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HomeMy WebLinkAbout#5185_2017_0531_TS_FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5185 Laboratory Name: Pace Mobile Acres Inspection Type: Field Municipal Maintenance Inspector Name(s): Tonja Springer Inspection Date: May 31, 2017 Date Forwarded for Initial Review: June 6, 2017 Initial Review by: Beth Swanson Date Initial Review Completed: June 6, 2017 Cover Letter to use: ❑ Insp. Initial ❑Insp. No Finding ❑Corrected ® Insp. Reg ❑Insp. CP ❑Insp. Reg. Delay Unit Supervisor/Chemist III: Todd Crawford Date Received: June 7, 2017 Date Forwarded to Admin.: June 12, 2017 Date Mailed: June 13, 2017 Special Mailing Instructions: Water -Resources June 13, 2017 5185 Mr. Joel Pace Pace Mobile Acres 13290 Buffalo Rd. Clayton, NC 27527 ROY COOPER MICHEAL S. REGAN S. JAY ZIMMERMAN Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Pace: Enclosed is a report for the inspection performed on May 31, 2017 by Tonja Springer. 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, Todd Crawford Technical Assistance & Compliance Specialist NC WW/GW Laboratory Certification Branch Attachment cc: Dana Satterwhite, Tonja Springer, Master File #5185 LABORATORY NAME: NPDES PERMIT #: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): • • It ' • • .1 Pace Mobile Acres NC0064246 13290 Buffalo Road Clayton, NC 27527 5185 May 31, 2017 Field Municipal Maintenance Tonja Springer LOCAL PERSON(S) CONTACTED: Joel Pace INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) program to verify its compliance with the requirements of 15A NCAC 2H .0800 for the analysis of environmental samples. GENERAL COMMENTS: The facility has all the equipment necessary to perform the analyses. Records are well organized and easy to retrieve. 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. Contracted analyses are performed by Pace Analytical Services, LLC - Raleigh NC (Certification #67). Current 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. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: The laboratory does not have a system of traceability in place. 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. This information must be retained for chemical, reagents, standards and consumables used for a period of five years. 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 2 #5185 Pace Mobile Acres Comment: Traceability is needed for the pH buffers, Total Residual Chlorine (TRC) DPD reagents and the gel standard. Using the log sheet provided by the inspector during the audit would satisfy this requirement. Proficiency Testing B. Finding: The preparation of PT samples is not documented. Requirement: 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. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: Dating and initialing the instruction sheet for the preparation of the TRC PT would satisfy the documentation requirement. C. Finding: The laboratory is not documenting pH and TRC PT sample analyses in the same manner as environmental samples. Requirement: All PT sample analyses must be recorded in the daily analysis records as for any environmental sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: The analysis of PT samples is designed to evaluate the entire process used to routinely report environmental analytical results; therefore, PT samples must be analyzed and the process documented in the same manner as environmental samples. Comment: PT sample results were documented directly on the vendor report form and not on the benchsheet. D. Finding: Additional Quality Control (QC) beyond what is routine for environmental samples is being analyzed with PT samples. Requirement: Laboratories shall conduct proficiency tests in accordance with their routine testing, calibration and reporting procedures, unless otherwise specified in the instructions supplied by the PT provider. They shall not be analyzed with additional quality control or replicated beyond what is routine for environmental sample analysis. Results from multiple analyses (when this is the routine procedure) must be calculated in the same manner as routine environmental samples. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: Corrective -action PTs, that are provided with the true values in a sealed envelope, are not considered PTs and do not meet the PT requirements outlined in 15A NCAC 2H .0800. In general, laboratories must not analyze PTs with known concentrations along with PTs with unknown concentrations, as this is not the routine testing protocol for environmental samples. This is not to say that they cannot be used for troubleshooting purposes before analyzing a remedial PT. This would be considered part of the corrective action plan. Comment: The laboratory's common practice was to analyze a known standard along with the PT sample as additional QC. Since this is not performed with all compliance samples, it is considered additional QC. Page 3 #5185 Pace Mobile Acres pH — Standard Methods, 4500 H+ B-2000 (Aqueous) Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous) E. Finding: The laboratory benchsheet is lacking pertinent data: sample site. Requirement: 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. Ref: 15A NCAC 02H .0805 (g) (1). Comment: Sample site is being documented for the Upstream and Downstream samples but not for the Effluent. pH — Standard Methods, 4500 H+ B-2000 (Aqueous) Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous) Temperature — Standard Methods, 2550 B-2000 (Aqueous) Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous) F. Finding: The laboratory benchsheet is lacking pertinent data: instrument identification. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: instrument identification. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH, NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine, NC WW/GW LC Approved Procedure for the Analysis of Temperature and NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. pH — Standard Methods, 4500 H+ B-2000 (Aqueous) Temperature — Standard Methods, 2550 B-2000 (Aqueous) Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous) G. Finding: Sample analysis time is not clearly documented as being analyzed in situ. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Date and time of sample collection; Date and time of sample analysis to verify the 15-minute holding time is met. 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 and NC WW/GW LC Approved Procedure for the Analysis of pH. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Date and time of sample collection; Date and time of sample analysis. 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 sample site. 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. Comment: There was only one time documented on the benchsheet, with no statement that the sample was analyzed in situ or on site. Page 4 #5185 Pace Mobile Acres Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous) H. Finding: The sample collection time and sample analysis time is documented as one time. Requirement: 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. Ref: 15A NCAC 02H .0805 (g) (1). Comment: The sample is collected and then brought back to the lab for analysis. Finding: A reagent blank was not analyzed with the preparation of the 5-point calibration curve. Requirement: 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., 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. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Comment: A reagent blank is made from the same laboratory water source used to make QC and/or calibration standards with DPD. The concentration of reagent blanks must not exceed 50% of the reporting limit (i.e., the lowest calibration or calibration verification standard concentration), unless otherwise specified by the reference method, or corrective action must be taken. J. Finding: The annual 5-standard calibration curve verification did not pass all the individual standard recovery criteria. Requirement: The values obtained must not vary by more than 10% of the known value for standard concentrations greater than or equal to 50 o/L and must not vary by more than 25% of the known value for standard concentrations less than 50 µg/L. The overall correlation coefficient of the curve must be 4.995. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Please submit an acceptable calibration curve verification with the inspection report response. Comment: The 50 µg/L standard recovery was 87% (i.e., not within ± 10%), so the curve verification is not acceptable. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for Pace Mobile Acres NPDES # NC0064246 for January and June 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 will help this laboratory to produce quality data and meet Certification requirements. The inspector would like to thank the staff for their assistance during Page 5 #5185 Pace Mobile Acres 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: June 6, 2017 Report reviewed by: Beth Swanson Date: June 7, 2017 r N N N �p U r Q O N @ U Z O m g o o V � COL c) JQ 7 N N Z) o 0 O a� 0 N M O W Q Q Z 3 O Q a a o 0 N N o N W CD O O °T ? V LLI U 0 O N a:H [0 Z Z O LU O O o LO p O v a N Z tp W N V n K