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HomeMy WebLinkAbout#544 - 09 - 2010 - FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only, Laboratory Cert. #: 544 Laboratory Name: Water Quality Lab & Operations, Inc. Inspection Type: Commercial Maintenance Inspector Name(s): Jason Smith, Chet Whiting Inspection Dater September 17, 2010 Date Report Completed: November 2 2010 Date Forwarded to Reviewer: November 2 2010 Reviewed by: Chet Whiting Date Review Completed: December 15, 2010 Cover Letter to use: _'..Insp. Initial X Insp. Reg. _ Insp. No Finding — Insp. CP Unit Supervisor: I Gary Francies Date Received: 12/17/2010 Date Forwarded to Alberta: 12/22/2010 Date Mailed:'nlb NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Governor Director December 23, 2010 544 Mr. Paul Isenhour Water Quality Lab & Operations, Inc. P.O. Box 1167 Banner Elk, NC 28604 SUBJECT: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Isenhour. Dee Freeman Secretary Enclosed is a report for the inspection performed on September 17, 2010 by Jason Smith and Chet Whiting. I apologize for the delay in getting this report to you. Where findings) ,are cited in this report, a response is required. Within 30 days of receipt, please supply this office with a written item for item description of how these finding(s) were corrected. 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 me at 828-296-4677. Sincerely, c Gary Zancies Unit Supervisor Laboratory Section CC: Jason Smith Master files DENR DWQ Laboratory Section NC Wastewater/Groundwater Laboratory Certification Branch One 1623 Mail Service Center, Ralegn, North Carolina 27699-1623 NorthC`irolina Location: 4405 Reedy Creek Road. Raleigh, North Carolina 27607-64.45 t� �Fytylkr �y f Phone: 919-733-3908 1 FAX: 919-733-6241 (f yt& yxL L Internet =Av,dvrglab.org An Epual Opportunity \Affirmative Action Employer Customer Service:1-877-623-6748 www.newaterquality.org LABORATORY NAME: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: • LOCAL PERSON(S) CONTACTED: Inspection Report Water Quality Lab & Operations, Inc. P.O. Box 1167 Banner Elk, NC 28604 544 September 17, 2010 Commercial Maintenance Jason Smith and Chet Whiting Paul Isenhour ' 1. INTRODUCTION: This laboratorywas inspected to verify its compliance with the requirements of 15A NCAC 2H .0800 for p y p q the analysis of environmental samples. if. GENERAL COMMENTS: The facility has all the equipment necessary to perform the analyses; however better maintenance of the equipment is required. Additional quality control and documentation needs to be implemented. The 1 laboratory was provided with new policies at the time of the inspection. Findings C, E, F, K, and Y are new policies that have been implemented by our program since the last inspection. The previous inspection was an abbreviated inspection of only field parameters. Findings EE, FF, and GG were cited in the previous report and have not been adequately addressed. It appears that better oversight corrected the findings for a while, but once regular reviews of benchsheets ended, the issues reemerged. III. FINDINGS REQUIREMENTS COMMENTS AND RECOMMENDATIONS: General Laboratory A. Finding:. The laboratories Standard Operating Procedures (SOPs) have not been updated since 2004. Requirement: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supporting records. _shall be' maintained as evidence that these practices are being effectively carried out. The quality control document shall be available for inspection by the State Laboratory. Ref: 15A NCAC 2H..0805 (a) (7). Comment: Please submit updated SOPs for all certified parameters by June 1, 2011 B. Finding: The sample receiving thermometer and Chemical Oxygen Demand reactor thermometer were not checked against a NISI certified or NIST traceable thermometer every 12 months. Page 2 #544 Water Quality Lab & Operations, Inc. Requirement: All thermometers must meet National Institute of Standards and Technology (NIST) specifications for accuracy or be checked, at a minimum annually (every twelve months), against a MIST traceable thermometer and corrections made. Ref: 15A NCAC 2H .0805 (a) (7) (0). C. Finding: The analytical balance has not been serviced. Requirement: Laboratory analytical balance(s) must be serviced by a qualified vendor/technician at a minimum every 12 months to ensure that the balance is functioning within required tolerances. Documentation that this service has been performed must be available for review upon request. If the operational capabilities of the balance are in question at any time during the 12-month period, corrective action must be taken. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. D. Finding: The analytical balance weights have not been verified against ASTM standard weights within five years. The last time this was performed was February, 2005._ Requirement: ASTM Class 1 and 2 weights must be verified at least every 5 years. ASTM Class 1 weights (20 g to 25 kg) and ASTM Class 2 weights (10 g to 1 mg) are equivalent to the NBS Class S weights specified in 15A NCAC 2H .0805 (a) (7) (K). Ref: North Carolina WastewaterlGroundwater Laboratory Certification Policy. E. Finding: The desiccators are not being properly maintained. The desiccant was pink indicating that the desiccant needed to be dried or replaced. The gasket on the door of one desiccator needed to be replaced. The glass top desiccator needed fresh grease applied to maintain an adeauate seal. Requirement: Facilities and equipment. Each laboratory requesting certification must contain or be.. equipped . with the following: Glassware, chemicals, supplies, and equipment required to perform .all analytical procedures included in their certification. Ref: 15A NCAC 2H .0805 (a) (6) (H).. . F. Finding: Auto-pipettors are not calibrated twice per year. Requirement: Mechanical volumetric liquid -dispensing devices (e.g., fixed and adjustable auto- pipettors, bottle -top. dispensers, etc.) must be calibrated at least twice per year, approximately six months apart. Each liquid -dispensing device must meet the manufacturer's statement of accuracy. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. G. Finding: The nitric acid used for metals preservation is not low level metals grade. Requirement: All acids used for this method must be of ultra high -purity grade or equivalent. EPA Method 200.7 Revision 4.4 (1994), Section 7, 1. Comment: The Winston-Salem Regional Office requested that the purity of the nitric acid be confirmed based upon anomalous metals results. Although this laboratory does not perform metals analyses, they preserve samples themselves using ACS grade nitric acid. In order to ensure samples are not contaminated, low level metals grade nitric acid must be used for preservation. Page 3 ##544 Water Quality Lab & Operations, Inc. Documentation Recommendation: The date on many benchsheets and logs is only recorded as month and day, with no indication of year. The year is sometimes listed with the start of a new year or log sheet. If the sheets get out of order, it may be impossible to determine, the year. it is recommended that the day, month, and year always be recorded in order to avoid any questionable documentation. H. Finding: The laboratory needs to increase the documentation of purchased materials and reagents. The date opened and expiration date is not recorded. Requirement: All chemicals, reagents, standards and consumabies used by the laboratory must have the following information documented: Date received, Date Opened (in use), Vendor, Lot Number, and Expiration Date (where specified). 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 primary standards, chemicals, reagents, and materials used for a period of five years. Consumable materials such as pH buffers, lots of pre -made standards and/or media, solids and bacteria filters, etc. are included in this requirement. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. I. Finding: The system of traceability needs improvement. It is not clear from the benchsheets .which lot numbers were used for calibration and which were used for verification. Requirement: See requirement for finding H. J. Finding Several instances of writing over a number as a means of error correction were observed.. 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: North Carolina Wastewater/ Groundwater Laboratory Certification Policy. Oil and Grease — EPA Method 1664 A Recommendation: ,While documented elsewhere, it is recommended that the laboratory document the recovery of the -Matrix Spike and Ongoing Precision and Recover standard on the benchsheet. Ammonia Nitrogen — Standard Methods, 181h Edition, 4500 NH3 F Chemical Oxygen Demand — Standard Methods, 18th Edition, 5220 D K. Finding: The laboratory is not analyzing matrix spikes. Requirement: Unless the referenced method states a greater.frequency, spike 5% of samples on a monthly basis. Laboratories analyzing less than 20 samples per month must analyze at least one matrix spike each month samples are analyzed. Prepare the matrix spike from a reference source different from that used for calibration unless otherwise stated in the method. If matrix spike .results are out of control, the results must be qualified or the laboratory must Page 4 { #544 Water Quality Lab & Operations, Inc. take corrective action to rectify the effect, use another method, or employ the method of standard additions. When the method of choice specifies matrix spike performance acceptance criteria for accuracy, and the laboratory chooses to develop statistically valid, laboratory -specific limits, the laboratory -generated limits cannot be less stringent than the criteria stated in the approved method. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy. L. Finding: A calibration blank and calibration verification standard (mid -range same source) are not analyzed at the end of the sample group and/or after every tenth sample. Requirement: The calibration blank and calibration verification standard (mid -range) must be analyzed initially (i.e., prior to sample analysis), after every tenth sample and at the end of each sample group to check for carry over and calibration drift. If either fall outside established quality control acceptance criteria, corrective action must be taken (e.g., repeating sample determinations since the last acceptable calibration verification, repeating the initial calibration, etc.). Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy based upon Standard Methods, 20'h Edition, 1020 B. (10) (c), 3020 B. (2) (b), and 4020 B..(2). Ammonia Nitrogen — Standard Methods, 181h Edition, 4500 NH3 F M. Finding: The laboratory's acceptance criterion for blanks is less than the reporting limit. Requirement: For analyses requiring a calibration curve, the concentration of method and reagent blanks must not exceed 50% of the reporting limit, unless otherwise specified by the reference method. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy.:: . N. Finding: The volume of 1 ON NaOH is not documented. Requirement: Record volume of 1 ON NaOH added. Ref: Standard Methods, 181h Edition, 4500 NH3 F. (4) (e). O. Finding: After the addition of the 10 N NaOH, the phi is verified to be greater than 11 with Ammonia pH Adjusting ISA; however the elevated pH is not documented. Requirement: Add a sufficient volume of 10N NaOH solution to raise pH above 11. Ref: Standard Methods, 18't' Edition, 4500 NH3 F. (4) (b). Requirement: Supporting records shall be maintained as evidence that these practices are being effectivelycarried out. Ref: 15A NCAC 2H .0805 (a) (7). Chemical Oxygen Demand — Standard Methods,18'h Edition, 5220 D P. Finding: The correlation coefficient of the calibration curve is not calculated. Requirement: When linear regression is used, use the minimum correlation coefficient specified in the method. If the minimum correlation coefficient is not specified, then a minimum value of 0.995 (or a coefficient of determination, r2, of 0.99) is required. Ref: North Carolina Wastewater/Groundwater-Laboratory Certification Policy based upon Standard Methods, 20th Edition, 1020 B. (10) (b). Page 5 4544 Water Quality Lab & Operations, Inc. Settleable Solids — Standard Methods, 18" Edition, 2540 F Q. Finding: The start time, forty five minute stir time, and end time of the procedure are not documented. This is considered pertinent information. Requirement: All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC 2H .0805 (a) (7) (A) Total Suspended Solids — Standard Methods, 18`h Edition, 2540 D R. Finding: A minimum dried residue weight gain of 1 mg is used to determine the reporting limit. Requirement: The minimum reporting value is established at 2.5 mg/L when 1000 mL of sample is analyzed. The minimum weight gain allowed by any approved method is 2.5 mg. In instances where the weight gain is less than the required 2.5 mg, the value must be reported as less than the appropriate value based upon the volume used. For example, if 500 mL of sample is analyzed and < 2.5 mg of dried residue is obtained, the value reported would be < 5 mg/L. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy based upon Standard Methods, 20th and.215t Editions, 2540 D. (3) (b). S. Finding:. The time samples are placed in the oven and the time samples are removed is not documented. This is considered pertinent information. Requirement: All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC 2H .0805 (a) (7) (A). Comment: In order to document the method required one hour minimum drying time and the drying time that documented constant weight in the last study, it is necessary to document these times:: T. Finding: The column header on the benchsheet lists the weights as grams; however, results are recorded in milligrams. Requirement: All laboratories must use printed laboratory bench worksheets that include a space to enter the signature or initials of the analyst, date of analyses, sample identification, volume.of sample analyzed, value from the measurement system, factor and final value to be reported and each item must be recorded each time samples are analyzed. Ref: 15A NCAC 2H .0805 (a).(7) (H). Specific Conductance -- Standard Methods, 18" Edition, 2510 B U. Finding: Duplicates were not consistently analyzed at the required frequency. Requirement: Analyze five percent of all samples in duplicate to document precision. Laboratories analyzing less than 20 samples per month must analyze at least one duplicate each month samples are analyzed. Ref: 15A NCAC 2H .0805 (a) (7) (C). Fecal Coliform -- Standard Methods, 18th Edition, 9222 D V. Finding: The NIST thermometer is graduated in 1 °C increments. This is not acceptable to check the thermometer used in the fecal incubator. Page 6 #544 Water Quality Lab & Operations, Inc. Requirement: All thermometers must meet National Institute of Standards and Technology (NIST) specifications for accuracy or be checked, at a minimum annually (every twelve months), against a NIST traceable thermometer and corrections made. Ref: 15A NCAC 2H .0805 (a) (7) (0). --� Comment: A thermometer igraduated in 0.1 °C increments must be used. W. Finding: Only two analyses are performed for consumable comparison testing. Requirement: It is required that when a new lot of culture medium, pads, or membrane fitters is to be used, a comparison of the current lot in use, (reference lot) against the new lot (test lot), be made. As a minimum, make single analyses on five positive samples. Ref: Standard Methods, 18th Edition, 9020 B. (3) (d). Biochemical OnMen Demand— Standard Methods, 184h Edition, 5210 B Recommendation: The 21s' Edition of Standard Methods requires that the dilution water blank Dissolved Oxygen (DO) uptake in 5 days must not be more than 0.20 mg/L and preferably not more than 0.10 mg/L. It is recommended that the laboratory read the DO, measurements to two decimal points in order to clearly document this method criterion. X. Finding: The majority of bottles in the incubator had very large air bubbles possibly indicating a significant loss of DO during the incubation period that did not result from the oxidation of organic matter by the bacteria present. This may result in a false high BOD value. No air bubbles should be present during incubation. Requirement: Fill bottles with enough dilution water, seeded if necessary, so that insertion of stopper will,displace all air, leaving no bubbles. Determine initial DO ... and replace any displaced contents with dilution water to fill the bottle. Stopper tightly, water -seal, and incubate for 5 days at 20 °C. Ref: Standard Methods, 18'h Edition, 5210 B. (4) (f) (2). Comment: The stirrer on the DO probe Is no longer functioning. In order to stir the sample, a stir bar is placed in the bottle during DO measurement. It appears that there is not enough dilution water added to the bottle after removal of the stir bar and/or the water seal is not adequate and evaporation is occurring. Y. Finding: Extra nutrient, mineral, and buffer solutions are not added to the Biochemical Oxygen Demand (BOD) bottles containing more than 67% (> 201 mL) sample. Requirement: When a bottle contains more than 67% of the sample after dilution, nutrients may .be limited in the diluted sample and, subsequently, reduce biological activity. In such samples, add the nutrient, mineral, and buffer solutions (3a through e) directly to individual BOD bottles at a rate of 1 mL/L (0,33 mL/300-mL bottle) or use commercially -prepared solutions designed to dose the appropriate bottle size. Ref: North Carolina Wastewater/Groundwater Laboratory Certification Policy based upon Standard Methods, 20th Edition, 5210 B, (4) (f) and Standard Methods, 215' Edition, 5210 B. (5) (c) (2). Comment: Dilution water prepared as normal with nutrient, mineral, and buffer solutions would still be used in the BOD bottles. For the bottles containing more than 67% sample, extra nutrient, mineral, and buffer solutions would be added in addition to the dilution water. Recommendation: Rather than pipetting 0.33 mL of each reagent into the BOD bottle, it is recommended that commercially prepared nutrient buffer pillows for 300 mL bottles be used. Page 7 #544 Water Quality Lab & Operations, Inc. Field Testing Recommendation: Rather than recording the amount of drift that occurs when analyzing midday and end of day pH standards, record the actual pH obtained at these times. Z. Finding: The laboratory needs to increase the documentation of purchased materials and reagents used by field personnel. Requirement: See requirement for finding H AA. Finding: The pH and DO meters temperature sensors were not checked against a NIST certified or NIST traceable thermometer every 12 months. This was last performed in February, 2009. Requirement: All thermometers must meet National Institute of Standards and Technology (NIST) specifications for accuracy or be checked, at a minimum annually (every twelve months), against a NIST traceable thermometer and corrections made. Ref: 15A NCAC 2H .0805 (a) (7) (0). BB. Finding: The Total Residual Chlorine (TRC) meters have not had their internal curves verified .. every 12 months. This was last performed in February, 2009. Requirement: For analytical procedures requiring analysis of a series of standards, the concentrations of these standards must bracket the concentration of the samples analyzed. One .of. .the standards must have a concentration equal to the laboratory's lower reporting concentration for the parameter involved. For metals by AA or ICP, a series of at least three standards must be analyzed along with each group of samples. For colorimetric analyses, a series of five standards for a curve prepared annually or three standards for curves established each day or standards as set forth in the analytical procedure must be analyzed to establish a standard curve. The curve must be updated as set forth in the standard procedures, each time the slope :changes by more than 10 percent at mid -range, each time a new stock standard is prepared, or at least every twelve months. Each analyst performing the analytical procedure must produce a standard curve. Ref: 15A NCAC 2H .0805 (a) (7) (1). CC. Finding: The gel standards used to verify the TRC calibration curves daily have not been assigned.new true values every 12 months. This was last performed in February, 2009. Requirement: Purchased "Gel -type" or sealed liquid ampoule standards may be used for daily calibration verification only. These standards must be verified initially and every 12 months thereafter, with the standard curve. The assigned values will be used for the next twelve months, or until a new curve verification is performed. The gel 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..Ref:. Technical Assistance for Field Analysis of Total Residual Chlorine. DD. Finding:, Gel standard values were consistently outside of the acceptable range for one meter/operator. This was not addressed nor resolved. Requirement: Any time quality control results indicate an analytical problem, the problem must be.resoived and any samples involved must be rerun if the holding time has not expired. Ref: 15A NCAC 2H .0805 (a) (7) (F). Page 8 #544 Water Quality Lab & Operations, Inc. Comment: It appears that due to a personnel change, the gel standards were switched between meters without changing the acceptable range on the benchsheet. It seems that the gel standard values were acceptable; however there is no documentation to confirm this. Recommendation: It is recommended that the gel standards used be identified by lot number on the benchsheets and/or calibration logs in order to avoid this situation. EE. Finding: Analyst initials are not consistently documented on calibration logs. Requirement: All laboratories must use printed laboratory bench worksheets that include a space to enter the signature or initials of the analyst, date of analyses, sample identification, volume of sample analyzed, value from the measurement system, factor and final value to be reported and each item must be recorded each time samples are analyzed. Ref: 15A NCAC 2H .08D5 (a) (7) (H). FF. Finding: Sample collection and analysis times continue to not be consistently documented. Cited previously on February 19, 2009. Requirement: See requirement for finding DD. GG. Finding: The documented time of pH, DO, and TRC meter calibrations continue to occasionally be later than sample analysis times. Cited previously on February 19, 2009. Requirement: The meter must be calibrated prior to the analysis of samples. Ref: Technical Assistance for Field Analysis of pH and Technical Assistance for Field Analysis of Dissolved Oxygen.— . .:..:...... Requirement: Instruments are to be calibrated or a calibration check must be performed prior to analysis of samples each day compliance monitoring is performed. Ref: Technical Assistance for Field Analysis of Total Residual Chlorine. HH. Finding: Post calibration checks and/or recalibrations for DO, pH, and TRC continue to not be consistently performed. Cited previously on February 19, 2009. Requirement: When performing analysis at multiple sampling locations, re -calibrations) must be performed every four hours. Ref: Technical Assistance for Field Analysis of Dissolved Oxygen. Requirement: If compliance samples are analyzed throughout the day, a post calibration check must be analyzed mid -day and at the end of the run (i.e., roughly every 4 hours based on an eight hour -day); -::Ref: Technical Assistance for Field Analysis of Total Residual Chlorine and Technical Assistance for Feld Analysis of pH. IV. PAPER TRAIL INVFSTiGATION: The paper. trailconsisted 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 Town of Crossnore (NPDES permit #NC0026654) and Jonas Ridge (NPDES permit #NC0060224) for January, 2010, Hawksnest Utilities (NPDES permit #NC0058891), Gamp Broadstone (NPDES permit #NC©032166), Willow Valley (NPDES permit #NC0061425), and Mill Ridge (NPDES permit #NC0030473) for June, 2010. The following errors were noted: Page 9 #544 Water Quality Lab & Operations, Inc. Date Parameter Location Value on Benchsheet Value on DMR 6-8-10 Total Residual Chlorine Camp Broadstone Effluent No value. <15 pg/L 6-29-10 Total Residual Chlorine Camp Broadstone Effluent No value. <15 pg/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 forwarded to the Regional Office. V. CONCLUSIONS: i We are concerned with the findings that were cited previously and not corrected. C 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 (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, The inspectors 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 Date: November 2, 2010 Report reviewed by: Chet Whiting Date: December 15, 2010