLUSIONS:
Correcting the above-cited findings 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: Todd Crawford Date: April 7, 2014
Report reviewed by: Jason Smith Date: April 10, 2014