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INSPECTION REPORT ROUTING SHEET
To be attached to all inspection reports in-house only.
Laboratory Cert. #: 5211
Laboratory Name: Town of White Lake WWTP
Inspection Type: Field Maintenance
Inspector Name(s): Tonja Springer
Inspection Date: 11/19/2014
Date Report Completed: 12/5/2014
Date Forwarded to Reviewer: 12/5/2014
Reviewed by: Todd Crawford
Date Review Completed: 12/5/2014
Cover Letter to use: Insp. Initial Insp. Reg.
Insp. No Finding Insp. CP
Corrected Insp. Reg. Delay
Unit Supervisor/Chemist III: Dana Satterwhite
Date Received: 12/9/2014
Date Forwarded to Linda: 12/17/2014
Date Mailed: 12/18/2014
_____________________________________________________________________
On-Site Inspection Report
LABORATORY NAME: Town of White Lake WWTP
ADDRESS: P.O Box 7250
White Lake, NC 28337
NPDES PERMIT # NC0023353
CERTIFICATE #: 5211
DATE OF INSPECTION: November 19, 2014
TYPE OF INSPECTION: Field Maintenance
AUDITOR(S): Tonja Springer
LOCAL PERSON(S) CONTACTED: Bill Stafford and Tim Frush
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 facility has all the equipment necessary to perform the analyses.
Contracted analyses are performed by Environment 1, Inc. (Certification #10).
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 requirement associated with Finding H has been implemented by our program since the last
inspection.
III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS:
Quality Control
Comment: Data from the contract lab reports that does not meet all quality control requirements is not
qualified on the Discharge Monitoring Report (DMR). The Quality Assurance Policies for Field
Laboratories document states: When quality control (QC) failures occur, the laboratory must attempt
to determine the source of the problem and must apply corrective action. Part of the corrective action is
notification to the end user. If data qualifiers are used to qualify samples not meeting QC requirements,
the data may not be useable for the intended purposes. It is the responsibility of the laboratory to
provide the client or end-user of the data with sufficient information to determine the usability of the
qualified data. Where applicable, a notation must be made on the Discharge Monitoring Report (DMR)
form, in the comment section or on a separate sheet attached to the DMR form, when any required
sample quality control does not meet specified criteria and another sample cannot be obtained.
Notification of acceptable corrective action (i.e., a statement that qualifiers from contract lab reports will
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be documented on the DMR) was received by email on 12/2/2014. No further response is necessary
for this finding.
Documentation
Comment: Error corrections are not performed properly. Corrections were not initialed or dated. The
Quality Assurance Policies for Field Laboratories states: All documentation errors must be corrected by
drawing a single line through the error so that the original entry remains legible. Entries shall not be
obliterated by erasures or markings. Wite-Out®, correction tape or similar products designed to obliterate
documentation are not to be used. Write the correction adjacent to the error. The correction must be
initialed by the responsible individual and the date of change documented. All data and log entries must
be written in indelible ink. Pencil entries are not acceptable. Notification of acceptable corrective action
(i.e., a statement that date and initials will be documented with error corrections) was received by email
on 12/2/2014. No further response is necessary for this finding.
Comment: The laboratory benchsheets for Temperature, Dissolved Oxygen, Total Residual Chlorine,
and pH were lacking pertinent data: Instrument identification. The NC WW/GW LC Approved Procedure
for the Analysis of pH, NC WW/GW LC Approved Procedure for the Analysis of Temperature, NC
WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen, and NC WW/GW LC Approved
Procedure for the Analysis of Total Residual Chlorine documents state: The following must be
documented in indelible ink whenever sample analysis is performed: Instrument Identification. Notification
of acceptable corrective action (i.e., a statement that the benchsheet provided at the time of the
inspection that includes a space for instrument identification will be implemented 12/9/2014) was received
per telephone conversation on 12/8/2014 from Mr. Bill Stafford. No further response is necessary for
this finding.
A. Finding: The laboratory needs to increase the documentation of purchased 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: The Quality Assurance Policies for Field Laboratories. Please submit a copy
of an updated completed benchsheet that includes the required traceability information
with the response to this report.
Comment: An updated benchsheet with traceability information was faxed to our office on
December 9, 2014. All the traceability information was documented on the benchsheet with the
exception of the actual date for the date received, date opened and expiration date. The dates
documented must be included with the month/day/year in order to be able to trace the reagents to
the benchsheet. When a manufacturer does not give a day for expiration, the laboratory may
assign the last day of the month.
B. Finding: The laboratory is not maintaining temperature sensor calibration documentation for 5
years.
Requirement: Thermometers and temperature measuring devices, used to measure
temperature for compliance monitoring, must be checked every 12 months against a NIST
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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. The
following must be documented in indelible ink whenever sample analysis is performed: The
temperature correction (even if it is zero) must be posted on the meter as well as in hard copy
format (to be retained for 5 years). Ref: NC WW/GW LC Approved Procedure for the Analysis of
Temperature. Please submit a copy of the temperature sensor verification with the
response to this report.
Comment: The temperature sensor on the Dissolved Oxygen meter used to obtain reported
temperature values has been checked against a National Institute of Standards and Technology
(NIST) traceable thermometer and is posted on the meter but the paperwork wasn’t available at
the time of the inspection.
C. Finding: The laboratory is not documenting the signature or initials of all analysts.
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 benchsheets must provide a space for the signature or initials of the analyst, and
proper units of measure for all analytes. Ref: 15A NCAC 2H .0805 (g) (1). Please send copies of
two weeks of completed benchsheets with the response to this report. Do not send a blank
benchsheet.
Comment: There are two analysts that are involved in sample collection and analysis and only
one analyst is initialing laboratory benchsheets. One analyst does the analysis and calls out the
result for another analyst to document the result on the benchsheet.
pH – Standard Methods, 4500 H+ B-2000
Comment: Buffers are not poured fresh each analysis day. Standard Methods, 4500 H+B-2000. (3) (a)
states: Because buffer solutions may deteriorate as a result of mold growth or contamination, prepare
fresh. Growth of mold was observed at the time of the inspection in the secondary bottles used for the
pH buffers. Notification of acceptable corrective action (i.e., a statement that fresh buffer solutions will
be used each time an analysis is performed and fresh buffers will be poured into a beaker instead of
using the plastic bottles.) was received by email on 12/2/2014. No further response is necessary for
this finding.
Total Residual Chlorine – Standard Methods, 4500 Cl G-2000
D. Finding: The Total Residual Chlorine meter factory set curve is not verified every twelve months.
Requirement: Instruments are to be calibrated according to the manufacturer’s procedure or a
standard curve verification must be performed prior to analysis of samples each day compliance
monitoring is performed. Standard curve verification checks must be performed for the standard
curve and/or program used for sample analysis. Ref: NC WW/GW LC Approved Procedure for
the Analysis of Total Residual Chlorine.
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 initially and at least every 12 months. The values obtained must not vary by more than
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10% of the known value for standard concentrations greater than or equal to 50 µg/L and must
not vary by more than 25% of the known value for standard concentrations less than 50 µg/L. The
overall correlation coefficient of the curve must be ≥0.995. When a five-standard annual
verification curve is generated, 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 the samples are analyzed. Ref: NC WW/GW LC Approved
Procedure for the Analysis of Total Residual Chlorine. Please send a copy of the calibration
curve verification upon completion.
Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC
2H .0805 (g) (1).
Recommendation: It is recommended that the laboratory verify the internal calibration using
the following concentrations: 10 (or 15), 20, 50, 200 and 400 µg/L. This will verify the analytical
range used to measure Proficiency Testing (PT) samples, gel standards; as well as.
environmental samples.
Comment: The laboratory sent the meter back to Hach Company for calibration and servicing
in 2014. When it was returned, Hach Company supplied paperwork that stated the meter had
been calibrated. The laboratory was under the impression this met the NC WW/GW LC
Approved Procedure for the Analysis of Total Residual Chlorine requirement for the annual
calibration curve verification since the manufacturer’s paperwork stated it had been calibrated.
E. Finding: The laboratory is not validating the annual calibration curve verifications against the
required criteria.
Requirement: The values obtained must not vary by more than 10% of the known value for
standard concentrations greater than or equal to 50 µg/L and must not vary by more than 25% of
the known value for standard concentrations less than 50 µg/L. The overall correlation coefficient
of the curve must be ≥0.995. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total
Residual Chlorine
Comment: The factory set annual calibration curve verifications analyzed by the lab from 2008
through 2012 did not meet all the acceptance criteria requirements. The curves that were
submitted either had several standards that were outside the acceptance criteria and/or the overall
correlation coefficient did not meet the >0.995 acceptance criteria.
F. Finding: The Gel® standard is not verified 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. It is only necessary to verify the gel or sealed liquid standard
which falls within the concentration range of the curve used to measure sample concentrations.
For example, if you are measuring samples against a low range curve, a 200 g/L standard
would be verified. Ref: Approved Procedure for the Analysis of Total Residual Chlorine. Please
send a copy of the Gel® standard verification upon completion.
Comment: The Gel® standard was verified in September, 2014 but the actual date was not
documented on the benchsheet. The Gel® standard will need to be verified against the verified
calibration curve and reassigned a new value.
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G. Finding: Values are being reported as less than the permit limit on the Discharge
Monitoring Report (DMR).
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. Example: If the laboratory chooses to have a lower reporting limit
of 17 µg/L for total residual chlorine, you must analyze at least a 17 g/L or lower standard and
report lower concentrations as <17 µg/L or < the concentration of the chosen standard. Ref: NC
WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine.
Comment: An annual verification curve has not been analyzed to determine the lower
reporting limit. The laboratory is reporting “< 17 µg/L”, which is their permit limit.
Proficiency Testing
Comment: The preparation of Total Residual Chlorine (TRC) Proficiency Testing (PT) samples was
not documented. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2 document
states: 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 fo rmat. The
diluted PT sample becomes a routine environmental sample and is added to a routine sample batch for
analysis. Dating and initialing the instruction sheet for the preparation of the TRC PT would satisfy the
documentation requirement. This requirement is a new policy that has been implemented by our
program since the last inspection. Notification of acceptable corrective action (i.e., a statement that
preparation of the TRC PT will be documented) was received by email on 12/2//2014. No further
response is necessary for this finding.
Comment: The laboratory is not analyzing Proficiency Testing (PT) samples in the same manner as
environmental samples. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2
document states: 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. This requirement is a new policy that
has been implemented by our program since the last inspection. Known standards are being analyzed
with the unknown samples. These constituted an additional level of QC that is not analyzed with routine
compliance samples. However, known samples are recommended when analyzing remedial PT
samples as part of the troubleshooting and corrective action process. Notification of acceptable
corrective action (i.e., a statement that only unknown samples will be analyzed in the future) was
received by email on 12/2/2014. No further response is necessary for this finding.
H. Finding: The laboratory is not documenting Proficiency Testing (PT) sample analyses in the
same manner as environmental samples.
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: PT samples are not being documented on the benchsheets. Results were only
documented on the vendor reporting form and then submitted electronically.
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IV. PAPER TRAIL INVESTIGATION:
The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.)
and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division
of Water Resources. Data were reviewed for January, June and September, 2014. No transcription errors
were detected. It appears the facility is 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 and data review process. Please respond to all findings.
Report prepared by: Tonja Springer Date: December 5, 2014
Report reviewed by: Todd Crawford Date: December 5, 2014