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HomeMy WebLinkAbout#5655_2021_1122_TS_FINAL January 28, 2022 5655 Mr. Austin Smith Smithfield Fresh Meats Corp – Clinton P.O. Box 49 Clinton, NC 28329 Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Smith: Enclosed is a report for the inspection performed on November 22, 2021 by Tonja Springer. 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 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. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Tonja Springer, Todd Crawford, #5655 On-Site Inspection Report LABORATORY NAME: Smithfield Fresh Meats Corp - Clinton NC GENERAL PERMIT #: NCG060000 ADDRESS: 424 East Railroad Street Clinton, NC 28328 CERTIFICATE #: 5655 DATE OF INSPECTION: November 22, 2021 TYPE OF INSPECTION: Field Industrial Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Austin Smith and Rick Bowen 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 June 1, 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 ensure 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. Page 2 #5655 Smithfield Fresh Meats Corp – Clinton 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”. Contracted analyses are performed by Environmental Chemists, Inc. (Certification # 94). 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 not documenting traceability information for pH buffers. 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). 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 Policy. Comment: The laboratory is documenting Vendor, Lot Number and Expiration Date on the benchsheet. Date opened and date received is only documented on the pH buffer bottles. While this can provide a traceability link to analyses by looking at the dates that the chemicals were in use, that link is lost once the bottles are discarded B. Finding: Uncertified Data for Conductivity is not documented as such on the benchsheet. Requirement: Each certified Field Laboratory shall be in accordance with Paragraph (e) of this Rule. Ref: 15A NCAC 02H .0805 (g) (17). Requirement: All Uncertified Data shall be documented as such on the benchsheet and on the final report. Ref: 15A NCAC 02H .0805 (e) (3). Quality Control C. Finding: SOPs are not being reviewed every two years. 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 3 #5655 Smithfield Fresh Meats Corp – Clinton Comment: The most recent revision/review date for the pH SOP is listed as May 30, 2017. Reporting D. Finding: The laboratory does not report results of all tests on the characteristics of the effluent when duplicate sample analyses are performed. 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 the monthly report forms. Ref: 15A NCAC 2B .0506 (b) (3) (J). Comment: The following convention must be followed when deciding which pH value to report in the daily cell: - Any value in violation of permit limits must be reported in the daily cell. If multiple samples yielded noncompliant results, the most extreme noncompliant value must be reported in the daily cell. - If all values taken during the day were compliant with the permit limits, the value closest to the bounds of the limit range (high or low) must be reported in the daily cell. - All values not reported in the daily cell must be reported in the comment section. Comment: Duplicates are being analyzed for pH but only one result is being reported. Comment: Sample duplicates are not a required quality control element for Field parameters. Recommendation: It is recommended that the laboratory no longer analyze duplicates for pH. E. Finding: The laboratory does not report all 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 the monthly report forms. Ref: 15A NCAC 2B .0506 (b) (3) (J). Comment: Conductivity is being analyzed for process control purposes, but it is collected at the effluent sampling point. It must be reported on the Discharge Monitoring Report (DMR) as uncertified data, per 15A NCAC .0805 (g) (17) and (e) (3). Recommendation: It is recommended that the laboratory change the sampling point if they wish to keep analyzing this parameter for process control. F. Finding: Data qualifiers from the contract laboratory reports are not being transferred to the DMR. Requirement: Each certified Field Laboratory shall be in accordance with Paragraph (e) of this Rule. Ref: 15A NCAC 02H .0805 (g) (17). Requirement: Reported data associated with quality control failures, improper sample collection, holding time exceedances, or improper preservation shall be qualified as such. Ref: 15A NCAC 02H .0805 (e) (5). Page 4 #5655 Smithfield Fresh Meats Corp – Clinton Comment: The BOD qualifier (i.e., All QC required for DO depletion not met. Results estimated”) was not transferred to the DMR from the client report for the sample collected on October 19, 2021. G. Finding: Composite sample dates are being reported incorrectly on the DMR. Requirement: Time of sample collection begins when the last aliquot is dispensed into the composite sample container. Ref: U.S. EPA NPDES Inspection Manual, Interim Revised Version, January 2017; Chapter 5, Page 105. Comment: The date of collection is being reported on the DMR as the date the 24-hour compositor is set up, not the date the last aliquot is dispensed into the composite sample container. The collection date and collection time cannot be on different days. The collection date documented on the benchsheet is the date the composite sample is removed from the compositor, which is correct. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for Smithfield Fresh Meats Corp - Clinton (NPDES permit # NCG060000). Data were reviewed for January, March and October 2021. No transcription errors were observed. The facility 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: Tonja Springer Date: December 15, 2021 Report reviewed by: Jason Smith Date: December 16, 2021 Certificate Number:5655 Effective Date:1/1/2022 Expiration Date:12/31/2022 Lab Name:Smithfield Fresh Meats Corp – Clinton Address:424 East Railroad Street Clinton, NC 28328-0049 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 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.