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HomeMy WebLinkAbout#206_2017_0208_BS_FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 206 Laboratory Name: Monroe WWTP Lab Inspection Type: Municipal Maintenance Inspector Name(s): Beth Swanson, Gary Francies and Anna Ostendorff Inspection Date: February 8-9, 2017 Date Forwarded for Initial Review: February 17, 2017 Initial Review by: Anna Ostendorff Date Initial Review Completed: February 22, 2017 Cover Letter to use: ❑ Insp. Initial ❑Insp. No Finding ®Corrected ❑ Insp. Reg ❑Insp. CP ❑Insp. Reg. Delay Unit Supervisor/Chemist III: Gary Francies Date Received: 2/23/17 Date Forwarded to Admin.: 3/8/2017 Date Mailed: Special Mailing Instructions: Send copy to Wes Bell, MRO LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): On -Site Inspection Report Monroe WWTP Lab NC0024333 775 Treeway Dr Monroe, NC 28110 206 February 8-9, 2017 Municipal Maintenance LOCAL PERSON(S) CONTACTED: INTRODUCTION: Beth Swanson, Gary Francies and Anna Ostendorff Stephanie Cooke and Kyle Ketchum 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 staff were receptive to recommendations and worked quickly to institute all necessary changes, where applicable. The laboratory's corrective responses that were received prior to writing the inspection report were thorough and included proper documentation and ideas to prevent recurrence of several findings. The laboratory is commended on this effort. 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 February 8, 2018. The labor8itory 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 #206 Monroe WWTP Lab (e.g. Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPS for the proper use of the word "should". Laboratory Fortified Matrix (LFM) and Laboratory Fortified Matrix Duplicate (LFMD) are also known as Matrix Spike (MS) and Matrix Spike Duplicate (MSD) and may be used interchangeably in this report. 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 Shealy Environmental Services, Inc. (Certification # 329). Current 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 Comment: The temperature verification log was lacking pertinent data: units of measure. The log did not include units for temperature (i.e., °C) on the National Institute of Standards and Technology (NIST) and laboratory thermometer reading columns. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states: 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. Notification of acceptable corrective action (i.e. an updated benchsheet with °C on the applicable columns implemented February 13, 2017 and a statement that a yearly review of the benchsheet would be conducted to verify all documentation requirements are met) was received by email on February 14, 2017. No further response is necessary for this Finding. Comment: Some analysts were not consistently performing proper error corrections. There were a few instances of write-overs and one analyst was not initialing and dating the corrections on field data. NC WW/GW LC Policy states: All documentation errors must 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. Write the correction adjacent to the error. The correction must be initialed by the responsible individual and the date of change documented. Notification of acceptable corrective action (i.e., a statement that all pertinent staff were reminded February 10, 2017 that proper error corrections include one line through the error, initials of the person making the correction and the date it was made and a statement that a weekly benchsheet review will be conducted going forward to ensure the correct procedure is performed) was received by email on February 14, 2017. No further response is necessary for this Finding. Comment: The dates opened or in use were not consistently documented for all purchased materials and reagents. Despite this, the system of traceability used by the laboratory is very effective, since all reagent and standard preparation is documented in a logbook and benchsheets contain applicable lot numbers. The lack of traceability is evident only on a small number of prepared reagents where the date opened for the source material was not being documented beyond recording it on the bottle. NC WW/GW LC Policy states: 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 (where specified). Consumable materials such as pH buffers, lots of pre -made standards and/or media, solids and Page 3 #206 Monroe WWTP Lab bacteria filters, etc. are included in this requirement. Notification of acceptable corrective action (i.e. a statement that the process of documenting the date opened or in use for reagents and/or consumables and a weekly review of the log book was implemented on February 13, 2017) was received by email on February 17, 2017. No further response is necessary for this Finding. Quality Control Comment: The laboratory had not established a policy for assigning expiration dates for chemicals, reagents or consumables which are received without an expiration date specified by the vendor. During the inspection, a potassium permanganate powdered reagent was discovered with no assigned expiration date. NC WW/GW LC Policy states: If no expiration date is given, the laboratory must have a policy for assigning an expiration date. If no date received or expiration date can be determined, the item should be discarded. Notification of acceptable corrective action (i.e., The laboratory stated it implemented a practice on February 13, 2017 that when the manufacturer has not indicated an expiration date for a reagent, the assigned expiration date will be two years from the date it is received. Also, the laboratory stated that a new potassium permanganate reagent was ordered on February 13, 2017 and will replace the reagent currently in use immediately upon its arrival) was received by email on February 17, 2017. No further response is necessary for this Finding. Proficiency Testin Comment: The laboratory did not have a documented plan for PT procedures. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: 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. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2 document states: Laboratories must have a documented plan (this is usually detailed in the laboratory's Quality Assurance Manual) 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 proficiency testing and any inter -laboratory organized studies, as applicable. The laboratory must also be able to explain when proficiency testing is not possible for certain parameters 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 proficiency testing results and related corrective action responses. Laboratory Standard Operating Procedures (SOPs) must address how low level samples will be analyzed, including concentration of the sample or adjustment of the normality of a titrant. These instructions shall be followed when the concentration of a PT sample falls below the range of their routine analytical method. Instructions shall also be included in the laboratory's SOP for how high level samples will be analyzed, including preparation of multiple dilutions of the sample. These instructions will be followed when the concentration of a PT falls above the range of their routine analytical method. Notification of acceptable corrective action (i.e., a statement that the laboratory's QA and QC SOP (i.e., SOP 8040L-02) was updated to include a section for PT preparation and reporting which was implemented on February 13, 2017) was received by email on February 15, 2017. No further response is necessary for this Finding. Comment: The preparation of PT samples is not documented. The auditors mentioned during the inspection that dating and initialing the instruction sheet for the preparation of PT samples that are packaged as ampules rather than full volume samples would satisfy the documentation requirement. The Proficiency Testing Requirements, February 20, 2012, Revision 1.2 document states: PT samples received as ampules must be diluted according to the PT provider's instructions. The preparation of PT samples must be documented in a traceable log or other traceable format. The diluted PT sample becomes a routine environmental sample and is added to a routine sample batch for analysis. Notification of acceptable corrective action (i.e., a statement Page 4 #206 Monroe WWTP Lab that the laboratory would implement the practice of dating and initialing the PT vendor's instructions to verify sample preparation beginning with any applicable PT samples received after February 13, 2017) was received by email on February 15, 2017. No further response is necessary for this Finding. Bacteria- Coliform Fecal — Standard Methods, 922213-1997 (MF) (Aqueous) Comment: An observation was made during the inspection that the fecal water bath thermometer may be touching the bottom of the incubator during use. This is not ideal since the heating elements for water baths are often housed at the bottom. The laboratory stated by email on February 14, 2017 that a rubber band has been placed on the thermometer to keep it from slipping too far into the water bath. Comment: A recommendation was made during the inspection to add the word "additional" to the column on the benchsheet labeled "Na2S2O3 added". The samples are collected in bottles that contain an Na2S2O3 tablet, therefore, Na2S2O3 is added to all samples. However, the column had "Y/N" in each cell and the analyst would circle "N" when no additional Na2S2O3 was needed after the check for total residual chlorine (TRC). An updated benchsheet implemented March 6, 2017 with the column now labeled "additional Na2S2O3 added" was received by email on March 6, 2017. Comment: The laboratory was not documenting on the benchsheet the calculation and acceptability of duplicate results and data that did not meet all QC requirements was not qualified on the electronic Discharge Monitoring Report (eDMR). The laboratory's duplicate acceptance criterion was ± 20% Relative Percent Difference (RPD), which was not a realistic criterion for the duplicates that were .being analyzed (i.e., 50 mL of effluent which had <20 colonies). North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: 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. NC WW/GW LC Policy states: 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, in the comment section or on a separate sheet attached to the DMR form, when any required sample quality control does not meet specified criteria, and another sample cannot be obtained. Notification of acceptable corrective action (i.e., The laboratory submitted an updated benchsheet implemented February 13, 2017 which stated the new acceptance criterion in use for duplicate plates with 0-20 counts, which is ± 5 colony difference, and a column to document the % RPD or difference for all duplicates. A statement was also provided which said all duplicates that do not meet established acceptance criteria will be qualified on the eDMR beginning February 13, 2017. The laboratory stated that a weekly data review and an annual benchsheet review to assess compliance with QC and documentation requirements was also implemented February 13, 2017.) was received by email on February 17, 2017. No further response is necessary for this Finding. Comment: The dilution water was placed in a non -sterilized container. The squeeze bottle was not being sterilized before use, which could introduce contamination. The water blanks performed by the laboratory have not detected any contamination to this point. Standard Methods, 9222 D-1997. (2) (b) states: Filtration of sample: Follow the same procedure and precautions as prescribed under Section 9222B.5b above. Standard Methods, 9222 B-1997. (5) (c) states: Alternatively, rinse funnel by a flow of sterile dilution water from a squeeze bottle. This is satisfactory only if the squeeze bottled and its contents do not become contaminated during use. Notification of acceptable corrective action (i.e. a statement that the squeeze bottle was autoclaved on February 10, 2017 and will be autoclaved with the daily contents going forward) was received by email on February 14, 2017. No further response is necessary for this Finding. Page 5 #206 Monroe WWTP Lab Comment: The prepared dishes were placed in a plastic container for incubation. The plastic container does not allow water to fully surround the dishes and may not maintain the proper temperature. Standard Methods 9222 D-1997. (2) (d) states: Incubation: Place prepared dishes in waterproof plastic baps or seal, invert, and submerge petri dishes in water bath, and incubate for 24 ± 2 h at 44.5 ± 0.2 °C. Notification of acceptable corrective action (i.e. a statement that the practice of placing the prepared dishes in a zippered plastic bag and weighing down the bag so all dishes are submerged was implemented on February 14, 2017) was received by email on February 17, 2017. No further response is necessary for this Finding. Comment: The laboratory was not documenting their use of heat -indicating tape. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: Each laboratory shall develop and maintain a document outlining the analytical quality control practices used for the parameters included in their certification. Supportinq records shall be maintained as evidence that these practices are being effectively carried out. Standard Methods, 9020 B-2005. (4) (h) states: Use heat -indicating tape to identify supplies and materials that have been sterilized. Notification of acceptable corrective action (i.e., an updated benchsheet implemented February 13, 2017 with the additional column "autoclave tape turned black" as well as a statement that a yearly review of the log would be conducted to verify all documentation requirements are met) was received by email on February 14, 2017. No further response is necessary for this Finding. Comment: Plate comparison counts were not being conducted and/or documented. The supervisor was recounting the weekend operator's plates each week, but the process was not documented. A monthly recount amongst all analysts and a recount of the primary analyst against herself was not conducted. Standard Methods, 9020 B-2005. (9) (a) states: 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. Notification of acceptable corrective action (i.e., an updated benchsheet implemented February 13, 2017 which included additional lines for the analyst monthly self -check, analyst to analyst monthly check and weekend recount documentation) was received by email on February 14, 2017. No further response is necessary for this Finding. Comment: The laboratory was not monitoring the quality of the reagent water used in fecal coliform analysis. NC WW/GW LC Policy states: At a minimum, reagent water used to prepare buffered dilution/rinse water or media must be analyzed at least every twelve months for the following parameters: Specific Conductance, Total Organic Carbon, Cadmium, Chromium, Copper, Nickel, Lead, and Zinc. Maximum Acceptable Limits are: Total Organic Carbon < 1.0 mg/L Specific Conductance < 2 pmhos/cm Heavy Metals, single element < 0.05 mg/L Heavy Metals, Total of cited elements < 0.10 mg/L Notification of acceptable corrective action (i.e., a statement that a sample of the laboratory's reagent water was submitted to their contract lab on February 16, 2017 and that the annual requirement has been added to the Annual Work Plan document to prevent recurrence of the Finding) was received by email on February 17, 2017. No further response is necessary for this Finding. Page 6 #206 Monroe WWTP Lab BOD — Standard Methods, 5210 B-2001 (Hach 10360-2011, Rev. 1.2) (LDO) (Aqueous) Comment: During data review, it was discovered that some values had been incorrectly calculated due to errors in the Excel spreadsheet. It was recommended that the laboratory institute a method to check that cells have not been edited in a_ way that causes erroneous values. The laboratory stated by email on February 14, 2017 that the cells will be checked for accuracy during the weekly benchsheet data review. This was implemented February 13, 2017. Comment: The units of measure for pH were not documented on the benchsheets. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (H) states: 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. Notification of acceptable corrective action (i.e., an updated benchsheet implemented February 16, 2017 with pH units of S.U. in all applicable spaces) was received by email on February 17, 2017. No further response is necessary for this Finding. Comment: Samples chosen for duplicate analyses were not randomly selected. Only the influent was being duplicated. Standard Methods, 5020 B-2010. (2) (f) states: When appropriate (Table 5020:1), randomly select routine samples to be analyzed twice. Notification of acceptable corrective action (i.e., a statement that the practice of periodically duplicating the effluent, and not only the influent, would be implemented February 15, 2017) was received by email on February 14, 2017. No further response is necessary for this Finding. Comment: The laboratory was not documenting that samples were checked for residual chlorine. This is considered pertinent information. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states: 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. Standard Methods, 5210 B-2001. (4) (b) (2) states: If residual chlorine is present, dechlorinate sample. Notification of acceptable corrective action (i.e., an updated benchsheet implemented February 15, 2017 which has a column for check marks to indicate residual chlorine for the sample was checked at collection along with a statement that a yearly review of the benchsheet would be conducted to verify all documentation requirements are met) was received by email on February 14, 2017. No further response is necessary for this Finding. Comment: The laboratory was not providing sufficient documentation to show initial DOs are measured within 30 minutes of preparing dilutions. This is considered pertinent information. The laboratory was only documenting the time samples were placed into the incubator to demonstrate that they met holding time constraints. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states: 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. Standard Methods, 5210 B-2001. (5) (g) states: After preparing dilution, measure initial DO within 30 minutes. Notification of acceptable corrective action (i.e., an updated benchsheet implemented February 15, 2017 which has an additional space to enter the dilution start time along with a statement that a yearly review of the benchsheet would be conducted to verify all documentation requirements are met) was received by email on February 14, 2017. No further response is necessary for this Finding. Chlorine, Total Residual — Standard Methods, 4500 CI G-2000 (Aqueous) Comment: The laboratory was not analyzing a reagent blank when QC or calibration standards were prepared. The laboratory analyzes a prepared standard daily. The NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine document states: Reagent Blank: A reagent blank (sometimes also referred to as a method blank) is only required when laboratory water is used to make quality control and/or calibration standards. If you are using a sealed standard (e.g., Page 7 #206 Monroe WWTP Lab gel) for your daily check standard, a reagent blank would only be analyzed when preparing the annual 5-point calibration curve or 5 annual calibration curve verification standards. Notification of acceptable corrective action (i.e., The laboratory stated the practice of analyzing an LRB any time prepared standards are analyzed was implemented February 13, 2017. The LRB has an acceptance criterion of <_'/2 the lowest calibration standard. Documentation of a calibration curve verification performed February 15, 2017 showing the analysis of an acceptable LRB was also submitted.) was received by email on February 15, 2017. No further response is necessary for this Finding. Comment: The laboratory was using a 1-minute color development time after DPD powder is added. Hach DPD powder is utilized. The use of prepackaged powdered reagent is an allowable change according to the method flexibility described in Code of Federal Regulations, Title 40, Part 136; Federal Register Vol. 77, No. 97, May 18, 2012; 136.6. (b) (4), which states: Some examples of the allowed types of changes, provided the requirements of this section are met include: (xiii) The use of prepackaged reagents. As such, the proper procedure for using the packaged reagents would then be determined by the manufacturer's instructions. Hach Company, "Current Technology of Chlorine Analysis for Water and Wastewater", 2002 states: For successful testing, especially in treated effluents, strict adherence to the development time is necessary. Three to six minutes of development time are sufficient to resolve all chloramine forms without significant error from competing reactions. Notification of acceptable corrective action (i.e., a statement that the practice of allowing a 3-minute reaction time after addition of DPD was implemented February 13, 2017) was received by email on February 15, 2017. No further response is necessary for this Finding. Conductivity — Standard Methods, 2510 B-1997 (Aqueous) Comment: The Automatic Temperature Compensator (ATC) had not been verified. The laboratory was under the impression that the temperature sensor itself only had to be verified at three different temperatures. The NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity) document states: The Automatic Temperature Compensator (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. Notification of acceptable corrective action (i.e., documentation of an acceptable ATC check performed February 14, 2017 with a statement that the check will be performed every 12 months and verification it has been included in the Annual Work Plan document to prevent the recurrence of the Finding) was received by email on February 17, 2017. No further response is necessary for this Finding. Conductivity — Standard Methods, 2510 B-1997 (Aqueous) pH — Standard Methods, 4500 H+ B-2000 (Aqueous) Comment: The laboratory benchsheet was lacking pertinent information: True values of buffers and standard used for calibration. The field benchsheet identified three pH buffers but did not state which were used for calibration and the 1000 ps/cm conductivity calibration standard true value was not documented at all. The NC WW/GW LC Approved Procedure for the Analysis of pH and the NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity) documents state: The following must be documented in indelible ink whenever sample analysis is performed: True value of the buffers (standard) used for calibration. Notification of acceptable corrective action (i.e., an updated benchsheet implemented February 13, 2017 with the true values of the pH buffers and conductivity standard used for calibration identified along with a statement that a yearly review of the benchsheet would be conducted to verify all documentation requirements are met) was received by email on February 15, 2017. No further response is necessary for this Finding. Page 8 #206 Monroe WWTP Lab pH — Standard Methods, 4500 H+ B-2000 (Aqueous) Dissolved Oxygen — Hach 10360-2011, Rev. 1.32 (LDO) (Aqueous) Comment: The laboratory benchsheet was lacking pertinent data: Instrument identification. The laboratory has two meters for both pH and dissolved oxygen (DO) but the benchsheet only documented the meter type, not a specific identifier for each one. The NC WW/GW LC Approved Procedure for the Analysis of pH and the NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen documents state: The following must be documented in indelible ink whenever sample analysis is performed: Instrument Identification. Notification of acceptable corrective action (i.e., The laboratory submitted a statement that the multiple pH and DO meters were designated Meter #1 and Meter #2 as applicable and documentation of an updated field parameter benchsheet implemented February 13, 2017 showing the specific meter number. Accompanying statements said that if the laboratory obtains additional meters in the future, those meters will be treated likewise and a yearly review of the benchsheet would be conducted to verify all documentation requirements are met.) was received by email on February 15, 2017. No further response is necessary for this Finding. pH — Standard Methods, 4500 H+ B-2000 (Aqueous) Comment: The field benchsheet was lacking pertinent data: units of measure for pH (i.e., S.U.). North Carolina Administrative Code, 15A NCAC 02H .0805 (a) (7) (H) states: 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. 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. Notification of acceptable corrective action (i.e., an updated benchsheet implemented February 13, 2017 with all units of measure for pH, as S.U., documented along with a statement that a yearly review of the benchsheet would be conducted to verify all documentation requirements are met) was received by email on February 15, 2017. No further response is necessary for this Finding. Residue, Suspended —Standard Methods, 2540 D-1997 (Aqueous) Comment: The suspended residue oven thermometer was not verified at its temperature of use (i.e., 104 °C). The laboratory's NIST thermometer does not measure up to 104 °C so the oven thermometer was verified at 18 °C. NC WW/GW LC Policy states: The verification must be performed at a temperature that corresponds to the temperature used by the incubator, refrigerator, freezer, etc. Notification of acceptable corrective action (i.e., a statement that an NIST traceable thermometer was purchased on February 13, 2017 which will be put into place upon receipt then replaced upon the expiration date stated by the manufacturer) was received by email on February 14, 2017. No further response is necessary for this Finding. Comment: Filters were not weighed to constant weight prior to sample analysis, nor was a dry filter blank analyzed with each set of samples. NC WW/GW LC Policy states: 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. Notification of acceptable corrective action (i.e., a statement that the practice of analyzing a dry blank with each set of samples was implemented February 13, 2017 and that the dry blank must have a weight difference of no more than ± 0.5 mg) was received by email on February 17, 2017. No further response is necessary for this Finding. Page 9 #206 Monroe WWTP Lab Comment: The laboratory was not consistently drying the samples for the minimum amount of time verified by the annual drying study. The most recent drying study was conducted for 1 hour and 8 minutes and the data review showed several drying times less than this. The laboratory believed that the requirement was 1 hour, regardless of the time verified in the annual study. NC WW/GW LC Policy states: Constant weights must be documented. The approved methods require the following: "Repeat the cycle of drying, cooling, desiccating, and weighing until a constant weight is obtained or until the weight change is less than 4% of the previous weight or 0.5 mg, whichever is less." In lieu of this, an annual study documenting the time required to dry representative samples to a constant weight may be performed. Verify minimum daily drying time is greater than or equal to the time used for the initial verification study drying cycle. Drying cycles must be a minimum 1 hour for verification. Notification of acceptable corrective action (i.e., documentation of an updated drying study conducted for 1 hour on February 14, 2017 and a statement that the SOP was updated to say that the time used in the annual drying study is the minimum daily drying time, which pertinent staff have been notified to implement going forward) was received by email on February 15, 2017. No further response is necessary for this Finding. Comment: No acceptance criterion was established to evaluate the precision of sample duplicate analyses for results less than 10 mg/L. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) states: 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. Notification of acceptable corrective action (i.e., a statement that an acceptance criterion of ± 3 mg/L for sample results from 2.5 to 10 mg/L was implemented February 13, 2017) was received by email on February 15, 2017. No further response is necessary for this Finding. Nitrogen, Ammonia — Standard Methods, 4500 NH3 C-1997 (Aqueous) Comment: The laboratory was not analyzing an LFM/LFMD at the required frequency. The LFM/LFMD was analyzed once per week. Standard Methods, 4020 B-2009, Rev. 2011, Table 4020:1 and (2) (g) state: When appropriate for the analyte (Table 4020:1), include at least one LFM/LFMD daily or with each batch of 20 or fewer samples. Notification of acceptable corrective action (i.e., a statement that the practice to analyze the LFM/LFMD each day was implemented February 13, 2017) was received by email on February 15, 2017. No further response is necessary for this Finding. Comment: The laboratory was not randomly selecting samples to fortify. Only the influent sample was being used to prepare the LFM/LFMD. Standard Methods, 4020 B-2009, Rev. 2011. (2) (g) states: To prepare an LFM, add a known concentration of analytes (ideally from a second source) to a randomly selected routine sample without increasing its volume by more than 5%. Notification of acceptable corrective action (i.e., a statement that beginning February 13, 2017 a different sample type has been fortified each day and the pertinent staff have been trained to continue this procedure) was received by email on February 15, 2017. No further response is necessary for this Finding. Comment: The laboratory is not adjusting the sample or spike concentration for spike volumes >1% of the total sample volume. The laboratory was using 10% spike solution per total volume to prepare the LFM/LFMD. NC WW/GW LC Policy states: If the spike solution volume constitutes >1% of the total sample volume, the sample concentration or spike concentration must be adjusted by calculation. Notification of acceptable corrective action (i.e., a statement that a 1000 mg/L NHa- N standard was ordered February 13, 2017 and the procedure to add 1 mL of this standard to 100 mL of the influent sample and 300 mL of the effluent sample will be implemented immediately upon receipt of the standard) was received by email on February 17, 2017. No further response is necessary for this Finding. Page 10 #206 Monroe WWTP Lab Comment: Preservative was not being added to reagent blanks or laboratory fortified blanks (LFB). Standard Methods, 1020 B-2011. (5) states: A reagent blank (method blank) consists of reagent water (see section 1080) and all reagents (including preservatives) that normally are in contact with a sample during the entire analytical procedure. Standard Methods, 1020 B-2011. (6) states: A laboratory fortified blank [laboratory control standard (LCS)] is a reagent water sample (with associated preservatives) to which a known concentration of the analyte(s) of interest has been added. Notification of acceptable corrective action (i.e., a statement that the practice of preparing the method blank and standard, the LFB, by adding preservative was implemented February 13, 2017) was received by email on February 15, 2017. No further response is necessary for this Finding. Comment: The laboratory was not documenting that the sample pH was 9.5 S.U. prior to distillation. This is considered pertinent information. North Carolina Administrative Code, 15A NCAC 2H .0805 (a) (7) (A) states: 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. Standard Methods, 4500 NH3 B-1997. (4) (b) states: Add 25 mL borate buffer solution and adjust to pH 9.5 with 6N NaOH using a pH meter. Notification of acceptable corrective action (i.e., an updated benchsheet with a column for verifying that the pH of the sample is adjusted to 9.5 S.U. and statement that the pertinent staff have been notified to implement the practice beginning March 6, 2017) was received by email on March 6, 2017. No further response is necessary for this Finding. Temperature — Standard Methods, 2550 B-2000 (Aqueous) Comment: Temperature was not being analyzed in -situ or immediately at the collection site. The sample was brought into the lab and measured within 15 minutes using the temperature sensor on the combination conductivity and pH meter. Code of Federal Regulations, Title 40, Part 136; Federal Register Vol. 77, No. 97, May 18, 2012; Table II states: Maximum holding time: Analyze. The NC WW/GW LC Approved Procedure for the Analysis of Temperature document states: Immediate (i.e., in situ) analysis is required. Acceptable corrective action (i.e., it was stated during the inspection that beginning February 9, 2017, Temperature is analyzed in situ using the laboratory's calibrated NIST thermometer) was performed by the laboratory and approved by the, auditor on the second day of the inspection. No further response is necessary for this Finding. IV. PAPER TRAIL INVESTIGATION: A representative of the Division of Water Resources' Mooresville Regional Office conducted a plant inspection with paper trail on January 11, 2017. As such, an abbreviated paper trail was conducted during the audit. 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 the Monroe WWTP Lab (NPDES permit # NC0024333) for November 2016. No transcription errors were detected. The facility appears to be doing a good job of accurately transcribing data. V. CONCLUSIONS: All Findings noted during the inspection were adequately addressed prior to the completion of this report. The inspector would like to thank the staff for its assistance during the inspection and data review process. No response is required. Report prepared by: Beth Swanson Date: February 17, 2017 Report reviewed by: Anna Ostendorff Date: February 22, 2017 J Water nlesourcx:'> ENVIROOMFOTA1. (10ALI I Y March 8, 2017 206 Ms. Stephanie Cooke Monroe WWTP Lab P.O. Box 69 Monroe, NC 28111-0069 ROY COOPER Governor MICHEAL S. REGAN Secretor, S. JAY ZIMMERMAN Director SUBJECT: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Cooke: Enclosed is a report for the inspection performed on February 8-9, 2017 by Beth Swanson, Anna Ostendorff, and myself. Since the Finding(s) cited during the inspection were all corrected prior to the completion of the enclosed report, a response is not required. The staff is commended for taking the initiative in correcting the Findings in such a timely manner. 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, Gary Francies, Technical Assistance/Compliance Specialist Division of Water Resources Attachment cc: Beth Swanson Master file t \ % w � k ' ) { ) e 2 \ § k \ { ® \ \ j E \ \ § { ° _ k E \ a) \ e o ! / / R « � /co 2 E / . / { / % a)] k \ \ § \ $ z . R ] 2 S \ \ / ® § 0 - k g § \ / \ 0 �C _ I ) ] � - o m $ 2 § ® / ) e / \ m) j)cr \ -\ or j % % c 3 ƒ -J ° / o o r ° z ± / 8 @< § / \ T u ) ( #y `« E {) [ 0 < CO § \ \ `- o a « a O» 3 0° 2 z =® 0 e§ \/ � b N §§§ o{ o\ o\/ u o m§° a G c o o a o a 0 0 3 u e - $ ) r e m 0$ o a o= o g ■ g m a )\ \ $< 7 0 7 2ƒ 0$ 2}§ 7& 7 G\ 3 7 < / _ = o o e z ± e bG