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HomeMy WebLinkAbout#5662_2023_0627_TLH_FINAL NC Department of Environmental Quality | Division of Water Resources | Laboratory Certification Branch 4405 Reedy Creek Road | 1623 Mail Service Center | Raleigh, North Carolina 27699-1623 919-733-3908 August 14, 2023 5662 Mr. Daniel Elks Town of Chocowinity WTP 3391 HWY 17 South Chocowinity, NC 27817 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Elks: Enclosed is a report for the inspection performed on June 27, 2023 by Tom Halvosa. 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, please supply this office with a written item for item description of how these Finding(s) were corrected. Please describe the steps taken to prevent recurrence and include an implementation date for each corrective action. 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 02H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will not reflect any changes made during the audit. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you have questions or need additional information, please contact me at (919) 733- 3908 Ext. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Tom Halvosa, Todd Crawford, #5662 On-Site Inspection Report LABORATORY NAME: Town of Chocowinity WTP NPDES PERMIT #: NC0087041 and NC0083224 ADDRESS: 1100 Hill Rd. Chocowinity, NC 27817 CERTIFICATE #: 5662 DATE OF INSPECTION: June 27, 2023 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR: Tom Halvosa LOCAL PERSON(S) CONTACTED: Daniel Elks and Gregory Judy I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. Staff were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2023 PT Calendar Year have not yet been analyzed. The laboratory is reminded that results must be received by this office directly from the vendor by September 30, 2023. The laboratory did not have Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in place for all currently certified parameter methods. These documents must be submitted for review as specified in Finding A. The laboratory is reminded that SOPs are required to be reviewed at least every two years and are intended to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word “should”. Contracted analyses are performed by Waypoint Analytical - Greenville (Certification #10). Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. Page 2 #5662 Town of Chocowinity WTP III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: The laboratory does not have QA/SOP documents for each certified parameter method or a documented plan for PT procedures. Requirement: Laboratory Procedures. Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. A copy of each analytical method or Approved Procedure and Standard Operating Procedure shall be available to each analyst and available for review upon request by the State Laboratory. Standard Operating Procedure documentation shall state the effective date of the document and shall be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and any revisions made in all Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Laboratories must have a documented plan [this is usually detailed in the laboratory’s Quality Assurance Manual or may be a separate Standard Operating Procedure (SOP)] of how they intend to cover the applicable program requirements for Proficiency Testing per their scope of accreditation. This plan shall cover any commercially available PT Samples and any inter-laboratory organized studies, as applicable. The plan must also address the laboratory’s process for submission of PT Sample results and related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.0. Comment: The laboratory must have QC/SOP documents for the PT procedures and parameter methods included on their Certified Parameter Listing (CPL) by January 31, 2024. These must be submitted for review upon completion. SOP templates have been developed and are available for download on the NC WW/GW LCB website. Comment: The laboratory’s PT procedure may be outlined in each of the applicable parameter method SOPs. The NC WW/GW LCB SOP Templates include a section for the PT procedure. B. Finding: The laboratory is not documenting the barometric pressure and salinity values used to calibrate the Dissolved Oxygen (DO) meter. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Calibration variables (temperature, elevation or barometric pressure [in mmHg], and salinity). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: After the Inspection, the laboratory was given instructions on how to display the barometric pressure on their meter. The laboratory is using a default value of zero for salinity during calibration but this is not documented. A blanket statement may be added to the benchsheet that states that they are using a salinity value of zero ppt. C. Finding: The laboratory does not always retain benchsheets for five years. Page 3 #5662 Town of Chocowinity WTP Requirement: All analytical records, including original observations and information necessary to facilitate historical reconstruction of the calculated results, shall be maintained for five years. Ref: 15A NCAC 02H .0805 (g) (1). Comment: There has been a change in supervisor in the last 6 months and it was not clear where the previous supervisor kept all laboratory records. Recommendation: It is recommended that the laboratory add language to their SOPs that states where records will be stored for the required 5-year retention period. D. Finding: Error corrections are not properly performed. Requirement: All documentation errors shall 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; instead the correction shall be written adjacent to the error. The correction shall be initialed by the responsible individual and the date of change documented. Ref: 15A NCAC 02H .0805 (g) (1). Comment: There were numerous instances of write-overs and strike-through corrections without initials of the responsible individual or the date of correction. E. Finding: The laboratory is lacking a documented training program. Requirement: Each laboratory shall develop and implement a documented training program that includes the following: that staff have the education, training, experience, or demonstrated skills needed to generate quality control results within method-specified limits and that meet the requirements of these Rules; that staff have read the laboratory quality assurance manual or applicable Standard Operating Procedures; that staff have obtained acceptable results on Proficiency Testing Samples pursuant to Rule .0803(1) of this Section or other demonstrations of proficiency (e.g., side-by-side comparison with a trained analyst, acceptable results on a single-blind performance evaluation sample, an initial demonstration of capability study prescribed by the reference method). Ref: 15A NCAC 02H .0805 (g) (5). Comment: The laboratory’s training program may be outlined in each of the applicable parameter SOPs. The NC WW/GW LCB SOP Templates include an Employee Training section. F. Finding: The laboratory is not documenting traceability information for purchased materials, reagents and standards. Requirement: 15A NCAC 02H .0805 (a) (7) (K) and (g) (7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: Date received, Date Opened (in use), Vendor, Lot Number, and Expiration Date (where specified). 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 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: Page 4 #5662 Town of Chocowinity WTP NC WW/GW LCB Traceability Documentation Requirements for Chemicals, Reagents, Standards and Consumables Policy. Comment: An example receipt log was provided to the laboratory at the time of inspection. G. Finding: Chemical containers are not dated when received and when opened. Requirement: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). Proficiency Testing H. Finding: The laboratory is not documenting the preparation of the TRC PT Samples. Requirement: PT Samples received as ampules are diluted according to the Accredited PT Sample Provider’s instructions. It is important to remember to document the preparation of PT Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a routine Compliance Sample and is added to a routine sample batch for analysis. No documentation is needed for whole volume PT Samples which require no preparation, however the instructions must be maintained. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Comment: Dating and initialing the TRC instructions that come with the PT samples will suffice. Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) I. Finding: The laboratory did not assign a true value to the gel-type standard prior to initial use. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Purchased “gel-type” or sealed liquid standards may be used only for daily calibration curve verifications. These standards must have a true value assigned initially and every 12 months thereafter. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: When this is done, these standards may be used after the manufacturer’s expiration date. It is only necessary to assign a true value to the gel-type or sealed liquid standard which falls within the concentration range of the calibration curve used to measure sample concentrations. For example, if you are measuring samples against a low-range calibration curve, a 200 μg/L standard would be verified, and not the 800 μg/L standard since the 800 μg/L standard would be measured using a high-range calibration curve. J. Finding: The laboratory is not verifying the instrument’s Factory-set Calibration Curve every 12 months. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Annual Factory-set Calibration Curve Verification: This type of calibration curve verification must be performed initially, at least every 12 months and any time the instrument optics are serviced. Zero the instrument with a Calibration Blank and then analyze a Method Page 5 #5662 Town of Chocowinity WTP Blank and a series of five standards (do not use gel or sealed liquid standards for this purpose). The calibration standard values obtained must not vary by more than ±10% from the known value for standard concentrations greater than or equal to 50 μg/L and must not vary by more than ±25% from the known value for standard concentrations less than 50 μg/L. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The Annual Factory-set Calibration Curve Verification expired on May 10, 2023. After the inspection, on June 29, 2023, the laboratory successfully performed the verification of the internal curve and assigned a true value for their gel standard. The date of expiration was on the benchsheet but was overlooked. Please respond with the corrective actions taken to prevent recurrence of this Finding. K. Finding: The laboratory is reading sample results prior to allowing the minimum 3-minute color development time. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Daily Sample Analysis Procedure: • Add DPD/buffer within 15 minutes of collection • Wait 3 - 6 minutes • Read sample result • Document required information Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Requirement: Some examples of the allowed types of changes, provided the requirements of this section are met include: (xiii) The use of prepackaged reagents. As such, the proper procedure for using the packaged reagents would then be determined by the manufacturer’s instructions. Ref: Code of Federal Regulations, Title 40, Part 136; Federal Register Vol. 77, No. 97, May 18, 2012; 136.6. (b) (4). Requirement: For successful testing, especially in treated effluents, strict adherence to the development time is necessary. Three to six minutes of development time are sufficient to resolve all chloramine forms without significant error from competing reactions. Ref: Hach Company, “Current Technology of Chlorine Analysis for Water and Wastewater”, 2002. Dissolved Oxygen L. Finding: The laboratory is attempting to analyze samples without submerging the probe tip into the sample. Requirement: Put the probe in the sample 25 mm (1 inch) or more. Do not put the probe on the bottom or sides of the container. Stir the sample at a moderate rate or put the probe in flowing conditions. Ref: Hach DOC022.53.80021 LDO101 User Manual, May 2022, Section 6.2. Comment: The laboratory was attempting to analyze compliance samples as if they were performing a water-saturated air calibration. During the inspection, the laboratory was instructed to submerge probe tip into sample and stir to get the correct reading. Page 6 #5662 Town of Chocowinity WTP pH – Standard Methods, 4500 H+ B-2011 (Aqueous) M. 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-2011. (6). Comment: Per PT Vendor instructions, the PT Sample results should be reported to two decimal places, which is an exception to the requirement for Compliance Samples. Recommendation: The laboratory currently reports pH sample results to two decimal places. It is recommended that the laboratory continue to measure and document sample results on the benchsheet to two decimal places, and to round to the nearest 0.1 S.U. when reporting results on the Discharge Monitoring Report (DMR). Temperature – Standard Methods, 2550 B-2010 (Aqueous) N. Finding: The temperature sensor on the pH meter used to obtain compliance temperature values has not been verified against a Reference Temperature-Measuring Device. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: All compliance temperature-measuring devices without an NIST traceable certificate, or with an expired NIST traceable certificate, must be verified against a Reference Temperature-Measuring Device and the process documented initially and every 12 months. Verification documentation must include the serial number of the device being checked. The serial number, stated accuracy and expiration date of the Reference Temperature-Measuring Device used in the comparison must also be documented. Verification data must be kept on file and be available for inspection for 5 years. (Note: International Organization for Standardization (ISO) 17025 compliant vendors or other Certified laboratories may provide assistance in meeting this requirement. When an ISO compliant vendor provides this assistance, they must provide the serial number, accuracy and calibration date for the Reference Temperature-Measuring Device used for the verification. When a Certified laboratory provides this service, they must provide a copy of the NIST traceable certificate of the Reference Temperature-Measuring Device used for the verification). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: The laboratory voluntarily relinquished certification of the parameter on June 27, 2023. No further response is required for this Finding. Reporting O. Finding: The laboratory does not report results of all tests on the characteristics of the effluent on their DMR. Requirement: The results of all tests on the characteristics of the effluent, including but not limited to NPDES Permit Monitoring Requirements, shall be reported on monthly report forms. Ref: 15A NCAC 02B .0506 (b) (3) (J). Page 7 #5662 Town of Chocowinity WTP Comment: The laboratory had been analyzing the temperature of compliance samples; however, they do not have any permit requirements for that parameter. Since there was no column in which to report Temperature on their DMRs, they were not reporting any of that data. After the inspection, the laboratory requested to delete Temperature from their CPL and will no longer analyze compliance samples for Temperature. The Parameter Method was deleted from their CPL effective June 27, 2023. P. Finding: The laboratory is producing Uncertified Data without reporting it as such. Requirement: “Uncertified Data" means any analytical result, including the Supporting Records, obtained using a method or procedure that is not acceptable to the State Laboratory pursuant to these Rules; analytical results produced by a laboratory for an analysis not within the scope of the rules of this Section; or analytical results produced by a laboratory without proper Certification. Ref: 15A NCAC 02H .0803 (35). Requirement: All Uncertified Data shall be documented as such on the benchsheet and on the final report. Ref: 15A NCAC 02H .0805 (e) (3). Comment: At the time of the inspection, the laboratory was not properly certified for the parameter method in use. They were certified for SM 4500 O G-2016, which is a membrane sensor technology. In practice, they were using luminescence sensor technology, which is a separate parameter method (i.e., SM 4500 O H-2016). An Amendment Application was submitted on July 14, 2023 requesting the addition of the SM 4500 O H-2016 method which was added to their CPL on August 1, 2023. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for Town of Chocowinity WTP (NPDES permit # NC0087041 and NC0083224) for June and December 2022 and April 2023. The following errors were noted: Date Permit Parameter Location Value on Benchsheet Value on DMR 6/7/2022 NC0083224 TRC Effluent <10 µg/L 10 µg/L 6/7/2022 NC0087041 TRC Effluent <10 µg/L 10 µg/L 6/14/2022 NC0083224 TRC Effluent <10 µg/L 10 µg/L 6/14/2022 NC0087041 TRC Effluent <10 µg/L 10 µg/L 4/5/2023 NC0087041 All Parameters Effluent - Results were reported on 4/4/2023 To avoid questions of legality, it is recommended that you contact the appropriate Regional Office (RO) for guidance as to whether an amended DMR(s) will be required. In addition to the issues in the table above, the discussion needs to address the issues in Finding L. 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 laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for their assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Page 8 #5662 Town of Chocowinity WTP Report prepared by: Tom Halvosa Date: July 7, 2023 Report reviewed by: Jill Puff Date: July 7, 2023 Certificate Number:5662 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Town of Chocowinity WTP Address:1100 Hill Rd. Chocowinity, NC 27817 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:6/27/2023 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) DISSOLVED OXYGEN SM 4500 O G-2016 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.