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HomeMy WebLinkAbout#5701_2023_1214_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 February 29, 2024 5701 Mr. Rod Holley Maple Commerce Park WWTP 444 Maple Road Currituck, NC 27929 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Holley: Enclosed is a report for the inspection performed on December 14, 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 (984) 220- 5439. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Tom Halvosa, #5701 On-Site Inspection Report LABORATORY NAME: Maple Commerce Park WWTP WATER QUALITY PERMIT #: WQ0035231 and WQ0035706 ADDRESS: 105 Barco Way Maple, NC 27929 CERTIFICATE #: 5701 DATE OF INSPECTION: December 14, 2023 TYPE OF INSPECTION: Field Municipal Initial AUDITOR: Tom Halvosa LOCAL PERSON CONTACTED: Rod Holley 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. The analyst was forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples have been analyzed for the 2023 PT Calendar Year and the graded results were 100% acceptable. Any time changes are made to laboratory procedures, QA/SOP document(s) must be updated and relevant staff retrained. Staff must acknowledge that they have read and understand the changes as part of the documented training program. The same requirements apply when changes are made in response to Findings, Recommendations or Comments listed in this report, to ensure the methods are being performed as stated, references to methods are accurate, and the QA and/or SOP document(s) is in agreement with each approved practice, test, analysis, measurement, monitoring procedure or regulatory requirement being used in the laboratory. In some instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. Revisions to the SOPs, based on the Findings, Comments and Recommendations within this report must be submitted to this office by March 31, 2024. 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”. Page 2 # 5701 Maple Commerce Park WWTP Contracted analyses are performed by Environmental Chemists Inc./Outer Banks Div. (Certification # 628). The Approved Procedure document for the analysis of the facility’s currently certified Field Parameter was provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: The laboratory pH benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; the laboratory identification; the instrument identification; the proper units of measure and the quality control assessments. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the method or Standard Operating Procedure; the laboratory identification; the instrument identification; the proper units of measure and the quality control assessments. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (A), (B), (C), (L) and (O). Comment: The laboratory was provided with an example pH benchsheet at the time of the inspection. B. Finding: Uncertified data is not documented as such on the benchsheets. Requirement: Each certified Field Laboratory shall be in accordance with Paragraph (e) of this Rule. Ref: 15A NCAC 02H .0805 (g) (17). Requirement: All uncertified data must be clearly documented as such on the benchsheet and on the final report. Ref: 15A NCAC 02H .0805 (e) (3). Comment: The benchsheets do not identify process control data which includes uncertified parameter analyses. This makes it appear that uncertified analyses are being performed on regulatory compliance samples. C. 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: NC WW/GW LCB Traceability Documentation Requirements for Chemicals, Reagents, Standards and Consumables Policy (03/27/2020). Page 3 # 5701 Maple Commerce Park WWTP Comment: The laboratory was provided with an example receipt log for purchased materials, reagents and standards at the time of the inspection. D. 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). 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. After the inspection, the laboratory was provided with an example of training documentation. Proficiency Testing F. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. Requirement: All PT Sample analyses must be recorded in the same daily analysis records (e.g., benchsheets) as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. 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 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all Parameter Methods. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 4.0. Comment: The laboratory’s current practice is to record the instrument reading directly into the PT Vendor’s electronic submission form. No record of the analysis is maintained. G. Finding: PT Samples are not analyzed in the same manner as routine Compliance Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each Parameter Method and in each associated matrix on the laboratory’s CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, distillations and extractions) and Page 4 # 5701 Maple Commerce Park WWTP the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Comment: The laboratory is analyzing the PT Samples multiple times and averaging the two values that are closest to each other for reporting to the PT vendor. Reporting H. Finding: The laboratory does not report results of all tests on the characteristics of the effluent. Requirement: Reporting shall be in accordance with 15A NCAC 02B .0506 except as otherwise provided by applicable rules in this Subchapter. Ref: 15A NCAC 02T .0105 (l). 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). Comment: The laboratory is recording the temperature of the effluent when analyzing compliance samples for pH. Temperature is not a parameter on any of their permits. I. Finding: Data qualifiers from the contract laboratory reports are not being transferred to the DMR. Requirement: Each certified Field Laboratory shall be in accordance with Paragraph (e) of this Rule. Ref: 15A NCAC 02H .0805 (g) (17). Requirement: Reported data associated with quality control failures, improper sample collection, holding time exceedances, or improper preservation shall be qualified as such. Ref: 15A NCAC 02H .0805 (e) (5). pH - Standard Methods, 4500 H+ B-2011 (Aqueous) Recommendation: The laboratory currently reports pH compliance sample results to one decimal place on their benchsheet. It is recommended that the laboratory measure and document sample results on the benchsheet to two decimal places and round to the nearest 0.1 S.U. when reporting results on the Non-Discharge Monitoring Report (NDMR). J. Finding: The laboratory is not analyzing a check standard buffer after calibration and prior to sample analysis. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Instruments are to be calibrated according to the manufacturer’s calibration procedure prior to analysis of samples each day compliance monitoring is performed. Calibration must include at least two buffers. The meter calibration must be verified with a third standard buffer solution (i.e., check buffer) prior to sample analysis. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Page 5 # 5701 Maple Commerce Park WWTP Comment: Following the inspection, the laboratory emailed documentation showing they began analyzing and evaluating a check standard buffer on December 15, 2023. K.Finding: The pH probe is not being stored in the recommended storage solution. Requirement: The pH probe must be stored in the solution recommended by the probe manufacturer between analyses. A solution with a conductivity greater than 4000 µhos/cm is recommended. Tap water is a better substitute than distilled water, but pH 4 buffer is best for the single glass electrode and saturated KCl is preferred for the calomel and Ag/AgCl reference electrode. Saturated KCl is preferred for a combination electrode. Keep electrodes wet by returning them to the storage solution whenever the pH meter is not in use. Ref: Standard Methods, 4500 H+ B-2011. (4) (a). Requirement: Probes can become permanently damaged if kept in a storage solution that is not specified by the manufacturer. Use only the specified storage solution (Hach pH electrode storage solution or 3 M KCl). Do not store the probe in deionized water or in samples of low ionic strength. Put the soaker bottle that contains the storage solution on the probe when not in use. Make sure to only use the specified storage solution. Ref: Hach User Manual, DOC022.53.80023 PHC101 6/2021, Edition 5, Section 8.4. Comment: The laboratory stores the electrode in de-ionized (DI) water. IV. CONCLUSIONS: Correcting the above-cited Findings 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. Report prepared by: Tom Halvosa Date: January 11, 2024 Report reviewed by: Tonja Springer Date: January 16, 2024 Certificate Number:5701 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Maple Commerce Park Address:540 Barco Drive Maple, NC 27929 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment: 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 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.