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HomeMy WebLinkAbout#5381_2022_0602_JMS_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 June 22, 2022 5381 Mr. Chris Elliott Cleveland County Water Treatment Plant P.O. Box 788 Lawndale, NC 28090 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Elliott: Enclosed is a report for the inspection performed on June 2, 2022 by Jason Smith. 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. 251. Sincerely, Anna Ostendorff Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Jason Smith, Master File #5381 On-Site Inspection Report LABORATORY NAME: Cleveland County Water Treatment Plant NPDES PERMIT #: NCG590004 ADDRESS: 435 Casar-Lawndale Rd Lawndale, NC 28090 CERTIFICATE #: 5381 DATE OF INSPECTION: June 2, 2022 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Jason Smith LOCAL PERSON(S) CONTACTED: Chris Elliott 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 for the 2022 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, 2022. The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in advance of the inspection. These documents were reviewed prior to the inspection for preparatory reasons. The laboratory is reminded that 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 December 31, 2022. Page 2 #5381 – Cleveland County Water Treatment Plant The laboratory is also reminded that SOPs 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 Meritech, Inc. (Certification #165). Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. 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: Error corrections are not dated, and some instances of multiple lines being used were observed. B. 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). C. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; the laboratory identification; the instrument identification; the sample collector; the signature or initials of the analyst; sample identification; the proper units of measure; 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 sample collector; the signature or initials of the analyst; sample identification; the proper units of measure; 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), (D), (E), (I), (L), and (O). Comment: The proper units of measure for pH (i.e., Standard Units or S.U.) are not documented. Comment: The pH benchsheet only documents “initials” and the TRC benchsheet only documents the “analyst initials”. Both sample collector and sample analyst must be identified. If the same person collects and analyzes the sample, the column header could be labeled “sample collector/analyst” to meet this requirement. Comment: Acceptance ranges of quality control standards (i.e., pH calibration verification standard and TRC gel standard) must be documented for quality control assessments. Page 3 #5381 – Cleveland County Water Treatment Plant Comment: The sample identification on the TRC benchsheet is “results of sample” without any indication of where the sample was collected. The sample identification on the pH benchsheet is “lagoon results”. Recommendation: It is recommended that the samples be identified as “lagoon effluent”. D. Finding: The laboratory benchsheet is lacking required documentation: Facility name or permit number. 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: Facility name or permit number. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH and NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). E. Finding: The laboratory benchsheet is lacking required documentation: True values of pH buffers used for calibration. 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: True values of buffers used for calibration. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Comment: The calibration log identifies the 4 and 10 S.U. calibration buffers and the 7 S.U. verification buffer but does not identify the 7 S.U. calibration buffer. Comment: The benchsheet must identify the true value (i.e., expected value) of the buffers used for calibration and the value obtained for the calibration verification buffer analyzed after calibration is complete. It is not required to document the pH values obtained during the calibration. F. Finding: The laboratory benchsheet is lacking required documentation: Date of most recent TRC calibration curve verification. 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: Date of most recent calibration curve generation or calibration curve verification. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). G. Finding: The preparation of standards and reagents are not documented in such a way as to provide traceability from preparation to analysis. Finding: 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 Page 4 #5381 – Cleveland County Water Treatment Plant 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. Comment: This Finding applies to the preparation of the TRC curve verification standards. Proficiency Testing H. Finding: The laboratory is not documenting the preparation of 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, February 19, 2020, Revision 5, Section 3.6. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. Reporting 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-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 DMR. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for the Cleveland County Water Treatment Plant (NPDES permit # NCG590004) for January, March and May 2022. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data. Page 5 #5381 – Cleveland County Water Treatment Plant V. CONCLUSIONS: Correcting the above-cited Findings and implementing the recommendation 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: Jason Smith Date: June 13, 2022 Report reviewed by: Michael Cumbus Date: June 14, 2022 Certificate Number:5381 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Cleveland County Sanitary District Address:435 Casar-Lawndale Rd Lawndale, NC 28090- 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 CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (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.