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HomeMy WebLinkAbout#5652_12_2014_final INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5652 Laboratory Name: The University of North Carolina at Chapel Hill Bingham Facility Inspection Type: Field Initial Inspector Name(s): Tonja Springer Inspection Date: 11/12/2014 Date Report Completed: 11/21/2014 Date Forwarded to Reviewer: 12/4/2014 Reviewed by: Jason Smith Date Review Completed: 12/4/2014 Cover Letter to use: Insp. Initial Insp. Reg. Insp. No Finding Insp. CP Corrected Insp. Reg. Delay Unit Supervisor/Chemist III: Dana Satterwhite Date Received: December 4, 2014 Date Forwarded to Linda: December 9, 2014 Date Mailed: December 10, 2014 _____________________________________________________________________ On-Site Inspection Report LABORATORY NAME: The University of North Carolina at Chapel Hill Bingham Facility ADDRESS: 1120 Estes Drive Ext. CB #1650 Chapel Hill, NC 27599-1650 WATER QUALITY PERMIT # : WQ0023896 CERTIFICATE #: 5652 DATE OF INSPECTION: November 12, 2014 TYPE OF INSPECTION: Field Initial AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Larry Daw, Jamie Smith and Clay Teague 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: This was the laboratory’s first inspection. The facility is neat and well organized and has all the equipment necessary to perform the analyses. Benchsheets are well designed, easy to follow and concise. Records are well organized and easy to retrieve. The laboratory has been proactive in keeping up with updates and changes required by this program. Contracted analyses are performed by Environmental Chemists, Inc. (Envirochem) (Certification #94). An amendment form was completed at the time of the inspection to remove Dissolved Oxygen (DO) from the laboratory’s certificate attachment. The amendment form was processed and the parameter was removed from the certified attachment effective November 12, 2014. 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: Documentation Comment: Error corrections were not performed properly. No correction date was being documented. The Quality Assurance Policies for Field Laboratories 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. Demonstration of acceptable corrective action (i.e., a copy of the logbook showing a dated error correction) was received by email on 11/12/2014. No further response is necessary for this finding. Page 2 #5652 The University of North Carolina at Chapel Hill Bingham Facility Proficiency Testing Comment: The preparation of Total Residual Chlorine (TRC) Proficiency Testing (PT) samples was not documented. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2. 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. Dating and initialing the instruction sheet for the preparation of the TRC PT would satisfy the documentation requirement. Demonstration of acceptable corrective action (i.e., a copy of the TRC PT preparation instructions that were initialed and dated) was received by email on 11/12/2014. No further response is necessary for this finding. A. 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. Recommendation: PT samples are analyzed by all three operators and one value is randomly picked for reporting. The laboratory is commended for being proactive to assure that all operators are proficient in their abilities to perform the analysis accurately. It is recommended that the laboratory manually grade the remaining operator’s PT results and take documented corrective action any time an operator receives a result that would have been graded unacceptable. It is additionally recommended that a remedial blind PT be analyzed by any operator that would have received unacceptable results to demonstrate their analytical system is back in control. pH – Standard Methods, 4500 H+ B-2000 Comment: Values were reported that exceed the method specified accuracy of 0.1 units. Standard Methods, 4500 H+ B-2000 (6) states in part: 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) was received by e-mail on November 12, 2014. No further response is necessary for this finding. Total Residual Chlorine – Standard Methods, 4500 Cl G-2000 Comment: The laboratory does not have a permit limit. The factory set curve was verified on the HACH Pocket Colorimeter II and the HACH Pocket Colorimeter II backup meter n the low and high range. The lowest allowable reporting level for the pocket colorimeter is 0.1 mg/L. Therefore; only a high range curve verification is needed. Any samples below the 0.1 mg/L value would then been reported as <0.1 mg/L. Comment: The laboratory is not reporting all tests on the characteristics of the effluent on the monthly report form. The North Carolina Administrative Code 15A NCAC 2B .0506 (b) (3) (J) states: The results of all tests on the characteristics of the effluent, including but not limited to NPDES permit monitoring requirements, shall be reported on the monthly report forms. The facility voluntarily analyzed two samples on 7/11/2014 but only reported the highest value of 2.28 mg/L. The laboratory may report the second value on the back or as an attachment to the monthly report or the laboratory may average the results for reporting in the daily cell. Notification of acceptable corrective action (i.e., a statement that in the future all compliance data analyzed will be reported on the Non-Discharge Monitoring Report Page 3 #5652 The University of North Carolina at Chapel Hill Bingham Facility (NDMR). Data that does not fit in the daily cell on the NDMR will be included in the comment section) was received by email on November 12, 2014. No further response is necessary for this finding. B. Finding: The laboratory has not initially verified the concentration of the Gel® standard used with the HACH Pocket Colorimeter II. Requirement: Purchased “Gel-type” or sealed liquid ampoule standards may be used for daily standard curve verification only. These standards must be verified initially and every 12 months thereafter, with the standard curve. When this is done, these standards may be used after the manufacturer’s expiration date. It is only necessary to verify the gel or sealed liquid standard which falls within the concentration range of the curve used to measure sample concentrations. Ref: Approved Procedure for the Analysis of Total Residual Chlorine. Comment: The gel standard was purchased within the last month. Comment: The gel standard can be verified initially in house by reading the gel standard 3 times and taking the average as the obtained “true value”. The value of the Gel® standard obtained, will be the “true value” used throughout the year and until a new curve is verified. When this is done every twelve months, this standard may be used after the manufacturer’s expiration date. Comment: The laboratory has 2 sets of gels. A high range set and a low range set. All the standards in each set are read each day of analysis. It is recommended that the lab only read the standard that falls in the range of the samples analyzed. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to Non-Discharge Monitoring Reports (NDMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for WQ0023896 for July, August, and September, 2014. The following errors were noted: Sample Collection Date Parameter Location Value on Benchsheet Value on NDMR 7/3/2014 Total Residual Chlorine Effluent >10 mg/L Not Reported 7/7/2014 Total Residual Chlorine Effluent >10 mg/L Not Reported 7/11/2014 Total Residual Chlorine Effluent 2.24 Not Reported 7/14/2014 Total Residual Chlorine Effluent 1.44 mg/L 1.94 mg/L Comment: The laboratory contacted Mr. Ray Milosh at the Raleigh Regional Office concerning the Non-Discharge Monitoring Report for July, 2014 via email on November 12, 2014. A copy of this report will be made available to the Regional Office. V. CONCLUSIONS: Correcting the above-cited findings and implementing the recommendation 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: December 4, 2014 Report reviewed by: Jason Smith Date: December 4, 2014