HomeMy WebLinkAbout#121_2017_0613_TS_FINALTo be attached to all inspection reports in-house only.
Laboratory Cert. #:
121
Laboratory Name:
Hillsborough WWTP
Inspection Type:
Municipal Maintenance
Inspector Name(s):
Tonja Springer and Todd Crawford
Inspection Date:
June 13, 2017
Date Forwarded for Initial
Review:
July 6, 2017
Initial Review by:
Anna Ostendorff
Date Initial Review
Completed:
July 11, 2017
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:
July 25, 2017
Date Forwarded to Admin.:
July 27, 2017
Date Mailed:
August 2, 2017
Special Mailing Instructions:
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ENVIRONMI-Al FA(.. (pk AIJI Y
August 2, 2017
121
Mr. Matthew Silinski
Hillsborough WWTP
P.O. Box 429
Hillsborough, NC 27278
ROY COOPER
Governor
MICHEAL S. REGAN
SecretnrP
S. JAY ZIMMERMAN
Direetar
Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC)
Maintenance Inspection
Dear Mr. Silinski:
Enclosed is a report for the inspection performed on June 13, 2017 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 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 (919) 733-3908 ext. 251.
Sincerely,
D�
Todd Crawford
Technical Assistance & Compliance Specialist
NC WW/GW Laboratory Certification Branch
Attachment
cc: Dana Satterwhite, Tonja Springer, Master File #121
LABORATORY NAME: Hillsborough WWTP
NPDES PERMIT : NCO026433
ADDRESS: 355 Elizabeth Brady Rd.
Hillsborough, NC 27278
CERTIFICATE #: 121
DATE OF INSPECTION: June 13, 2017
TYPE OF INSPECTION: Municipal Maintenance
AUDITOR(S): Tonja Springer and Todd Crawford
LOCAL PERSON(S) CONTACTED: Matthew Silinski and Jeff Mahagan
INTRODUCTION:
This laboratory was inspected by representatives 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 environmental samples.
II. GENERAL COMMENTS:
The auditors found this lab to have excellent organization. This was evident from viewing records
and observing the layout and actions which help streamline the day to day activities of the lab.
The laboratory analyst has implemented an excellent system of chemical and reagent traceability
to source materials. Staff were forthcoming and seemed eager to adopt necessary changes.
All required Proficiency Testing (PT) samples for the 2017 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, 2017.
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 June 2018.
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.
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
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#121 Hillsborough WWTP
(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.
Contracted analyses are performed by Meritech, Inc. (Certification #165).
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Documentation
A. Finding: Units of measure are not documented.
Requirement: All laboratories must use printed laboratory bench worksheets that
include a space to enter the signature or initials of the analyst, date of analyses, sample
identification, volume of sample analyzed, value from the measurement system, factor
and final value to be reported and each item must be recorded each time samples are
analyzed. Ref: North Carolina Administrative Code, 15A NCAC 02H .0805 (a) (7) (H).
Comment: The units of measure are not documented in the following locations:
® Total Suspended Residue benchsheet — Filter Weight + Dried Sample column and
Initial Filter Weight column.
® pH benchsheet — Units for slope (e.g.%)
® Upstream and Downstream benchsheet — no units for the DO and Temperature.
B. Finding: Some benchsheet references do not accurately reflect the laboratory's certified
methods.
Requirement: Each laboratory shall develop and maintain a document outlining the
analytical quality control practices used for the parameters included in their certification.
Supporting records shall be maintained as evidence that these practices are being
effectively carried out. Ref: 15A NCAC 2H .0805 (a) (7).
Comment: The benchsheet for Dissolved Oxygen (DO) references 181h Edition 4500-0 G
instead of SM 4500 O G-2001.
Comment: The benchsheet for Total Suspended Solids (TSS) references Standard
Methods 20th Edition 1997 2540 D instead of SM 2540 D-1997. While this Edition of
Standard Methods contains the promulgated (or approved) method,this is not the current
method reference format listed in the Code of Federal Regulations, Title 40, Part 136;
Federal Register Vol. 77, No. 97, May 18, 2012.
Proficiency Testing
C. Finding: The laboratory is not analyzing Proficiency Testing (PT) Samples in the same
manner as compliance samples.
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#121 Hillsborough WWTP
Requirement: As specified in 15 NCAC 2H .0800, in order to meet the minimum
standards for Certification, laboratories must use acceptable analytical methods. The
acceptable methods are those defined or referenced in the current State and federal
regulations for the environmental matrix being tested. All samples, (including PT
Samples) that are, or that may, be used for Certification purposes, must be analyzed
using approved methods only. All PT Samples are to be analyzed and the results
reported in a manner consistent with the routine analysis and reporting requirements of
Compliance Samples. Laboratories must document any exceptions. All PT Sample
analyses must be recorded in the daily analysis records as for any Compliance Sample.
This serves as the permanent laboratory record. 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 routine procedure) must be calculated in the
same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements,
May 31, 2017, Revision 2.0.
Comment: PT samples are analyzed multiple times for Total Suspended Solids and
Total Residual Chlorine, but samples are not.
D. Finding: The preparation of Proficiency Testing (PT) Samples is not documented.
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 (e.g., pH), but it is recommended that the instructions be
maintained. Ref: Proficiency Testing Requirements, May 31, 2017, Revision 2.0.
Comment: The new analyst stated that he was not aware of any prep documentation
from the previous analyst. PT samples for 2017 have not yet been analyzed.
Comment: Dating and initialing the instruction sheet for the preparation of the Total
Residual Chlorine PT would satisfy the documentation requirement.
Bacteria- Coliform Fecal — Standard Methods, 9222 D-1997 (MF) (Aqueous)
Comment: Sterilized bottles are checked for sterility one sample bottle per batch at three
dilutions. It is not required to analyze the batch sterility check in multiple dilutions. At a minimum
test for sterility one sample bottle per batch sterilized in the laboratory or one sample bottle per
lot of purchased as pre -sterilized, or at a set percentage such as 1 to 4%.
E. Finding: The time filtration begins is not recorded on the benchsheet to show that no
more than 30 minutes passed before filters were placed into the incubator. This is
considered pertinent information.
Requirement: Place all prepared cultures in the water bath within 30 min after filtration.
Ref: Standard Methods, 9222 D-1997. (2) (d).
Requirement: All analytical data pertinent to each certified analysis must be filed in an
orderly manner to be readily available for inspection upon request. This is considered
pertinent information. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A).
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#121 Hillsborough WWTP
Comment: At the time of the inspection the analyst stated that he is careful to make sure
all plates are in the incubator within 30 minutes but it was not being documented.
F. Finding: The sterilized rinse/dilution water is not stored in the refrigerator after opening.
Requirement: Store under refrigerated conditions after opening and discard if turbidity
develops. Use within 6 months. Ref: SM 9050 C-2006. (1) (a) (3).
G. Finding: Plate comparison counts are not being conducted.
Requirement: For routine performance evaluation, repeat counts on one or more
positive samples at least monthly, record results, and compare the counts with those of
other analysts testing the same samples. Replicate counts for the same analyst should
agree within 5% (within analyst repeatability of counting) and those between analysts
should agree within 10% (between analysts reproducibility of counting). If they do not
agree, initiate investigation and any necessary corrective action. Ref: Standard
Methods, 9020 B-2005. (9) (a).
Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous)
H. Finding: The barometric pressure at the time of meter calibration is not documented.
Requirement: Calibration documentation must include the following, where applicable
to the instrument used and the type of calibration performed: elevation, temperature,
barometric pressure (in mmHg), salinity, slope, or % efficiency. Ref: NC WW/GW LC
Approved Procedure for the Analysis of Dissolved Oxygen.
Temperature — Standard Methods, 2550 B-2000 (Aqueous)
Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous)
I. Finding: Only one time for sample collection and analysis was documented on the
benchsheet, without noting samples are analyzed in situ.
Requirement: Alternatively, since EPA requires samples to be analyzed immediately, one
time may be documented for collection and analysis with the notation that samples are
measured in situ or immediately at the sampling site (i.e., immediately following collection
at a location as near to the collection point as possible). When this `one time' option is
used, state that the documented time is both collection and analysis time. Ref: NC
WW/GW LC Approved Procedure for the Analysis of Temperature.
Requirement: Alternatively, one time may be documented for collection and analysis with
the notation that samples are measured in situ or immediately at the sample site. Ref: NC
WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen.
Comment: The time sampled is documented on the benchsheet.
Temperature — Standard Methods, 2550 B-2000 (Aqueous)
Recommendation: Unless greater precision is required by the permit or data receiving agency, it
is recommended that all temperatures reported for compliance monitoring, be reported in whole
numbers as recommended by the Precision in Discharge Monitoring Reports document found
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#121 Hillsborough WWTP
here: http://Portal.ncdenr.org/c/document library/get file? uuid=1407b370-e848-4550-9f4b-
21 a2f05b95e4&groupld=38364
Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous)
J. Finding: The average is not used for the true value of the standard solution used to
prepare the daily check standard.
Requirement: If purchased standard solutions in sealed ampules with a stated range and
average value are used, the average value must be used for the true value of the
standard. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual
Chlorine.
Comment: The sealed ampules' standard solution concentration range was 25-30 lag/L
with an average of 27.44 tag/L. The true value being used was 25 lag/L. In the data
reviewed, the daily check standard was being evaluated against the ± 10 % acceptance
criterion and was typically measuring approximately 27 lag/L, which was also within the
acceptance criteria of the average concentration.
K. Finding: The laboratory benchsheet was lacking pertinent data: meter calibration time.
Requirement: The following must be documented in indelible ink whenever sample
analysis is performed: Meter calibration time. NC WW/GW LC Approved Procedure for
the Analysis of Total Residual Chlorine.
L. Finding: The laboratory is not analyzing samples according to the method referenced on
their Certified Parameter Listing (CPL).
Requirement: Compensate for color and turbidity by using sample to zero photometer.
Ref: Standard Methods, 4500 CI G-2000. (1) (b).
Comment: Samples are being filtered according to the Hach method 10014. The method
referenced on the CPL is Standard Methods, 4500 Cl G-2000 which does not include
filtering.
pH — Standard Methods, 4500 H+ B-2000 (Aqueous)
Recommendation: It is recommended to change the column header to "time analyzed" instead
of "time ran."
IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks,
etc.) and contract lab reports to electronic Discharge Monitoring Reports (eDMRs) submitted to
the North Carolina Division of Water Resources. Data were reviewed for Hillsborough WWTP
(NPDES permit # NC0026433) for August 2016, and January and April 2017. No transcription
errors were detected. The facility appears to be doing a good job of accurately transcribing
data.
V. CONCLUSIONS:
Correcting the above -cited Findings and implementing the Recommendations will help this
laboratory to produce quality data and meet Certification requirements. The inspector would like
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#121 Hillsborough WWTP
to thank the staff for their assistance during the inspection and data review process. Please
respond to all Findings and include supporting documentation and implementation
dates for each corrective action.
Report prepared by: Tonja Springer Date: July 6, 2017
Report reviewed by: Anna Ostendorff Date: July 11, 2017
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