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HomeMy WebLinkAbout#5631_03_2014_FINALINSPECTION REPORT ROUTING SHEET To 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: 5631 Carolina's Best Seafood LLC Field Initial Nick Jones March 6, 2014 April 3, 2014 April 3, 2014 Todd Crawford April 4, 2014 ® Insp. Initial ❑ Insp. Reg. ❑ Insp. No Finding ❑ Insp. CP ❑ Corrected Gary Francies ril 7. 2014 Date Forwarded to Linda: April'9, 2014 Date Mailed: 4/ 1 D I I'+ U__ Pat McCrory Governor April 9, 2014 5631 Thomas Tsiaras Carolina's Best Seafood, LLC 975 Gull Rock Rd Englehard, NC 27284 Joan E. Skvarla, III Secretary Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Tsiaras: Enclosed is a report for the inspection performed on March 6, 2014 by Nick Jones. 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. Attachment cc: Nick Jones Master File Sincerely, Gary Francies, Technical Assistance/Compliance Specialist Division of Water Resources, NCDENR Water Sciences Section NC WastewatertGroundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location: 4405 Reedy Creek Road, Raleigh, North Carolina 27607 Phone: 919-733-39031FAX: 919-733-6241 internet: www.dwglab.org An Equal Opportunity \ Affirmative fiction Employer LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: I. INTRODUCTION: On -Site Inspection Report Carolina's Best Seafood, LLC NC008935 975 Gull Rock Rd Englehard, NC 27284 5631 March 6, 2014 Field Initial Nick Jones Thomas Tsiaras 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. Laboratory personnel communicate well with sample collectors and coordinate sample analyses effectively to manage workload and holding times. Proficiency Testing (PT) samples have not been analyzed for all certified parameters for the 2014 proficiency testing calendar year. The laboratory is reminded that these results must be submitted to this office directly from the vendor by September 30, 2014. Contracted analyses are performed by Microbac Laboratories, Inc. (Certification #11). 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. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Quality Control A. Finding: The laboratory needs to increase the documentation of purchased materials and reagents. Page 2 #5631 — Carolina's Best Seafood, LLC 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. Comment: An example traceability log sheet that documents all required traceability information was supplied by the auditor during the inspection. Documentation B. Finding: The lab was utilizing a pencil for documentation. 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. C. Finding: The lab does not have a benchsheet for the analysis of pH. 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 02H .0805 (g) (1). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: date and time of sample collection, date and time of sample analysis to verify the 15 minute holding time is met (alternatively, one time may be documented for collection and analysis with the notation that samples are measured in situ or immediately at the sample site), sample site including facility name and location, ID, etc, collector's/analyst's name or initials, meter calibration and meter calibration time(s), true values of buffers used for calibration, true value for the check standard buffer, value obtained for the check standard buffer (verification of t 0.1 S.U.), true value and value obtained for the post analysis calibration verification(s), where applicable, report all data values to the nearest 0.1 pH unit, traceability for chemicals, reagents, standards and consumables, instrument identification, parameter analyzed, data qualifier(s), Page 3 #5631 — Carolina's Best Seafood, LLC when applicable, equipment maintenance (recommended). Ref: NC WW/GW LC Approved Procedure for Analysis of pH. Comment: An example benchsheet that documents all required items was provided by the auditor during the inspection. Proficiency Testing D. Finding: The laboratory is not documenting 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. E. Finding: The lab was not retaining the reporting forms used to report the PT results to the vendor. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 2H .0805 (a) (7) (G)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT analyses and the associated quality control analyses conducted by all method technologies. These records shall include a copy of the reporting forms used by the laboratory to report the analytical results to the PT provider. If the analytical results for the PT samples were entered or uploaded electronically to a provider website, the laboratory shall retain a copy of the on-line data entry summary or similar documentation of entry of the PT results from the PT provider website. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. PH — Standard Methods, 4500 H+ B-2000 F. Finding: The lab is not calibrating the meter prior to analysis of samples each day compliance monitoring is performed. Requirement: Instruments are to be calibrated according to the manufacturer's calibrationprocedure prior to analysis of samples each day compliance monitoring is performed. The meter must be calibrated with at least two buffers. In addition to the calibration buffers, the meter calibration must be verified with a third standard buffer solution. The calibration and check standard buffers must bracket the range of the samples being analyzed. A portion of the buffer solutions should not be used for more than one calibration. Discard any used buffer portions. The check standard buffer must read within ±0.1 S.U. to be IV. Page 4 #5631 — Carolina's Best Seafood, LLC acceptable. If the meter verification does not read within f0.1 S.U., the meter must be recalibrated before any samples are analyzed. Ref: NC WW/GW LC Approved Procedure for Analysis of pH. 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 Carolina's Best Seafood, LLC (NPDES permit # NC008935) for October, November and December, 2013. 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 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: Nick Jones Report reviewed by: Todd Crawford Date: April 3, 2014 Date: April 4, 2014