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HomeMy WebLinkAbout#5708_2022_0808_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 September 7, 2022 5708 Ms. Deborah Bradley Tryon WWTP 301 North Trade Street Tryon, NC 28782 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Initial Inspection Dear Ms. Bradley: Enclosed is a report for the inspection performed on August 8, 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 #5708 On-Site Inspection Report LABORATORY NAME: Tryon WWTP NPDES PERMIT #: NC0021601 ADDRESS: 1526 E. Howard St Tryon, NC 28782 CERTIFICATE #: 5708 DATE OF INSPECTION: August 8, 2022 TYPE OF INSPECTION: Field Municipal Initial AUDITOR(S): Jason Smith LOCAL PERSON(S) CONTACTED: Deborah Bradley and Michael Fife 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 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 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 March 1, 2023. 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”. Page 2 #5708 – Tryon WWTP Contracted analyses are performed by Environmental Testing Solutions (Certification #600). 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 overwriting was observed. B. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; the laboratory identification; the instrument identification; the date and time of sample collection; the date of sample analyses; the time of sample analyses; 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 laboratory identification; the instrument identification; the date and time of sample collection; the date of sample analyses; the time of sample analyses; 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), (B), (C), (F), (G), (H) and (L). 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 Dissolved Oxygen (DO), NC WW/GW LCB Approved Procedure for the Analysis of pH, NC WW/GW LCB Approved Procedure for the Analysis of Specific Conductance (Conductivity), NC WW/GW LCB Approved Procedure for the Analysis of Temperature, and NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The sample collection and analysis times are not clearly identified. The initial time recorded, labeled “Time”, is the collection time for pH, Dissolved Oxygen (DO), Temperature and Total Residual Chlorine (TRC). It is also the analysis time for pH, DO and Temperature. The final time recorded, labeled “Ran Time”, is only the analysis time for TRC. A statement may be added to the benchsheet to document which samples are analyzed in-situ or at the time of sample collection. Comment: The stream sampling benchsheet documents the collection time and has a note the “stream samples are ran on site”. This statement gives no indication of the time between sample collection and analysis; making it impossible to determine if the holding times were Page 3 #5708 – Tryon WWTP met. This needs to be clarified to indicate that the samples are analyzed immediately or in- situ or the time documented may be changed to “collection/analysis time”. Comment: The proper units of measure were missing for DO on the DO calibration log and the blank on the TRC calibration log. C. Finding: The laboratory is not documenting the 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 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: A statement may be added to the benchsheet stating that the meter is always calibrated at 0 ppt Salinity. D. Finding: The laboratory does not document the pH meter calibration during sludge analysis. Requirement: A record of instrument calibration or calibration verification shall be documented and available for inspection upon request. Ref: 15A NCAC 02H .0805 (g) (3). E. Finding: The laboratory is not documenting the percent recovery of Conductivity standards on laboratory benchsheets. 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. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (O). Comment: The percent sign for the acceptance criterion of the Conductivity standard is not visible on the benchsheet and must also be corrected. F. 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). G. Finding: The preparation of standards and reagents are not documented in such a way as to provide traceability from preparation to analysis. 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 Page 4 #5708 – Tryon WWTP 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. Comment: This Finding applies to prepared pH buffers and TRC 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. I. 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. Requirement: The analysis of Proficiency Testing (PT) Samples is designed to evaluate the entire process used to routinely analyze and report Compliance Sample results. PT Samples must be analyzed the same as Compliance Samples. Also, documentation must be made on the same benchsheets used for Compliance Samples. Ref: NC WW/GW LCB Proficiency Testing Samples Analyzed and Documented Same as Compliance Samples Policy. J. Finding: The laboratory does not have a documented plan for PT procedures. 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 Page 5 #5708 – Tryon WWTP 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 laboratory must also be able to explain when PT Sample analysis is not possible for certain methods and provide a description of what the laboratory is doing in lieu of Proficiency Testing. This shall be detailed in the plan. 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, February 19, 2020, Revision 5, Section 3.0. Conductivity – Standard Methods, 2510 B-2011 (Aqueous) K. Finding: The Automatic Temperature Compensator (ATC) was not verified prior to initial use and every 12 months thereafter. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The Automatic Temperature Compensator (ATC) must be verified prior to initial use and annually (i.e., 12 months) thereafter at two temperatures by analyzing a standard or sample at 25°C (i.e., the temperature to which conductivity values are reported) and a temperature(s) that brackets the temperature ranges of the environmental samples routinely analyzed. This may require the analysis of a third temperature reading that is > 25°C. As the temperature increases or decreases, the value of the conductivity standard or sample must be within ±10% of the true value of the standard or ±10% of the value of the sample at 25°C. If not, corrective action must be taken. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Specific Conductance (Conductivity). Conductivity – Standard Methods, 2510 B-2011 (Aqueous) Dissolved Oxygen – Standard Methods, 4500 O G-2016 (Aqueous) L. Finding: When analyses are performed at multiple sample sites, the laboratory is not calibrating prior to sample analysis at each sample site or performing a Post-Analysis Calibration Verification. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: When performing analyses at multiple sample sites, the meter must be calibrated at each sample site prior to analysis or a post-analysis calibration verification must be performed at the end of the run, regardless of meter type. The calculated theoretical DO value must verify the meter reading within ±0.5 mg/L. If the meter verification does not read within ±0.5 mg/L of the theoretical DO, corrective action must be taken. If the meter is not calibrated at each sample site, it is recommended that a mid-day calibration be performed when samples are extended over an extended period of time. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Page 6 #5708 – Tryon WWTP Requirement: When performing multiple sample analyses, a post-analysis calibration verification must be analyzed at the end of the run. It is recommended that a mid-day or a mid-batch calibration verification be performed when samples are analyzed over an extended period of time. The value obtained for the post-analysis calibration verification check-standard must read within 10% of the standard’s true value. If the obtained value is outside of the ±10% range, corrective action must be taken. If recalibration is necessary, all samples analyzed since the last acceptable calibration verification must be reanalyzed, if possible. If samples cannot be reanalyzed, the data must be qualified. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Specific Conductance (Conductivity). pH – SW-846 9040 C (Aqueous) pH – SW-846 9045 D (Non-Aqueous) Comment: At the time of the inspection, the laboratory was certified for pH by SW -846 9040 C and SW -846 9045 D for sludge analyses. The laboratory was not aware that the 2019 Rule revision allowed field labs to get certified for Vector Attraction Reduction (VAR) options for sludge analyses. The laboratory submitted an amendment to request dropping SW -846 9040 C and 9045 D and adding VAR Option 6 to more accurately reflect the sample analyses. M. Finding: The pH meter calibration is not verified with a check buffer prior to sample analysis. Requirement: The meter calibration must be verified with a third standard buffer solution (i.e., calibration check buffer) prior to sample analysis. The calibration and check standard buffers must bracket the range of the samples being analyzed. All calibration check standard buffers must read within ±0.1 S.U. of its true value 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 SW-846 pH Calibration Verification Policy. Comment: When the laboratory updates their Certified Parameter Listing (CPL) to include VAR Option 6, the meter calibration must be verified with a third standard buffer solution (i.e., check buffer) prior to sample analysis as outlined in the Approved Procedure document. Temperature – Standard Methods, 2550 B-2010 (Aqueous) N. Finding: The thermometer calibration verification documentation does not include the stated accuracy of the Reference Temperature-Measuring Device that was used in the comparison. 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 Page 7 #5708 – Tryon WWTP the Reference Temperature-Measuring Device used for the verification). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: Thermometers are verified by a contractor. The contractor has been notified of the requirements in Findings N and O and provided with the Approved Procedure for the Analysis of Temperature. O. Finding: The compliance temperature-measuring device is not checked at two temperatures that bracket the range of observed sample temperatures. 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. Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) P. Finding: The laboratory is not analyzing a Method Blank when using laboratory-prepared standards. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Method Blanks would be required when using laboratory-prepared standards [including Proficiency Testing (PT) Samples] and anytime sample dilutions are performed. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Requirement: The Method Blank is deionized or distilled water from the same source used to prepare the calibration verification standards or the PT Sample, and is analyzed like a sample (i.e., with DPD/buffer added). The concentration of the Method Blank must not exceed 50% of the reporting limit (i.e., the lowest calibration verification standard concentration) or corrective action must be taken. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). 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 Tryon WWTP (NPDES Permit #NC0021601) for January, March and April 2022. The following errors were noted: Page 8 #5708 – Tryon WWTP Date Parameter Location Value on Benchsheet *Contract Laboratory Data Value on DMR 1/4/2022 Dissolved Oxygen Effluent 6.7 mg/L 6.8 mg/L 1/4/2022 Copper Effluent *0.01 mg/L 0.01 µg/L 3/1/2022 Copper Effluent *0.013 mg/L 0.013 µg/L 3/13/2022 Temperature Effluent 13 °C 14 °C 3/22/2022 Dissolved Oxygen Effluent 6.4 mg/L 6.3 mg/L 3/30/2022 pH Effluent 7.1 S.U. 7.2 S.U. 4/5/2022 Copper Effluent *0.006 mg/L 0.006 µg/L Comment: The monthly Copper results have all been reported with the wrong units of measure resulting in them being reported low by a factor of one thousand. Mikal Wilmer with the Asheville Regional Office was notified of this issue and will follow-up with the facility regarding revised DMRs. 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 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: August 25, 2022 Report reviewed by: Tonja Springer Date: August 26, 2022 Certificate Number:5708 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Tryon WWTP Address:301 North Trade Street Tryon, NC 28782 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:10/26/2021 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 CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) CONDUCTIVITY SM 2510 B-2011 (Aqueous) DISSOLVED OXYGEN SM 4500 O G-2016 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) SW-846 9040 C (Aqueous) SW-846 9045 D (Non-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.