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HomeMy WebLinkAbout#5353_2021_1122_TS_FINAL January 25, 2022 5353 Mr. Neil Carroll Town of Roseboro P.O. Box 848 Roseboro, NC 28382- Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Carroll: Enclosed is a report for the inspection performed on November 22, 2021 by Tonja Springer. 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 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: Tonja Springer, Todd Crawford, #5353 On-Site Inspection Report LABORATORY NAME: Town of Roseboro NPDES PERMIT #: NC0026816 ADDRESS: 10160 Roseboro Hwy. Roseboro, NC 28382 CERTIFICATE #: 5353 DATE OF INSPECTION: November 22, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Neil Carrol and John Puglisi I. INTRODUCTION: This laboratory was inspected by representatives 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. The laboratory does not have Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in place for currently certified parameter methods. 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, the laboratory must update the QA/SOP document(s) and inform relevant staff. Any changes made in response to the pre- audit review or to Findings, Recommendations or Comments listed in this report must be incorporated to ensure the method is 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. 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 Environmental Chemists, Inc. (EnviroChem) (Certification # 94). Page 2 #5353 Town of Roseboro 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 describes the method in such detail that an experienced analyst unfamiliar with the method can obtain acceptable results and meet documentation requirements. SOPs must be developed which describe in detail how a method is performed in that particular laboratory. Templates are available on our website for all Field Parameters to aid in constructing SOPs. The Dissolved Oxygen (DO) and Temperature SOPs must be submitted for review by May 31, 2022. Comment: The SOP for DO only includes directions for calibrating the meter. The laboratory does not have an SOP for Temperature. Documentation B. 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 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: Some instances of overwriting were observed on the following dates: October 7, 2020, November 13, 2020, December 2, 2020, December 30, 2020 and January 20, 2021. C. Finding: Documentation of the calibration variables for the DO meter does not include all pertinent data. 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], Page 3 #5353 Town of Roseboro and salinity). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: Only Temperature is being documented for the calibration. The benchsheet has a column labeled “Adjusted Air Calibration” in which Temperature is being documented. The other calibration variables (e.g., salinity, elevation or barometric pressure) must also be documented. These variables may have been programmed in the meter initially. Comment: Per NC WW/GW LC Branch policy, facilities may use a default value of zero ppt for Salinity when calibrating the DO meter unless it is known or suspected that the Salinity value of the samples being analyzed is > 9 ppt. In those situations, actual Salinity values must be used. Regardless of which value is used, it must be documented. D. Finding: Documentation of the compliance temperature-measuring device calibration verification does not include the stated accuracy of the Reference Temperature-Measuring Device used for 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 a valid NIST certificate must be checked initially and every 12 months against an NIST traceable temperature- measuring device and the process documented. Documentation must include the serial number of the device being checked. The serial number, stated accuracy and expiration date of the NIST traceable 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: Vendors or other Certified laboratories may provide assistance in meeting this requirement. When a vendor or other Certified laboratory provides this assistance, they must provide a copy of their NIST Certificate or the serial number, accuracy and calibration expiration date.) Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Requirement: All NIST traceable temperature-measuring devices must have a stated accuracy of at least ± 0.5°C and be within their expiration date. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: This Finding applies to the verification performed by the Environmental Chemists, Inc. (EnviroChem) (Certification # 94). E. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference. 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. Each item shall be recorded each time sample are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (A). Comment: The method reference is not documented on the benchsheet for Temperature. Quality Control Page 4 #5353 Town of Roseboro F. Finding: Temperature sensor check readings for the YSI Model 550 A DO meter used to obtain compliance Temperature values varied more than 0.5°C from the National Institute of Standards and Technology (NIST) traceable thermometer readings. 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. Please submit a copy of the temperature-measuring device verification with the response to this report. Dissolved Oxygen – Standard Methods, 4500 O G-2016 (Aqueous) G. Finding: The meter is not being calibrated according to the manufacturer’s instructions. 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. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Requirement: Calibration In % Saturation mode 1. Ensure that the sponge inside the instrument’s calibration chamber is moist. Insert the probe into the calibration chamber. 2. Power the instrument on and allow readings to stabilize. This may take 5 to 15 minutes, depending on the age of the instrument and condition of the probe. 3. Press and release both the UP ARROW and DOWN ARROW keys at the same time to enter the calibration menu. 4. Press the Mode key until “%” is displayed on the right side of the screen for oxygen units. Press ENTER. 5. The LCD will prompt you to enter the local altitude in hundreds of feet. Use the arrow keys to increase or decrease the altitude. When the proper altitude appears on the LCD, press the ENTER key. EXAMPLE: Entering the number 12 here indicates 1200 feet. 6. CAL will now display in the lower left corner of the screen, the calibration value in the lower right corner and the current DO reading (before calibration) will be the main display. Once the current DO reading is stable, press the ENTER button. 7. The LCD will prompt you to enter the approximately salinity of the water you are about to analyze. You can enter any number from 0 to 70 parts per thousand (PPT) of salinity. Use the arrow keys to increase or decrease the salinity setting. When the correct salinity appears on the LCD press ENTER key. The instrument will return to normal operation. Ref: YSI 550A Operator’s Manual. Comment: Per NC WW/GW LC Branch policy, facilities may use a default value of zero ppt for Salinity when calibrating the DO meter unless it is known or suspected that the Salinity value of the samples being analyzed is > 9 ppt. In those situations, actual Salinity values must be used. Regardless of which value is used, it must be documented. Comment: For calibration in % Saturation mode, the approximate altitude (in feet) of the region where you are located is required. This information can be obtained over the internet or from a local airport or weather station. To convert from meters to feet, divide by 0.3048. Page 5 #5353 Town of Roseboro Comment: Switch the meter back to mg/L after the % Saturation calibration. Comment: The following calibration steps are being followed by the laboratory, which do not match either the mg/L or % Saturation calibration instructions from the instrument manual 1) Make sure the sponge is wet. 2) Insert probe into chamber. 3) Turn instrument on and allow to stabilize. (may take 5-15 minutes). Note temperature displayed. 4) Press and release both the UP and DOWN arrow keys at the same time and release. This enters calibration menu. “CAL” should be displayed. 5) Press mode until mg/L is displayed on the right side of screen. Press enter. (arrow pointing to left). 6) Using temperature noted from 3 above, refer to DO/Temp chart, adjust readings with UP and DOWN arrows until correct reading is displayed. Press enter twice. Comment: Using mg/L mode during calibration requires a solution of known concentration. If wishing to calibrate in mg/L mode, these instructions are also found in the YSI 550A Operator’s Manual. H. Finding: The laboratory is not calibrating the DO meter prior to sample analysis at each sample site or performing a Post-Analysis Calibration Verification when analyses are performed at multiple sample sites. 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, a post-analysis calibration verification Standard must be analyzed at the end of the run for all types of DO probes, unless the meter is recalibrated at each sample site. Below is a procedure for verifying the calibration of a DO probe. 1) Follow the manufacturer’s instructions for meter operation. 2) Place probe in a plastic bag, the probe storage cup, the storage well of the meter (each containing a wet sponge), or a BOD bottle partially filled with water. Allow appropriate instrument warm up time. 3) Read DO and temperature. 4) Check the reading vs. the solubility table below and apply appropriate atmospheric (barometric) pressure or altitude correction factor. 5) Calculated DO value must verify meter reading within ± 0.5 mg/L (do NOT calculate and apply a correction factor to calculated theoretical DO). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: This is applicable since the laboratory is analyzing upstream and downstream samples. Temperature – Standard Methods, 2550 B-2010 (Aqueous) Recommendation: It is recommended that Temperature results be reported on the DMR in whole numbers, as stated in the “Precision in Discharge Monitoring Reports” document issued by the Division of Water Resources. Reporting I. Finding: Data qualifiers from the contract laboratory reports are not being transferred to the DMR. Page 6 #5353 Town of Roseboro 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: See the table in the Paper Trail Investigation section. 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 Town of Roseboro (NPDES permit # NC0026816) for November 2020, March 2021 and June 2021. The following errors were noted: Sample Collection Date Parameter Location Contract Lab Report Qualifier 6/30/2021 BOD Effluent Sample estimated. Did not meet quality control requirements. 6/30/2021 BOD Influent Blank above acceptance limit. Upstream results for Temperature (17.4 °C), DO (6.20 mg/L) and Downstream results for Temperature (11.7 °C), DO (6.04 mg/L) were reported on November 11, 2020 instead of November 13, 2020. Upstream results for Temperature (7.2°C) and DO (10.76 mg/L) and Downstream results for Temperature (7.6°C) and DO (10 mg/L) were reported on November 18, 2020 instead of November 19, 2020. 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: Tonja Springer Date: December 9, 2021 Report reviewed by: Tom Halvosa Date: December 10, 2021 Certificate Number:5353 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:Town of Roseboro Address:10160 Roseboro Hwy. Roseboro, NC 28382- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:11/1/2021 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) 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.