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HomeMy WebLinkAbout#5117_2023_0523_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 June 21, 2023 5117 Mr. Brandon Johnson Town of Angier WWTP P.O. Box 278 Angier, NC 27501- Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Johnson: Enclosed is a report for the inspection performed on May 23, 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: Todd Crawford, Tonja Springer, #5117 On-Site Inspection Report LABORATORY NAME: Town of Angier WWTP WATER QUALITY PERMIT #: WQ0002638 ADDRESS: 420 Campbell Street Angier, NC 27501 CERTIFICATE #: 5117 DATE OF INSPECTION: May 23, 2023 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Brandon Johnson 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 December 31, 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”. Page 2 # 5117 Town of Angier WWTP Contracted analyses are performed by Pace Analytical Services LLC - Huntersville NC (Certification # 12). 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: Comment: The facility has a Non-discharge Surface Irrigation permit. At the time of the inspection, no spray events had occurred since April 2022. Only 2022 Proficiency Testing (PT) data were available for review. Documentation Recommendation: It is recommended that the name of the PT study be documented (e.g., NSI WP- 272) in the space provided for Facility/Sample location. The facility name is already documented at the top of the benchsheet. Recommendation: The make and model of the meter is documented on the benchsheet for the instrument identification. It is recommended to include the serial number of the meter. Comment: Chemical containers are not dated when opened. North Carolina Administrative Code, 5A NCAC 02H .0805 (g) (7) states: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). Acceptable corrective action was taken at the time of the inspection (i.e., the date opened was documented on the reagent containers currently in use). No further response is necessary for this Corrected Finding. Comment: The three gel-type standard values used to assign the true value are not documented. North Carolina Administrative Code, 5A 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 true value. Acceptable corrective action was taken at the time of the inspection (i.e., the gel standard was read three times and readings documented and gel standard assigned a new true value). No further response is necessary for this Corrected Finding. 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 benchsheet does not reference the currently approved methods. Page 3 # 5117 Town of Angier WWTP Requirement: Laboratory procedures shall comply with Subparagraph (a) (1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the method or Standard Operating Procedure. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (A). Comment: The methods are documented as follows on the benchsheets: Total Residual Chlorine (TRC) SM 4500 Cl G -2000 and pH SM 4500 H+B-2000. The Standard Methods references must be updated to the currently approved and certified method. C. 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. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (O). Comment: This Finding applies to TRC and pH. The concentration acceptance range for the TRC Daily Check Standard and the pH buffer check acceptance criterion are 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. No data were observed where the QC results were outside the acceptance criteria. D. Finding: The units of measure for pH (i.e., Standard Units or S.U.) are not documented on the calibration log. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the proper units of measure. Each item shall be recorded each time samples are analyzed. Ref: 15A NCAC 02H .0805 (g) (2) (L). E. Finding: The laboratory is not documenting the check standard buffer value obtained. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Value obtained for the check buffer. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Requirement: A record of instrument calibration or calibration verification shall be documented and available for inspection upon request. Ref: 15A NCAC 02H .0805 (g) (3). 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. Page 4 # 5117 Town of Angier WWTP Proficiency Testing F. Finding: The laboratory does not have a documented plan for PT procedures. Requirement: Each laboratory shall develop documentation outlining the analytical quality control practices used for the Parameter Methods included in its Certification, including Standard Operating Procedures for each certified Parameter Method. Quality assurance, quality control, and Standard Operating Procedure documentation shall indicate the effective date of the document and be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and any revisions made in all quality assurance, quality control, and Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. The quality assurance, quality control, and Standard Operating Procedure documents shall be available for inspection by the State Laboratory. Ref: 15A NCAC 02H .0805 (a) (7). Requirement: Laboratories must have a documented plan [this is usually detailed in the laboratory’s Quality Assurance Manual or may be a separate Standard Operating Procedure (SOP)] of how they intend to cover the applicable program requirements for Proficiency Testing per their scope of accreditation. This plan shall cover any commercially available PT Samples and any inter-laboratory organized studies, as applicable. The plan must also address the laboratory’s process for submission of PT Sample results and related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.0. G. 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. Comment: This Finding applies to TRC. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. H. Finding: PT Samples are not analyzed in the same manner as routine Compliance Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each Parameter Method and in each associated matrix on the laboratory’s CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, distillations and extractions) and the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor Page 5 # 5117 Town of Angier WWTP recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Comment: The laboratory is currently analyzing PT Samples in duplicate and averaging the results, which is not how Compliance Samples are treated. Sample duplicates are not required for Field Parameters. Quality Assurance/Quality Control (QA/QC) I. Finding: SOPs have not been updated for all the methods included on the laboratory’s Certified Parameters Listing (CPL). Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. A copy of each analytical method or Approved Procedure and Standard Operating Procedure shall be available to each analyst and available for review upon request by the State Laboratory. Standard Operating Procedure documentation shall state the effective date of the document and shall be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and any revisions made in all Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. Ref: 15A NCAC 02H .0805 (g) (4). Comment: An SOP describes the method in such detail that an experienced analyst unfamiliar with the method can obtain acceptable results and meet documentation requirements. SOPs must describe in detail how a method is performed. Comment: The laboratory does have an SOP for pH and TRC, but it only includes procedural steps for the calibration and sample analysis. The laboratory must have updated QC/SOP documents for the parameters included on their CPL by December 31, 2023. These must be submitted for review upon completion. SOP templates were left with the laboratory at the time of the inspection. Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) J. Finding: The laboratory is not analyzing a Method Blank when using laboratory-prepared standards. 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). Requirement: The Method Blank is deionized or distilled water from the same source used to prepare the calibration verification standards or the PT Sample, and is analyzed like a sample (i.e., with DPD/buffer added). The concentration of the Method Blank must not exceed 50% of the reporting limit (i.e., the lowest calibration verification standard concentration) or corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The prepared PT Sample is considered a laboratory-prepared standard. Page 6 # 5117 Town of Angier WWTP IV. PAPER TRAIL INVESTIGATION: No paper trail was conducted at the time of the inspection. 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: June 6, 2023 Report reviewed by: Jill Puff Date: June 6, 2023 Certificate Number:5117 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Town of Angier WWTP Address:420 Campbell Street Angier, NC 27501- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:7/3/2017 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) pH SM 4500 H+B-2011 (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.