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HomeMy WebLinkAbout#5639_2021_0628_MC_FINAL September 10, 2021 5639 Ms. Kelly Nance Pace South Carolina - Field Laboratory and Service Center 106 Vantage Point Dr West Columbia, SC 29172 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Nance: Enclosed is a report for the inspection performed on June 28, 2021 by Michael Cumbus. I apologize for the delay in getting this report to you. 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 2H .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. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Michael Cumbus On-Site Inspection Report LABORATORY NAME: Pace South Carolina – Field Laboratory and Service Center ADDRESS: 228 Westinghouse Blvd., Suite 101 Charlotte, NC 28273 CERTIFICATE #: 5639 DATE OF INSPECTION: June 28, 2021 TYPE OF INSPECTION: Field Commercial Maintenance AUDITOR(S): Michael Cumbus LOCAL PERSON(S) CONTACTED: Kelly Nance, Kristina Bouknight and Michael Kilpatrick 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 2021 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, and editorial and substantive revision requirements and recommendations were made by this program outside of this formal report process. Although subsequent revisions were not requested to be submitted, they must be completed by March 31, 2022. The laboratory is reminded that any time changes are made to laboratory procedures, the laboratory must update the QA/SOP document(s) and inform relevant staff. Any changes made in response to the pre-audit review or to Findings, Recommendations or Comments listed in this report must be incorporated to insure the method is 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. 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 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 #5639 Pace South Carolina – Field Laboratory and Service Center Contracted analyses are performed by Pace South Carolina – Analytical Laboratory (Certification # 329). 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 Comment: The laboratory needs to increase the legibility of the Chain of Custodies (COCs) and the laboratory benchsheets. Several instances were noted where data recorded was difficult to discern. A. Finding: The laboratory is not consistently documenting the signature or initials of the analyst. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the signature or initials of the analyst. 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) (E). Comment: During the data audit it was noted that the laboratory has sections for multiple parameter analyses on each benchsheet and space designated for the analyst’s initials with each parameter. The analysts are not always initialing the analyses they perform. Since each section represents a separate analysis, each section needs to be signed or initialed by the analyst. B. Finding: Documentation of the calibration variables for the DO meter does not include all pertinent data. 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: calibration variables (temperature, elevation or barometric pressure [in mmHg], and salinity. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). Comment: The laboratory is using the default salinity value of zero in its daily calibrations. However, this must be documented in the instrument calibration log. Chlorine, Total Residual – Standard Methods, 4500 Cl G-2011 (Aqueous) C. Finding: The laboratory is using an elevated reporting limit which does not demonstrate compliance with NPDES permit requirements. 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 Page 3 #5639 Pace South Carolina – Field Laboratory and Service Center 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: During the paper trail data review, it was noted that the laboratory currently lists a reporting limit of 50 µg/L on their reports for the City of Belmont (NPDES Permit #NC0021181). The established reporting limit as determined during the annual calibration verification is 15 µg/L. During an audit on March 15, 2018, laboratory staff mentioned that clients had requested that the reporting limit be raised to 50 µg/L. The City of Belmont has a permit limit of 28 µg/L. A result of < 50 µg/L does not demonstrate that the laboratory can adequately meet the client’s permit requirements. Examination of Discharge Monitoring Reports (DMRs) showed many instances of results for Total Residual Chlorine (TRC) reported as “< 28 µg/L”. Data for a sample collected March 8, 2021 reported a result of 33 µg/L. Further examination of documentation revealed that the analysts are recording the results on the Chain of Custody (COC) as well as the laboratory benchsheet. Values below the permit limit of 28 µg/L for the City of Belmont WWTP (NPDES Permit # NC0021181) are recorded as “< 28 µg/L” on the COC. Values above the permit limit are recorded as actual values. Comment: Section 9.5 of the SOP notes that “Results transcribed onto chain-of-custody records are considered preliminary.” The laboratory needs to remind clients that preliminary results are not considered certified data. Recommendation: It is recommended that the laboratory amend their COC to note that any analytical results documented on the COC are preliminary and not considered certified data. Conductivity – EPA 180.1, Rev. 1982 (Aqueous) Comment: No compliance samples for the State of North Carolina have been analyzed for the past few years. Comment: The temperatures used during the last Automatic Temperature Compensator (ATC) check were 19.0, 25.1 and 31.5 °C. Prior to resuming analysis of NC compliance samples, the laboratory must perform the ATC check at temperatures that bracket the expected range of sample temperatures. This may require a check at a lower temperature than currently used. Temperature – Standard Methods, 2550 B-2010 (Aqueous) D. Finding: An inconsistency was noted between the SOP and laboratory practice as follows: the laboratory is only recording the temperature reading after applying the temperature measuring device’s correction factor. The SOP (document #ME001HP-06) Section 9.2.1 states to record both the unadjusted and adjusted values. 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). Page 4 #5639 Pace South Carolina – Field Laboratory and Service Center Comment: The laboratory benchsheet does not have a place to record both readings. The verifications for the current temperature-measuring devices have a correction factor of zero. Current laboratory practice is typically to replace any instrument that requires a correction factor. Laboratory personnel also indicated that if the device were not replaced, the analyst would record the corrected temperature reading on the benchsheet. If a correction factor needed to be applied, data recreation to the original device reading would be difficult. The SOP must be updated to reflect what the laboratory’s actual practice is. Recommendation: NC WW/GW LCB does not require a correction factor to be applied if it is within ± 0.5°C. If the correction is larger, the device may not be used for compliance monitoring. It is recommended that the laboratory cease using a correction factor or note on the laboratory benchsheet and the SOP that the value reported is the corrected temperature. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, client reports, etc.). Data were reviewed for the following project numbers: WA06030, WB01031, WC08030, WC22035, WD02049, WD13060, WD16080, WE03040, WE12052, WE18044, WF03050, WF08033. No transcription errors were observed. The laboratory appears to be doing a good job of accurately transcribing data. 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: Michael Cumbus Date: July 26, 2021 Report reviewed by: Jason Smith Date: July 30, 2021 Certificate Number:5639 Effective Date:1/1/2021 Expiration Date:12/31/2021 Lab Name:Pace South Carolina - Field Laboratory and Service Center Address:228 Westinghouse Blvd., Suite 101 Charlotte, NC 28273 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:8/4/2021 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 EPA 120.1, Rev. 1982 (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.