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HomeMy WebLinkAbout#40_2018_1128_JMS_FINALLaboratory Cert. ##: 40 Laboratory Name: Pace Analytical Services LLC — Asheville NC Inspection Type: Commercial Maintenance Abbreviated Inspector Name(s): Jason Smith Inspection Date: November 28, 2018 Date Forwarded for Initial Review: December 20, 2018 Initial Review by: Tom Halvosa Date Initial Review Completed: December 31, 2018 Cover Letter to use: ❑ Insp. Initial ❑ Insp. Reg ❑Insp. No Finding ®Insp. CP ❑Corrected ❑Insp. Reg. Delay Unit Supervisor/Chemist III: Todd Crawford Date Received: January 2, 2019 Date Forwarded to Admin.: January 8, 2019 Date Mailed: January 8, 2019 Special Mailing Instructions: S. Ik UjAN IL INDA CU l-PF fs 't . frlt,�ri'rn Owe, "o', rrvr'rorament"I Quahfxy January 8, 2019 40 Mr. Barry Johnson Pace Analytical Services LLC - Asheville NC 2225 Riverside Drive Asheville, NC 28804 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Johnson: Enclosed is a report for the inspection performed on November 28, 2018 by Jason Smith. Where Finding(s) are cited in this report, a response is required. Within thirty days of receipt, 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 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 wish to obtain an electronic copy of this report by email or if you have questions or need additional information, please contact me at (828) 296-4677. Sincerely, Todd Crawford Technical Assistance & Compliance Specialist NC WW/GW Laboratory Certification Branch Attachment cc: Dana Satterwhite, Jason Smith, Master File #40 North Carolina Department of Environmental Quality I Division of Water Resources 1623 Mail Service Center I Raleigh, North Carolina 27699-1623 Phone 919.733.3908/Fax 919.733.6241 LABORATORY NAME: Pace Analytical Services LLC —Asheville NC ADDRESS: 2225 Riverside Drive Asheville, NC 28804 CERTIFICATE : 40 DATE OF INSPECTION: November 28, 2018 TYPE OF INSPECTION: Commercial Maintenance Abbreviated AUDITOR(S): Jason Smith LOCAL PERSON(S) CONTACTED: Barry Johnson and Eric Setzer This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A NCAC 2H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: This was an abbreviated audit performed in conjunction with technical assistance requested by the laboratory. The laboratory requested technical assistance to discuss troubleshooting persistent unacceptable BOD blank results (>0.20 mg/L) which have occurred over the past few months. Kathy Jimison, the laboratory analyst at the Asheville Regional Office of the NC Division of Water Resources, also attended to provide assistance. All required Proficiency Testing (PT) Samples have been analyzed and the laboratory has fulfilled its PT requirements for the 2018 PT Calendar Year. The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedures (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 December 31, 2019. 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 insure 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. Page 2 ##40 Pace Analytical Services LLC — Asheville NC The laboratory is also reminded that SOPS are intended to describe procedures exactl 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". Requirements that reference 15A NCAC 2H .0805 (a) (7) (A), stating "All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request", are intended to be a requirement to document information pertinent to reconstructing final results and demonstrating method compliance. Use of this requirement is not intended to imply that existing records are not adequately maintained unless the Finding speaks directly to that. - - • -III III,�. • Documentation Comment: The laboratory analyzes samples manually as well as with a Skalar automated analyzer. Recommendation: It is recommended that the laboratory maintain detailed notes about the effect of procedural changes as part of the troubleshooting process. This will help identify which combination of changes produces the best results. A. Finding: Documentation for manual analyses does not demonstrate that the initial Dissolved Oxygen (DO) is measured within 30 minutes of sample preparation. This is considered pertinent data. Cited previously on July 25, 2017. Requirement: After preparing dilution, measure initial DO within 30 min. Ref: Standard Methods, 5210 B-2011. (5) (g). Requirement: All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request. Ref: 15 NCAC 21-1.0805 (a) (7) (A). Comment: The laboratory corrected this Finding for manual analysis on the printed benchsheets in use at the time of the last inspection. Since then, they have started entering the data into an Excel spreadsheet which does not include this information. Recommendation: The automated analyzer measures the DO immediately after sample preparation and this is documented in the SOP. It is recommended that a statement indicating this be added to the automated analysis print out. Recommendation: It is recommended that the SOP (Section 12.5.1.8) refer to the specific section of the automated analyzer instruction manual that describes analysis of DO immediately after the bottle is prepared. IV. PAPER TRAIL INVESTIGATION: No paper trail performed. Page 3 ##40 Pace Analytical Services LLC — Asheville NC We are concerned that the correction for the previously cited Finding was not addressed when the laboratory began using an electronic data entry system. Laboratory Decertification Ref: 15A NCAC 2H .0807 (a) (1), (13) and (14): A laboratory may be decertified for any or all parameters for up to one year for any or all of the following infractions: (1) Failing to maintain the facilities, or records, or personnel, or equipment, or quality control program as set forth in the application, and these Rules; or (13) Failing to respond to requests for information by the date due; or (14) Failing to comply with any other terms, conditions, or requirements of this Section or of a Laboratory certification. Correcting the above -cited Finding and implementing the Recommendation will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for its assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation and implementation dates for each corrective action. 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