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HomeMy WebLinkAbout#5242_2017_0927_TS_FINALLaboratory Cert. # Laboratory Name: Inspection Type: INSPECTION REPORT ROUTING SWEET To be attached to all inspection reports in-house only. 5242 Town of Ansonville WWTP Field Municipal Maintenance Inspector Name(s): Tonja Springer Inspection Date: September 27, 2017 Date Forwarded for Initial October 17, 2017 Review: Initial Review by: Beth Swanson Date Initial Review October 18, 2017 Completed: ❑ Insp. Initial ® Insp. Reg Cover Letter to use: ❑Insp. No Finding ❑Insp. CP ❑Corrected ❑Insp. Reg. Delay Unit Supervisor/Chemist III: I Todd Crawford Date Received: October 19, 2017 Date Forwarded to Admin.: I October 26, 2017 Date Mailed: I October 27, 2017 Special Mailing Instructions: Water Resources ENVIRONMENTAL QUALITY October 27, 2017 5242 Ms. Dianna McLaughlin Town of Ansonville WWTP P.O. Box 437 Ansonville, NC 28007 ROY COOPER MICHEAL S. REGAN S. JAY ZIMMERMAN Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. McLaughlin: Enclosed is a report for the inspection performed on September 27, 2017 by Tonja Springer. 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, Tonja Springer, Master File #5242 Water Sciences Section NC Wastewater/Groundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location: 4405 Reedy Creek Road, Raleigh, North Carolina 27607 Phone: 919-733-39081FAX: 919-733-6241 Internet: ham://deq.nc.00viabouUdivisionslwater-resources/water•resources-data/water-sciences-home-page/laboratory-certification branch LABORATORY NAME: NPDES PERMIT#: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): Town of Ansonville WWTP NCO081825 8778 US Hwy. 52 N Ansonville, NC 28007 5242 September 27, 2017 Field Municipal Maintenance Tonja Springer LOCAL PERSON(S) CONTACTED: Dianna McLaughlin I. INTRODUCTION: 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 environmental samples. II. GENERAL COMMENTS: The inspection was requested by the Fayetteville Regional Office of the NC Department of Environmental Quality (NCDEQ) Division of Water Resources due to concerns about the lack of supporting documentation. The lack of supporting documentation is a violation of 15A NCAC 02B .0506 (a)(1)(D) which states: "In order to document information contained in reports submitted to the Director pursuant to this Section, the owner of each pollution control facility is required to retain or have readily available for inspection by the Division, the following items for a period of at least three years from report submission: (i) the original laboratory reports from any certified laboratory utilized for sample analysis. Such reports must be signed by the laboratory supervisor, and must indicate the date and time of sample collection and analysis, and the analysts' name; (ii) bench notes and data logs for sample analyses performed by the pollution control facility staff or operator in responsible charge, whether or not the facility has a certified lab; and (iii) copies of all process control testing" and 15A NCAC 2H .0805 (g) (1) which states: "Data pertinent to each analysis must be maintained for five years". The laboratory analyst was forthcoming and receptive, and worked quickly to begin implementing the necessary changes in response to the Findings and Recommendations made during the inspection. All required Proficiency Testing (PT) Samples have been analyzed for the 2017 PT Calendar Year and the graded results were 100% acceptable. Contracted analyses are performed by Environment, Inc. (Certification #10). Page 2 #5242 Town of Ansonville WWTP Current Quality Assurance Policies for Field Laboratories and Approved Procedure documents for the analysis of the facility's currently certified Field Parameters were provided at the time of the inspection. Requirements that reference 15A NCAC 2H .0805 (g) (1), stating "Data pertinent to each analysis must be maintained for five years. Certified Data must consist of date collected, time collected, sample site, sample collector, and sample analysis time. The field benchsheets must provide a space for the signature or initials of the analyst and proper units of measure for all analyses", are intended to be a requirement to document all pertinent information for historical reconstruction of data. It is not intended to imply that existing records are not adequately maintained unless the Finding speaks directly to that. The laboratory requested deletion of Dissolved Oxygen (DO) by Standard Methods 4500 O G- 2001 from their Certified Parameters Listing (CPL) during the audit since monitoring for this parameter is not required on their National Pollutant Discharge Elimination System (NPDES) permit. This request was processed on October 16, 2017 with an effective date of September 27, 2017. III. FINDINGS REQUIREMENTS COMMENTS AND RECOMMENDATIONS: Proficiency Testing A. Finding: The preparation of 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: Dating and initialing the instruction sheet for the preparation of the Total Residual Chlorine (TRC) PT Sample would satisfy the documentation requirement. B. Finding: The laboratory is not analyzing PT Samples in the same manner as routine Compliance Samples. 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. Ref: Proficiency Testing Requirements, May 31, 2017, Revision 2.0. Page 3 #5242 Town of Ansonville WWTP Comment: The laboratory was analyzing pH PT samples multiple times and reporting an average of all results. Compliance samples are not analyzed and reported in this manner. Comment: The laboratory's common practice was to analyze a known standard along with the PT Sample as additional QC. Since this is not performed with all Compliance Samples, it is considered additional QC. However, additional QC is recommended when analyzing remedial PT Samples as part of the troubleshooting and corrective action process. C. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. 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. Ref: Proficiency Testing Requirements, May 31, 2017, Revision 2.0. Comment: The analysis of PT samples is designed to evaluate the entire process used to routinely report environmental analytical results; therefore, PT samples must be analyzed and the process documented in the same manner as Compliance Samples. Comment: PT results are documented directly on PT vendor reporting forms, which are kept in a file dating back to 2010. Documentation D. Finding: The laboratory needs to increase the traceability documentation of purchased materials and reagents. Requirement: All chemicals, reagents, standards and consumables used by the laboratory must have the following information documented: Date Received, Date Opened (in use), Vendor, Lot Number, and Expiration Date. Consumable materials such as pH buffers and lots of pre -made standards are included in this requirement. Ref: Quality Assurance Policies for Field Laboratories. Please submit a copy of the traceability documentation with the report reply. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Comment: There is no traceability documentation for pH buffers or Total Residual Chlorine DPD reagents. Comment: A reagent log was provided at the time of the inspection. An email was received on October 11, 2017 indicating that the lab is now documenting a system of Page 4 #5242 Town of Ansonville WVVfP traceability for all chemicals, reagents, standards and consumables using the reagent log provided after the inspection. Supporting documentation was not submitted. E. Finding: All original records are not being maintained for five years. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Comment: Benchsheets for June 1 thru July 27, 2017 were submitted to the auditor for review prior to the inspection. Based on the feedback provided to the laboratory, the analyst believed the benchsheets were not valid, discarded them all and discontinued their use on future analyses beginning August 23, 2017. Comment: Between August 23, 2017 and the inspection, testing data was written on a piece of paper, transported back to the laboratory, and transferred onto the electronic Discharge Monitoring Report (eDMR). The original paperwork was then discarded. Temperature — Standard Methods, 2550 B-2000 (Aqueous) F. Finding: The temperature sensor on the pH meter used to obtain reported temperature values has not been checked against a National Institute of Standards and Technology (NIST) traceable thermometer every 12 months. Requirement: All thermometers and temperature measuring devices used for compliance monitoring must be checked every 12 months against a NIST traceable temperature measuring device and the process documented. NIST traceable temperature measuring devices used for this verification must have a stated accuracy of at least ± 0.5 °C. The thermometer/meter readings on the meter being checked must be less than or equal to 0.5°C from the NIST traceable temperature measuring device reading. The calibration verification documentation must include the serial number of the thermometer/meter being checked and the NIST traceable temperature measuring device that was used in the comparison. Document the verification data and keep on file. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: There were no records to show that the temperature sensor check has ever been performed. Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous) Recommendation: It is recommended to use volumetric glass pipettes when making the five - standard annual calibration verification curve. The disposable pipettes may not provide the accuracy required for standard preparation at the parts per billion (ppb) level. Recommendation: It is recommended that a lint -free product be used to wipe the gel standards and sample cells to remove any fingerprints. Toilet tissue may scratch or leave fibers on the cell which may interfere with accurate measurements. G. Finding: The meter is not being zeroed with a calibration blank each day samples are analyzed. Requirement: Analyze a calibration blank to zero the instrument and analyze a check standard each day that samples are analyzed. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Page 5 #5242 Town of Ansonville WV TP Comment: The laboratory was zeroing the meter with a sample even though there was no color or turbidity interference. Comment: The gel standard blank can be used as the calibration blank. H. Finding: The calibration curve is not verified with a check standard each day that samples are analyzed. Requirement: When a five -standard annual standard curve verification is used, the laboratory must check the calibration curve each analysis day. To do this, the laboratory must analyze a calibration blank to zero the instrument and analyze a check standard each day that samples are analyzed. The value obtained for the check standard must read within 10% of the true value of the check standard. If the obtained value is outside of the ±10% range, corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Comment: A check standard was being analyzed and documented prior to August 23, 2017. I. Finding: The laboratory is not analyzing a reagent blank with prepared standards. Requirement: Reagent Blank: A reagent blank (sometimes also referred to as a method blank) is only required when laboratory water is used to make quality control and/or calibration standards. If you are using a sealed standard (e.g., gel) for your daily check standard, a reagent blank would only be analyzed when preparing the annual 5- point calibration curve or 5 annual calibration curve verification standards. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Comment: A reagent blank is made from the same laboratory water source used to make QC and/or calibration standards with DPD. The concentration of reagent blanks must not exceed 50% of the reporting limit (i.e., the lowest calibration or calibration verification standard concentration), unless otherwise specified by the reference method, or corrective action must be taken. Comment: A reagent blank was not analyzed when the annual 5-point curve verification standards were prepared. J. Finding: The laboratory is not verifying the Gel® Standard concentration every 12 months. Requirement: Purchased "Gel -type" or sealed liquid ampoule standards may be used for daily standard curve verification only. These standards must be verified initially and every 12 months thereafter, with the standard curve. When this is done, these standards may be used after the manufacturer's expiration date. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Please submit a copy of the Gel® Standard verification with the report reply. Comment: The Gel® Standard had not been verified since it was verified initially. At the time of the inspection the gel standard was read 3 times and a true value assigned. Recommendation: A five -standard annual verification curve was analyzed on July 5, 2017 in the range of 25, 50, 100, 200, 400 pg/L. It is recommended that the curve be reanalyzed with a range of 25, 30, 50, 200, 400 pg/L and the Gel® Standard be verified Page 6 #5242 Town of Ansonville WWTP against the new curve and assigned a true value. This will put both the annual verification and gel verification on the same schedule which will be easier to remember. Some commercial laboratory facilities may be able to provide assistance with the field photometric meter curve verifications. K. Finding: Values less than the established reporting limit are being reported on the eDMR. Requirement: The concentrations of the calibration standards must bracket the concentrations of the samples analyzed. One of the standards must have a concentration equal to or below the lower reporting concentration for Total Residual Chlorine. The lower reporting limit must be less than or equal to the permit limit. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Comment: The facility's permit limit is 28 pg/L. The laboratory currently has established a lower reporting limit of 25 pg/L by having verified that concentration when verifying the latest calibration curve. Values with concentrations less than 25 pg/L must be reported as "< 25 pg/U on the eDMR. IV. PAPER TRAIL INVESTIGATION: No paper was trail performed since there were no benchsheets. Comment: The lack of supporting documentation for data reported on an eDMR could give the perception of falsified data. Falsified data or information is defined in NC Administrative Code 15A NCAC 02H .0803 (6) as "data or information which has been made untrue by alteration, fabrication, omission, substitution, or mischaracterization". 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 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: Tonja Springer Date: October 17, 2017 Report reviewed by: Beth Swanson Date: October 19, 2017 \ ( / z ( G 4 \z \ / OD 0 \ \ / j / \ \ \ cr c / u o / \ G ° 0 § u o \LLj } \ j n § 0 / / \ ) \ / £