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HomeMy WebLinkAbout#5431_2022_0216_JP_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 April 8, 2022 5431 Mr. Kevin Perdue Vance County Schools 208 Welcome Avenue Henderson, NC 27536 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Perdue: Enclosed is a report for the inspection performed on February 16, 2022 by Jill Puff. 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 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, Jill Puff, Master File #5431 On-Site Inspection Report LABORATORY NAME: Vance County Schools NPDES PERMIT #: NC0035491 ADDRESS: 6655 Broad St. Middleburg, NC 27537 CERTIFICATE #: 5431 DATE OF INSPECTION: February 16, 2022 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Jill Puff and Anna Ostendorff LOCAL PERSON(S) CONTACTED: Chris Pulley 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 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 did not have Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in place for all currently certified parameters. These documents must be submitted for review as specified in Finding A. 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 September 30, 2022. Page 2 #5431 Vance County Schools The laboratory is also 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 Pace Analytical Services, LLC – Raleigh NC (Certification # 67). 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: General Laboratory A. Finding: SOPs have not been developed for all the methods included on the laboratory’s Certified Parameters Listing (CPL). Requirement: 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). Comment: An SOP was available for pH, but not for Temperature or Dissolved Oxygen (DO). Comment: The laboratory must submit an updated QA/SOP document for the parameters included on their CPL by September 30, 2022. Documentation: B. Finding: The laboratory benchsheet is lacking required documentation: meter calibration time. 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: Meter calibration and meter calibration time(s). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). C. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; the instrument identification and the proper units of measure. 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 instrument identification, the proper units of measure. 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), (C) and (L). Page 3 #5431 Vance County Schools Comment: The method or SOP reference is not documented on the benchsheet. Comment: The instrument identification is not documented on the benchsheet. This finding applies to Temperature. Comment: The units of measure are not documented on the benchsheet. This finding applies to the pH buffers. Recommendation: The laboratory benchsheet for DO contains the instrument model but not the serial number. It is recommended that the laboratory add the serial number to the benchsheet to improve the legal defensibility of the data. Recommendation: It is recommended that the laboratory add the NC WW/GW Laboratory Certification number (#5431) to the benchsheet to improve the legal defensibility of the data. D. 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). 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 Policy. Comment: The laboratory does not have a traceability log. E. Finding: The laboratory is not documenting the temperature, barometric pressure and salinity values used to calibrate the DO meter. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The laboratory must document each time that a calibration is performed. Calibration documentation must include the instrument identification as well as the temperature, the elevation or barometric pressure (in mmHg), and the salinity* of the sample to be analyzed. After calibration, record the final DO reading in mg/L or % saturation. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: The laboratory benchsheet for DO includes a section for air calibration. The laboratory does not document calibration temperature or barometric pressure. These values are displayed on the screen of the DO meter. A default salinity value of zero must also be documented per NC WW/GW LCB policy. F. Finding: Error corrections are not always 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 Page 4 #5431 Vance County Schools 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: On October 15, 2021, the temperature reading was partially over-written. On October 23, 2021, the pH value correction was not dated. Proficiency Testing G. 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 daily analysis records as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, 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, February 19, 2020, Revision 5, Section 4.0. 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 Compliance Samples. The data does not include quality control assessments, units of measure, traceability for buffers, instrument identification, parameter analyzed, method reference or SOP reference. NC WW/GW LCB Policy was updated on March 9, 2022 to include the requirement that PT Sample analysis be documented on the same benchsheet that is used for Compliance Samples. Temperature – Standard Methods, 2550 B-2010 (Aqueous) Comment: Temperature is being reported to 0.1°C on the DMR. Recommendation: Unless greater precision is required by the permit or data receiving agency, it is recommended that all temperatures reported for compliance monitoring, be reported in whole numbers as recommended by the DWR’s Precision in Discharge Monitoring Reports document. H. Finding for Immediate Response: The Reference Temperature-Measuring Device does not have a stated accuracy of ± 0.5 °C and is not able to distinguish temperature changes of 0.1 °C. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H 0805(g) (4). Requirement: A Reference Temperature-Measuring Device is an NIST traceable temperature-measuring device used only to verify the calibration of other temperature- measuring devices. It must have a stated accuracy of ± 0.5 °C, be able to distinguish temperature changes of 0.1 °C and equilibrate rapidly. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Page 5 #5431 Vance County Schools Comment: The NIST-traceable thermometer used to verify the pH meter temperature sensor did not meet the specifications for a Reference Temperature-Measuring device. The NIST Traceable thermometer that was used had a stated accuracy of ± 1.0 °C. Comment: A Notice of Finding for Immediate Response (NOFIR) was issued due to the impact on reported data and so the laboratory would have the temperature sensor verified more quickly than if waiting to first receive the inspection report to take corrective action. A response due date of March 4, 2022 was negotiated. The laboratory purchased a thermometer with an NIST certificate for compliance monitoring and submitted the certificate along with the updated benchsheet documenting the change on March 1, 2022. Respond with measures taken to prevent recurrence of this Finding. I. Finding for Immediate Response: The annual temperature-measuring device check procedure is not performed correctly. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H 0805(g) (4). Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against a Reference Temperature-Measuring Device and record all four readings. The readings from both devices must agree within 0.5ºC. If they do not, the device may not be used for temperature compliance monitoring. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: The pH meter used for compliance Temperature monitoring is only verified at a single temperature. The only documentation was a sticker on the pH meter with the date and correction. Comment: A Notice of Finding for Immediate Response (NOFIR) was issued due to the impact on reported data and so the laboratory would have the temperature sensor verified more quickly than if waiting to first receive the inspection report to take corrective action. A response due date of March 4, 2022 was negotiated. The laboratory purchased a thermometer with an NIST certificate for compliance monitoring and submitted the certificate along with the updated benchsheet documenting the change on March 1, 2022. Respond with measures taken to prevent recurrence of this Finding. J. Finding for Immediate Response: Temperature sensor check readings for devices used for compliance monitoring varied more than 0.5°C from the Reference Temperature- Measuring Device reading. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H 0805(g) (4). Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against an NIST traceable temperature-measuring device and record all four readings. The readings from both devices must agree within 0.5ºC. If they do not, the device may not be used for temperature compliance monitoring. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: A Notice of Finding for Immediate Response (NOFIR) was issued due to the impact on reported data and so the laboratory would have the temperature sensor verified more quickly than if waiting to first receive the inspection report to take corrective action. A Page 6 #5431 Vance County Schools response due date of March 4, 2022 was negotiated. The laboratory purchased a thermometer with an NIST certificate for compliance monitoring and submitted the certificate along with the updated benchsheet documenting the change on March 1, 2022. Respond with measures taken to prevent recurrence of this Finding. pH – Standard Methods, 4500 H+ B-2011 (Aqueous) K. Finding: Fresh pH buffers are not used for meter calibration. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The calibration and check standard buffers must bracket the range of the samples being analyzed. A portion of the standard buffer is not to be used for more than one calibration. Discard any used buffer portions. Do not pour unused portions back into the original bottle. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Comment: The laboratory pours a fresh aliquot of buffer solution weekly for calibration of the pH meter five days a week. L. Finding: The acceptance criterion for the check standard buffer is not being assessed. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the quality control assessments. Ref: 15A NCAC 02H .0805 (g) (2) (O). Requirement: All check standard buffers must read within ±0.1 S.U. to be acceptable. If the meter verification does not read within ±0.1 S.U., corrective actions must be taken before any samples are analyzed. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Comment: The laboratory is documenting the check standard buffer but the analyst stated he was not assessing those values against the acceptance criterion. NC WW/GW LCB requires the check standard buffers to read within ±0.1 S.U. of the true value to be acceptable. There were no instances observed in the data reviewed where the check buffer exceeded the acceptance criterion. Reporting M. Finding: The laboratory is not correctly transcribing analytical results from the contract laboratory to the DMR. Requirement: Daily analyses must be performed using EPA-approved methods that are capable of producing results less than or equal to the corresponding permit limits, where such methods exist. In the case of ‘non-detect’ values, permittees (or their laboratories) are expected to report daily values to the Practical Quantitation Level (PQL) for each parameter (or “<[PQL] for values less than the PQL). Ref: Precision in Discharge Monitoring Reports, Section 3.1. Comment: Values below the detection limit were consistently reported as “1” instead of the listed detection limit preceded by the less than (<) symbol. N. Finding: Data qualifiers from the contract laboratory reports are not being transferred to the DMR. Page 7 #5431 Vance County Schools 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). Comment: The effluent analyzed by Pace Analytical Services, LLC – Raleigh NC on August 11, 2021, August 25, 2021, October 13, 2021, December 1, 2021 and December 15, 2021 was lacking the following qualifications on the DMR: BOD – B2 – Oxygen usage is less than 2.0 for all dilutions set. The reported value is an estimated less than value and is calculated for the dilution using the most amount of sample. The effluent analyzed by Pace Analytical Services, LLC – Raleigh NC on October 27, 2021 was lacking the following qualifications on the DMR: BOD – R6 – The RPD between valid sample dilutions exceeded 30%. The effluent analyzed by Pace Analytical Services, LLC – Raleigh NC on December 1, 2021 was lacking the following qualifications on the DMR: BOD – L2 – Analyte recovery in the laboratory control sample (LCS) was below QC limits. Results for this analyte in associated samples may be biased low; Fecal Coliform - D6 - The precision between the sample and sample duplicate exceeded laboratory control limits. Recommendation: To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether an amended DMR(s) will be required. A copy of this report will be made available to the Regional Office. 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 Vance County Schools (NPDES permit # NC0035491) for August, October and December 2021. The following errors were noted: Date Parameter Location Value on Benchsheet *Contract Laboratory Data Value on DMR 8/11/2021 Biochemical Oxygen Demand Effluent <2 mg/L* 1 mg/L 8/11/2021 Residue Suspended Effluent <2.5 mg/L* 1 mg/L 8/11/2021 Fecal Coliform Effluent <1 #/100 mL* 1 #/100mL 8/11/2021 Ammonia Nitrogen Effluent <0.1 mg/L* 1 mg/L 8/25/2021 Biochemical Oxygen Demand Effluent <2 mg/L* 1 mg/L 8/25/2021 Residue Suspended Effluent <2.5 mg/L* 1 mg/L 8/25/2021 Fecal Coliform Effluent <1 #/100 mL* 1 #100mL 8/25/2021 Ammonia Nitrogen Effluent <0.1 mg/L* 1 mg/L 10/13/2021 Biochemical Oxygen Demand Effluent <2 mg/L* 1 mg/L 10/13/2021 Residue Suspended Effluent <2.5 mg/L* 1 mg/L 10/13/2021 Fecal Coliform Effluent <1 #/100 mL* 1 #/100mL 10/13/2021 Ammonia Nitrogen Effluent <0.1 mg/L* 1 mg/l 10/27/2021 Biochemical Oxygen Demand Effluent <2 mg/L* 1 mg/L 12/3/2021 pH Effluent 7.4 S.U. 7.3 S.U. 12/15/2021 Fecal Coliform Effluent 4.1 #/100 mL* 1 #/100mL 12/15/2021 Ammonia Nitrogen Effluent <0.1 mg/L* 4.1 mg/L Page 8 #5431 Vance County Schools To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether an amended DMR(s) will be required. A copy of this report will be made available to the Regional Office. V. CONCLUSIONS: Correcting the above-cited Findings and implementing the Recommendation(s) 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: Jill Puff Date: February 23, 2022 Report reviewed by: Tom Halvosa Date: February 25, 2022 Certificate Number:5431 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Vance County Schools Address:6655 Broad St. Middleburg, NC 27537 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:9/1/2021 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 DISSOLVED OXYGEN SM 4500 O G-2016 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) TEMPERATURE SM 2550 B-2010 (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.