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HomeMy WebLinkAbout#5432_11_2014_FINALNorth -A 01 10A RUDER • Department Environment • ti Natural Resources Pat McCrory Governor November 24, 2014 5432 Ms. Barbara Auman Auman Mobile Home Park, LLC 3910 - 2 N Main St. High Point, NC 27265 John E, Skvarla, III Secretary Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Auman: Enclosed is a report for the inspection performed on November 4, 2014 by Beth Swanson and myself. 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. 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 us at (828) 296-4677. Attachment cc: Beth Swanson Master File Sincerely, COY Gary Francies, Technical Assistance/Compliance Specialist Division of Water Resources 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: 919-733-39081 FAX: 919-733.6241 Internet: www.dwglab.org An Equal OpportunitytAtfirmative Action Employer INSPECTION 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: 5432 Auman Mobile Home Park, LLC Field Maintenance Beth Swanson and Gary Francies November 4, 2014 November 17. 2014 November 17, 2014 Todd Crawford November 17, 2014 ❑ Insp. Initial ® Insp. Reg. ❑ Insp. No Finding ❑ Insp. CP ❑ Corrected ❑ Insp. Reg. Delay Gary Francies 11 /18/2014 11 /21/2014 kkI-A(Lq On -Site Inspection Report LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: INTRODUCTION: Auman Mobile Home Park, LLC NCO055212 3910 - 2 N Main St. High Point, NC 27265 5432 November 4, 2014 Field Maintenance Beth Swanson and Gary Francies Barbara Auman and Bo Einig 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 to perform the analyses. Additional analyses are performed by Research & Analytical Laboratories (Certification #34). 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 inspection. The requirements associated with Findings B, E, G and H have been implemented by our program since the last inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation Comment: The combined benchsheet for pH, Temperature and Dissolved Oxygen used by the facility was lacking instrument ID. The NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen, NC WW/GW LC Approved Procedure for the Analysis of pH and NC WW/GW LC Approved Procedure for the Analysis of Temperature 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 a revised benchsheet showing the instrument ID had been put into use on November 11, 2014) was received via a phone conversation on November 12, 2014. No further response is necessary for this finding. Page 2 #5432 Auman Mobile Home Park, LLC A. Finding: All original records were not on file. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Comment: Stream testing data is initially written on a piece of paper, transferred to a steno notebook, and then brought back to the office to be transferred to the daily benchsheet. The original paperwork is then discarded. Original observations must be maintained so that the accuracy of data transcription can be verified. B. Finding: The laboratory needs to increase the documentation of purchased materials. Requirement: All consumables used by the laboratory must have the following information documented: Date Received, Date Opened (in use), Vendor, Lot Number, and Expiration Date. 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. Comment: An updated benchsheet with a space for pH buffer lot number and expiration date was provided by email to the laboratory on November 5, 2014. Recommendation: It is recommended that the date the bottle was opened be written on the paper inserts that come with the buffer solutions to satisfy the rest of the documentation requirements. The inserts would then be stored with all other required documentation for a period of five years. D. Finding: Error corrections are not performed properly. Requirement: 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. Ref: Quality Assurance Policies for Field Laboratories. Comment: An instance of using Wite-Out® correction fluid was found on the Discharge Monitoring Report (DMR) for January 30, 2014. PH - Standard Methods, 4500 H+B-2000 Comment: A post analysis check standard is not required since pH is only performed at the facility's primary location. Comment: The temperature. sensor on the pH meter does not need to be verified since that meter is not currently used to obtain temperature compliance data; the Dissolved Oxygen meter is used. Page 3 #5432 Auman Mobile Home Park, LLC E. Finding: Values were reported that exceed the method specified accuracy of 0.1 units. Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents the limit of accuracy under normal conditions, especially for measurement of water and poorly buffered solutions. For this reason, report PH values to the nearest 0.1 pH unit. Ref: Standard Methods, 4500 H+ B-2000, (6). F. Finding: Sample collection and/or analysis time is not documented correctly. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Date and time of sample collection; Date and time of sample analysis to verify the 15 minute holding time is met. Alternatively, one time may be documented for collection and analysis with the notation that samples are measured in situ or immediately at the sample site. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: On numerous instances, it was noted that the benchsheets listed an "analysis time" that occurred before "collection time". This was likely an error in filling out the benchsheet. Since pH is analyzed at the sample site, the collection and analysis time can be considered the same time. A revised benchsheet provided to the facility has one column designated "Time" that should prevent confusion. Proficiency Testing G. 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: The PT result is not being recorded on the facility's benchsheet and retained. It is written on the side of the PT sample bottle and discarded. H. 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. Since this is not performed with all environmental samples, it is considered additional quality control. However, known samples are recommended when analyzing remedial PT samples as part of the troubleshooting and corrective action process. Page 4 #5432 Auman Mobile Home Park, LLC IV PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing laboratory benchsheets and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for January, May and August, 2014. The following errors were noted: Date Parameter Location Value on Benchsheet Value on DMR 1/16/14 Temperature Effluent 4.0 °C 4.1 °C 1/16/14 Temperature Upstream 3.1 °C 3.0°C 1/23/14 Dissolved Oxygen Upstream 12.92 mg/L 12.94 mg/L 1/30/14 Dissolved Oxygen Effluent 12.53 mg/L 14.22 mg/L 5/7/14 Dissolved Oxygen Effluent 8.76 mg/L 11.25 mg/L 5/15/14 pH Effluent 5/15/14 Dissolved Oxygen Effluent 7.97 mg/L 7.98 mg/L 5/15/14 Dissolved Oxygen Upstream 9.98 mg/L 9.62 mg/L 5/15/14 Dissolved Oxygen Downstream 9.87 mg/L 9.57 mg/L 8/13/14 Dissolved Oxygen Upstream 7.87 mg/L 7.89 mg/L 8/13/14 Dissolved Oxygen Downstream 9.94 mg/L 7.94 mg/L *pH data analyzed on this day was recorded on the DMR on 5/21/14 Comment: There were no analyses documented on the benchsheet for 5/21/14, however values were reported for that date on the DMR. This is when it was discovered that the benchsheet was not the original record. See Finding A above. Comment: Effluent data analyzed on 5/28/14 was reported as being analyzed on 5/27/14. Recommendation: Due to the number of errors noted in the paper trail investigation it is recommended that a system of checking the data entered on the DMR be implemented. It would be beneficial to have a second person review the accuracy of data transcription to the DMR. At a minimum, the person entering the data should review the transcriptions to the DMR after some time has passed from the original data entry. In order to avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether amended DMRs 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: Beth Swanson Date: November 17, 2014 Report reviewed by: Todd Crawford Date: November 17, 2014