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HomeMy WebLinkAbout#134_2017_0316_TS_FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 134 Laboratory Name: Moore Co. Water Pollution Control Plant Inspection Type: Commercial Maintenance Inspector Name(s): Tonja Springer and Todd Crawford Inspection Date: March 16, 2017 Date Forwarded for Initial Review: May 9, 2017 Initial Review by: Jason Smith Date Initial Review Completed: May 11, 2017 Cover Letter to use: ❑ Insp. Initial ❑Insp. No Finding ❑Corrected ® Insp. Reg ❑Insp. CP ❑Insp. Reg. Delay Unit Supervisor/Chemist III: Todd Crawford Date Received: May 15, 2017 Date Forwarded to Admin.: June 2, 2017 Date Mailed: June 5, 2017 Special Mailing Instructions: WaterResources ENV I R,ONi N6HW AL QUAL.?T Y June 5, 2017 134 Ms. Connie Flowers Moore Co. Water Pollution Control Plant 1094 Addor Road Aberdeen, NC 28315 ROY COOPER ,,,,,, MICHEAL S. REGAN S. JAY ZIMMERMAN Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Flowers: Enclosed is a report for the inspection performed on March 16, 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, Todd Crawford Technical Assistance & Compliance Specialist NC WW/GW Laboratory Certification Branch Attachment cc: Dana Satterwhite, Tonja Springer, Master File# 134 Water Sciences Section NC WastewaterlGroundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location: 4405 Reedy Creek Road, Raleigh, North Carolina 27607 Phone: 919-733-39081 FAX: 919-733-6241 Internet: http:I/deg.nc.gov/about/d iv is ion slwater-resources/water-resources-data/water-sciences-home-page/laboratorycertif!cation -branch On -Site Inspection Report LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: I. INTRODUCTION: Moore Co. Water Pollution Control Plant NCO037508 1094 Addor Road Aberdeen, NC 28315 134 March 16, 2017 Commercial Maintenance Tonja Springer and Todd Crawford Janna Scherer Nall and Connie Flowers 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. 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 staff were receptive to recommendations and worked quickly to institute all necessary changes. The laboratory's corrective action responses, that were received prior to writing the inspection report, were thorough and included proper documentation and strategies to prevent recurrence of those Findings. The laboratory is commended on this effort. The laboratory type was changed in our database from Commercial to Municipal at the laboratory's request effective April 27, 2017. 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 March 16, 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. Page 2 #134 Moore Co. Water Pollution Control Plant 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 (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word "should". Laboratory Fortified Matrix (LFM) and Laboratory Fortified Matrix Duplicate (LFMD) are also known as Matrix Spike (MS) and Matrix Spike Duplicate (MSD) and may be used interchangeably in this report. 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 Research & Analytical Laboratories (Certification # 34). Current 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 Comment: Error corrections were not always properly performed on the TSS benchsheet. There were a few instances of write-overs. NC WW/GW LC Policy states: All documentation errors must 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. Write the correction adjacent to the error. The correction must be initialed by the responsible individual and the date of change documented. All data and log entries must be written in indelible ink. Notification of acceptable corrective action (i.e., a statement that the correct procedure for error correction was discussed with staff and notice posted for the laboratory with an implementation date of March 20, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding Quality Control Comment: Duplicate analyses are not required for Field parameters (i.e., pH, Temperature, Dissolved Oxygen (DO), Settleable Residue, Total Residual Chlorine and Conductivity). Bacteria- Coliform Fecal — Standard Methods, 9222D-1997 (MF) (Aqueous) Comment: Incubator temperature was only being checked one time per day. Standard Methods, 9020 B-2005. (4) (n) states: When incubator is in use, monitor and record calibration - corrected temperature twice daily. Notification of acceptable corrective action (i.e., a log to record temperature in the morning and in the afternoon with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: The start time that the sample is filtered was not recorded on the benchsheet to show that no more than 30 minutes passed before filters were placed into the incubator. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states: All analytical data pertinent to each certified analysis must be filed in an orderly manner to be readily available for inspection upon Page 3 #134 Moore Co. Water Pollution Control Plant request. This is considered pertinent information. Notification of acceptable corrective action (i.e. an updated benchsheet that included filtration start time with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: Duplicates were not analyzed at the required frequency. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (C) states: Analyze five percent of all samples in duplicate to document precision. Laboratories analyzing less than 20 samples per month must analyze at least one duplicate each month samples are analyzed. Notification of acceptable corrective action (i.e., a statement that two duplicates will be analyzed each month with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: Final results were not calculated correctly when no filters contained colony counts in the 20-60 range. Results were not calculated correctly on the following data reviewed: December 6, 2016 sample #1206030 reported 9 cfu/100mL instead of 8 cfu/100mL, December 7, 2016 sample #120744 reported 7 cfu/100mL instead of 6 cfu/100mL and December 9, 2016 sample #1209063 reported 4 cfu/100mL instead of 5 cfu/100mL. There were 3 dilutions (100 mL, 50 mL and 20 mL) analyzed for those samples. None of the samples contained counts in the 20-60 range. Only the counts of the 100 ml samples were being reported. The miscalculated results were only off by 1 cfu/100mL and did not exceed the facility's compliance limit. The NC WW/GW LC Fecal Coliform Reporting Policy document states: If all counts are below the lower limit (20) of the ideal counting range: (a) Select the count most nearly acceptable and compute the count using the general formula. Report the count as an Estimated Count per 100 ml: or (b) Total the counts on all filters and report as number per 100 ml. For example, if 50, 25, and 10 ml portions were examined and counts were 15, 6, and 0 coliform colonies respectively, calculate results as follows and report the count as 25 colonies per 100 ml. Notification of acceptable corrective action (i.e., a statement that the final results are now being calculated using the 2 (b) rule when no colonies are in the 20-60 range with an implementation date of March 20, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: The NIST thermometer used to verify the fecal water bath thermometer is only graduated to 0.2°C. Standard Methods, 9020 B 4 (a) — 2005 states: Use glass or metal thermometer graduated in increments to monitor required analytical temperature range for incubators and refrigerators. For example, use thermometer graduated to 0.1 °C for incubators operated above 40°C. Annually, calibrate and record accuracy of all temperature -monitoring devices by comparison with a NIST certified thermometer, or equivalent. Notification of acceptable corrective action (i.e., a statement that a new NIST traceable thermometer in increments of 0.1 °C was purchased on March 23, 2017 and documentation of the calibration on April 10, 2017) was received by email on March 24, 2017 and June 1, 2017. No further response is necessary for this Finding. A. Finding: Consumable materials used for the Fecal Coliform MF method are not tested. Requirement: Before a new lot of consumable materials are used for the Fecal Coliform MF method, those materials must be tested and compared to those currently in use to ensure they are reliable. Consumable materials included in this requirement are: membrane filters and/or pads (often packaged together) and media. It is recommended that only one consumable be tested at a time. At a minimum, make single analyses on five positive samples that will yield 20-60 colonies for both the current lot and the new lot. There are two options for determining acceptance of results: Option 1: Follow the acceptance criteria described in Standard Methods 9020 B 5. f 2) a) and b). Option 2: Compare the average colony count of each five -sample set and evaluate against your routine sample duplicate acceptance criterion. Ref: NC WW/GW Page 4 #134 Moore Co. Water Pollution Control Plant LC Policy. Please obtain (i.e., purchase or borrow) a new lot of media and perform the consumable testing on your current media and submit the results of this study with your response to this report. Comment: A copy of the Fecal Coliform Reporting Policy document was provided at the time of the inspection. B. Finding: Culture positive plates are not analyzed with each batch of prepared media. Requirement: A culture positive must be analyzed with each batch of prepared media and once per week for purchased ready -to -use media. A sample volume that yields a countable plate must be analyzed so that individual colonies may be verified to have proper morphology (i.e. color, shape, size, surface appearance). Ref: NC WW/GW LC Policy. C. Finding: The laboratory is not monitoring the quality of the reagent water used in fecal coliform analysis. Requirement: At a minimum, reagent water used to prepare buffered dilution/rinse water or media must be analyzed at least every twelve months for the following parameters: Specific Conductance, Total Organic Carbon, Cadmium, Chromium, Copper, Nickel, Lead, and Zinc. Maximum Acceptable Limits are: Total Organic Carbon < 1.0 mg/L Specific Conductance < 2 pmhos/cm Heavy Metals, single element < 0.05 mg/L Heavy Metals, Total of cited elements < 0.10 mg/L If the facility is using vendor purchased dilution/rinse water, this testing is not required as long as the Certificate of Analysis from the manufacturer meets these requirements and is kept on file. Ref: NC WW/GW LC Policy. D. Finding: Sample bottle sterility is not verified. Requirement: Minimally test for sterility one sample bottle per batch sterilized in the laboratory, or at a set percentage such as 1 to 4%. This is performed by adding sterile dilution/rinse water to the bottle after sterilization and then subsequently analyzing it as a sample. Document results. If sample bottles or bags are purchased pre -sterilized, verification of sterilization is not required if the laboratory maintains copies of the Certificate of Analysis from the vendor. Ref: NC WW/GW LC Policy. E. 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). Page 5 #134 Moore Co. Water Pollution Control Plant BOD — Standard Methods, 5210 B-2001 (Aqueous) Comment: Samples were not properly adjusted for pH. An industry sample analyzed on December 7, 2016 for Thermal Metal was diluted more than 0.5% during pH adjustment. Standard Methods, 5210 B-2001. (4) (b) (1) states: Check pH; if it is not between 6.0 and 8.0, adjust sample temperature to 20 ± 3 °C, then adjust pH to 7.0 to 7.2 using a solution of sulfuric acid or sodium hydroxide of such strength that the quantity of reagent does not dilute the sample by more than 0.5%. The pH of dilution water should not be affected by the lowest sample dilution. Always seed samples that have been pH adjusted. Notification of acceptable corrective action (i.e., a statement that 10N H2SO4 & 10N NaOH will be used to adjust pH and confirmation that sample isn't diluted more than 0.5% with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: Influent samples analyzed more than six hours after collection were not seeded. Standard Methods 5210 B-2001. (4) (d) states: Some samples (for example, some untreated industrial wastes, disinfected wastes, high -temperature wastes, wastes having pH values less than 6 or greater than 8, or wastes stored more than 6 h after collection) do not contain a sufficient microbial population. Seed such samples by adding a population of suitable microorganisms. Notification of acceptable corrective action (i.e., a statement that all samples are now being seeded if greater than 6 hours from collection time with an implementation date of March 20, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: Seed controls with less than 2.0 mg/L Dissolved Oxygen (DO) depletion were used for seed correction calculation. The seed correction factor was incorrectly calculated on March 12, 2016. The error did not affect the final result. Standard Methods, 5210 B-2001. (6) (d) states: For the ratio method, divide the DO depletion by the volume of seed in milliliters for each seed control bottle having a 2.0 mq/L depletion and greater than 1.0 mg/L minimum residual DO and average the results. Notification of acceptable corrective action (i.e., a statement that seed corrections are now being calculated correctly, using the seed controls having a 2.0 mg/L depletion and greater than 1.0 mg/L minimum residual DO with an implementation date of March 20, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: The laboratory was not stirring the seed during transfer to BOD bottles. POLYSEEDO manufacturer's instructions state: Continue to gently stir the POLYSEEDO solution while adding to seed controls, GGA standard and all samples. Notification of acceptable corrective action (i.e., a statement that seed will be stirred while transferring to bottles with an implementation date of March 20, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. F. Finding: The documentation does not demonstrate that initial DO readings are measured within 30 minutes of sample dilution. This is considered pertinent information. Requirement: After preparing dilution, measure initial DO within 30 min. Ref: Standard Methods, 5210 B-2001. (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: 15A NCAC 2H .0805 (a) (7) (A). Comment: Currently, only"time in the incubator" is documented. In order to show that 30 minutes or less have passed from preparing the dilution to measuring the initial DO, a Page 6 #134 Moore Co. Water Pollution Control Plant second time is required. This is often achieved by documenting the time the dilutions are prepared. Nitrogen, Ammonia —Standard Methods, 4500 NH3 D-1997 (Aqueous) Comment: The laboratory was not analyzing an LFM/LFMD. Standard Methods, 4020 B-2009, Rev. 2011, Table 4020: 1 and (2) (g) state: When appropriate for the analyte (Table 4020: 1), include at least one LFM/LFMD daily or with each batch of 20 or fewer samples. Notification of acceptable corrective action (i.e., a statement that an LFM/LFMD has been added to the benchsheet, and an updated benchsheet which includes space for the LFM/LFMD with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: The laboratory was not analyzing a calibration blank after every tenth sample and at the end of each sample group. NC WW/GW LC Policy states: The calibration blank and calibration verification standard (mid -range) must be analyzed initially (i.e., prior to sample analysis), after every tenth sample and at the end of each sample group to check for carry over and calibration drift. If either fall outside established quality control acceptance criteria, corrective action must be taken (e.g., repeating sample determinations since the last acceptable calibration verification, repeating the initial calibration, etc.). Notification of acceptable corrective action (i.e., an updated benchsheet which includes a space for the calibration blank after every 10 samples and at the end of the sample group, with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: The laboratory was not analyzing a Method Blank. Standard Method, 4020 B-2009. (2) (d) states: Include at least one MB daily or with each batch of 20 or fewer samples, whichever is more frequent. Any constituent(s) recovered must generally be less than or equal to one-half the reporting level (unless the method specifies otherwise). This may include re -analyzing the sample batch. North Carolina Wastewater/Groundwater Laboratory Certification Policy states: The concentration of Method Blanks (MB) and Continuing Calibration Blanks (CCB) must not exceed 50% of the reporting limit standard concentration. Notification of acceptable corrective action (i.e., an updated benchsheet which includes a space for the Method Blank with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding Comment: The laboratory was not documenting that the sample pH was adjusted to >11 S.0 during the analysis. This is considered pertinent information. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states: 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. Notification of acceptable corrective action (i.e., an updated benchsheet which includes space to document the pH > 11 S.U, with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: Samples were not being checked for Total Residual Chlorine and neutralized if necessary. This only applies if analyzing influent or industrial pre-treatment samples, since the WWTP utilizes Ultra Violet disinfection. Standard Methods, 4500 NH3 A-1997. (2) states: Residual Chlorine reacts with ammonia; remove by sample pretreatment. If a sample is likely to contain residual chlorine, immediately upon collection, treat with dechlorinating agent as in 4500-NH3. B.3d. Notification of acceptable corrective action (i.e., a statement that Total Residual Chlorine strips, with a detection limit of 0.5 mg/L, are being used to check for Total Residual Chlorine with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Page 7 #134 Moore Co. Water Pollution Control Plant Comment: Values less than the established reporting limit were being reported on the electronic Discharge Monitoring Report (eDMR). The laboratory's reporting limit is 1 mg/L based upon the lowest calibration standard. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (1) states: For analytical procedures requiring analysis of a series of standards, the concentrations of those standards must bracket the concentration of the samples analyzed. One of the standards must have a concentration equal to the laboratory's lower reporting concentration for the parameter involved. Notification of acceptable corrective action (i.e., a statement that the laboratory will begin reporting effluent concentrations below 1 mg/L as <1 mg/L on February eDMR) was received by email on March 24, 2017. No further response is necessary for this Finding. Residue, Suspended —Standard Methods, 2540 D-1997 (Aqueous) Comment: Filters were not weighed to constant weight prior to sample analysis, nor was a dry filter blank analyzed with each set of samples. NC WW/GW LC Policy states: If pre -prepared filters are not used, the method requires that filters must be weighed to a constant weight after washing. Repeat cycle of drying, cooling, desiccating, and weighing until a constant weight is obtained or until weight change is less than 4% of the previous weighing or 0.5 mg, whichever is less. In lieu of this process, it is acceptable to analyze a single daily dry filter blank to fulfill the method requirement of drying all filters to a constant weight prior to analysis. Notification of acceptable corrective action (i.e., a statement that a dry filter blank is being analyzed each analysis day with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Conductivity —Standard Methods, 2510 B-1997 (Aqueous) Comment: The incorrect true value was documented for the check standard on the benchsheet. The true value documented was 100 Nmhos/cm instead of 99.8 Nmhos/cm. The NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity) states: The following must be documented in indelible ink whenever sample analysis is performed: True value of the calibration verification check standard. Notification of acceptable corrective action (i.e., updated benchsheet which included the correct check standard value of 99.8 Nmhos/cm with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Comment: The laboratory benchsheet was lacking pertinent data: meter calibration time and time of sample analysis. The NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity) states: The following must be documented in indelible ink whenever sample analysis is performed: Meter calibration time and time of sample analysis. The North Carolina Administrative Code, 15A NCAC 2H .0805 (g) (1) states: Certified Data must consist of date collected, time collected, sample site, sample collector, and sample analysis time. Notification of acceptable corrective action (i.e., an updated benchsheet which included the meter calibration time and time of sample analysis with an implementation date of April 3, 2017) was received by email on March 24, 2017. No further response is necessary for this Finding. Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous) Comment: The barometric pressure at the time of meter calibration is not documented. The NC WW/GW LC Approved Procedure for the Analysis of DO states: 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. Acceptable corrective action (i.e., the benchsheet was updated to include barometric pressure) was performed by the laboratory and approved by the auditor during the inspection. No further response is necessary for this Finding. Page 8 #134 Moore Co. Water Pollution Control Plant 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. The following data were reviewed for Moore Co. Water Pollution Control Plant (NPDES permit # NC0037508): Field parameter data for June 2016; BOD, Fecal Coliform and Ammonia data for July 2016; TSS data for January 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 Finding(s) 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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