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Home My WebLink About#5390 12-Final INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5390 Laboratory Name: LTH3 Operations Inspection Type: Field Maintenance Inspector Name(s): Jeffrey R. Adams Inspection Date: July 30, 2012 Date Report Completed: August 10, 2012 Date Forwarded to Reviewer: August 10, 2012 Reviewed by: Chet Whiting Date Review Completed: August 13, 2012 Cover Letter to use: Insp. Initial X Insp. Reg. Insp. No Finding Insp. CP __ Corrected Unit Supervisor: Dana Satterwhite Date Received: August 15, 2012 Date Forwarded to Linda: August 27, 2012 Date Mailed: August 27, 2012 _____________________________________________________________________ On-Site Inspection Report LABORATORY NAME: LTH3 Operations NPDES PERMIT #: NC0037869; NC0056731; NC0042803 ADDRESS: 4620 Reigal W ood Road Durham, NC 27712 CERTIFICATE #: 5390 DATE OF INSPECTION: July 30, 2012 TYPE OF INSPECTION: Field Maintenance AUDITOR(S): Jeffrey R. Adams LOCAL PERSON(S) CONTACTED: Thomas Harden I. INTRODUCTION: This laboratory was inspected 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 not been analyzed for all certified parameters for the 2012 calendar year. The laboratory obtained unacceptable PT results for Total Residual Chlorine. A remedial PT is due by September 21, 2012. The laboratory was given a packet containing North Carolina Laboratory Certification quality control requirements and policies during the inspection. The requirements associated with Findings A, B, C and F are new policies that have been implemented by our program since the last inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: 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 Page 2 #5390 LTH3 Operations standards are included in this requirement. Ref: Quality Assurance Policies for Field Laboratories. Comment: The laboratory had no documentation showing when pH buffers and Total Residual Chlorine DPD reagents were received and opened (or put in use). Proficiency Testing B. 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. C. Finding: The laboratory is not documenting Proficiency Testing (PT) sample analyses in the same manner as environmental samples (i.e., 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. Dissolved Oxygen – Standard Methods, 18th Edition, 4500 O G D. Finding: The DO probe was being stored in a dirty storage well. Requirement: A best effort must be made to perform analyses in a manner where possible sources of contamination or error will not be introduced. Ref: Quality Assurance Policies for Field Laboratories. Comment: The instrument has a convenient calibration/storage chamber built into the instrument’s side. This chamber provides an ideal storage area for the probe during transport and extended non- use. If you look into the chamber, you will notice a small round sponge in the bottom. Carefully add 3 to 6 drops of clean water into the sponge. Turn the instrument over and allow any excess water to drain out of the chamber. The wet sponge creates a 100% water saturated environment for the probe which is ideal for dissolved oxygen calibration. To keep the probe from drying out, store the probe in the calibration/storage chamber with the wet sponge. Ref: YSI Operators Manual Sections 3.4 and 4.5 (8). YSI 1/07. Comment: If the membrane is coated with oxygen consuming (e.g., bacteria) or oxygen evolving organisms (e.g., algae), erroneous readings may occur. Ref: YSI Operators Manual Section 4.5 (2). YSI 1/07. Recommendation: It is recommended that a light colored sponge be used in the storage chamber to discern cleanliness. Total Residual Chlorine – Standard Methods, 18th Edition, 4500 Cl G Page 3 #5390 LTH3 Operations Comment: The laboratory is using an instrument that is no longer in production, and the manufacturer is no longer in business. This means that technical support is no longer offered. It is recommended that the laboratory consider obtaining another instrument for analyzing Total Residual Chlorine of its effluent. E. Finding: The annual calibration curve verification does not bracket the concentration of the annual Proficiency Testing (PT) samples. 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. Ref: Approved Procedure for the Field Analysis of Total Residual Chlorine. Recommendation: It is recommended that the laboratory verify the internal calibration using the concentrations: 15, 20, 50, 200 and 400 µg/L. This will verify the analytical range used to measure Proficiency Testing (PT) samples as well as environmental samples. Comment: The assigned value of the PT sample was 232 µg/L. The laboratory’s curve consisted of the following concentrations: 15, 25, 50, 100 and 200 µg/L. F. Finding: The laboratory is reporting the Total Residual Chlorine values on the DMR as < 50 µg/L. Requirement: Facilities will still be required to report actual results on their monthly DMR submittals, but for compliance purposes all TRC values below 50µg/L will be treated as zero. For example, if the facility has a limit of 17 µg/L and reports a TRC value of 40 µg/L on the DMR, this value will be considered complaint under this new policy. Ref: Total Residual Chlorine Compliance Memo dated May 1, 2008 to NPDES Permittees from NC DWQ Point Source Branch Supervisor, Matt Matthews. A copy of this memo is enclosed with this report. Comment: The instrument was verified to 15 µg/L so actual values will be reported down to that level. Any values below that concentration will be reported as <15 µg/L. Temperature – Standard Methods, 18th Edition, 2550 B G. Finding: The temperature sensors on the pH and DO meters used to obtain reported temperature values has not been checked every 12 months against a NIST thermometer. Requirement: Thermometers and temperature measuring devices, used to measure temperature for compliance monitoring, must be checked every 12 months against a NIST traceable thermometer. The thermometer/meter readings must be less than or equal to 1ºC from the NIST traceable thermometer reading. The documentation must include the serial number of the NIST traceable thermometer that was used in the comparison. Document any correction that applies on both the thermometer/meter and on a separate sheet to be filed. Ref: Approved Procedure for Field Analysis of Temperature. Please submit a copy of the sensor checks with the response to this report. H. Finding: The laboratory’s National Institute of Standards and Technology (NIST) traceable thermometer (H-B S/N #0559506) calibration expired on June 16, 2011. Requirement: NIST traceable thermometers used to verify the calibration of other thermometers or temperature sensors (i.e., limited use only) must be recalibrated in Page 4 #5390 LTH3 Operations accordance with the manufacturer’s recalibration date. If no recalibration date is given, the NIST traceable thermometer must be recalibrated every 5 years. Ref: Approved Procedure for Field Analysis of Temperature. Please submit documentation of the calibration verification with the response to this report. Comment: This thermometer is used to verify the calibration of the temperature sensors used to report temperature for compliance monitoring. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing field testing records and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Quality. Data were reviewed for LTH3 Operations for Arbor Hill MHP (NPDES permit #NC0037869); Grande Oaks (NPDES permit NC0056731 and Birchwood MH & RV Park (NPDES #NC0042803) for March, April and May, 2012. The following error was noted: Grande Oaks WWTP NPDES #NC0056731 Date Parameter Location Value on Benchsheet *Contract Data Value on DMR 5/3/12 BOD Effluent * 2.5 mg/L < 2.5 mg/L 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 10, 2012 Report reviewed by: Chet Whiting Date: August 13, 2012