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INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 5301
Laboratory Name: Village of Bald Head Island, Utilities Dept.
Inspection Type: Field Maintenance
Inspector Name(s): Todd Crawford
Inspection Date: July 13, 2011
Date Report Completed: July 18, 2011
Date Forwarded to Reviewer: July 18, 2011
Reviewed by: Jeff Adams
Date Review Completed: July 18, 2011
Cover Letter to use: Insp. Initial Insp. Reg. Insp. No Finding X Insp. CP corrected
Unit Supervisor: Dana Satterwhite
Date Received: July 20, 2011
Date Forwarded to Linda: August 18, 2011
Date Mailed: August 18, 2011
_____________________________________________________________________
LABORATORY NAME: Village of Bald Head Island, Utilities Dept.
NPDES PERMIT #: WQ0000193 and NC0085553
ADDRESS: P.O. Box 3009
Bald Head Island, NC 28461
CERTIFICATE #: 5301
DATE OF INSPECTION: July 13, 2011
TYPE OF INSPECTION: Field Municipal Maintenance
AUDITOR(S): Todd Crawford
LOCAL PERSON(S) CONTACTED: David Suther and Mike Fishburn
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 facility has all the equipment necessary to perform the analyses. Improvements in documentation
and peer review are needed.
A description of current field lab policies and technical assistance documents for the analysis of the
facility’s currently certified parameters as well as Discharge Monitoring Report (DMR) calculations and
reporting guidance were provided at the time of the inspection.
The requirements associated with Findings A and D are new policies that have been implemented by
our program since the last inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
General Laboratory
Comment: The facility had recently acquired a new permit (NC0085553) which requires the
temperature to be reported. The facility was reporting the temperature without certification. The North
Carolina Administrative Code, 15A NCAC 2H .0804 (a) states: Commercial, Municipal, Industrial and
Other facilities are required to obtain certification for field parameters which will be reported by the
client to comply with State surface water, groundwater, and pretreatment Rules. An amendment form
was filled out during the inspection to add Temperature to the list of certified parameters. No further
response is necessary for this finding.
Documentation
A. Finding: The laboratory needs to increase the documentation of purchased materials and
reagents, as well as, documentation of standards and reagents prepared in the laboratory.
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
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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.
B. Finding: Numbers are being improperly rounded.
Requirement: Rounding off by dropping digits that are not significant. If the digit 6, 7, 8, or 9
is dropped, increase the preceding digit by one unit; if the digit 0, 1, 2, 3, or 4 is dropped, do not
alter the preceding digit. If the digit 5 is dropped, round off the preceding digit to the nearest
even number: thus 2.25 becomes 2.2 and 2.35 becomes 2.4. Ref: Standard Methods, 21st
Edition, 1050 B. (2).
Comment: Numbers ending with a 5 were always rounded up and more often than not,
numbers were rounded by simply dropping the last number, and were done so with no
adjustment to the preceding number at all.
C. Finding: Proficiency Testing (PT) samples were not documented in the same manner as
routine environmental samples.
Requirement: 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 environmental samples. Ref: Quality
Assurance Policies for Field Laboratories.
Quality Control
Comment: All three pH buffer solutions were past their expiration dates. Two of them expired in
March, 2011 and one expired in May, 2011. The Quality Assurances Policies for Field Laboratories
document states that: Adherence to manufacturer expiration dates is required. Chemicals, reagents,
standards, consumables exceeding the expiration date can no longer be considered reliable. If the
expiration is only listed as a month and year (with no specific day of the month), t he last day of the
month will be considered the actual date of expiration. Monitor materials for changes in appearance or
consistency. Any changes may indicate potential contamination and the item should be discarded even
if the expiration date is not exceeded. If no expiration date is given, the laboratory must have a policy
for assigning an expiration date. If no date received or expiration date can be determined, the item
should be discarded. An order for new pH buffers had already been placed before the inspection but
had not been received yet. The new buffers are now being used. No further response is necessary
for this finding.
D. Finding: The temperature sensing device on the Dissolved Oxygen and pH meter has not been
calibrated against an National Institute of Standards and Technology (NIST) certified or
traceable thermometer annually (every 12 months). Cited previously on 04/17/06.
Requirement: All temperature sensing devices on meters must be calibrated against a NIST
certified or NIST traceable thermometer annually (every 12 months) and proper corrections
made and documented. The meter reading must be less than 1ºC from the NIST certified
reading to be acceptable. Document the serial number and manufacturer of the NIST
thermometer that was used in the comparison. Document any correction that applies (even if z
ero) on both the meter and on a separate sheet to be filed. Ref: Technical Assistance for Field
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Analysis of Dissolved Oxygen and Technical Assistance for Field Analysis of pH. Please send a
copy of the temperature sensor check documentation with your response.
Residue, Settleable – Standard Methods, 21st Edition, 2540 F
E. Finding: The reporting limit is being incorrectly reported as <0.5 ml/L on the DMR.
Requirement: The reporting limit is determined by the graduations on the Imhoff cone, which
has markings down to 0.1 ml. Actual results should be reported down to 0.1 ml/L. Results,
which fall below 0.1ml/L, must be reported as <0.1ml/L. Ref: Technical Assistance for Field
Analysis of Settleable Solids.
Dissolved Oxygen – Standard Methods, 21st Edition, 4500 O G
Recommendation: Samples must be analyzed within 15 minutes (40 CFR Part 136 Table II); however,
immediate analysis is recommended due to the unstable nature of dissolved oxygen samples. Ref:
Technical Assistance for Field Analysis of Dissolved Oxygen.
Temperature – Standard Methods, 21st Edition, 2550 B
F. Finding: Temperature measurements are not being made directly in the influent stream and
are therefore not within the required holding time.
Requirement: Analyze. Ref: Code of Federal Regulations, Title 40, Part 136; Federal Register
Vol. 72, No. 47, March 12, 2007; Table II.
Comment: The description of the holding time in the Code of Federal Regulations as “analyze”
infers that the measurement must be taken immediately, in the source.
G. Finding: The analysis time is not being documented.
Requirement: 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 bench sheets must provide a space for the signature or initials of the
analyst, and proper units of measure for all analyses. Ref: 15A NCAC 02H .0805 (g) (1).
Comment: Only the collection time is being documented and that is done on the Chain of
Custody (COC) form that is sent to the contract lab with subcontracted samples. The temperature
reading on the COC does not indicate that temperature reading was taken in the effluent stream.
Temperature readings must be taken directly in the effluent stream and that analysis time and
temperature reading be documented on a laboratory benchsheet. A blanket statement may be
used to indicate that reading was taken “in-situ”, in which case only an analysis time need be
documented.
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 NPDES permit #s WQ0000193 and NC0085553 for March, April and May, 2011. No
errors were detected for permit #NC0085553. The following errors were noted for permit
#WQ0000193:
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Sample Date Parameter Location Value on Benchsheet Value on DMR
02/08/11 pH Effluent 6.7 S.U. 3.7 S.U.
02/09/11 Ammonia Effluent <0.2 mg/L 0.02 mg/L
03/10/11 pH Effluent 5.44 S.U. 6.8 S.U.
03/30/11 Settleable Matter Effluent No Data <0.5 mg/L
04/12/11 pH Effluent 7.10 S.U. 7.2 S.U.
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 forwarded to the Regional Office.
Comment: “Less than” signs are not being consistently documented on the DMRs. Also, monthly
averages are not being correctly calculated when one or more of the daily numbers is a “less than”
value. Proper averaging in these situations was discussed during the inspection and guidance
documentation was also provided.
V. CONCLUSIONS:
We are concerned with the findings that were cited previously and not corrected.
Laboratory Decertification Ref: 15A NCAC 2H .0807 (a) (1), (13) and (14):
A laboratory may be decertified for any or all parameters for up to one year for any or all of the
following infractions:
(1) Failing to maintain the facilities, or records, or personnel, or equipment, or quality control
program as set forth in the application, and these Rules; or
(13) Failing to respond to requests for information by the date due; or
(14) Failing to comply with any other terms, conditions, or requirements of this Section or of a
Laboratory certification.
Correcting the above-cited findings and implementing the recommendations will help this lab to
produce quality data and meet certification requirements. Please respond to all findings.
Report prepared by: Todd Crawford Date: July 18, 2011
Report reviewed by: Jeff Adams Date: July 18, 2011