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Home My WebLink About#5322 12-Final INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5322 Laboratory Name: John Poteat Inspection Type: Field Commercial Maintenance Inspector Name(s): Jeffrey R. Adams Inspection Date: August 16, 2012 Date Report Completed: August 22, 2012 Date Forwarded to Reviewer: August 22, 2012 Reviewed by: Jason Smith Date Review Completed: August 27, 2012 Cover Letter to use: Insp. Initial X Insp. Reg. Insp. No Finding Insp. CP __ Corrected Unit Supervisor: Dana Satterwhite Date Received: August 29, 2012 Date Forwarded to Linda: October 19, 2012 Date Mailed: October 22, 2012 _____________________________________________________________________ On-Site Inspection Report LABORATORY NAME: John Poteat NPDES PERMIT #: NC0042285; NC0043559 ADDRESS: P.O. Box 16474 Chapel Hill, NC 27516 CERTIFICATE #: 5322 DATE OF INSPECTION: August 16, 2012 TYPE OF INSPECTION: Field Commercial Maintenance AUDITOR(S): Jeffrey R. Adams LOCAL PERSON(S) CONTACTED: John Poteat 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 laboratory was clean and records were well organized; however, some quality control procedures need to be implemented. Proficiency Testing (PT) samples have been analyzed for all certified parameters for the 2012 proficiency testing calendar year. Current quality assurance policies for Field laboratories and approved procedures for the analysis of the facility’s currently certified parameters were provided at the time of the inspection. The requirements associated with Findings A, B, C and D are new policies that have been implemented by our program since the last inspection. Contracted analyses are performed by Pace Analytical, Inc. (Certification #67). III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: General Recommendation: In order to improve the quality of the data being reported, it is recommended that the laboratory expand their data verification system to include a technical peer review process to check for accuracy and completeness of data on laboratory benchsheets and Discharge Monitoring Report (DMR) forms. Steps must be taken to minimize and correct errors in calculations and may include checks for the following: transcription errors, errors of omission, calculation errors, correct application of dilution factors, etc. The transcription errors noted in the Paper Trail Investigation section of this report, underscore the importance of this type of technical peer review process. Page 2 #5322 John Poteat Traceability A. Finding: The laboratory needs to increase the 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. A system (e.g., traceable identifiers) must be in place that links standard/reagent preparation information to analytical batches in which the solutions are used. Documentation of solution preparation must include the analyst’s initials, date of preparation, the volume or weight of standard(s) used, the solvent and final volume of the solution. This information as well as the vendor and/or manufacturer, lot number, and expiration date must be retained for chemicals, reagents, standards and consumables used for a period of five years. Consumable materials such as pH buffers and lots of pre-made standards are included in this requirement. Ref: Quality Assurance Policies for Field Laboratories. Proficiency Testing B. Finding: The laboratory is not analyzing Proficiency Testing (PT) samples in the same manner as environmental samples. Requirement: 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 and any other samples analyzed according to the requirements of 15A NCAC 2H .0800. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: The laboratory’s common practice was to analyze a known standard along with the PT sample as additional quality control. C. Finding: The preparation of Proficiency Testing (PT) samples is not documented. Requirement: PT samples received as ampules must be diluted according to the PT provider’s instructions. The preparation of PT samples must be documented in a traceable log or other traceable format. The diluted PT sample becomes a routine environmental sample and is added to a routine sample batch for analysis. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. D. Finding: The laboratory is not documenting Proficiency Testing (PT) sample analyses in the same manner as environmental samples (e.g., on a laboratory benchsheet or field notebook). Requirement: All PT sample analyses must be recorded in the daily analysis records as for any environmental sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: There was no supporting documentation of the PT analyses. Only a copy of the electronic data submittal to the PT vendor was retained, as required. Temperature – Standard Methods, 18th Edition, 2550 B E. Finding: The alcohol in the National Institute of Standards and Technnology (NIST) traceable thermometer, used for verifying temperature sensors on the DO instruments used to obtain reported temperature values, was separated and was not measuring accurately. Page 3 #5322 John Poteat Requirement: Each facility must have glassware, chemicals, supplies, equipment, and a source of distilled or deionized water that will meet the minimum criteria of the approved methodologies. Ref: 15A NCAC 02H .0805 (g) (4). Please perform temperature sensor verification checks with an appropriate NIST traceable thermometer for each instrument and submit copies of the documentation with the response to this report. F. Finding: There was no documentation confirming when the NIST traceable thermometer was calibrated, therefore, NIST traceability cannot be confirmed. Requirement: NIST traceable thermometers used to verify the calibration of other thermometers or temperature sensors (i.e., limited use only) must be recalibrated in accordance with the manufacturer’s recalibration date and the process documented. If no recalibration date is given, the NIST traceable thermometer must be recalibrated every 5 years. Ref: NC WW/GW LC Approved Procedure for Field Analysis of Temperature. Please submit documentation of the NIST traceability for the thermometer that will be used to verify the DO meter temperature sensors with the response to this report. Comment: The laboratory may either have this thermometer calibrated to NIST traceable specifications or a new thermometer may be obtained and a copy of the certificate of NIST traceability submitted with the response to this report. Total Residual Chlorine – Standard Methods, 18th Edition, 4500 Cl G G. Finding: The laboratory is not verifying the instruments’ internally stored curves every 12 months. Requirement: Analyze a water blank to zero the instrument and then analyze a series of five standards. The curve verification must check 5 concentrations (not counting the blank) that bracket the range of the samples to be analyzed. This type of curve verification must be performed at least every 12 months. The values obtained must not vary by more than 10% of the known value for standard concentrations greater than or equal to 50 g/L and must not vary by more than 25% of the known value for standard concentrations less than 50 g/L. The overall correlation coefficient of the curve must be ≥0.995. Ref: NC WW/GW LC Approved Procedure for Field Analysis of Total Residual Chlorine. Please submit calibration verification curves for each instrument with the response to this report. Recommendation: It is recommended that the laboratory verify the internal calibration using the concentrations: 10, 20, 50, 200 and 400 µg/L. This will verify the analytical range used to measure Proficiency Testing (PT) and environmental samples, demonstrate accuracy at or below client permit limits and allow the use of the 0.20 mg/L (i.e., 200 µg/L) Gel Standard as the midrange daily check standard. Comment: The laboratory is using 2 different Hach DR-2800 instruments. Each instruments’ internal calibration curve must be verified every 12 months. Documentation showed the last time either instrument was verified was on November 20, 2009. H. Finding: The lab is reporting results less than the lower reporting concentration from the last verified calibration curve for Total Residual Chlorine on the monthly Discharge Monitoring Reports (DMRs). Page 4 #5322 John Poteat Requirement: The concentrations of the calibration standards or calibration verification 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. Ref: NC WW/GW LC Approved Procedure for Field Analysis of Total Residual Chlorine. Comment: Currently, all values greater than 1.0 µg/L are reported on the Discharge Monitoring Report (DMR). Any sample concentration lower than 1.0 µg/L is being reported as <1.0 µg/L on the DMR. The lowest concentration used to verify the calibration curve is 10 µg/L; therefore, results less than 10 µg/L must be reported as “<10 µg/L” in the daily cells on the DMR. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing field testing records and contract lab reports to DMRs submitted to the North Carolina Division of Water Quality. Data were reviewed for The Trails Subdivision (NPDES permit #NC0042285) and Fearrington Village WWTP (NPDES permit #NC0043559) for April, May and June, 2012. The following reporting errors were noted: The Trails Subdivision permit #NC0042285 Date Parameter Location Value on Benchsheet *Contract Data Value on DMR 4/5/12 Fecal Coliform Effluent *<2 2 4/12/12 Fecal Coliform Effluent *<2 2 6/14/12 Fecal Coliform Effluent *<2 2 6/21/12 Fecal Coliform Effluent *<2 2 6/28/12 Fecal Coliform Effluent *<2 2 Fearrington Village WWTP permit #NC0043559 Date Parameter Location Value on Benchsheet *Contract Data Value on DMR 4/12/12 Total Kjeldahl Nitrogen Effluent *<0.25 mg/L 0.25 mg/L 4/20/12 Ammonia Effluent *<0.08 mg/L 0.008 mg/L 5/3/12 Total Kjeldahl Nitrogen Effluent *<0.25 mg/L 0.25 mg/L 5/17/12 Total Kjeldahl Nitrogen Effluent *<0.25 mg/L 0.25 mg/L 6/6/12 Fecal Coliform Effluent *15 CFU/100 ml 16 CFU/100 ml 6/8/12 Total Residual Chlorine Effluent 19 µg/L 21.9 µg/L Comment: The lab is not calculating the geometric mean for fecal coliform and the monthly averages for the other permitted parameters correctly. This was noted for the following parameters at each permitted location for the month of June, 2012: Page 5 #5322 John Poteat The Trails Subdivision Fearrington Village WWTP BOD BOD Ammonia Nitrogen Ammonia Nitrogen Fecal Coliform Fecal Coliform Total Suspended Residue Total Suspended Residue pH (should not report a monthly average for pH) All averages are to be calculated as the arithmetic mean of the recorded values with the exception of that of Fecal Coliform, which is to be calculated as a geometric mean. It was also noted that values with a “less than” sign were reported in the “average” field on the DMR. Comment: For calculation purposes only, recorded values of less than a detectable limit (< #.##) may be considered to equal zero (0) for all parameters except Fecal Coliform, for which values of "less than" may be considered to be equal to one (1). Therefore, if all monthly values are “less than” values, the monthly arithmetic average would be “zero”. Values of results which are less than a detectable limit should be reported in the daily cells using the "less than" symbol (<) and the detectable limit used during the testing (or the value with appropriate unit conversion). Please note there is never a case when an average would need to be recorded along with a "less than" symbol. Instructions for completing a DMR and calculation of data (i.e., NC DWQ NPDES Permitting Guidance for DMR Calculations and Directions for Completing Monthly Discharge Monitoring Reports) can be found at http://portal.ncdenr.org/web/wq/swp/ps/npdes/forms under Compliance Forms. Comment: Additionally, the units of measure and parameter codes were not always documented in the column headers for each parameter on the DMR. All data values must be accompanied by corresponding units of measurement, noted at the top of the data column for the particular parameter. If your permit contains a numeric limit for any parameter, then the reporting units must be the same units of measurement of that limit. Parameter codes for the more commonly monitored parameters can be found on the back of form MR-1 or MR-1.1. A complete list of parameter codes can be found on the NPDES website. In order to avoid questions of legality, it is recommended that you contact the appropriate Regional Office for Guidance as to whether an amended Discharge Monitoring Report will be required. A copy of this report will be made available to the Regional Office. V. CONCLUSIONS: Correcting the above-cited findings and implementing the recommendations 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 and data review process. Please respond to all findings. Report prepared by: Jeffrey R. Adams Date: August 22, 2012 Report reviewed by: Jason Smith Date: August 27, 2012