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HomeMy WebLinkAbout#5061_2023_0824_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 September 14, 2023 5061 Mr. Robert Long Jr. Burlington Industries - Richmond Plant P.O. Box 250 Cordova, NC 28330- Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Long: Enclosed is a report for the inspection performed on August 24, 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, #5061 On-Site Inspection Report LABORATORY NAME: Burlington Industries - Richmond Plant NPDES PERMIT #: NC0043320 ADDRESS: 740 Old Cheraw Hwy. Cordova, NC 28330 CERTIFICATE #: 5061 DATE OF INSPECTION: August 24, 2023 TYPE OF INSPECTION: Field Industrial Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Robert Long 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 have been analyzed and the laboratory has fulfilled its PT requirements for the 2023 PT Calendar Year. Any time changes are made to laboratory procedures, QA/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”. Contracted analyses are performed by Microbac Laboratories, Inc. (Certification #11). Page 2 #5061 Burlington Industries - Richmond Plant 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: Chemical containers are not consistently dated when received and when opened. Requirement: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). C. Finding: The laboratory benchsheet does not reference the currently approved methods. 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: Dissolved Oxygen (DO) SM 4500 O G-2011 and pH SM 4500 H+B. The correct references for the laboratory’s currently certified methods are SM 4500 O G-2016 and SM 4500 H+B-2011, which may be located on the Certified Parameters Listing (CPL) included with this report. D. Finding: The laboratory is not documenting 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). 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 (03/27/2020). Comment: This Finding applies to pH, Conductivity and Total Residual Chlorine. Comment: Dates opened are written on the pH buffer bottles, as required. While this can provide a traceability link to analyses while the chemicals are still in use, that link is lost once the bottles are discarded. Page 3 #5061 Burlington Industries - Richmond Plant Comment: An example reagent/standard receipt log was given at the time of inspection. E. Finding: The laboratory is not documenting the QC assessments for Conductivity. 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. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (O). Comment: The laboratory is documenting the value of the check standard and the acceptance criterion but is not documenting the evaluation that this criterion is being met. No data were reviewed where the QC results were outside the acceptance range. Proficiency Testing F. 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: The instruction sheet is dated but not initialed. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. G. 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 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 multiple times 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) H. Finding: Chemicals and/or reagents are used beyond the expiration date. Page 4 #5061 Burlington Industries - Richmond Plant Requirement: Chemical containers shall be dated when received and when opened. Reagent containers shall be dated, identified, and initialed when prepared. Chemicals and reagents exceeding the expiration date shall not be used. Chemicals and reagents shall be assigned expiration dates by the laboratory if not given by the manufacturer. If the laboratory is unable to determine an expiration date for a chemical or reagent, a one-year time period from the date of receipt shall be the expiration date unless degradation is observed prior to this date. Ref: 15A NCAC 02H .0805 (g) (7). Comment: The second source Conductivity standard 147 µmhos/cm was expired. A new standard has been ordered and the laboratory will continue to use the expired standard until it arrives. Reporting I. Finding: Values less than the established reporting limit for Total Residual Chlorine (TRC) are being reported on the DMR. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: For all calibration options, the range of standard concentrations must bracket the permitted discharge limit concentration, the range of sample concentrations to be analyzed and anticipated PT Sample concentrations. One of the standards must have a concentration less than the permitted Daily Maximum Limit. The lower reporting limit concentration is equal to the lowest standard concentration. Sample concentrations that are less than the lower reporting limit must be reported as a less-than value. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The lowest standard concentration analyzed in the most recent calibration curve verification was 15 µg/L. Samples with concentrations less than that must be reported as < 15 µg/L on the DMR. Currently, the laboratory is using a reporting limit of 10 µg/L and reporting results above this limit as the value displayed by the instrument. Conductivity – Standard Methods, 2510 B-2011 (Aqueous) J. Finding: The Automatic Temperature Compensator (ATC) is not verified every 12 months. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The Automatic Temperature Compensator (ATC) must be verified prior to initial use and annually (i.e., 12 months) thereafter at two temperatures by analyzing a standard or sample at 25°C (i.e., the temperature to which conductivity values are reported) and a temperature(s) that brackets the temperature ranges of the environmental samples routinely analyzed. This may require the analysis of a third temperature reading that is > 25°C. As the temperature increases or decreases, the value of the conductivity standard or sample must be within ±10% of the true value of the standard or ±10% of the value of the sample at 25°C. If not, corrective action must be taken. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Specific Conductance (Conductivity). Comment: The last ATC verification was done on March 12, 2022. Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) Comment: The laboratory was using all 3 gel-type standards as a daily check. The laboratory is now only using the gel-type standard in the range of the calibration curve, which is all that is required. The “gel-type” or sealed liquid standards must have a true value assigned initially and every 12 months thereafter. Page 5 #5061 Burlington Industries - Richmond Plant When this is done, these standards may be used after the manufacturer’s expiration date. It is only necessary to assign a true value to the gel-type or sealed liquid standard which falls within the concentration range of the calibration curve used to measure sample concentrations. For example, if you are measuring samples against a low-range calibration curve, a 200 μg/L standard would be verified, and not the 800 μg/L standard since the 800 μg/L standard would be measured using a high- range calibration curve. IV. CONCLUSIONS: Correcting the above-cited Findings will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the analyst 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: September 7, 2023 Report reviewed by: Jason Smith Date: September 8, 2023 Certificate Number:5061 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Burlington Industries - Richmond Plant Address:740 Old Cheraw Hwy. Cordova, NC 28330- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:8/24/2021 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) CONDUCTIVITY SM 2510 B-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.