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INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 5275
Laboratory Name: Town of Southern Pines WTP
Inspection Type: Field Maintenance
Inspector Name(s): Tonja Springer
Inspection Date: March 11, 2014
Date Report Completed: March 24, 2014
Date Forwarded to Reviewer: March 24, 2014
Reviewed by: Todd Crawford
Date Review Completed: March 24, 2014
Cover Letter to use: Insp. Initial Insp. Reg.
Insp. No Finding Insp. CP
Corrected
Unit Supervisor/Chemist III: Dana Satterwhite
Date Received: 3/24/2014
Date Forwarded to Linda: April 1, 2014
Date Mailed: April 2, 2014
_____________________________________________________________________
On-Site Inspection Report
LABORATORY NAME: Town of Southern Pines WTP
WATER QUALITY PERMIT # : NC0049778
ADDRESS: 261 Thunder Road
Pine Bluff, NC 28373
CERTIFICATE #: 5275
DATE OF INSPECTION: March 11, 2014
TYPE OF INSPECTION: Field Maintenance
AUDITOR(S): Tonja Springer
LOCAL PERSON(S) CONTACTED: David McKew
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.
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 Environment 1, Inc. (Certification #10) and Pace Analytical
Services, Inc. (Certification #67).
The requirements associated with Findings A, B, G, J and K have been implemented by our program
since the last inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Recommendation: The laboratory’s data defensibility would be improved with the addition of an
instrument maintenance log. This can be as simple as a description in a comment box on a
benchsheet. One example of instrument maintenance is replacing a bulb on the Total Residual
Chlorine meter.
Documentation
A. Finding: The laboratory needs to increase the documentation of purchased materials and
reagents such as the pH buffers and DPD reagents.
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#5275 Town of Southern Pines WTP
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. 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 and lots of pre-made
standards are included in this requirement. Ref: Quality Assurance Policies for Field
Laboratories.
Total Residual Chlorine – Standard Methods, 4500 Cl G-2000
pH – Standard Methods, 4500 H+ B-2000
B. Finding: Instrument identification for the pH and Total Residual Chlorine meters is not
documented on the benchsheet.
Requirement: The following must be documented in indelible ink whenever samples analysis is
performed: Instrument identification. Ref: NC WW/GW LC Approved Procedure for the Analysis
of Total Residual Chlorine and NC WW/GW LC Approved Procedure for the Analysis of pH.
C. Finding: The time of meter calibration is not documented.
Requirement: A record of instrument calibration where applicable, must be filed in an orderly
manner so as to be readily available for inspection upon request. Ref: 15A NCAC 2H .0805 (g)
(2).
D. Finding: Process control data is not documented as such.
Requirement: 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. Ref: 15A NCAC 2H .0805 (g) (1).
Total Residual Chlorine – Standard Methods, 4500 Cl G-2000
Recommendation: A second set of gel standards has been purchased. It is recommended that the new
set be verified against the annual verification curve whenever it is done for 2014 and be used as a
backup. Both sets of gel standards will need to be assigned some type of identification so that the gel
standard being used and it’s assigned true value can be linked to the samples.
Recommendation: It is recommended that the true value obtained for the gel standards be put on the
side of the gel standard box.
E. Finding: The true value of the check standard is not documented.
Requirement: The following must be documented in indelible ink whenever sample analysis is
performed: True value for the check standard. Ref: NC WW/GW LC Approved Procedure for
the Analysis of Total Residual Chlorine.
F. Finding: The meter is being zeroed each analysis day with a sample instead of calibration blank.
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#5275 Town of Southern Pines WTP
Requirement: The laboratory must analyze a calibration blank to zero the instrument and
analyze a check standard each day that samples are analyzed. Ref: NC WW/GW LC Approved
Procedure for the Analysis of Total Residual Chlorine.
Comment: The gel standard blank can be used as the calibration blank.
Comment: The only time a sample is used to zero the instrument is if there is some type of
interference.
G. 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.
Comment: Retaining the PT sample instruction sheet from the vendor, signed and dated by the
technician, will satisfy this requirement.
pH – Standard Methods, 4500 H+ B-2000
Recommendation: The slope is being documented on the benchsheet. It is recommended that the
acceptance criterion also be documented on the benchsheet as a quick reference for to verify it is within
the manufacturer’s acceptable criterion.
Recommendation: The pH buffer check is being documented on the benchsheet. It is recommended
that the acceptance criterion of the pH buffer check also be documented to verify that it is within the
method’s acceptable criterion of +0.1 pH units.
H. Finding: The benchsheet did not contain all pertinent information.
Requirement: Data pertinent to each analysis must be maintained for five years. Certified Data
must consist of date collected, time collected, samples site, sample collector, and sample
analysis time. The field benchsheets must provide a space for the signature of the analyst, and
proper units of measure for all analyses. Ref: 15A NCAC 2H .0805 (g) (1).
Comments: Units were not being documented on the pH calibration documentation.
I. Finding: Values were reported that exceed the method specified accuracy of 0.1 units.
Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of
±0.02 unit and an accuracy of ±0.05 unit can be achieved. 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. Ref: Standard
Methods, 4500 H+ B-2000, (6).
Proficiency Testing
J. Finding: The laboratory is not analyzing Proficiency Testing (PT) samples in the same manner
as environmental samples.
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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. Since this is not performed with all environmental samples, it
is considered additional quality control. However, known samples are recommended when
analyzing remedial PT samples as part of the troubleshooting and corrective action process.
K. 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.
Comment: The analysis of PT samples is designed to evaluate the entire process used to
routinely report environmental analytical results; therefore, PT samples must be analyzed and
the process documented in the same manner as environmental samples.
Comment: The PT sample results are being documented directly on the vendor’s reporting
form and not being documented on the benchsheet in the same manner as the environmental
samples.
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing laboratory benchsheets and contract lab reports to Discharge
Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were
reviewed for September, 2013, and January and February, 2014. The following error was noted:
Date Parameter Location Value on
Benchsheet Value on DMR
1/7/2014 Total Residual Chlorine Effluent < 20 µg/L <0.20 µg/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.
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: Tonja Springer Date: March 24, 2014
Report reviewed by: Todd Crawford Date: March 24, 2014