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HomeMy WebLinkAbout#5148_2023_0316_TS_FINAL NC Department of Environmental Quality | Division of Water Resources | Laboratory Certification Branch 4405 Reedy Creek Road | 1623 Mail Service Center | Raleigh, North Carolina 27699-1623 919-733-3908 March 31, 2023 5148 Mr. Tommy Fields Fairmont Regional WWTP P.O. Box 248 Fairmont, NC 28340- Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Fields: Enclosed is a report for the inspection performed on March 16, 2023 by Tonja Springer. Where Finding(s) are cited in this report, a response is required. Within thirty days, please supply this office with a written item for item description of how these Finding(s) were corrected. Please describe the steps taken to prevent recurrence and include an implementation date for each corrective action. 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 02H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will not reflect any changes made during the audit. Copies of the checklists completed during the inspection may be requested from this office. Thank you for your cooperation during the inspection. If you have questions or need additional information, please contact me at (919) 733- 3908 Ext. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Tonja Springer, Todd Crawford, #5148 On-Site Inspection Report LABORATORY NAME: Fairmont Regional WWTP NPDES PERMIT #: NC0086550 ADDRESS: 133 Woodrow Rd. Orrum, NC 28340 CERTIFICATE #: 5148 DATE OF INSPECTION: March 16, 2023 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Tommy Fields I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. The analyst was forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2023 PT Calendar Year have not yet been analyzed. The laboratory is reminded that results must be received by this office directly from the vendor by September 30, 2023. Any time changes are made to laboratory procedures, Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) must be updated and relevant staff retrained. Staff must acknowledge that they have read and understand the changes as part of the documented training program. The same requirements apply when changes are made in response to Findings, Recommendations or Comments listed in this report, to ensure the methods are being performed as stated, references to methods are accurate, and the QA and/or SOP document(s) is in agreement with each approved practice, test, analysis, measurement, monitoring procedure or regulatory requirement being used in the laboratory. In some instances, the laboratory may need to create an SOP to document how new functions or policies will be implemented. Revisions to the SOPs, based on the Findings, Comments and Recommendations within this report must be submitted to this office by September 30, 2023. The laboratory is reminded that SOPs are required to be reviewed at least every two years and are intended to describe procedures exactly as they are to be performed. Use of the word “should” is not appropriate when describing requirements (e.g., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word “should”. Contracted analyses are performed by Environmental Chemists Inc. (EnviroChem) (Certification #94) and TBL Environmental Laboratory Inc. (Certification #37). Page 2 #5148 Fairmont Regional WWTP Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: The laboratory is lacking a documented training program. Requirement: Each laboratory shall develop and implement a documented training program that includes the following: that staff have the education, training, experience, or demonstrated skills needed to generate quality control results within method-specified limits and that meet the requirements of these Rules; that staff have read the laboratory quality assurance manual or applicable Standard Operating Procedures; that staff have obtained acceptable results on Proficiency Testing Samples pursuant to Rule .0803(1) of this Section or other demonstrations of proficiency (e.g., side-by-side comparison with a trained analyst, acceptable results on a single- blind performance evaluation sample, an initial demonstration of capability study prescribed by the reference method). Ref: 15A NCAC 02H .0805 (g) (5). B. Finding: The laboratory is not documenting all traceability information for purchased materials, reagents and standards. Requirement: 15A NCAC 02H .0805 (a) (7) (K) and (g) (7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: 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: NC WW/GW LCB Traceability Documentation Requirements for Chemicals, Reagents, Standards and Consumables Policy. Comment: The lot numbers of the pH buffers are currently documented on the benchsheet, but the rest of the required information is not recorded. There is no traceability information documented for Total Residual Chlorine (TRC) DPD reagents. Comment: The laboratory had been documenting traceability information on a log until 2021 when a new analyst began work and was not aware of the log. C. Finding: Chemical containers are not dated when received and when opened. Requirement: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). D. Finding: The laboratory benchsheet does not reference the currently approved methods. Requirement: Laboratory Procedures: Laboratory procedures shall comply with Subparagraph (a) (1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Analytical methods, sample preservation, sample containers, and sample holding times shall conform to the requirements found in: 40 CFR Part 136 and 40 CFR Part 503. Ref: 15A NCAC 02H .0805 (a) (1) (A). Page 3 #5148 Fairmont Regional WWTP Comment: The methods are documented as follows on the benchsheets: TRC SM 4500 Cl G- 2000, pH SM 4500 H+B-2000, Temperature SM 2550 B-2000. The Standard Methods references must be updated to the currently approved and certified method. E. Finding: The laboratory benchsheet is lacking required documentation: Date of most recent TRC calibration curve verification. Requirement: The following must be documented in indelible ink whenever sample analysis is performed. Date of most recent calibration curve generation or calibration curve verification. Ref: NC WWGW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). F. Finding: The laboratory is not documenting the assessment of QC standards on the laboratory benchsheet. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the quality control assessments. Ref: 15A NCAC 02H .0805 (g) (2) (O). Comment: This Finding applies to TRC and pH. The acceptance range for the TRC Daily Check Standard is documented on the benchsheet, the pH buffer check acceptance criterion is not documented on the benchsheet. There is no documentation showing that the analyst assesses the values obtained against the acceptance ranges. A check box indicating that the acceptance criterion has been met would satisfy this requirement. Proficiency Testing G. Finding: The laboratory is not documenting PT Sample analyses in the same manner as routine Compliance Samples. Requirement: All PT Sample analyses must be recorded in the same daily analysis records (e.g., benchsheets) as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT Samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all Parameter Methods. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 4.0. Comment: Current laboratory practice is to record the results of PT analyses solely on the reporting form that accompanies the PT Samples. Calibration information is documented on the daily benchsheet. H. Finding: The laboratory is not documenting the preparation of PT Samples. Requirement: PT Samples received as ampules are diluted according to the Accredited PT Sample Provider’s instructions. It is important to remember to document the preparation of PT Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a routine Compliance Sample and is added to a routine sample batch for analysis. No documentation is needed for whole volume PT Samples which require no preparation, however the instructions must be maintained. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Page 4 #5148 Fairmont Regional WWTP Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. Temperature – Standard Methods, 2550 B-2010 (Aqueous) Comment: Temperature is being reported to 0.1°C on the Discharge Monitoring Report (DMR). Recommendation: Unless greater precision is required by the permit or data receiving agency, it is recommended that all temperatures reported for compliance monitoring, be reported in whole numbers as recommended by the Division of Water Resource’s Precision in Discharge Monitoring Reports document. I.Finding for Immediate Response: The VWR Scientific glass thermometer used to obtain compliance temperature values has not been checked against a Reference Temperature- Measuring Device every 12 months. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: All compliance temperature-measuring devices without an NIST traceable certificate, or with an expired NIST traceable certificate, must be verified against a Reference Temperature-Measuring Device and the process documented initially and every 12 months. Verification documentation must include the serial number of the device being checked. The serial number stated accuracy and expiration date of the Reference Temperature-Measuring Device used in the comparison must also be documented. Verification data must be kept on file and be available for inspection for 5 years. (Note: International Organization for Standardization (ISO) 17025 compliant vendors or other Certified laboratories may provide assistance in meeting this requirement. When an ISO compliant vendor provides this assistance, they must provide the serial number, accuracy and calibration date for the Reference Temperature-Measuring Device used for the verification. When a Certified laboratory provides this service, they must provide a copy of the NIST traceable certificate of the Reference Temperature-Measuring Device used for the verification). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Temperature. Comment: A Notice of Finding for Immediate Response (NOFIR) was issued due to the impact on compliance data and so the laboratory would utilize an acceptable temperature-measuring device more quickly than if waiting to first receive the inspection report to take corrective action. The laboratory was instructed to submit verification that an acceptable temperature measuring device is being used. Comment: The laboratory currently uses a VWR Glass Thermometer (Serial #210413321) for compliance measurements. After the NOFIR was issued, TBL Environmental Laboratory Inc. (Cert #37) performed the annual temperature verification on March 22, 2023. The original due date for corrective action was April 5, 2023. However, the Reference Thermometer used for the verification had an expired certificate. TBL Environmental Laboratory Inc. has indicated that a new Reference Thermometer will be ordered, or the current Reference Thermometer will be recalibrated. TBL Environmental Laboratory Inc. will then perform another verification for the Town of Fairmont. Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) Comment: The three gel-type standard readings used to assign the true value are not documented. North Carolina Administrative Code, 15 NCAC 02H. 0805 (g) (1) states: All analytical records, including original observations and information necessary to facilitate historical reconstruction of the calculated results, shall be maintained for five years. All analytical data and records pertinent to each certified analysis shall be available for inspection upon request. The NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine document states: To assign a true value to the gel-type or sealed liquid standard: 1. Zero the instrument with the calibration blank. 2. Read and record gel standard values. 3. Repeat steps 1 and 2 at least two more times. 4. Assign the average value as the Page 5 #5148 Fairmont Regional WWTP true value. Acceptable corrective action (i.e., gel standard was read three times and readings documented and gel standard assigned a true value of 221 µg/L) was performed by the laboratory and observed and approved by the auditor during the inspection. The gel standard verification was performed by Town of Pembroke Wastewater Laboratory (Cert #552). An updated spreadsheet that includes directions to document all 3 gel standard values was sent to Town of Pembroke Wastewater Laboratory on March 20, 2023. No further response is necessary for this Corrected Finding. J. Finding: The laboratory is not analyzing a Method Blank. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Method Blanks would be required when using laboratory-prepared standards [including Proficiency Testing (PT) Samples] and anytime sample dilutions are performed. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Reporting K. Finding: The laboratory does not report results of all tests on the characteristics of the effluent. Requirement: The results of all tests on the characteristics of the effluent, including but not limited to NPDES permit monitoring requirements, shall be reported on the monthly report forms. Ref: 15A NCAC 02B .0506 (b) (3) (J). Comment: The laboratory analyzes Temperature immediately using a thermometer and reports this result. A sample is also analyzed immediately using the Dissolved Oxygen (DO) meter. The Temperature of the DO sample is recorded, but not reported. IV. PAPER TRAIL INVESTIGATION: No paper trail was conducted. A paper trial was conducted by the Fayetteville Regional Office on February 14, 2023. V. CONCLUSIONS: Correcting the above-cited Findings and implementing the Recommendation(s) will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for their assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Tonja Springer Date: March 27, 2023 Report reviewed by: Jill Puff Date: March 27, 2023 Certificate Number:5148 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Fairmont Regional WWTP Address:133 Woodrow Rd. Orrum, NC 28369 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:8/18/2021 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) DISSOLVED OXYGEN SM 4500 O G-2016 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) TEMPERATURE SM 2550 B-2010 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.