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HomeMy WebLinkAbout#5174_2022_0524_JMS_FINALNC 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 22, 2022 5174 Mr. Kyle H. Cook Waynesville Water Treatment Plant 341 Rocky Branch Rd Waynesville, NC 28786 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Cook: Enclosed is a report for the inspection performed on May 24, 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 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. 251. Sincerely, Anna Ostendorff Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Jason Smith, Asheville Regional Office, Master File #5174 On-Site Inspection Report LABORATORY NAME: Waynesville Water Treatment Plant NPDES PERMIT #: NC0049409 ADDRESS: 341 Rocky Branch Rd Waynesville, NC 28786 CERTIFICATE #: 5174 DATE OF INSPECTION: May 24, 2022 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Jason Smith LOCAL PERSON(S) CONTACTED: Kyle Cook, Hugh Parrott and Cody Stiles 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. Staff were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples have been analyzed for the 2022 PT Calendar Year and the graded results were 100% acceptable. The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in advance of the inspection. These documents were reviewed prior to the inspection for preparatory reasons. 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. I n 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, 2022. Page 2 #5174 – Waynesville Water Treatment Plant The laboratory is also reminded that SOPs 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 Testing Solutions, Inc. (Certification #600) and Suspended Residue analyses are performed by the Town of Waynesville WWTP (Certification #194). 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 Recommendation: It is recommended that the Monthly Effluent Samples benchsheet be updated to indicate that the Turbidity samples are analyzed by Environmental Testing Solutions and that the Suspended Residue samples are analyzed by the Town of Waynesville WWTP. A. Finding: Error corrections are not properly performed. 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 are 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 (g) (1). Comment: Error corrections are not dated. 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 laboratory was emailed an example traceability log after the inspection. C. Finding: The laboratory benchsheet is lacking required documentation: the method or Standard Operating Procedure reference; the laboratory identification; the instrument identification; the proper units of measure. Page 3 #5174 – Waynesville Water Treatment Plant 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; the laboratory identification; the instrument identification; the proper units of measure. 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) (A), (B), (C) and (L). Comment: The units of measure for Total Residual Chlorine (TRC) on the Gel Standard Documentation sheet incorrectly documents the units of measure as “mg/L” and must be corrected to “µg/L”. This Gel Standard Documentation sheet is not required since the verification of the gel standard is also documented on the curve verification spreadsheet. Comment: On the Monthly Effluent Samples benchsheet, the units of measure for Total Suspended Solids must be corrected from “mL/L” to “mg/L” and the units of measure for pH must be corrected from “units” to “Standard Units” or “S.U.”. D. Finding: The laboratory benchsheet is lacking required documentation: Facility name or permit number. 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: Facility name or permit number. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH and NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). E. Finding: The laboratory benchsheet is lacking required documentation: Date of most recent TRC calibration curve verification. 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: 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). F. Finding: The laboratory benchsheet is lacking required documentation: pH meter calibration time. 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: Meter calibration and meter calibration time(s). Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. Proficiency Testing 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 Page 4 #5174 – Waynesville Water Treatment Plant 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. H. 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 daily analysis records as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 19, 2020, Revision 5, Section 3.6. Requirement: The analysis of Proficiency Testing (PT) Samples is designed to evaluate the entire process used to routinely analyze and report Compliance Sample results. PT Samples must be analyzed the same as Compliance Samples. Also, documentation must be made on the same benchsheets used for Compliance Samples. Ref: NC WW/GW LCB Proficiency Testing Samples Analyzed and Documented Same as Compliance Samples Policy. Comment: PT Sample results are entered into the online reporting form and not documented on the laboratory benchsheet. Quality Control I. Finding: SOPs have not been reviewed or updated every two years for all of the methods included on the laboratory’s Certified Parameters Listing (CPL). Requirement: 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: The SOPs were created in 2019 and were next reviewed in May 2022 in preparation for the inspection. J. 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). Comment: The laboratory used NC WW/GW LCB provided SOP templates that included a training program but deleted this section from their SOP without implementing it. Page 5 #5174 – Waynesville Water Treatment Plant Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) K. Finding: The laboratory is not verifying the instrument’s Factory-set Calibration Curve initially and every 12 months. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Annual Factory-set Calibration Curve Verification: This type of calibration curve verification must be performed initially, at least every 12 months and any time the instrument optics are serviced. Zero the instrument with a Calibration Blank and then analyze a Method Blank and a series of five standards (do not use gel or sealed liquid standards for this purpose). The calibration standard values obtained must not vary by more than ±10% from the known value for standard concentrations greater than or equal to 50 μg/L and must not vary by more than ±25% from the known value for standard concentrations less than 50 μg/L. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Comment: The laboratory verified the curve on May 17, 2022 after reviewing the SOP and Approved Procedure when preparing for the inspection. The calibration curve for the meter was not initially verified when it was purchased more than five years ago. L. 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). Comment: The laboratory currently prepares a daily calibration standard from Potassium Permanganate, which requires the analysis of a Method Blank. If the laboratory chooses to verify the curve with a gel standard instead, the method blank will no longer be required to be analyzed daily. However, it would still be required to be analyzed with the annual curve verification and PT Sample analyses. Reporting M. 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 monthly report forms. Ref: 15A NCAC 02B .0506 (b) (3) (J). Comment: The contract laboratory analyzes and provides results to the laboratory for Iron and Manganese for the quarterly sample. These results are not reported on the DMR. Since the permit does not require analysis of these parameters, they do not have to be analyzed but must be reported on the DMR if they are. Page 6 #5174 – Waynesville Water Treatment Plant N. Finding: Values less than the established reporting limit are being reported on the DMR for Total Residual Chlorine. 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 current curve verification establishes the reporting limit at 10 µg/L. In the data reviewed, the following results were reported on the DMR below the reporting limit and should have been reported as <10 µg/L: January 17, 2022, TRC = 3 µg/L; March 2, 2022, TRC = 7 µg/L; and March 16, 2022, TRC = 9 µg/L. 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 submitted to the North Carolina Division of Water Resources. Data were reviewed for the Waynesville Water Treatment Plant (NPDES permit # NC0049409) for September 2021, January 2022 and March 2022. The following errors were noted: Date Parameter Location Contract Laboratory Data Value on DMR 9/14/2021 Iron Effluent 0.13 mg/L Not Reported 9/14/2021 Manganese Effluent 0.057 mg/L Not Reported 9/14/2021 Fluoride Effluent <0.1 mg/L 0 mg/L 9/14/2021 Total Phosphorus Effluent <0.02 mg/L 0 mg/L 9/14/2021 Aluminum Effluent 1.1 mg/L 1.1 µg/L 3/8/2022 Iron Effluent 0.131 mg/L Not Reported 3/8/2022 Manganese Effluent 0.065 mg/L Not Reported 3/8/2022 Aluminum Effluent 0.552 mg/L 0.552 µg/L To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether an amended DMR(s) will be required. A copy of this report will be made available to the Regional Office. Page 7 #5174 – Waynesville Water Treatment Plant V. CONCLUSIONS: Correcting the above-cited Findings and implementing the recommendation 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: May 31, 2022 Report reviewed by: Tom Halvosa Date: June 8, 2022 Certificate Number:5174 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Waynesville Water Treatment Plant Address:341 Rocky Br. Rd. Waynesville, NC 28786- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment: 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.