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HomeMy WebLinkAbout#667_1218_FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: Laboratory Name: Inspection Type: Inspector Name(s): Inspection Date: Date Report Completed: Date Forwarded to Reviewer: Reviewed by: Date Review Completed: Cover Letter to use: Unit Supervisor/Chemist III: Date Received: Date Forwarded to Linda: Date Mailed: Crvl 667 Pace Analytical Services, Inc. — Ormond Beach FL Maintenance/Abbreviated/Desk Audit Dana Satterwhite, Gary Francies Roy Byrd 11/20/2015 — 12/18/2015 01 /08/2016 01 /08/2016 Gary Francies 1 /22/2016 ❑ Insp. Initial ❑ Insp. No Finding ❑ Corrected ® Insp. Reg. ❑ Insp. CP ❑ Insp. Reg. Delay Dana Satterwhite 1 /22/2016 1 /25/2016 1 /26/2016 — / r t c (l PAT MCCRORY r, dtrPt f $fl T Water Resources LNVIRONM ENI AL QUALIT Y January 27, 2016 667 Ms. Lynn Baylor Pace Analytical Services - Florida 8 E Tower Circle Ormond Beach, FL 32174 DONALD R. VAN DER VAART S. JAY ZIMMERMAN it ...�,. Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Baylor: Enclosed is a report for the inspection performed on January 8, 2016 by Dana Satterwhite, Gary Francies and Roy Byrd. 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. 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. Attachment cc: Beth Swanson Gary Francies f S.mcerely, �- E � Dana Sklerwhite'/ r Environmental Program Supervisor III NC WW/GW Laboratory Certification Branch 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: 919-733-3908t. FAX:919-733-6241 Internet: In .1/portaimcdenr.org/web/wg/iab/cent On -Site Inspection Report LABORATORY NAME: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: INTRODUCTION: Pace Analytical Services, Inc. 8 E Tower Circle Ormond Beach, FL 32174 667 November 20, 2015 — 12/18, 2015 Maintenance/Abbreviated/Desk Audit Dana Satterwhite, Gary Francies, Roy Byrd Mr. Barry Johnson 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. GENERAL COMMENTS: This was an abbreviated audit performed at the request of the Division of Water Resources and was limited to data for the following Pace Project Numbers: 92261557, 92265303, 92260963 and 92265356. The laboratory sent complete data packages which included raw data [i.e., instrument printouts and/or benchsheets] including associated calibration curves, associated digestion logs, chain of custody records, method detection limit study summaries and standard operating procedures. Proficiency Testing (PT) samples have been analyzed for all certified parameters. The laboratory has fulfilled its PT requirements for the 2015 proficiency testing calendar year. Contracted analyses were performed by Pace Analytical Services, Inc. — Minneapolis, MN (Certification #530) and Pace Analytical Services, Inc. —Asheville, NC (Certification #40). The laboratory is reminded that any time changes are made to laboratory operations; the laboratory must update the Quality Assurance (QA)/Standard Operating Procedures (SOP) document(s). Any changes made in response to the 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 approved practice and regulatory requirements. In some instances, the laboratory may need to create a SOP to document how new functions or policy will be implemented. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Standard Operating Procedures (SOPs) Recommendation: It is recommended that all SOPs be reviewed and evaluated for use of the word "should". SOPs are intended to describe procedures exactly as they are to be performed. While some uses of the word "should" versus "must" are noted in Finding A, not all have been listed in this report. Page 2 #667 - Pace Analytical Services, Inc. A. Finding: An inconsistency and/or omission was noted between the Standard Operating Procedure (SOP) and laboratory practice as follows: The SOP does not describe in detail how the method is performed. Determination of Hexavalent Chromium by EPA 218.7 SOP SOP# S-FL-1-050-rev.07 - Section 4 - The SOP does not describe mitigation and/or corrective actions for the interferences listed. SOP# S-FL-1-050-rev.07 - Section 9.4 - The SOP lists 1000 mM Ammonium Hydroxide. It appears that this should be 100 mM Ammonium Hydroxide. SOP# S-FL-1-050-rev.07 - Section 9.6 - The SOP lists the concentration of the Chromium Stock standard as 10000 mg/L. It appears it should be 1000 mg/L. SOP# S-FL-1-050-rev.07 - Section 9.6 - The SOP lists the amount of Potassium Dichromate (K2Cr2O7) as 0.238 g. It appears it should be 0.283 g. SOP# S-FL-1-050-rev.07 - Section 12.5 - Evaluate the use the of word "should" in this section. 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). Please submit updated SOPs with the items listed above addressed by April 30, 2016. B. Finding: Spike preparation is not recorded accurately. 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 Florida Benchsheet Checklist (e.g., Pace Project Number 92265356) lists the amount of matrix spiking solution used as 0.25 ml for the 25 ng/L spike and 0.75 ml for the 75 ng/L spike. It appears the amounts used should be 0.025 ml and 0.075 ml, respectively. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, chain - of -custody forms, etc.) and client reports. Data were reviewed for the following Pace Project Numbers: 92261557, 92265303, 92260963 and 92265356. 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 recommendation will help this lab to produce quality data and meet certification requirements. The inspector would like to thank the staff for its assistance during the inspection. Please respond to all Findings and include an implementation date for each corrective action. Report prepared by: Dana Satterwhite Date: 1/8/2016