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HomeMy WebLinkAbout#37_2016_0405_TS_FINALTo be attached to all inspection reports in-house only. Laboratory Cert. #: Laboratory Name: Inspection Type: Inspector Name(s): Inspection Date: Date Report Completed: Date Forwarded to Reviewer: Reviewed by: Date Review Completed: Cover Letter to use: Unit Supervisor/Chemist III: Date Received: Date Forwarded to Admin: 37 TBL Environmental Laboratory, Inc. Commercial Maintenance Tonia Springer, Dana Satterwhite, and Todd Crawford April 5, 2016 May 25, 2016 Mav 25. 2016 Nick Jones May 26, 2016 ❑ Insp. Initial ❑ Insp. Reg. ❑ Insp. No Finding ❑ Insp. CP ❑ Corrected ® Insp. Reg. Delay Todd Crawford June 6. 2016 June 29, 2016 June 30. 2016 Special Mailing Instructions: Copy Chris Goforth - DW Water Resources June 30, 2016 37 Ms. Pamela S. Hester TBL Environmental Laboratory, Inc. P.O. Box 589 Lumberton, NC 28359 PAT MCCRORY DONALD R. VAN DER VAART S. JAY ZIMMERMAN Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Hester: Enclosed is a report for the inspection performed on April 5, 2016 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. 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, Chris Goforth LABORATORY NAME: TBL Environmental Laboratory, Inc. ADDRESS: P.O. Box 589 Lumberton, NC 28359 CERTIFICATE : 37 DATE OF INSPECTION: April 5, 2016 TYPE OF INSPECTION: Commercial Maintenance AUDITOR(S): Tonja Springer, Dana Satterwhite and Todd Crawford LOCAL PERSON(S) CONTACTED: Pam Hester, Tara Knecht, and Tasha Ivey 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 laboratory was immaculate and well organized. The facility has all the equipment necessary to perform the analyses. Analytical data pertinent to each certified analysis was filed in an orderly manner and was readily available for inspection upon request. The organizational culture of this laboratory is one that focuses on quality of data. Laboratory personnel were knowledgeable and forthcoming and accessible to answer questions that arose during the inspection. Laboratory staff were forthcoming and seemed eager to adopt necessary changes. We would like to thank the laboratory for being a good steward and neighbors to the other laboratories and communities in the area by providing assistance, consultation regarding laboratory analyses, result interpretation and plant operation. All required Proficiency Testing (PT) samples for the 2016 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, 2016. 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 October 3, 2016. 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 a SOP to document how new functions or policies will be implemented. Page 2 #37 TBL Environmental Laboratory, Inc. 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 (e.g. 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. Contracted analyses are performed by Environmental Science Corporation dba: ESC Lab Sciences (Certification #375), Environment 1, Inc. (Certification #10), and Pace Analytical Services, Inc.- Huntersville (Certification #12). Quality Control Comment: Duplicate analyses are not required for Field parameters (i.e., pH, and Conductivity). Comment: The sample preservation and storage temperature requirements may be changed in accordance with 40 CFR Part 136.3 Table II in all pertinent SOPs and in practice. The current practice is "at or below 4°C." 40 CFR Part 136.3 Table II allows 56°C for most inorganic parameters and <10°C for bacterial tests, without evidence of freezing. Additionally, the holding time for Fecal Coliform and Total Coliform may be extended from 6 hours to 8 hours. Fecal Coliform sample analysis should begin as soon as possible after receipt; sample incubation must be started no later than 8 hours from time of collection. Recommendation: It is recommended the laboratory follow The Division of Water Resources (DWR) guidance for significant figures reporting. The North Carolina Division of Water Resources, Water Quality Permitting Section has developed an NPDES Compliance Guidance Document titled, Significant Figures and Their Use on Discharge Monitoring Reports (DMRs). This document provides guidance to promote the consistent use of significant figures in preparing Discharge Monitoring Reports (DMRs). If you have any questions about the guidance provided in this document, please contact Mr. Mike Templeton, P.E. Water Quality Permitting Section, Wastewater Branch at mike.templeton&ncdenr.gov . Comment: The infrared (IR) detection device is not checked each day of use, by performing a single check of the IR thermometer. NC WW/GW LC Policy states: Each day of use, perform a single check of the IR thermometer by checking the temperature of a bottle of water at the temperature of interest that contains a calibrated thermometer. Agreement between the two must be within 0.5°C, or the device must be rechecked. If the second calibration verification fails, the device must be repaired or replaced. Document the semi-annual and daily calibration checks. The correction factor must be indicated on the thermometer and applied when recording temperature measurements. Notification of acceptable corrective action (i.e., IR thermometer check log showing documented temperatures with an implementation date of 4/13/2016) was received by email on 5/9/2016. No further response is necessary for this Finding. A. Finding: The laboratory is not verifying the IR detection device at two different temperatures. Requirement: When an IR detection device is used to measure the temperature of samples, the device must be verified at least every six months using a National Institute of Standards and Technology (NIST) traceable thermometer at a minimum of two different temperatures over the full temperature range that the IR thermometer will be used (e.g., 0°C to 10°C for a sample receipt thermometer). Agreement between the two must be within 0.5°C, or the device must be rechecked. If the second calibration verification fails, the device must be repaired or replaced. Page 3 #37 TBL Environmental Laboratory, Inc. Document the semi-annual and daily calibration checks. The correction factor must be indicated on the thermometer and applied when recording temperature measurements. Ref: NC WW/GW LC Policy. Comment: The laboratory is verifying the IR detection every six months, but only at only one temperature. Proficiency Testing (PT) B. Finding: The laboratory does not have a documented plan for analysis of PT samples. 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). Requirement: 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. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. C. Finding: The laboratory is not analyzing PT samples in the same manner as compliance samples. Requirement: 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 and any other samples analyzed according to the requirements of 15A NCAC 2H .0800. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: The laboratory's common practice was to analyze a known standard along with the PT sample as additional quality control. Since this is not performed with all environmental samples, it is considered additional quality control. However, known samples are recommended when analyzing remedial PT samples as part of the troubleshooting and corrective action process. Documentation Comment: All the benchsheets referenced Standard Methods, 1811 Edition rather than the Standard Methods Committee approval year. Revised benchsheets were submitted on 4/6/2016 showing the 18tn Edition had been removed but the approval year was not documented. The format for all the certified parameters are as follows: Fecal Coliform (SM 9222 D-1997), Total Coliform (SM 9222 B-1997), BOD (SM 5210 B-2001), COD (SM 5220 D-1997), Conductivity (SM 2510 B-1997), Ammonia (SM 4500 NHs D- 1997), pH (SM 4500 H+B-2000) and TSS (SM 2540 D-1997). Page 4 #37 TBL Environmental Laboratory, Inc. Recommendation: It is recommended to document the laboratory name on the benchsheets. Comment: The laboratory needs to increase the documentation of purchased materials, consumable materials and reagents, as well as documentation of standards and reagents prepared in the laboratory. The laboratory recorded date received and date opened on the bottles, but the traceable connection is lost once the bottles are discarded. 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. 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. Notification of acceptable corrective action (i.e., a traceability log documenting purchased materials and reagents currently in-house with an implementation date of 4/7/2016) was received by email on 4/19/2016. No further response is necessary for this Finding. Bacteria — Coliform, Fecal — Standard Methods, 9222 D-1997 (MF) (Aqueous) Comment: The laboratory is using a partial immersion thermometer in the fecal water bath improperly. The thermometer was resting at the bottom. The "Selecting Alternatives to Mercury -Filled Thermometers" document found here: http://www.epa.gov/mercurv/alternatives.htm states: Thermometers with no indicated depth are the total immersion type. When a partial -immersion thermometer is used, the bottom of the thermometer up to the immersion line should be exposed to the temperature being measured, with the remainder of the thermometer exposed to ambient conditions. When a total immersion thermometer is used, the bulb and the entire portion of the stem containing liquid, except for the last 1 cm, are exposed to the temperature being measured. If the thermometer is not used in this manner, the thermometer immersion is incorrect. Notification of an acceptable corrective action (i.e., a statement that thermometer is no longer resting at the bottom and the water is up to the immersion line, with an implementation date of 4/5/2016) was sent by email on 5/24/2016. No further response is necessary for this Finding. Comment: The laboratory is not monitoring the quality of the reagent water used in fecal coliform analysis. Distilled water is purchased from Walmart in gallon jugs. The water is then poured into a carboy and filtered through Organic/Mixed Bed DI water filter from Thermo. NC WW/GW LC Policy states: At a minimum analysis must be performed for conductivity, TOC, Cd, Cr, Cu, Pb and Zn. Maximum acceptable limits for reagent water quality are given in Standard Methods 9020 B-2005 Table 9020: Il. If these limits are not met, investigate and correct or change water source. Notification of acceptable corrective action (i.e., two final reports from Element One showing the reagent water was analyzed for TOC, Cd, Cr, Cu, Pb and Zn. The conductivity was analyzed in house. An annual requirement to monitor water was implemented on 4/11/2016) was sent by email on 4/19/2016 and 6/23/2016. No further response is necessary for this Finding. Comment: The time that samples are removed from the incubator are routinely documented. The second set of samples analyzed on 1/12/2016 did not have the time out of incubator documented. No other instances of this type omission were observed. BOD —Standard Methods, 5210 B-2001 (Aqueous) Comment: Units of measure are not documented on the benchsheet for the column headers associated with Initial DO ([DO) and Final DO (FDO). The North Carolina Administrative Code, 15 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 Page 5 #37 TBL Environmental Laboratory, Inc. must be recorded each time samples are analyzed. Notification of acceptable corrective action (i.e., updated benchsheet that included units of measure over the column headers for IDO and FDO with an implementation date of 4/14/2016) was received by email on 4/19/2016. No further response is necessary for this Finding. D. Finding: Potassium Bi-iodate is being used reducing in BOD samples. Requirement: Determine required volume of Na2SO3 solution on a 100 to 1000-mL portion of neutralized sample by adding 10 mL 1 + 1 acetic acid or 1 + 50 H2SO4, 10 mL potassium iodide (KI) solution (10 g/100 mL) per 1000 mL sample and titrating with Na2SO3 solution to the starch - iodine end point for residual. Ref: SM 5210 B. (4) (b) (2). Comment: The bi-iodate treatment for reducing agents was a common practice in the past, however it has never been prescribed by the method. E. Finding: The lab is utilizing indicator strips to verify the presence/absence of residual chlorine. Requirement: It is acceptable to screen samples with DPD powder for the presence of total residual chlorine (use pillows appropriate for the volume of sample tested). Generally, total residual chlorine test strips are not adequate; however, these may be used for samples where interference with DPD precludes their use. Ref: NC WW/GW LC Policy. F. Finding: The lab is measuring sample volumes <20 mLs without using wide tip pipets. Requirement: Sample volumes less than 20 mLs must be measured using a wide -tip pipet. Ref: NC WW/GW LC Policy. G. Finding: Sodium sulfite is not prepared each day it is used. Requirement: This solution is not stable; prepare daily. Ref: Standard Methods 5210 B-2001. (3) (f)• Comment: The laboratory is making it weekly. At one point it was being prepared daily. COD —Standard Methods, 5220 D-1997 (Aqueous) Comment: The laboratory is having each analyst verify the factory -set curve annually. The factory -set curve can be verified annually by one analyst and used by all the analysts. Recommendation: It is recommended that the laboratory implement a temperature grid check of the block digester by alternating the well location of the thermometer each time samples are digested and by rotating the location of the standards, samples and blanks. This will document heating uniformity and consistency of all sample wells in the block. H. Finding: Calibration curve verifications do not always indicate a linear response between the true concentration of the check standards and the % transmittance concentration determined by the instrument. Requirement: When linear regression is used, use the minimum correlation coefficient specified in the method. If the minimum correlation coefficient is not specified, then a minimum value of 0.995 (or a coefficient of determination, r2, of 0.99) is required. Ref: NC WW/GW LC Policy. Page 6 #37 TBL Environmental Laboratory, Inc. Recommendation: For the calibration curve verifications, plot True Value versus Obtained Value instead of True Value versus Transmittance to more accurately demonstrate the linear relationship between the true concentrations of the check standards and the concentrations determined by the instrument. Finding: The laboratory is not analyzing LFMs. Requirement: When appropriate for the analyte (Table 5020: 1), include at least one LFM/LFMD daily or with each batch of 20 or fewer samples. 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%. Ref: Standard methods, 5020 B-2010. (2) (g). Comment: Analysis of an LFMD is not necessarily required for this method. Table 5020: I, Footnote 2 states that either an LFMD or sample duplicate may be analyzed. J. Finding: Quantitation at 1 to 2 times the Method Reporting Limit (MRL) is not verified at least quarterly. Requirement: Verify quantitation at the MRL initially and at least quarterly (preferably daily) by analyzing a QC sample (subjected to all sample -preparation steps) spiked at a level 1 to 2 times the MRL. Ref: Standard Methods, 5020 B-2010. (1) (c). K. Finding: Calibration and/or QC standard recoveries are not evaluated against the required method acceptance criterion of < 5% difference from the true value. Requirement: Prepare calibration curve for each new lot of tubes or ampules or when standards prepared in ¶ a above differ by >_ 5% from calibration curve. Ref: 5220 D-1997. (4) (c). L. Finding: Corrective action is not consistently initiated when QC failures occur. Requirement: When quality control (QC) failures occur, the laboratory must attempt to determine the source of the problem and must apply corrective action. Ref: NC WW/GW LC Policy. Comment: On 1/5/2015 the 250 mg/L calibration standard was outside the >_ 5% from calibration curve acceptance criterion and no corrective action was taken. M. Finding: Reagent water is not being used as a reference solution on the Low Range curve. Requirement: At 420 nm, use reagent water as a reference solution. Measure all samples, blanks, and standards against the solution. The absorption measurement of an undigested blank containing dichromate, with reagent water replacing sample, will give initial dichromate absorption. Any digested sample, blank, or standard that has a COD value will give lower absorbance because of the decrease in dichromate ion. Ref: Standard Methods, 5220 D-1997. (4) (b). Comment: The laboratory was using a digested blank as the reference solution. This is only allowed on the high range curve. N. Finding: The digested blank is not being subtracted from the samples analyzed on the Low Range curve. Page 7 #37 TBL Environmental Laboratory, Inc. Requirement: Analyze a digested blank to confirm good analytical reagents and to determine the blank COD; subtract blank COD from sample COD. Ref: Standard Methods, 5220 D-1997. (4) (b). O. Finding: The % Transmittance is not being documented on the benchsheet. This is considered pertinent information. Requirement: 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. Ref: 15A NCAC 2H .0805 (a) (7) (A)• Comment: The retained documentation must include all information required for the historical reconstruction of the data (e.g., SOPs, instrument readings, analytical results, calibration curves, standard and sample preparation information, sample receiving information, QC data, and the final report with narrative/data qualifiers). Nitrogen, Ammonia — Standard Methods, 4500 NH3 D-1997 (Aqueous) P. Finding: The volume of 10N NaOH (ISA solution) added to the samples, blanks and calibration standards was not documented on the benchsheet. Requirement: Record volumes of 10N NaOH added. Ref: Standard Methods, 4500 NH3 D-1997. (4)(e). Requirement: The following formula must be used in the calculation: mg NH3—N/L=AxBX 10( 0+D) (100 + C) A= Dilution Factor B= Concentration of NH3-N/L, mg/L, from calibration curve C= Volume of 10N NaOH added to the calibration standards, mL D= Volume of 10N NaOH added to sample, MI Ref: Standard Methods, 4500 NH3 D-1997. (5). Q. Finding: The laboratory is not analyzing an LFM/LFMD. Requirement: When appropriate for the analyte (Table 4020:1), include at least one LFM/LFMD daily or with each batch of 20 or fewer samples. 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%. Ref: SM 4020 B-2009, Rev. 2011, Table 4020: 1 and (2) (g)• Comment: The laboratory is analyzing sample duplicates at a frequency of 10% of samples. Sample duplicates are not required for this method. R. Finding: Verification of pH adjustment to >11 S.U. is not documented. This is considered pertinent information. Requirement: Add a sufficient volume of 10N NaOH solution (1 mL usually is sufficient) to raise pH above 11. Ref: Standard Methods, 4500 NH3 D-1997. (4) (b). Page 8 #37 TBL Environmental Laboratory, Inc. Requirement: 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. Ref: 15A NCAC 2H .0805 (a) (7) (A)• Comment: The laboratory uses pH paper for the verification but it is not documented. A check box indicating the pH >11 S.U. may be used. S. Finding: Quantitation at 1 to 2 times the Method Reporting Limit (MRL) was not verified initially and at least quarterly thereafter. Requirement: Verify quantitation at the MRL initially and at least quarterly (preferably daily) by analyzing a QC sample (subjected to all sample -preparation steps) spiked at level 1 to 2 times the MRL. Ref: Standard Methods, 4020 B-2009. (1) (c). Residue, Suspended — Standard Methods, 2540 D-1997 (Aqueous) Recommendation: It is recommended to maintain pre -prepared filters in their tube containers and store in an adequately sealed desiccator (i.e., grease, vacuum, seals in good shape) until needed for sample analysis. Minimize opening desiccator because moist air enters. Recommendation: A set of Class 2 weights were purchased. It is recommended to put the date purchased and the date verified on the new class 2 weights container. It is on the associated paperwork. Comment: The serial number or some other form of unique identification of the thermometer is not documented on the oven temperature daily log to provide linkage to the annual thermometer calibrations. This is considered pertinent information. The 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 example updated oven temperature daily log with identification of the thermometer to link to the annual thermometer calibration with an implementation date of 4/6/2016) was received by email on 4/19/2016. No further response is necessary for this Finding. Comment: Filters are not weighed to constant weight prior to sample analysis, nor is a dry filter blank analyzed with each set of samples. The laboratory is using pre -prepared filters [meaning they have been rinsed but not pre -weighed] and analyzing a wet blank each day samples are analyzed. NC WW/GW LC Policy states: If pre -prepared filters [meaning pre -prepared and pre -weighed] 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 a dry filter blank is being analyzed instead of a wet filter blank, with an implementation date of 4/6/2016) was received by email on 4/19/2016. No further response is necessary for this Finding. Comment: Filter traceability information is not documented in a way to provide linkage between the filters and the data sets in which they are used. 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). A_ system (e.g., traceable identifiers) must be in place that links standard/reagent preparation information to analytical batches in which the solutions are used. Documentation of solution preparation must include the analyst's initials, date of preparation, the volume or weight of standard(s) used, the solvent and final volume of the solution. This information as well as the vendor and/or manufacturer, lot Page 9 #37 TBL Environmental Laboratory, Inc. 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. Notification of acceptable corrective action (i.e., submission of an example benchsheet documenting the filter lot numbers and consumables supply log documenting filter traceability information that provides linkage to the lot numbers on the benchsheets, with an implementation date of 4/7/2016) was received by email on 4/19/2016. No further response is necessary for this Finding. Temperature — Standard Methods, 2550 B-2000 (Aqueous) T. Finding: The laboratory is analyzing samples and reporting data for parameters without North Carolina Wastewater/Groundwater Laboratory Certification. Requirement: Commercial laboratories are required to obtain certification for parameters which will be reported by the client to comply with State surface water monitoring, groundwater, and pretreatment Rules. Ref: 15A NCAC 2H .0804 (a). Please submit an amendment form requesting certification with the report reply. pH —Standard Methods, 4500 H+B-2000 (Aqueous) U. Finding: The pH meter calibration log sheet did not contain all of the necessary labeling information. No units of measure are associated with slope efficiency (i.e., %). 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: 15 NCAC 2H .0805 (a) (7) (H) Conductivity —Standard Methods, 2510 B-1997 (Aqueous) Comment: A calibration verification check standard is not being analyzed each analysis day. The NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity) document states: Analyze and document a calibration verification check standard prior to environmental sample analysis. It is recommended that this standard value bracket (may be higher or lower than the calibration standard, as applicable) the expected range of sample values measured. The value obtained for the calibration verification check standard must read within 10% of the true value of the calibration verification check standard. If the obtained value is outside of the 10% range, corrective action must be taken. Notification of acceptable corrective action (i.e., a statement that two calibration standards and one second source check standard close to the range of samples analyzed are now being analyzed, with an implementation date of 4/14/2016) was received by email on 4/19/2016. No further response is necessary for this Finding. V. Finding: The Automatic Temperature Compensator (ATC) has not been verified. Requirement: The ATC must be verified annually (i.e., every twelve months) and the process documented. The ATC must be verified by analyzing a standard at 25 °C (i.e., the temperature that conductivity values are compensated to) and a temperature(s) that brackets the temperature ranges of the samples to be analyzed. This may require the analysis of a third temperature reading that is > 25 'C. Ref: NC WW/GW LC Approved Procedure for the Analysis of Specific Conductance (Conductivity). Please submit a copy of the verification with the inspection report reply. Page 10 #37 TBL Environmental Laboratory, Inc. Comment: Anticipated temperatures can be obtained from a review of the Discharge Monitoring Reports (DMRs) from the peak summer and winter months. Historical data should provide a reasonably accurate estimation of ranges that will bracket the expected sample temperatures. Comment: At the time of the inspection, a copy of the Approved Procedure for the Analysis of Specific Conductance (Conductivity) was provided that includes directions on how to verify the ATC. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) Discharge Monitoring Reports (DMRs), and client reports. Conductivity data were reviewed for January 7, 14 and 28, 2016, February 18, 2016 and March 17 and 24, 2016. Fecal Coliform data was reviewed for the Town of Gibson (Water Quality permit # WQ0002766) for March 9, 2016. Suspended Residue data were reviewed for Chemours Company — Fayetteville Works (NPDES permit # NC0003573) for August 6, 2015 and Fairmont Regional WWTP (NPDES # NC0086550) for August 5, 2015 and Laurel Hill (NPDES # NC0005479) for August 4, 2016. Ammonia data were reviewed for Fairmont Regional WWTP (NPDES # NC0086550) and Laurel Hill (NPDES # NC0005479) for August 4, 2016. No transcription errors were detected. The facility appears to be doing a good job accurately transcribing data. Results below the reporting limit are routinely reported correctly but there was this one instance on 8/4/2016 where the "less than" sign for Ammonia was left off. No other instances of this type omission were observed. V. I CONCLUSIONS: Correcting the above -cited Findings and implementing the recommendations will help this lab 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: Tonja Springer Date: May 11, 2016 Report reviewed by: Nick Jones Date: June 1, 2016