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HomeMy WebLinkAbout#5412_01_2014_FINAL-A NCDENR North Carolina Department of Environment and Natural Resources Division of Water Resources Water Qualify Programs Thomas A. Reeder Director February 26, 2014 5412 Mr. Bobby Sisk Town of Walnut Cove P.O. Box 734 Walnut Cove, NC 27052 John E. Skvarla, III Secretary Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Bobby Sisk: Enclosed is a report for the inspection performed on January 28, 2014 by Jason Smith. 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. Sincerely, Gary Francies Technical Assistance/Compliance Specialist Laboratory Section Enclosure cc: Master File, Jason Smith DENR DWR VVQP Laboratory Section; NC Wastewater/Groundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location: 4405 Reedy Creek Road. Raleigh, North Carolina 27607-8445 Phone: 919-733-39081FAX: 919-733-6241 Internet: www.dwglab.org An Eauai Opperiumty', Affirmative 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: 5412 Town of Walnut Cove Field Maintenance Jason Smith January 28, 2014 February 13. 2014 February 17, 2014 Nick Jones February 19, 2014 ❑ Insp. Initial ® Insp. Reg. ❑ Insp. No Finding ❑ Insp. CP ❑ Corrected Gary Francies February 19, 2014 2/26/2014 2/26/14 Ic LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: I. INTRODUCTION: On -Site Inspection Report Town of Walnut Cove NCO025526 P.O. Box 734 Walnut Cove, NC 27052 5412 January 28, 2014 Field Maintenance Jason Smith Bobby Sisk 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. GENERAL COMMENTS: The facility has all the equipment necessary to perform the analyses. During the inspection, the laboratory changed their contact and supervisor from Mark Bowman to Bobby Sisk, who is the current Operator in Responsible Charge (ORC). Proficiency Testing (PT) samples have been analyzed for all certified parameters for the 2013 proficiency testing calendar year and the graded results were 100% acceptable. 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. Contracted analyses are performed by Pace Analytical Services, Inc. - Eden (Certification #633). The requirements associated with Findings A, B, C, F, G, H, I, and J have been implemented by our program since the last inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. 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. Page 2 #5412 Town of Walnut Cove B. 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. Comment: An example traceability log was faxed to the facility on February 10, 2014. Implementation of this log will fulfill this requirement. C. Finding: Instrument identification is not documented on the benchsheets for Total Residual Chorine, Dissolved Oxygen, Temperature and pH. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Instrument identification. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine, NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen, NC WW/GW LC Approved Procedure for the Analysis of Temperature, and NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: A new benchsheet including spaces to list instrument ID was faxed to the laboratory on February 10, 2014. Implementation of this benchsheet will fulfill this requirement. D. Finding: Data that does not meet all quality control requirements is not qualified on the Discharge Monitoring Report (DMR). Requirement: 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. Ref: Quality Assurance Policies for Field Laboratories. Comment: The laboratory was not transcribing data qualifiers from the contract laboratory reports to the DMR. For example, the contract lab reported a data qualifier indicating that the Glucose/Glutamic Acid was not within the acceptable range of 198 ± 30.5 m/L on the final report for the March 26, 2013 Effluent Biochemical Oxygen Demand (BOD) sample. No qualifier was documented on the DMR. E. Finding: Data is not properly recorded on the DMR. Page 3 #5412 Town of Walnut Cove Requirement: Use of "less than" values. 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). 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. Ref: "Directions for Completing Monthly Discharge Monitoring Reports". Comment: Results reported by the contract laboratory as "NU were reported as "ND" on the DMR. Instead of doing this, the laboratory must report the value as less than the reporting limit listed by the contract laboratory. For example, if the contract laboratory's reporting limit for (BOD) is listed as 2 mg/L, report the result as <2 mg/L. Comment: The laboratory reports Total Residual Chlorine (TRC) results down to 0 pg/L. The reporting limit for TRC is determined by the lowest concentration verified during the annual curve verification, which was 25 lag/L the last time this was performed in 2013. So TRC results below 25 lag/L must be reported as <25 lag/L. Quality Assurance F. Finding: The automatic pipettor has not been calibrated annually. Requirement: Mechanical volumetric liquid -dispensing devices (e.g., fixed and adjustable auto- pipettors, bottle -top dispensers, etc.), used for critical measurements, must be calibrated at least every twelve months and documented. Each liquid -dispensing device must meet the manufacturer's statement of accuracy. For variable volume devices used at more than one setting, check the accuracy at the maximum, middle and minimum values. Testing at more than three volumes is optional. When a device capable of variable settings is dedicated to dispense a single specific volume, calibration is required at that setting only. Ref: Quality Assurance Policies for Field Laboratories. Comment: The automatic pipettor is used to pipet liquid reagents for Total Residual Chlorine (TRC) analyses. However, since this is not considered a critical measurement, calibration is not required when used only for this purpose. Recommendation: Since the automatic pipettor is used once each year to prepare the TRC Proficiency Testing (PT) sample; which is considered a critical measurement, it is recommended that this calibration be performed just before PT sample preparation. Comment: Purchasing and using a glass volumetric pipet for PT preparation as an alternative to this calibration was discussed during the inspection. Doing this would also be an acceptable response to this Finding. Please be sure to confirm the correct volume needed before purchasing the volumetric pipet. Proficiency Testing G. Finding: The laboratory is not documenting 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. Page 4 #5412 Town of Walnut Cove Comment: This means that the PT analyses must be documented on a benchsheet in the same manner as daily samples. H. Finding: The laboratory is analyzing additional quality control samples with the PT. Requirement: Laboratories shall conduct proficiency tests in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the PT provider. They shall not be analyzed with additional quality control or replicated beyond what is routine for environmental sample analysis. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: The laboratory analyzes a known sample along with the PT. 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. Finding: The laboratory is analyzing PT samples multiple times. Requirement: Laboratories shall conduct proficiency tests in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the PT provider. They shall not be analyzed with additional quality control or replicated beyond what is routine for environmental sample analysis. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. J. Finding: The preparation of 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. Comment: Retaining the PT sample instruction sheet from the vendor signed and dated by the technician will satisfy this requirement. pH — Standard Methods 4500 H+ B-2000 K. Finding: Units of measure are not documented on the benchsheet. 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 analyses. Ref: 15A NCAC 2H .0805 (g) (1). Comment: Proper units of measure for pH are Standard Units (S.U.). A new benchsheet including pH units of measure was faxed to the laboratory on February 10, 2014. Implementation of this benchsheet will fulfill this requirement. L. Finding: A check standard was not analyzed after meter calibration. Requirement: In addition to the calibration buffers, the meter calibration. must be verified with a third standard buffer solution. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Page 5 #5412 Town of Walnut Cove Comment: The analyst records the value of each buffer during the calibration of the meter. However, this may not represent the value obtained after calibration is complete. Comment: After the meter reports the calibration slope, analyze the 7 S.U. buffer and record the value obtained. The result must be ± 0.1 S.U. of the true value of the buffer (i.e., 6.9-7.1 S.U.). Temperature — Standard Methods 2550 B-2000 M. Finding: Temperature samples are not analyzed within the EPA approved holding time. Requirement: Temperature — Maximum holding time: Analyze. Ref: Code of Federal Regulation Title 40, Part 136; Federal Register Vol. 77, No. 97, May 18, 2012; Table II. Requirement: Immediate (i.e., in situ) analysis is required. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Recommendation: It is recommended that the laboratory purchase a traceable thermometer to analyze temperature in situ since none of the meters in use are portable. These traceable thermometers are relatively inexpensive, but must be either recalibrated or replaced by the expiration date provided by the manufacturer. Comment: The bench top meters are no longer required to have their temperature sensors checked annually since this is only required for meters used to report temperature results. Total Residual Chlorine — Standard Methods 4600 Cl G-2000 Comment: The laboratory is currently using liquid reagents and a flow -through cell for sample analysis. This is acceptable; however, the laboratory may choose to use powdered DPD and discontinue the use of the liquid reagents and flow -through cell in order to improve efficiency and reduce costs. Please note that a new curve verification, using the powdered DPD and/or a sample cuvette, instead of the flow -through cell, will have to be performed prior to implementing this change. Since a new curve verification is required by the Finding below, this would be a good time to implement this change. N. Finding: The calibration curve is not verified each day. Requirement: When a five -standard annual standard curve verification is used, 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 that samples are analyzed. The value obtained for the check standard must read within 10% of the true value of the check standard. If the obtained value is outside of the ±10% range, corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Recommendation: It is recommended that the daily curve verification be performed using gel standards. Once purchased, the requirement for beginning to use the gel standard is as follows: 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 lag/L standard would be verified, and not the 800 lag/L standard since the 800 lag/L standard would be measured using a high range curve. IV. Page 6 #5412 Town of Walnut Cove Immediately following curve verification: 1. Zero the instrument with the gel blank. 2. Read and record gel standard values. 3. Assign the obtained values as the true value. The assigned values will be used for the next twelve months, or until a new curve verification is performed. The gel/liquid standard verification must be performed for each instrument on which they are to be used. If multiple instruments and/or standard sets are used, each must have assigned values specific for the instrument and standard set. Documentation must link the gel standard identification to the meter with which the assigned value was determined. Some commercial laboratory facilities may be able to provide assistance with the field photometric meter curve verifications. Comment: The time of curve verification (gel standard analysis) must also be recorded. O. Finding: The annual curve verification performed by the contract lab was not acceptable. Requirement: Annual Factory -set Standard Curve Verification: Analyze a calibration blank to zero the instrument and then analyze a series of five standards (do not use gel or sealed liquid standards for this purpose). The curve verification must check 5 concentrations (not counting the blank) that bracket the range of the sample concentrations to be analyzed. This type of standard 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 ug/L and must not vary by more than 25% of the known value for standard concentrations less than 50 ug/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. Please submit an acceptable TRC curve verification with the reply to this report. Comment: The 100 pg/L standard read 111 pg/L, which is >10% of the true value and unacceptable. Also, the 500 pg/L standard was above the range of the meter and did not provide a reading resulting in only four concentrations being verified. In order to avoid this, it is recommended that the highest concentration be 400 pg/L. Recommendation: It is recommended that the following concentrations be analyzed for the curve verification: 25, 40, 50, 200, and 400 pg/L. 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 Resources. Data were reviewed for the Town of Walnut Cove (NPDES permit #NC0025526) for March, 2013. No transcription errors except those noted in Finding D were detected. 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: Jason Smith Report reviewed by: Nick Jones Date: February 13, 2014 Date: February 19, 2014