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HomeMy WebLinkAbout#5565_2021_0804_JP_FINAL October 22, 2021 5565 Mr. James Connolly City of Rocky Mount Tar River Reser. Water Treatment Plant P.O. Box 1180 Rocky Mount, NC 27802-1180 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Connolly: Enclosed is a report for the inspection performed on August 4, 2021 by Jill Puff. I apologize for the delay in getting this report to you. Where Findings 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 Findings were corrected. Please describe the steps taken to prevent recurrence and include an implementation date for each corrective action. If the Findings 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 2H .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 5565 On-Site Inspection Report LABORATORY NAME: City of Rocky Mount Tar River Reser. W ater Treatment Plant NPDES PERMIT #: NC0072125 ADDRESS: 4489 Leaston Road Rocky Mount, NC 27804 CERTIFICATE #: 5565 DATE OF INSPECTION: August 4, 2021 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Jill Puff and Anna Ostendorff LOCAL PERSON(S) CONTACTED: James Connolly and Greg Mann 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 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) during 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 March 1, 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 #5565 City of Rocky Mount Tar River Reser. Water Treatment Plant 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 Tar River Regional WWTP Lab (Certification # 125) and 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: The laboratory benchsheet is lacking required documentation: Instrument identification and 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 instrument identification and the proper units of measure. Each item shall be recorded each time that samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (C) and (L). Comment: Units for pH analyses are not documented. Instrumentation identification of the pH meter is not documented on the benchsheet. Units for Total Residual Chlorine (TRC) are absent only in the Instrument Readings column of the benchsheet. 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: Wite-out was used on multiple benchsheets to correct the pre-printed Instrument ID and serial number for the TRC meter. C. Finding: Chemical containers are not dated when opened. Requirement: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). Comment: The pH buffer containers are dated when received but not when opened. 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 Page 3 #5565 City of Rocky Mount Tar River Reser. Water Treatment Plant links standard/reagent preparation information to analytical batches in which the solutions are used. 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: Dates received are written on the pH buffer bottles, but dates opened are not documented. While this can provide a traceability link to analyses by looking at the dates that the chemicals were in use, that link is lost once the bottles are discarded. Comment: The laboratory benchsheet references the catalog number for the TRC gel standard instead of lot number. E. Finding: Documentation does not clearly state the time of the pH meter calibration. 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. Calibration must include at least two buffers. Document meter calibration and calibration time(s). The meter calibration must be verified with a third standard buffer solution (i.e., check buffer) prior to sample analysis. The calibration and check standard buffers must bracket the range of the samples being analyzed. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Comment: A check buffer is analyzed after calibration and before sample analysis and that time is labeled as “Recheck QC at end”. The documentation is not clear. Proficiency Testing F. 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 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 Page 4 #5565 City of Rocky Mount Tar River Reser. Water Treatment Plant results and related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.0. Requirement: SOPs must address situations where the instructions from the Accredited PT Provider for the preparation, analysis or result calculations would constitute a deviation from the laboratory’s routine procedure. Examples of this may include how low-level PT Samples will be analyzed, including concentration of the sample or adjustment of the normality of a titrant. These instructions shall be followed when the concentration of a PT Sample is below the range of their routine analytical method. Instructions shall also be included in the laboratory’s SOP for how high-level PT Samples will be analyzed, including preparation of multiple dilutions of the sample. These instructions will be followed when the concentration of a PT Sample is above the range of their routine analytical method. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.0. Quality Control G. Finding: The laboratory does not have 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; and 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). Reporting H. Finding: The laboratory does not report results of all tests on the characteristics of the effluent. Requirement: The results of all tests on the characteristics of the effluent, including but not limited to NPDES Permit Monitoring Requirements, shall be reported on monthly report forms. Ref: 15A NCAC 2B .0506 (b) (3) (J). Comment: The laboratory is analyzing the Temperature of the effluent while measuring the sample pH. Temperature results are not being reported on the Discharge Monitoring Report (DMR). The permit does not require Temperature monitoring. If this practice is continued, the laboratory will need to gain certification for Temperature. Temperature results must be reported as uncertified data in the comments section of the DMR until certification is obtained. Comment: Temperature is documented on the chain-of-custody to document the downward trend in temperature of transported samples. The laboratory may employ a temperature blank to document the downward trend in temperature to demonstrate thermal preservation. Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) Comment: The laboratory is currently analyzing each TRC compliance sample in duplicate. Sample duplicates are not a required quality control element for Field Parameters. All sample and duplicate values reviewed were less than the reporting limit. As a reminder, the lab would be required to Page 5 #5565 City of Rocky Mount Tar River Reser. Water Treatment Plant incorporate both values on the DMR in the case of any future values measured above the reporting limit. Recommendation: It is recommended that the laboratory no longer analyze duplicates for TRC. 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 City of Rocky Mount Tar River Reservoir WTP (NPDES permit # NC0072125) for February, April 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 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: August 11, 2021 Report reviewed by: Tonja Springer Date: September 30, 2021 Certificate Number:5565 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:City of Rocky Mount Tar River Reser. Water Treatment Plant Address:4489 Leaston Rd Rocky Mount, NC 27804 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.