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HomeMy WebLinkAbout#5519_2021_1021_MC_FINAL January 27, 2022 5519 Mr. Chris Marion Mount Airy WWTP Laboratory P.O. Box 70 Mount Airy, NC 27030 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Marion: Enclosed is a report for the inspection performed on October 21, 2021 by Michael Cumbus. 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: Michael Cumbus, Todd Crawford, #5519 On-Site Inspection Report LABORATORY NAME: Mount Airy WWTP Laboratory NPDES PERMIT #: NC0021121 ADDRESS: 1750 South Andy Griffith Parkway Mount Airy, NC 27030 CERTIFICATE #: 5519 DATE OF INSPECTION: October 20, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR: Michael Cumbus LOCAL PERSON CONTACTED: Chris Marion 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 have been analyzed for the 2021 PT Calendar Year and the graded results were 100% acceptable. The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in advance of the inspection. These documents were reviewed, and editorial and substantive revision requirements and recommendations were made by this program outside of this formal report process. Although subsequent revisions were not requested to be submitted, they must be completed by July 31, 2022. 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 Page 2 #5519 Mount Airy WWTP Laboratory 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 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: Several instances were noted where the error correction on the laboratory benchsheet was lacking the date that the correction was made. Several instances of the correction being written over the error were also noted. B. Finding: The laboratory benchsheet is lacking required documentation: sample identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the sample identification. 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) (I). Comment: Process control data is not documented as such due to a lack of sample identification. C. Finding: Chemical containers are not consistently dated when received and when opened. Requirement: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). Comment: The date opened was missing from the bottles of pH buffers. D. Finding: The laboratory is not documenting all 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 Page 3 #5519 Mount Airy WWTP Laboratory 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 Policy. Comment: The laboratory benchsheet has not been updated with the latest lots of pH buffers and DPD powder. E. Finding: The laboratory is not documenting the salinity value used to perform the Dissolved Oxygen (DO) meter 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: 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: The laboratory is using the default salinity value of zero, but this is not documented on the benchsheet. Proficiency Testing F. 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. G. Finding: PT Samples are not being analyzed in the same manner as routine Compliance Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each parameter method 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 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 Page 4 #5519 Mount Airy WWTP Laboratory routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Comment: The laboratory is currently analyzing PT samples in duplicate. Since it is not a required element for Field Parameters, compliance Samples for Field Parameters are not performed in duplicate. H. Finding: PT Samples are not being distributed among all analysts from year to year. Requirement: Laboratories shall also ensure that, from year to year, PT Samples are equally distributed among personnel trained and qualified for the relevant tests and instrumentation (when more than one instrument is used for routine Compliance Sample analyses), that represents the routine operation of the work group at the time the PT Sample analysis is conducted. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. QA/QC I. Finding: Data that does not meet all QC requirements is not qualified on the Discharge Monitoring Report (DMR). 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 laboratory was not consistently transcribing data qualifiers from the contract laboratory reports to the DMR. The following errors were noted: The BOD on the Influent collected January 19, 2021 performed by Meritech, Inc. was lacking qualification that no dilution depleted at least 2 mg/L oxygen and had at least 1 mg/L oxygen remaining. It is recommended that you contact the Winston-Salem 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. Chlorine, Total Residual – Standard Methods, 4500 Cl G-2011 (Aqueous) Comment: After analyzing the Daily Check Standard and the gel-type Blank, the laboratory is re- zeroing the instrument with an aliquot of unreacted sample. This practice was instituted when industrial samples were significantly impacting the analyses. While this practice is acceptable, it may be eliminated if the laboratory chooses, since the interferences are no longer present in the samples. J. Finding: Values less than the established reporting limit are being reported on the DMR. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: For all calibration options, the range of standard concentrations must bracket the permitted discharge limit concentration, the range of sample concentrations to be analyzed and anticipated PT Sample concentrations. One of the standards must have a concentration less than the permitted Daily Maximum Limit. The lower reporting limit concentration is equal to the lowest standard concentration. Sample concentrations that are less than the lower reporting limit must be reported as a less-than value. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G- 2011). Page 5 #5519 Mount Airy WWTP Laboratory Comment: The established reporting limit as determined during the annual calibration verification is 10 µg/L. Values with concentrations less than the lower reporting limit must be reported as < 10 µg/L on the DMR. pH – Standard Methods, 4500 H+ B-2011 (Aqueous) Comment: The laboratory is currently gently warming the buffers and samples to 25°C, as per the SOP. This step may potentially cause the holding time to be exceeded, since sample analysis is not considered to be in progress until the warming step is completed. While this is acceptable laboratory practice, provided the 15-minute holding time (from the time of collection to obtaining the result) is still met, it is not required as long as an Automatic Temperature Compensation (ATC) probe is connected to the meter. If the laboratory chooses to eliminate the warming step, the SOP will need to be updated accordingly. K. 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). Comment: Adding the acceptance criterion of ± 0.1 S.U. to the laboratory benchsheet column for the check standard would satisfy this requirement. Temperature – Standard Methods, 2550 B-2010 (Aqueous) L. Finding: 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 National Institute of Standards and Technology (NIST) traceable temperature-measuring device and record all four readings. The readings from both devices must agree within 0.5 ºC. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: The DO Meter used for compliance Temperature monitoring is only verified at a single temperature. Please submit a copy of a passing temperature verification of the compliance temperature-measuring device, along with a copy of the NIST Traceable certificate for the Reference device used to verify the meter, with the report response. M. Finding: The Reference Temperature-Measuring Device used to verify the temperature sensor on the DO meter is not NIST traceable. 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. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Page 6 #5519 Mount Airy WWTP Laboratory 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. Requirement: A Reference Temperature-Measuring Device is an NIST traceable temperature-measuring device used only to verify the calibration of other temperature- measuring devices (i.e., limited use only). This device must be able to distinguish temperature changes of 0.1°C and equilibrate rapidly. It must be recalibrated in accordance with the manufacturer’s recalibration date (not to exceed five years). If no recalibration date is given, the Reference Temperature-Measuring Device must be recalibrated, at a minimum, every five years. A new certificate of traceability must be issued and maintained for inspection upon request. Recalibrate sooner if the device has been exposed to temperatures beyond the manufacturer’s recommended range of use. Ref: NC WW/GW LCB Policy. Requirement: Temperature-measuring device calibrations are performed by NIST, the manufacturer or any International Organization for Standardization (ISO) 17025 compliant vendor and results in the issuance of a new certificate of traceability to NIST standards. Ref: NC WW/GW LCB Policy. Comment: The thermometer (ERTCO s/n 1751) used to verify the DO meter temperature sensor was not purchased with an NIST Certificate. The ERTCO thermometer is verified by Meritech, Inc. annually; however, this is not considered a calibration and does not result in the issuance of a certificate of traceability to NIST standards. 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 Mount Airy WWTP Laboratory (NPDES permit # NC0021121) for January, May and June 2021. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data 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: Michael Cumbus Date: October 27, 2021 Report reviewed by: Jill Puff Date: October 28, 2021 Certificate Number:5519 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:Mount Airy WWTP Laboratory Address:1750 South Andy Griffith Parkway Mount Airy, NC 27030 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) DISSOLVED OXYGEN SM 4500 O G-2011 (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.