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HomeMy WebLinkAbout#280_2022_0208_JMS_FINAL March 16, 2022 280 Mr. Bill Allen Town of Franklin WWTP P.O. Box 1479 Franklin, NC 28744 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Allen: Enclosed is a report for the inspection performed on February 8, 2022 by Jason Smith. 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 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. 251. Sincerely, Anna Ostendorff Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Jason Smith, Master File #280 On-Site Inspection Report LABORATORY NAME: Town of Franklin WWTP NPDES PERMIT #: NC0021547 ADDRESS: 399 Sierra Drive Franklin, NC 28734 CERTIFICATE #: 280 DATE OF INSPECTION: February 8, 2022 TYPE OF INSPECTION: Municipal Maintenance AUDITOR(S): Jason Smith LOCAL PERSON(S) CONTACTED: Bill Allen, Jason Hopkins and Jake Slagle 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. Benchsheets are well designed, easy to follow and concise. Records are well organized and easy to retrieve. All required Proficiency Testing (PT) Samples for the 2022 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, 2022. The laboratory is reminded that 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 March 1, 2023. Your auditor may suggest an order of priority based on the severity and quantity of findings. The laboratory is also 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 Page 2 #280 – Town of Franklin WWTP 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 Earth Environmental Services (Certification #352). III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: Error corrections are not performed properly. Requirement: All documentation errors shall 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 shall not to be used; instead, the correction shall be written adjacent to the error. The correction shall be initialed by the responsible individual and the date of change documented. Ref: 15A NCAC 02H .0805 (a) (7) (E). Comment: Error corrections are not dated. B. Finding: The laboratory benchsheets are lacking required documentation: the proper units of measure. 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. Ref: 15A NCAC 02H .0805 (a) (7) (F) (xii). Comment: This Finding applies to pH, Temperature, Biochemical Oxygen Demand (BOD) and Suspended Residue. Comment: The units of measure for Fecal Coliform need to be corrected from “MPN” to “MPN/100 mL”. C. Finding: The laboratory benchsheets are lacking required documentation: the instrument identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the instrument identification. Ref: 15A NCAC 02H .0805 (a) (7) (F) (iii). Comment: This Finding applies to pH, Temperature, Total Residual Chlorine (TRC) and BOD. D. Finding: The laboratory benchsheet is lacking required documentation: sample identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: sample identification. Ref: 15A NCAC 02H .0805 (a) (7) (F) (ix). Comment: This Finding applies to TRC. E. Finding: The laboratory benchsheet is lacking required documentation: Date of most recent calibration curve verification. Page 3 #280 – Town of Franklin WWTP Requirement: The State Laboratory may develop Approved Procedures for Field Parameters based upon the methods in any of the sources referenced in Parts(a)(1)(A) through (F) of this Rule. Ref: 15A NCAC 02H .0805 (a) (1) (F). 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 WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: This Finding applies to TRC. F. Finding: The laboratory benchsheet is lacking required documentation: Daily Check Standard analysis time(s). Requirement: The State Laboratory may develop Approved Procedures for Field Parameters based upon the methods in any of the sources referenced in Parts(a)(1)(A) through (F) of this Rule. Ref: 15A NCAC 02H .0805 (a) (1) (F). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Daily Check Standard analysis date and time(s). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: This Finding applies to TRC. G. Finding: The laboratory benchsheet is lacking required documentation: all quality control assessments. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: all quality control assessments. Ref: 15A NCAC 02H .0805 (a) (7) (F) (xv). Comment: This finding applies to pH, TRC, BOD, Suspended Residue and Fecal Coliform. Quality control results from standards, blanks and duplicates must be calculated, documented and evaluated. H. Finding: Documentation does not demonstrate that the initial DO for BOD analysis is measured within 30 minutes of sample preparation. This is considered pertinent data. Requirement: 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. Ref: 15A NCAC 02H .0805 (a) (7) (E). Requirement: After preparing dilution, measure initial DO within 30 min. Ref: Standard Methods, 5210 B-2016. (5) (g). Comment: The laboratory documents the time that samples are incubated which is still required. If samples are incubated within 30 minutes of preparation, documentation of the beginning time of sample preparation and time of incubation will demonstrate compliance with the requirement. Otherwise, the time of sample preparation, time of DO analysis and time of incubation must be documented. I. Finding: The laboratory is not documenting the preparation of Proficiency Testing (PT) Samples. Page 4 #280 – Town of Franklin WWTP 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, February 19, 2020, Revision 5, Section 3.6. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. J. Finding: The laboratory does not have a documented plan for all 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 laboratory must also be able to explain when PT Sample analysis is not possible for certain methods and provide a description of what the laboratory is doing in lieu of Proficiency Testing. This shall be detailed in the plan. 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, February 19, 2020, Revision 5, Section 3.0. Comment: The laboratory has PT SOPs for Field Parameters, but not for non-Field Parameters. K. Finding: The laboratory does not document SOP revisions. Requirement: 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. Ref: 15A NCAC 02H .0805 (a) (7). Recommendation: It is recommended that the laboratory add an SOP revision tracking table similar to those found in the Field Parameter SOP templates to their non-Field SOPs. The SOP revision tracking table is included in the laboratory’s current Field Parameter SOPs but has not been used yet due to them being completely rewritten last year. Page 5 #280 – Town of Franklin WWTP Quality Assurance/Quality Control L. Finding: Thermometers in the Fecal Coliform and BOD incubators are not verified against a Reference Temperature-Measuring Device at least every three months. Requirement: Digital temperature-measuring devices and temperature-measuring devices used in incubators shall be verified at the temperature of use every three months against a Reference Temperature-Measuring Device and their accuracy shall be corrected. Ref: 15A NCAC 02H .0805 (a) (7) (N) (iii). Comment: The laboratory verifies these thermometers every six months. Bacteria - Coliform Fecal – IDEXX Colilert ® 18 (MPN) (Aqueous) M. Finding: An acceptance criterion has not been established for Fecal Coliform duplicates. Requirement: Unless specified by the method or this Rule, each laboratory shall establish performance acceptance criteria for all quality control analyses. Each laboratory shall calculate and document the precision and accuracy of all quality control analyses with each sample set. When the method of choice specifies performance acceptance criteria for precision and accuracy, and the laboratory chooses to develop laboratory-specific limits, the laboratory-specific limits shall not be less stringent than the criteria stated in the approved method. Ref: 15A NCAC 02H .0805 (a) (7) (A). Comment: The laboratory will need to develop acceptance criterion for the duplicate. The lab must set an acceptance criterion at all concentration levels. IDEXX recommends basing acceptance on the 95% confidence range. Looking at the sample and duplicate ranges, they are acceptable as long as those 2 ranges overlap. Go to the following website to download a program where you can enter results and it will calculate the MPN and 95% confidence range- https://www.idexx.com/en/water/resources/mpn-generator/. Alternately, a chart that contains all possible MPN results with the corresponding 95% confidence levels can be found on the technical assistance portion of the NC WW/GW LCB website. N. Finding: The laboratory reports the arithmetic average (mean) of duplicate results. Requirement: Any average for Fecal Coliform is to be calculated as a geometric mean. Ref: Directions for Completing Monthly Discharge Monitoring Reports, Section II, (8). BOD – Standard Methods, 5210 B-2016 (Aqueous) O. Finding: Duplicates are not analyzed at the required frequency. Requirement: As a minimum, include one duplicate sample or one LFM duplicate with each sample set (batch) or on a 5% basis, whichever is more frequent, and process it independently through the entire sample preparation and analysis. Ref: Standard Methods, 5020 B-2017 (8) and Table 5020:I Footnote 2. Comment: The laboratory sets up BODs two days each week, but only analyzes a duplicate one day each week. P. Finding: The laboratory is not preparing the dilution water correctly. Page 6 #280 – Town of Franklin WWTP Requirement: Add 1 mL each of phosphate buffer, MgSO4, CaCl2, and FeCl3 solution/L to prepared source water (5210 B.4c). Ref: Standard Methods, 5210 B-2016 (5) (a). Comment: The laboratory uses Hach Nutrient Buffer Pillows (Hach Product Number 2436466) to prepare the dilution water. Per the manufacturer’s instructions, one pillow is to be added to 4 L of source water to meet the method requirements. The laboratory is adding one pillow to 3.79 L (one gallon) of distilled water. The laboratory must use 4 L to prepare the dilution water when using the Hach Nutrient Buffer Pillows. Chlorine, Total Residual – Standard Methods, 4500 Cl G-2011 (Aqueous) Recommendation: The laboratory currently verifies the calibration curve using 20, 70, 200, 300 and 500 µg/L standards. It is recommended that the laboratory verify 20, 40, 50, 200 and 400 µg/L standards. This places emphasis on the portion of the curve between the permit limit and compliance limit, which is the range of most samples. Q. Finding: The laboratory is not analyzing a Method Blank when required. Requirement: The State Laboratory may develop Approved Procedures for Field Parameters based upon the methods in any of the sources referenced in Parts(a)(1)(A) through (F) of this Rule. Ref: 15A NCAC 02H .0805 (a) (1) (F). 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). Residue, Suspended – Standard Methods, 2540 D-2015 (Aqueous) Comment: The laboratory weighs Suspended Residue filters to constant weight prior to sample analysis. This is no longer required in the 2015 revision of the method which is now approved. R. Finding: The laboratory does not analyze the correct volume for the blank. Requirement: The analysis of method blanks for the Residue methods shall be performed as follows: Total Suspended Residue: Using the same containers and glassware normally in contact with samples, put 30 ml of DI water through the sample filter and proceed through the entire analytical process. Acceptance criterion is ≤0.5 mg weight gain. Ref: NC WW/GW LCB Method Blank Analysis Requirement for Suspended, Dissolved and Total Residue Policy. Comment: The laboratory analyzes 20 mL for the blank. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for the Town of Franklin WWTP (NPDES permit # NC0021547) for January, May and September 2021. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data. Page 7 #280 – Town of Franklin WWTP V. CONCLUSIONS: Correcting the above-cited Findings and implementing the Recommendations 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: Jason Smith Date: February 16, 2022 Report reviewed by: Jill Puff Date: February 18, 2022 Certificate Number:280 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Town of Franklin WWTP Address:399 Sierra Drive Franklin, NC 28734- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:8/27/2021 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 BACTERIA - COLIFORM FECAL IDEXX Colilert ®18 (MPN) (Aqueous) BOD SM 5210 B-2016 (Aqueous) CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) RESIDUE, SUSPENDED SM 2540 D-2015 (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.