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HomeMy WebLinkAbout#5342_2017_0623_BS_FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5342 Laboratory Name: Pace Analytical Services LLC — Field Services NC Inspection Type: Field Commercial Maintenance Inspector Name(s): Beth Swanson, Gary Francies and Jason Smith Inspection Date: May 16, June 1 and June 23, 2017 Date Forwarded for Initial June 29, 2017 Review: Initial Review by: Jason Smith Date Initial Review July 5, 2017 Completed: ❑ Insp. Initial ® Insp. Reg Cover Letter to use: ❑Insp. No Finding ❑Insp. CP ❑Corrected ❑Insp. Reg. Delay Unit Supervisor/Chemist III: Gary Francies Date Received: 7/5/17 Date Forwarded to Admin.: 7/14/17 Date Mailed: qT' 7 Special Mailing Instructions: Wes Bell, MRO Water Resources rNVtFYONMENTAL QUA Li TY July 14, 2017 5342 Ms. Cheryl Johnson Pace Analytical Services LLC - Field Services NC 9800 Kincey Avenue - Suite 100 Huntersville, NC 28078- ROY COOPER MICHEAL S. REGAN S. JAY ZIMMERMAN Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Johnson: Enclosed is a report for the inspection performed on May 16, June 1, and June 23, 2017 by Beth Swanson, Jason Smith, and myself. 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. Ifyouwish 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 LABORATORY NAME: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: I. INTRODUCTION: Pace Analytical Services, LLC — Field Services NC 9800 Kincey Avenue - Suite100 Huntersville, NC 28078 5342 May 16, 2017, June 1, 2017 and June 23, 2017 Field Commercial Maintenance Beth Swanson, Gary Francies and Jason Smith Cheryl Johnson, Mark Swann (Asheville), Colley Frank (Huntersville) and William Thomas (Raleigh) 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 laboratory currently has staff performing field analyses out of four locations: Eden, Asheville, Huntersville and Raleigh. An abbreviated audit of the Eden -based analysts was performed August 25, 2015 and the report was sent September 11, 2015. Previous to that time, separate audits were conducted in July through September 2010 to inspect the three locations in operation at that time and were presented in one report. This report will combine Findings from the inspections of the Raleigh, Huntersville and Asheville -based field operations. All required Proficiency Testing (PT) samples have been analyzed for the 2017 PT calendar year and the graded results were 100% acceptable. 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. 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. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Proficiency Testing A. Finding: PT Samples are not equally distributed among qualified personnel from year to year. Page 2 #5342 Pace Analytical Services, LLC — Field Services NC 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 analyses), that represents the routine operation of the work group at the time the PT Sample analysis is conducted. Ref: Proficiency Testing Requirements, May 31, 2017, Revision 2.0. Documentation Recommendation (Huntersville, Raleigh): It is recommended that the field analysts document any equipment maintenance in their field notebooks, such as when membranes or probes are changed. Recommendation (Huntersville): It is recommended that the column header "open date" found in some field notebooks be changed to "in use". The true open date is recorded in the reagent receipt log and the dates documented in field notebooks are when the individual analyst begins using it. Comment (Asheville): Vendor information was missing from the traceability documentation. The analysts employ field notebooks where traceability information is maintained. The NC WW/GW LC Quality Assurance Polices for Field Laboratories document 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. This information as well as the vendor and/or manufacturer, lot number, and expiration date must be retained for chemicals, 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. Acceptable corrective action (i.e., the analysts added a space to document vendor information for reagents and added the information for the current items in their field notebook) was performed by the laboratory and approved by the auditor during the inspection. No further response is necessary for this Finding. Comment (Asheville): Only one time was documented on the field logs without noting that samples were analyzed immediately on site. This does not clearly demonstrate that samples are analyzed within holding time. The NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity), NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen, NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine, and NC WW/GW LC Approved Procedure for the Analysis of pH documents state: 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 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. The NC WW/GW LC Approved Procedure for the Analysis of Temperature document states: 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 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. Acceptable corrective action (i.e., the analysts added a statement at the beginning of their field notebook that unless otherwise noted, the time documented is both collection and analysis time) was performed by the laboratory and approved by the auditor during the inspection. No further response is necessary for this Finding. Page 3 #5342 Pace Analytical Services, LLC — Field Services NC B. Finding (Asheville, Huntersville): Error corrections are not always properly performed. Requirement: 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. Ref: Quality Assurance Policies for Field Laboratories. C. Finding (Huntersville): The laboratory does not document the date received of purchased materials and reagents in the receipt log. 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 (where specified). 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. Consumable materials such as pH buffers, lots of pre -made standards and/or media, solids and bacteria filters, etc. are included in this requirement. Ref: Quality Assurance Policies for Field Laboratories. Chlorine, Total Residual — Standard Methods, 4500 Cl G-2000 (Aqueous) Recommendation (Asheville, Raleigh): The low -range curve is verified with standard concentrations of 10 (in Raleigh), 15 (in Asheville), 50, 100, 200 and 400 pg/L. It is recommended that a standard be verified between the lowest standard concentration and 50 pg/L in place of the 100 pg/L standard to put emphasis on the compliance level portion of the curve. D. Finding (Raleigh): The laboratory is not documenting the assigned true value of the daily check standard for the Hach Pocket 11 colorimeter. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: True value of the check standard. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Comment: The check standard has been assigned a value, however, the analyst was documenting a range that had been written on the standard by another individual as the true value. The check standards reviewed were acceptable based on the actual true value assigned. E. Finding (Asheville, Huntersville): The laboratory is not analyzing a reagent blank with prepared standards. 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: The laboratory currently only prepares standards for the curve verification. F. Finding (Raleigh): The laboratory is not documenting the analysis of the reagent blank when the curve verification standards are prepared. This is considered pertinent data. Page 4 #5342 Pace Analytical Services, LLC — Field Services NC Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). 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. Conductivity — EPA 120.1, Rev. 1982 (Aqueous) Conductivity —Standard Methods, 2510 B-1997 (Aqueous) G. Finding (Huntersville, Raleigh): The Automatic Temperature Compensator (ATC) has not been verified at 25°C. Requirement: 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. Ref: NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity). Comment: The laboratory currently verifies the ATC at approximately room temperature (e.g., 19-22°C) instead of 25 ± 0.5°C. H. Finding (Raleigh): The ATC verification at 350C is not within ±10% of the true value of the standard. Requirement: As the temperature increases or decreases, the value of the conductivity standard or sample must be within ±10% of the true value of the standard or ±10% of the value of the sample at 25°C. If not, corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity). Comment: The ATC was verified on February 6, 2017 and the 1000 pS/cm standard heated to 35°C read 1712 pS/cm, which is not acceptable. Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous) Finding (Huntersville, Raleigh): The true value of the post analysis calibration verification is not documented. Requirement: The following must be documented in indelible ink whenever sample analysis is performed. True value and value obtained for the post analysis calibration verification(s), where applicable. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen (DO). J. Finding (Huntersville): The post analysis calibration verification acceptance criterion is ±10% of true value. Requirement: The calculated DO value must verify the meter reading within ±0.5 mg/L. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. Page 5 #5342 Pace Analytical Services, LLC — Field Services NC K. Finding (Raleigh): The acceptability of the post analysis calibration verification is not evaluated. Requirement: The calculated DO value must verify the meter reading within ±0.5 mg/L. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. Comment: The analyst records the DO value, temperature and barometric pressure at the end of the day in 100% moisture but does not evaluate whether that value is acceptable. Since the information recorded can be used to determine the theoretical values after the fact, a few verifications were evaluated during the inspection and were within acceptable limits. Dissolved Oxygen — Standard Methods, 4500 O G-2001 (Aqueous) pH — Standard Methods, 4500 H+ B-2000 (Aqueous) L. Finding (Huntersville): No corrective action is applied when post analysis calibration verifications do not meet acceptance criteria. Requirement: If the meter verification does not read within ±0.5 mg/L of the theoretical DO, corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of Dissolved Oxygen. Requirement: The post analysis check standard buffer(s) must read within ±0.1 S.0 or corrective actions must be taken. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Comment: Several instances were observed where the laboratory's acceptance criterion for the post analysis DO and pH checks were exceeded and no corrective action was taken (e.g., flag the data, recalibrate and reanalyze, etc). For DO, this was noted in the field notebook "Greg Grogan Book #4" in March and May 2017. Comment: It appears there are some issues when the check buffer is analyzed at extreme low temperatures (e.g., 1.6°C on March 15, 2017 in Jameson Humonvey Book #1). The true value of the buffer changes at different temperatures and the analysts are not always documenting and comparing it to the true value at the corresponding temperature. IV. PAPER TRAIL INVESTIGATION: Asheville The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for Ohio Electric (NPDES permit # NC0039152) for January and February 2017. The inspector mentioned during data review that less than ("<") symbols can be recorded on the DMR for results that are below the reporting limit, which would then be treated as zero for averaging purposes. No transcription errors were detected. The facility appears to be doing a good job of accurately transcribing data. Huntersville The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and client reports. Data were reviewed for the following project numbers: #92340797 (Firestone, May 15, 2017) and #J17040246 (Duke Marshall, May 4, 2017). No transcription errors were detected. The facility appears to be doing a good job of accurately transcribing data. Page 6 #5342 Pace Analytical Services, LLC — Field Services NC Raleigh No paper trail performed. 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 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. Report prepared by: Beth Swanson Date: June 29, 2017 Report reviewed by: Jason Smith Date: July 5, 2017