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HomeMy WebLinkAbout#5373_2018_0320_TH_FINALTo be attached to all inspection reports in-house only. Laboratory Cert. #: 5373 Laboratory Name: Town of Cary Inspection Type: Field Municipal Maintenance Inspector Name(s): Tom Halvosa, Todd Crawford Inspection Date: March 20, 2018 Date Forwarded for Initial Review: April 5, 2018 Initial Review by: Jason Smith Date Initial Review Completed: April 12, 2018 Cover Letter to use: ❑ Insp. Initial ® Insp. Reg ❑Insp. No Finding ❑Insp. CP ❑Corrected ❑Insp. Reg. Delay Unit Supervisor/Chemist III: Todd Crawford Date Received: April 12, 2018 Date Forwarded to Admin.: April 17, 2018 Date Mailed: April 17, 2018 Special Mailing Instructions: n, f r f t, Y € titer Resources 1-NVIRONMENEai_ Ga ALITY April 17, 2018 5373 Mr. Rick Jordan Town of Cary 400 James Jackson Ave. Cary, NC 27513 ROY COOPER MICHEAL S. REGAN LINDA CULPEPPER Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Jordan: Enclosed is a report for the inspection performed on March 20, 2018 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 Fihding(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, D� Todd Crawford Technical Assistance & Compliance Specialist NC WW/GW Laboratory Certification Branch Attachment cc: Dana Satterwhite, Tom Halvosa WATER QUALITY PERMIT #: CERTIFICATE : TYPE OF INSPECTION: AUDITORS: LOCAL PERSONS CONTACTED: INTRODUCTION: Town of Cary NC0048879 and NC0065102 WQ0018489 and WQ0017923 400 James Jackson Avenue Cary, NC 27513 5373 March 20, 2018 Field Municipal Maintenance Tom Halvosa and Todd Crawford Rick Jordan and Kenya D'Jon 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 environmental samples. GENERAL COMMENTS: The facility has all the equipment necessary to perform the analyses. Staff were forthcoming and seemed eager to adopt necessary changes. The laboratory separates their benchsheets into a "calibration" benchsheet and a "point of use" benchsheet for recording calibration and compliance data respectively. All required Proficiency Testing (PT) Samples for the 2018 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, 2018. Requirements that reference 15A NCAC 2H .0805 (g) (1), stating "Data pertinent to each analysis must be maintained for five years. Certified Data must consist of date collected, time collected, sample site, sample collector, and sample analysis time. The field benchsheets must provide a space for the signature or initials of the analyst and proper units of measure for all analyses", are intended to be a requirement to document all pertinent information for historical reconstruction of data. It is not intended to imply that existing records are not adequately maintained unless the Finding speaks directly to that. Page 2 #5373 Town of Cary Required analyses beyond the capability of this laboratory are performed by North Cary WRF (Certification # 107) and South Cary WRF (Certification # 278). Quality Assurance Policies for Field Laboratories and Approved Procedure documents for the analysis of the facility's currently certified Field Parameters were provided at the time of the inspection. ► � ► � ► ► ��i7l��l��l�����_1�17:7=[�7i41►�il��l�7_��[�7►�`3i Documentation Comment: During the inspection, the recommendation was made to document the acceptance range of the Daily Check Standard to make confirmation of the acceptability easier. The recommendation was accepted and the benchsheets were updated to include acceptance criterion of ± 10% recovery for the Daily Check Standard and immediately put into use. A. Finding: The laboratory benchsheet was lacking pertinent data: true value for the check standard, facility name, instrument identification (serial number preferred), parameter analyzed and method reference. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Facility name, parameter analyzed, method reference and thermometer/instrument identification (serial number preferred). Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine, NC WW/GW LC Approved Procedure for the Analysis of pH and NC WW/GW LC Approved Procedure for the Analysis of Temperature. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: True value of the Daily Check Standard(s). Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: True value for the check standard buffer. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: For the analysis of Total Residual Chlorine, the true value of the gel -type standard used for the Daily Check Standard was incorrectly listed on the calibration benchsheet as 1.59 mg/L. The actual true value established at the time of the annual Factory -set Calibration Curve Verification procedure was 1.5 mg/L. B. Finding: The laboratory needs to increase the traceability documentation of purchased materials and reagents. Requirement: All chemicals, reagents, standards and consumables used by the laboratory must have the following information documented: Date Received, Date Opened (in use), Vendor, Lot Number, and Expiration Date. Consumable materials such as pH buffers and lots of pre -made standards are included in this requirement. Ref: Quality Assurance Policies for Field Laboratories. Page 3 #5373 Town of Cary Comment: The laboratory does not document the vendor name for pH buffers in traceability documents. Proficiency Testing C. 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 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 (e.g., pH), but it is recommended that the instructions be maintained. Ref: Proficiency Testing Requirements, May 31, 2017, Revision 2.0. Comment: Dating and initialing the instruction sheet for each prepared TRC PT Sample would satisfy the documentation requirement. D. 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, May 31, 2017, Revision 2.0. Temperature — Standard Methods, 2550 B-2010 (Aqueous) E. Finding: The laboratory is not performing the annual temperature -measuring device check procedure correctly. 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°C. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Comment: The laboratory only checks the temperature -measuring device at one temperature. IV. PAPER TRAIL INVESTIGATION: This facility does not report compliance data on an electronic Discharge Monitoring Report (eDMR). Their compliance data is recorded and retained as part of a permit requirement of another parent facility (North Cary WRF). As such, a paper trail could not be performed. V. CONCLUSIONS: Correcting the above -cited Findings 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 and implementation dates for each corrective action. 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