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HomeMy WebLinkAbout#603_2019_0326_TLH_FINALROY COOPER Gi c i vrr ti , M IC AId`L ti Pi,E `A Il,,i.NDA CULPEPP R �"n fo tlo ,rri,ro.,.Wr 603 Mr. Clarence Thompson City of Sanford WTP Laboratory 7441 Poplar Springs Church Road Sanford, NC 27330 r,J0R1I-d wNWvINA April 10, 2019 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Thompson: Enclosed is a report for the inspection performed on March 26, 2019 by Tom Halvosa. 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 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 wish to obtain an electronic copy of this report by email or if you have questions or need additional information, please contact me at (828) 296-4677. Sincerely, Todd Crawford Technical Assistance & Compliance Specialist NC WW/GW Laboratory Certification Branch Attachment cc: Dana Satterwhite, Tom Halvosa, Master File# 603 North Carolina Department of Environmental Quality I Division of Water Resources 1623 Mail Service Center I Raleigh, Noah Carolina 27699-1623 Phone 919.733.3908/Fax 919.733.6241 Laboratory Cert. #: 603 Laboratory Name: City of Sanford WTP Laboratory Inspection Type: Municipal Maintenance Inspector Name(s): Tom Halvosa, Todd Crawford Inspection Date: March 26, 2019 Date Forwarded for Initial Review: April 4, 2019 Initial Review by: Tonja Springer Date Initial Review Completed: April 5, 2019 Cover Letter to use: ❑ Insp. Initial ® Insp. Reg ❑Insp. No Finding ❑Insp. CP ❑Corrected ❑Insp. Reg. Delay (to use: rt click, properties, check) Unit Supervisor/Chemist II: Todd Crawford Date Received: April 8, 2019 Date Forwarded to Admin.: April 10, 2019 Date Mailed: April 10, 2019 Special Mailing Instructions: CERTIFICATE : I. INTRODUCTION: City of Sanford WTP Laboratory NC0002861 7441 Poplar Springs Church Road Sanford, NC 27330 603 March 26, 2019 Municipal Maintenance Tom Halvosa, Todd Crawford Clarence Thompson This laboratory was inspected by representatives of the North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A NCAC 2H .0800 for the analysis of compliance monitoring samples. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. Staff were forthcoming and seemed eager to adopt necessary changes. All required Proficiency Testing (PT) Samples for the 2019 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, 2019. 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 April 4, 2020. 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 Page 2 #603 City of Sanford WTP Laboratory 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". Requirements that reference 15A NCAC 2H .0805 (a) (7) (A), stating "All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request", are intended to be a requirement to document information pertinent to reconstructing final results and demonstrating method compliance. Use of this requirement is not intended to imply that existing records are not adequately maintained unless the Finding speaks directly to that. Contracted analyses are performed by Environmental Conservation Laboratories, Inc. (Certification 591) and Meritech, Inc. (Certification #165). Approved Procedure documents for the analysis of the facility's currently certified Field Parameters were provided at the time of the inspection. Documentation Recommendation: It is recommended that the laboratory combine the pH calibration sheet data with the pH benchsheet. A. Finding: The laboratory needs to increase the traceability documentation of purchased materials and reagents, as well as documentation of standards and reagents prepared in the laboratory. Requirement: All chemicals, reagents, standards and consumables used by the laboratory must have the following information documented: 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. Ref: NC WW/GW LC Policy. Requirement: Supporting records shall be maintained as evidence that these practices are being effectively carried out. All analytical records must be available for a period of five years. Ref: 15A NCAC 2H .0805 (a) (7) and (a) (7) (G). Comment: The laboratory does not have a receipt log or a standard and reagent preparation log for the preparation of Total Residual Chlorine (TRC) calibration standards and Suspended Residue check standards. Example receipt log and standard and reagent preparation log templates were provided to the laboratory with instructions on use at the time of the inspection. B. Finding: The laboratory benchsheets for TRC and pH are lacking pertinent data: Permit number, instrument identification and method reference. Page 3 #603 City of Sanford WTP Laboratory Requirement: All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC 2H .0805 (a) (7) (A). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Permit number, instrument identification (serial number preferred) and method reference. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric) and NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: The benchsheets contained method references but did not include the correct revision years. C. Finding: The Suspended Residue and Turbidity benchsheets method references do not accurately reference the approved methods. Requirement: Laboratory Procedures. Analytical methods, sample preservation, sample containers and sample holding times shall conform to those requirements found in 40 CFR- 136.3. Ref: 15A NCAC 21-1.0805 (a) (1). Comment: The method approval years were outdated. D. Finding: The laboratory benchsheet for TRC is lacking meter calibration time. This is considered pertinent data. Requirement: All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC 2H .0805 (a) (7) (A). 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 LC Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric). E. Finding: The laboratory benchsheet for pH is lacking units of measure. This is considered pertinent data. Requirement: All laboratories must use printed laboratory bench worksheets that include a space to enter the signature or initials of the analyst, date of analyses, sample identification, volume of sample analyzed, value from the measurement system, factor and final value to be reported and each item must be recorded each time samples are analyzed. Ref: 15A NCAC 21-1.0805 (a) (7) (H). Requirement: All analytical data pertinent to each certified analysis must be filed in an orderly manner so as to be readily available for inspection upon request. Ref: 15A NCAC 2H .0805 (a) (7) (A). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Units of measure. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Page 4 #603 City of Sanford WTP Laboratory Quaiiiv Control F. Finding: SOPs have not been developed and/or updated for all the methods included on the laboratory's Certified Parameters Listing (CPL). Requirement: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supporting records shall be maintained as evidence that these practices are being effectively carried out. Ref: 15A NCAC 2H .0805 (a) (7). Comment: The laboratory SOPs are brief one or two paragraph descriptions of each method that are inadequate for use as an SOP. An effective SOP describes the method in such detail that an experienced analyst unfamiliar with the method can obtain acceptable results and meet documentation requirements. SOPs must be developed which describe in detail how a method is performed in that particular laboratory. An SOP format example, SOP cheat sheet and example SOPs for TRC, pH and Turbidity were provided to the laboratory before the inspection. G. Finding: The laboratory reagent blank for TRC sometimes exceeds 50% of the reporting limit. Requirement: For analyses requiring a calibration curve, the concentration of reagent, method and calibration blanks must not exceed 50% of the reporting limit or as otherwise specified by the reference method. Ref: NC WW/GW LC Policy. H. Finding: Data that does not meet all QC requirements is not qualified on the Discharge Monitoring Report (DMR). Requirement: When quality control (QC) failures occur, the laboratory must attempt to determine the source of the problem and must apply corrective action. If data qualifiers are used to qualify samples not meeting QC requirements, the data may not be useable for the intended purposes. A notation must be made on the Discharge Monitoring Report (DMR) form, when any required sample quality control does not meet specified criteria, and another sample cannot be obtained. Ref: NC WW/GW LC Policy. Comment: Results are not qualified when the TRC reagent blank does not meet the acceptance criterion and when the minimum required weight gain for Suspended Residue is not met. Qualifiers for Copper results from the contract laboratory were not reported on the DMR. Proficiency Testing Comment: The laboratory uses pre-printed benchsheets which always list the sample ID as "EFFLUENT.001" in the header. When the laboratory analyzes a PT Sample, they write the name of the PT study in the margin of the benchsheet. Recommendation: It is recommended that the laboratory cross out the word "EFFLUENT.001" on the benchsheet they use to document PT Sample results or redesign the benchsheet. Comment: The preparation of TRC PT Samples is not fully documented. The laboratory was retaining the instruction sheets for PT Sample preparations, however, they were not dating and initialing them. The Proficiency Testing Requirements, October 28, 2018, Revision 3. document states: 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 Page 5 #603 City of Sanford WTP Laboratory 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 (e.g., pH), but it is recommended that the instructions be maintained. Dating and initialing the instruction sheet for the preparation of the Total Residual Chlorine PT Sample would satisfy the documentation requirement. Acceptable corrective action (i.e. dating and initialing the instruction sheets) was performed by the laboratory and approved by the auditor during the inspection. No further response is necessary for this Corrected Finding. Finding: The laboratory does not have a documented plan for PT procedures. Requirement: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supporting records shall be maintained as evidence that these practices are being effectively carried out. Ref: 15A NCAC 2H .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 results and related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, October 29, 2018, Revision 3. J. Finding: Additional QC beyond what is routine for Compliance Samples is being analyzed with PT Samples. Requirement: Laboratories are required to analyze an appropriate PT Sample by each parameter method on the laboratory's CPL. The same PT Sample may be analyzed by one or more methods. Laboratories shall conduct the analyses in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the Accredited PT Sample Provider. This means that they are to be logged in and analyzed using the same staff, sample tracking systems, standard operating procedures including the same equipment, reagents, calibration techniques, analytical methods, preparatory techniques (e.g., digestions, distillations and extractions) and the same quality control acceptance criteria. PT Samples shall not be analyzed with additional quality control. They are not to be replicated beyond what is routine for Compliance Sample analysis. Although, it may be routine to spike Compliance Samples, it is neither required, nor recommended, for PT Samples. PT sample results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine Compliance Samples. Ref: Proficiency Testing Requirements, October 29, 2018, Revision 3. Comment: The laboratory is analyzing known PT Samples along with unknown PT Samples for TRC and pH on the same day. K. Finding: PT Samples have not been distributed among all analysts from year to year. Requirement: Laboratories shall also ensure that, from year to year, PT Samples are equally distributed among personnel trained and qualified for the relevant tests and instrumentation (when more than one instrument is used for routine Compliance Sample Page 6 #603 City of Sanford WTP Laboratory analyses), that represents the routine operation of the work group at the time the PT Sample analysis is conducted. Ref: Proficiency Testing Requirements, October 29, 2018, Revision 3. L. 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 laboratory is not reporting duplicate Suspended Residue results. The laboratory sometimes reports duplicates for TRC and pH. Duplicates are not required for pH and TRC. Comment: If the laboratory continues to analyze pH samples in duplicate they must adhere to the following rules: If more than one pH concentration has been taken for a particular day, these values cannot be averaged due to the logarithmic nature of pH concentration. All values must be reported on the DMR, either in the daily cell or the comments section. The following convention must be followed when deciding which 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. Chlorine, Total Residual — Standard Methods, 4500 Cl G-2011 (Aqueous) Comment: The laboratory is analyzing three daily check standards. Only one daily check standard is required. Comment: The sipper cell on the Hach DR 6000 Spectrophotometer was somewhat hazy, especially around the edges, and needed cleaning. Recommendation: It is recommended that the laboratory clean the sipper cell using the procedure described in the Equipment Maintenance section of the Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric) document provided to the laboratory at the time of the inspection. M. Finding: The laboratory is not verifying the instrument's Factory -set Calibration Curve every 12 months. 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 Reagent 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 tag/L and must not vary by more than 25% from the known value for standard concentrations less than 50 tag/L. Ref: NC WW/GW LC Approved Procedure for Analysis of Total Residual Chlorine (DPD Colorimetric). Comment: The factory -set calibration curve was last verified on March 8, 2018. Page 7 #603 City of Sanford WTP Laboratory Comment: Two drying periods are documented on the benchsheet but only one weighing is documented. The first drying period is just for the wet blank filter. However, a wet blank is not required. The sample is dried only once during the second drying period. Annual drying studies are used in place of drying to a constant weight. The last drying study was performed on December 6, 2018. Comment: The laboratory is splitting their Quarterly Check Standard, which they purchase from ERA, into two parts to analyze the standard in duplicate. The results do not meet the duplicate acceptance criteria. The quarterly check standard is not required to be analyzed in duplicate. Recommendation: It is recommended that the laboratory not split purchased check standards and use whole volumes instead. N. Finding: The laboratory is not analyzing a volume of sample to yield a minimum of 2.5 mg dried residue. Cited previously on July 2, 2009. Requirement: Choose sample volume to yield between 2.5 and 200 mg dried residue. If volume filtered fails to meet minimum yield, increase sample volume up to 1 L. If complete filtration takes more than 10 min, increase filter diameter or decrease sample volume. Ref: Standard Methods, 2540 D-2011 (3) (b). Comment: The laboratory sometimes has difficulty filtering their samples and therefore do not always use 1000 mL of sample as required by the method to yield between 2.5 and 200 mg dried residue. This is, in part, due to the small diameter filter used. Recommendation: It is recommended that the laboratory use a larger filter to either consistently obtain at least 2.5 mg of dried residue or filter 1000 mL of sample if possible within the 10-minute filtering time requirement. O. Finding: Filters are not weighed to constant weight prior to sample analysis, nor is a dry filter blank analyzed with each set of samples. Requirement: If pre -prepared filters are not used, the method requires that filters must be weighed to a constant weight after washing. Repeat cycle of drying, cooling, desiccating, and weighing until a constant weight is obtained or until weight change is less than 4% of the previous weighing or 0.5 mg, whichever is less. In lieu of this process, it is acceptable to analyze a single daily dry filter blank to fulfill the method requirement of drying all filters to a constant weight prior to analysis. Ref: NC WW/GW LC Policy. P. Finding: The laboratory is not washing the filter with at least three successive 20-mL portions of reagent grade water. Requirement: Apply vacuum and wash disk with three successive 20-mL portions of reagent grade water. Ref: Standard Methods, 2540 D-2011 (3) (a). Comment: The laboratory is only rinsing the filter with one portion of reagent grade water. Q. Finding: A check standard is not being analyzed quarterly. Requirement: Analyze one suspended residue, one dissolved residue, one residual chlorine and one oil and grease standard quarterly. Ref: 15 NCAC 2H .0805 (a) (7) (B). Page 8 #603 City of Sanford WTP Laboratory Comment: The laboratory has been analyzing the check standard annually during the last few years. The last weight check performed on April 19, 2018. Turbidi ® Standard Methods, 2130 B-2011 (Aqueous) R. Finding: The laboratory is not consistently calibrating the turbidimeter according to the manufacturer's operating instructions. Requirement: Nephelometer calibration: Follow the manufacturer's operating instructions. Ref: Standard Methods 2130, B-2011 (4) (b). Requirement: Calibrate the turbidimeter at least every 3 months or as specified by the regulating authority when data is used for USEPA reporting. Ref: Hach 2100N 08/2014, Edition 5 User Manual, Page 11. Comment: The laboratory missed the three-month period for calibration that was due in December 2018. The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for City of Sanford WTP Laboratory (NPDES permit # NC0002861) for April, August and December 2018. No transcription errors were observed. The facility appears to be doing a good job of accurately transcribing data. V. CONCLUSIONS: We are concerned with the Finding that was cited previously and not corrected. Laboratory Decertification Ref: 15A NCAC 2H .0807 (a) (1), (13) and (14): A laboratory may be decertified for any or all parameters for up to one year for any or all of the following infractions: (1) Failing to maintain the facilities, or records, or personnel, or equipment, or quality control program as set forth in the application, and these Rules; or (13) Failing to respond to requests for information by the date due; or (14) Failing to comply with any other terms, conditions, or requirements of this Section or of a Laboratory certification. 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 its 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: Tom Halvosa Date: April 4, 2019 Report reviewed by: Tonja Springer Date: April 5, 2019 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Lab Name: City of Sanford WI-P Laboratory Certificate Number: 603 Address: 7441 Poplar Springs Church Road Effective Date: 1/1/2019 Sanford, NC 27330 Expiration Date: 12l31/2019 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 (Pqueous) pH SM 4500 H+B-2011 (Aqueous) RESIDUE, SUSPENDED SM 2540 D-2011 (Aqueous) TURBIDITY SM 2130 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 21-1.0807.