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HomeMy WebLinkAbout#5445_2020_1106_JMS_FINAL December 3,2020 5445 Ms. Melanie Kemp Anchor QEA of North Carolina PLLC 231 Haywood Street Asheville, NC 28801 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Kemp: Enclosed is a report for the inspection performed on November 6, 2020 by Jason Smith. Where Finding(s) are cited in this report, a response is required. Within thirty days of receipt, please supply this office with a written item for item description of how th ese 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 wish to obtain an electronic copy of this report by email or if you have questions or need additional information, please contact me at (919) 733-3908 Ext. 251. Sincerely, Todd Crawford Environmental Program Supervisor II NC WW/GW Laboratory Certification Branch Attachment cc: Jason Smith, Master File #5445 Inspection Report LABORATORY NAME: Anchor QEA of North Carolina PLLC WATER QUALITY PERMIT #: WQ0004797 NC GENERAL PERMIT #: NCG030026 and NCG030499 ADDRESS: 231 Haywood Street Asheville, NC 28801 CERTIFICATE #: 5445 DATE OF INSPECTION: November 6, 2020 TYPE OF INSPECTION: Field Commercial Maintenance AUDITOR(S): Jason Smith LOCAL PERSON(S) CONTACTED: Matthew Fields and Jennifer Verde I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The inspection was performed remotely due to the coronavirus pandemic. The laboratory submitted the requested documentation and pictures of their reagents and instruments electronically. The inspection was performed by WebEx teleconference on November 6, 2020. The laboratory has all the equipment necessary to perform the analyses. Benchsheets are well designed, easy to follow and concise. Staff members were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples have been analyzed for the 2020 PT Calendar Year and the graded results were 100% acceptable. Contracted analyses are performed by Pace Analytical Services, LLC – Asheville, NC (Certification # 40). 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 May 2021. Page 3 #5445 Anchor QEA of North Carolina PLLC 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 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”. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation 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: The data reviewed included instances of overwriting, using more than a single line to mark out and the error corrections were not consistently initialed and dated. B. Finding: The laboratory needs to increase the traceability documentation of purchased materials and reagents. 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 LC Policy. Comment: The traceability log does not include the date opened or put into use. The calibration log includes a space for documenting the lot number and expiration date of the calibration reagents, but the lot numbers are not documented in the reviewed data. C. Finding: Uncertified data is not documented as such on the benchsheets. Requirement: All uncertified data must be clearly documented as such on the benchsheet and on the final report. Ref: 15A NCAC 02H .0805 (e) (3). Page 4 #5445 Anchor QEA of North Carolina PLLC Comment: This applies to Turbidity analyses. D. Finding: The laboratory benchsheet is lacking required documentation: the sample collector and 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 sample collector; 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) (D) and (E). Comment: The well sampling log identifies the “Sampling Personnel” but does not specify the sample collector or analyst when more than one person is participating in sampling. Comment: Please note that the sample analyst must initial or sign the benchsheet when samples are analyzed. The sample collector must be documented but does not have to initial or sign the form themselves. E. Finding: The laboratory benchsheet is lacking required documentation: all manual calculations. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: all manual calculations. 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) (N). Comment: This Finding applies to Conductivity. The percent recovery must be calculated and documented to demonstrate that it meets the acceptance criterion. F. Finding: The laboratory benchsheet is lacking required documentation: 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, sample site (ID or location), and permit number. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO), NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity), NC WW/GW LC Approved Procedure for the Analysis of pH and NC WW/GW LC Approved Procedure for the Analysis of Temperature. G. 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 LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Page 5 #5445 Anchor QEA of North Carolina PLLC Comment: Since the laboratory does not analyze saline samples, a blanket statement may be added to the benchsheet rather than documenting the Salinity with each calibration. For example, “Unless otherwise noted, all Dissolved Oxygen calibrations and measurements are performed at 0 ppt Salinity”. H. Finding: Values were reported that exceed the method specified accuracy of 0.1 units. Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents the limit of accuracy under normal conditions, especially for measurement of water and poorly buffered solutions. For this reason, report pH values to the nearest 0.1 pH unit. Ref: Standard Methods, 4500 H+ B-2011. (6). Conductivity – EPA 120.1, Rev. 1982 (Aqueous) Recommendation: The laboratory documents the units of measure as µS/cm on the benchsheet. It is recommended that the units of measure be changed to µmho/cm on the benchsheet since those are the units of measure on the reporting form (1 µmho/cm = 1 µS/cm). I. Finding: The Automatic Temperature Compensator (ATC) check is not being properly performed. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The 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 (see #3 below). The manner in which the ATC is verified may depend upon the meter’s capabilities and the manufacturer’s instructions. The following is one option. 1. Pour an adequate amount of conductivity standard or sample into a beaker or other container and analyze at 25 °C. Document the temperature and conductivity value. 2. Lower the temperature of the standard or sample (e.g., by placing the container in a refrigerator or ice chest) to less than the lowest anticipated sample temperature and analyze. Document the temperature and conductivity value. 3. If samples greater than 25 °C are to be analyzed, perform the following additional step: Raise the temperature above 25 °C to greater than the highest anticipated sample temperature (e.g., by placing the container in a hot water bath) and analyze. Document the temperature and conductivity value. 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 LC Approved Procedure for the Analysis of Specific Conductance (Conductivity). Please submit an updated ATC verification bracketing the range of compliance samples analyzed with the report reply. Comment: The ATC was verified at 10.5 °C, 24.8 °C and 35.3 °C. Sample results below 10.5 °C were included in the data submitted for review. J. Finding: The laboratory is not analyzing a second-source calibration verification check standard. Page 6 #5445 Anchor QEA of North Carolina PLLC Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Analyze and document a second-source calibration verification check standard prior to compliance sample analysis. It is recommended that this standard value approximate (may be higher or lower than the calibration standard, as applicable) the expected range of sample values measured. The value obtained for the calibration verification check-standard must read within 10% of the true value of the calibration verification check standard. If the obtained value is outside of the ±10% range, corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity). Comment: The calibration is verified using the calibration standard. A standard with a different manufacturer or lot number than the calibration standard must be used for calibration verification. Comment: Please note that Conductivity standards may not be diluted. Dissolved Oxygen – SM 4500 O G-2011 (Aqueous) K. Finding: The laboratory is not calibrating prior to sample analysis at each sample site or performing a Post-Analysis Calibration Verification when analyses are performed at multiple sample sites. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: When performing analyses at multiple sample sites, the meter must be calibrated at each sample site prior to analysis or a post-analysis calibration verification must be performed at the end of the run, regardless of meter type. The calculated theoretical DO value must verify the meter reading within ±0.5 mg/L. If the meter verification does not read within ±0.5 mg/L of the theoretical DO, corrective action must be taken. If the meter is not calibrated at each sample site, it is recommended that a mid-day calibration be performed when samples are extended over an extended period of time. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). Temperature – SM 2550 B-2010 (Aqueous) L. Finding: The annual temperature-measuring device check procedure is not performed correctly. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: To check a compliance temperature-measuring device, compare readings at two temperatures that bracket the range of compliance samples routinely analyzed against a National Institute of Standards and Technology (NIST) traceable temperature-measuring device and record all four readings. The readings from both devices must agree within 0.5 ºC. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Please submit an updated temperature verification bracketing the range of compliance samples analyzed with the report reply. Page 7 #5445 Anchor QEA of North Carolina PLLC Comment: The meter was verified at 10.5 °C and 35.3 °C. Sample results below 10.5 °C were included in the data submitted for review. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, chains of custody etc.) and client reports. Data were reviewed for Lassonde Pappas (formerly Clement Pappas) permit number WQ0004797 and Team Industries Andrews permit number NCG030026 for November 2019 and May 2020. 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 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: November 19, 2020 Report reviewed by: Anna Ostendorff Date: November 20, 2020 Certificate Number:5445 Effective Date:1/1/2020 Expiration Date:12/31/2020 Lab Name:Anchor QEA of North Carolina PLLC Address:231 Haywood Street Asheville, NC 28801- 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 CONDUCTIVITY EPA 120.1, Rev. 1982 (Aqueous) DISSOLVED OXYGEN SM 4500 O G-2011 (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.