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HomeMy WebLinkAbout#5488_2017_0525_JS_FINALINSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5488 Laboratory Name: Cliffside Sanitary District Inspection Type: Field Municipal Maintenance Inspector Name(s): Jason Smith Inspection Date: May 25, 2017 Date Forwarded for Initial Review: June 16, 2017 Initial Review by: Tonja Springer Date Initial Review Completed: June 16, 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: June 19, 2017 Date Forwarded to Admin.: June 20, 2017 Date Mailed: June 20, 2017 Special Mailing Instructions: Water Resources ENVIRONMENTAL .QUALITY June 20, 2017 5488 Mr. Mike Gibert Cliffside Sanitary District P. O. Box 122 Cliffside, NC 28024 ROY COOPER MICHEAL S. REGAN S. JAY ZIMMERMAN Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Mr. Gibert: Enclosed is a report for the inspection performed on May 24, 2017 by Jason Smith. 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 �a Todd Crawford Technical Assistance & Compliance Specialist NC WW/GW Laboratory Certification Branch Attachment cc: Dana Satterwhite, Jason Smith, Master File 5488 LABORATORY NAME: NPDES PERMIT#: ADDRESS: CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): r• • • • ,117 Cliffside Sanitary District NC0004405 136 Hawkins Loop Rd Mooresboro, NC 28114 5488 May 25, 2017 Field Municipal Maintenance Jason Smith LOCAL PERSON(S) CONTACTED: Mike Gibert I. 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. II. GENERAL COMMENTS: The facility has all the equipment necessary to perform the analyses. The laboratory analyst was very forthcoming and receptive to implementing the necessary changes in response to the Findings and Recommendations made during the inspection. 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 — Huntersville, NC (Certification #12). 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 Recommendation: It is recommended that the method references on the benchsheets be updated to match the laboratory's Certified Parameter List (CPL). The benchsheets currently reference 18th Edition of Standard Methods. A. Finding: The laboratory needs to increase the traceability documentation of purchased reagents. Page 2 #5488 Cliffside Sanitary District Requirement: All consumables used by the laboratory must have the following information documented: Date Received, Date Opened (in use), Vendor, Lot Number, and Expiration Date. 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. Ref: Quality Assurance Policies for Field Laboratories. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). Comment: Date received and opened were written on the reagent containers for Total Residual Chlorine and pH. While this can provide a traceability link to analyses by looking at the dates that the chemicals were in use, that link is lost once the bottles are discarded. B. Finding: Data that does not meet all quality control (QC) requirements is not qualified on the electronic Discharge Monitoring Report (eDMR). Requirement: When QC failures occur, the laboratory must attempt to determine the source of the problem and must apply corrective action. Part of the corrective action is notification to the end user. If data qualifiers are used to qualify samples not meeting QC requirements, the data may not be useable for the intended purposes. It is the responsibility of the laboratory to provide the client or end -user of the data with sufficient information to determine the usability of the qualified data. Where applicable, a notation must be made on the electronic Discharge Monitoring Report (eDMR) form, when any required sample quality control does not meet specified criteria and another sample cannot be obtained. Ref: Quality Assurance Policies for Field Laboratories. Comment: The laboratory qualified data prior to using the eDMR in July 2016. This practice was discontinued because the permittee was unaware of how to report them in the eDMR system. Technical assistance was provided at the time of the inspection and the laboratory should contact the Asheville Regional Office if any more difficulties are encountered. Quality Control C. Finding: Reagents are used beyond the expiration date. Requirement: Adherence to manufacturer expiration dates is required. Chemicals, reagents, standards, consumables exceeding the expiration date can no longer be considered reliable. If the expiration is only listed as a month and year (with no specific day of the month), the last day of the month will be considered the actual date of expiration. Monitor materials for changes in appearance or consistency. Any changes may indicate potential contamination and the item should be discarded even if the expiration date is not exceeded. 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. Ref: Quality Assurance Policies for Field Laboratories. Comment: The Total Residual Chlorine (TRC) buffer and DPD liquid reagents expired in February 2017. Proficiency Testing D. Finding: The preparation of Proficiency Testing (PT) samples is not documented. Page 3 #5488 Cliffside Sanitary District 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. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract lab reports to eDMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for the Cliffside Sanitary District (NPDES permit #NC0004405) for July, September and December 2016. 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 Recommendation will help this laboratory to produce quality data and meet Certification requirements. The inspector would like 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: Jason Smith Date: June 16, 2017 Report reviewed by: Tonja Springer Date: June 16, 2017 � % / k 2 a / t J / 00 p q \ ) } k * / d k a / e § e LLI w § 2 � § 0 j \ § / 7 / \ \ o ± _ u ° W S o ^ e f / ca ) \ ) ) ƒ ( 2 j £ §