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HomeMy WebLinkAbout#121_2017_0613_TS_FINALTo be attached to all inspection reports in-house only. Laboratory Cert. #: 121 Laboratory Name: Hillsborough WWTP Inspection Type: Municipal Maintenance Inspector Name(s): Tonja Springer and Todd Crawford Inspection Date: June 13, 2017 Date Forwarded for Initial Review: July 6, 2017 Initial Review by: Anna Ostendorff Date Initial Review Completed: July 11, 2017 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: July 25, 2017 Date Forwarded to Admin.: July 27, 2017 Date Mailed: August 2, 2017 Special Mailing Instructions: t,Voie?-,fir"es>o $ "s ENVIRONMI-Al FA(.. (pk AIJI Y August 2, 2017 121 Mr. Matthew Silinski Hillsborough WWTP P.O. Box 429 Hillsborough, NC 27278 ROY COOPER Governor MICHEAL S. REGAN SecretnrP S. JAY ZIMMERMAN Direetar Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Silinski: Enclosed is a report for the inspection performed on June 13, 2017 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 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 (919) 733-3908 ext. 251. Sincerely, D� Todd Crawford Technical Assistance & Compliance Specialist NC WW/GW Laboratory Certification Branch Attachment cc: Dana Satterwhite, Tonja Springer, Master File #121 LABORATORY NAME: Hillsborough WWTP NPDES PERMIT : NCO026433 ADDRESS: 355 Elizabeth Brady Rd. Hillsborough, NC 27278 CERTIFICATE #: 121 DATE OF INSPECTION: June 13, 2017 TYPE OF INSPECTION: Municipal Maintenance AUDITOR(S): Tonja Springer and Todd Crawford LOCAL PERSON(S) CONTACTED: Matthew Silinski and Jeff Mahagan INTRODUCTION: 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. II. GENERAL COMMENTS: The auditors found this lab to have excellent organization. This was evident from viewing records and observing the layout and actions which help streamline the day to day activities of the lab. The laboratory analyst has implemented an excellent system of chemical and reagent traceability to source materials. Staff were forthcoming and seemed eager to adopt necessary changes. All required Proficiency Testing (PT) samples for the 2017 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, 2017. The laboratory submitted their Quality Assurance (QA) and/or Standard Operating Procedures (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 2018. 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 Page 2 #121 Hillsborough WWTP (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 Meritech, Inc. (Certification #165). III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: Units of measure are not documented. 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: North Carolina Administrative Code, 15A NCAC 02H .0805 (a) (7) (H). Comment: The units of measure are not documented in the following locations: ® Total Suspended Residue benchsheet — Filter Weight + Dried Sample column and Initial Filter Weight column. ® pH benchsheet — Units for slope (e.g.%) ® Upstream and Downstream benchsheet — no units for the DO and Temperature. B. Finding: Some benchsheet references do not accurately reflect the laboratory's certified methods. 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 benchsheet for Dissolved Oxygen (DO) references 181h Edition 4500-0 G instead of SM 4500 O G-2001. Comment: The benchsheet for Total Suspended Solids (TSS) references Standard Methods 20th Edition 1997 2540 D instead of SM 2540 D-1997. While this Edition of Standard Methods contains the promulgated (or approved) method,this is not the current method reference format listed in the Code of Federal Regulations, Title 40, Part 136; Federal Register Vol. 77, No. 97, May 18, 2012. Proficiency Testing C. Finding: The laboratory is not analyzing Proficiency Testing (PT) Samples in the same manner as compliance samples. Page 3 #121 Hillsborough WWTP Requirement: As specified in 15 NCAC 2H .0800, in order to meet the minimum standards for Certification, laboratories must use acceptable analytical methods. The acceptable methods are those defined or referenced in the current State and federal regulations for the environmental matrix being tested. All samples, (including PT Samples) that are, or that may, be used for Certification purposes, must be analyzed using approved methods only. All PT Samples are to be analyzed and the results reported in a manner consistent with the routine analysis and reporting requirements of Compliance Samples. Laboratories must document any exceptions. All PT Sample analyses must be recorded in the daily analysis records as for any Compliance Sample. This serves as the permanent laboratory record. 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, May 31, 2017, Revision 2.0. Comment: PT samples are analyzed multiple times for Total Suspended Solids and Total Residual Chlorine, but samples are not. D. Finding: The preparation of Proficiency Testing (PT) Samples is not documented. 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: The new analyst stated that he was not aware of any prep documentation from the previous analyst. PT samples for 2017 have not yet been analyzed. Comment: Dating and initialing the instruction sheet for the preparation of the Total Residual Chlorine PT would satisfy the documentation requirement. Bacteria- Coliform Fecal — Standard Methods, 9222 D-1997 (MF) (Aqueous) Comment: Sterilized bottles are checked for sterility one sample bottle per batch at three dilutions. It is not required to analyze the batch sterility check in multiple dilutions. At a minimum test for sterility one sample bottle per batch sterilized in the laboratory or one sample bottle per lot of purchased as pre -sterilized, or at a set percentage such as 1 to 4%. E. Finding: The time filtration begins is not recorded on the benchsheet to show that no more than 30 minutes passed before filters were placed into the incubator. This is considered pertinent information. Requirement: Place all prepared cultures in the water bath within 30 min after filtration. Ref: Standard Methods, 9222 D-1997. (2) (d). Requirement: All analytical data pertinent to each certified analysis must be filed in an orderly manner to be readily available for inspection upon request. This is considered pertinent information. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A). Page 4 #121 Hillsborough WWTP Comment: At the time of the inspection the analyst stated that he is careful to make sure all plates are in the incubator within 30 minutes but it was not being documented. F. Finding: The sterilized rinse/dilution water is not stored in the refrigerator after opening. Requirement: Store under refrigerated conditions after opening and discard if turbidity develops. Use within 6 months. Ref: SM 9050 C-2006. (1) (a) (3). G. Finding: Plate comparison counts are not being conducted. Requirement: For routine performance evaluation, repeat counts on one or more positive samples at least monthly, record results, and compare the counts with those of other analysts testing the same samples. Replicate counts for the same analyst should agree within 5% (within analyst repeatability of counting) and those between analysts should agree within 10% (between analysts reproducibility of counting). If they do not agree, initiate investigation and any necessary corrective action. Ref: Standard Methods, 9020 B-2005. (9) (a). Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous) H. Finding: The barometric pressure at the time of meter calibration is not documented. Requirement: Calibration documentation must include the following, where applicable to the instrument used and the type of calibration performed: elevation, temperature, barometric pressure (in mmHg), salinity, slope, or % efficiency. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. Temperature — Standard Methods, 2550 B-2000 (Aqueous) Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous) I. Finding: Only one time for sample collection and analysis was documented on the benchsheet, without noting samples are analyzed in situ. Requirement: Alternatively, since EPA requires samples to be analyzed immediately, one time may be documented for collection and analysis with the notation that samples are measured in situ or immediately at the sampling site (i.e., immediately following collection at a location as near to the collection point as possible). When this `one time' option is used, state that the documented time is both collection and analysis time. Ref: NC WW/GW LC Approved Procedure for the Analysis of Temperature. Requirement: Alternatively, one time may be documented for collection and analysis with the notation that samples are measured in situ or immediately at the sample site. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. Comment: The time sampled is documented on the benchsheet. Temperature — Standard Methods, 2550 B-2000 (Aqueous) Recommendation: Unless greater precision is required by the permit or data receiving agency, it is recommended that all temperatures reported for compliance monitoring, be reported in whole numbers as recommended by the Precision in Discharge Monitoring Reports document found Page 5 #121 Hillsborough WWTP here: http://Portal.ncdenr.org/c/document library/get file? uuid=1407b370-e848-4550-9f4b- 21 a2f05b95e4&groupld=38364 Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous) J. Finding: The average is not used for the true value of the standard solution used to prepare the daily check standard. Requirement: If purchased standard solutions in sealed ampules with a stated range and average value are used, the average value must be used for the true value of the standard. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Comment: The sealed ampules' standard solution concentration range was 25-30 lag/L with an average of 27.44 tag/L. The true value being used was 25 lag/L. In the data reviewed, the daily check standard was being evaluated against the ± 10 % acceptance criterion and was typically measuring approximately 27 lag/L, which was also within the acceptance criteria of the average concentration. K. Finding: The laboratory benchsheet was lacking pertinent data: meter calibration time. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Meter calibration time. NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. L. Finding: The laboratory is not analyzing samples according to the method referenced on their Certified Parameter Listing (CPL). Requirement: Compensate for color and turbidity by using sample to zero photometer. Ref: Standard Methods, 4500 CI G-2000. (1) (b). Comment: Samples are being filtered according to the Hach method 10014. The method referenced on the CPL is Standard Methods, 4500 Cl G-2000 which does not include filtering. pH — Standard Methods, 4500 H+ B-2000 (Aqueous) Recommendation: It is recommended to change the column header to "time analyzed" instead of "time ran." IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to electronic Discharge Monitoring Reports (eDMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for Hillsborough WWTP (NPDES permit # NC0026433) for August 2016, and January and April 2017. No transcription errors were detected. The facility appears to be doing a good job of accurately transcribing data. V. CONCLUSIONS: 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 Page 6 #121 Hillsborough WWTP to thank the staff for their assistance during the inspection and data review process. Please respond to all Findings and include supporting documentation and implementation dates for each corrective action. Report prepared by: Tonja Springer Date: July 6, 2017 Report reviewed by: Anna Ostendorff Date: July 11, 2017 % w \ \ ® ) _ g \ j # \ / f) 0 {kX o w u eo 2 \ o fu E * o o \ (D E 2 ( n § § \ 5 o . ( a < 2 S % ■ § \ b a o / \ E \ \ ) . 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