Loading...
HomeMy WebLinkAbout#5628_0331finalTS_2015_A I CUDENR North Carolina Department of Environment and Natural Resources Pat McCrory Donald R, van der Vaart Governor Secretary May 11, 2015 5628 Debbie Locklear 265 McGirt Road Maxton, NC 28364 Subject: North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) Maintenance Inspection Dear Ms. Locklear: Enclosed is a report for the inspection performed on March 31, 2015 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 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 us at (919) 733-3908. Attachment cc: Tonja Springer Sincerely, Dana Satterwhite, Environmental Program Supervisor Division of Water Resources Water Sciences Section NC Wastewater/Groundwater Laboratory Certification Branch 1623 Mail Service Center, Raleigh, North Carolina 27699-1623 Location:4405 Reedy Creek Road, Raleigh, North Carolina 27607 Phone: 919-733-3908 l FAX:919-733-6241 Internet: www.dwalab.orq An Equal Opportunity � Affirmative Action Employer INSPECTION REPORT ROUTING SHEET To 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 Linda: Date Mailed: 5628 Robeson County Water Dept. Field Maintenance Tonia Springer March 31, 2015 April 24, 2015 April 27, 2015 Nick Jones April 27, 2015 ❑ Insp. Initial ❑ Insp. Reg. ❑ Insp. No Finding ❑ Insp. CID ❑ Corrected ® Insp. Reg. Delay Dana Satterwhite April 27, 2015 May 6, 2015 May 11, 2015 On -Site Inspection Report LABORATORY NAME: ADDRESS: NPDES PERMIT # CERTIFICATE #: DATE OF INSPECTION: TYPE OF INSPECTION: AUDITOR(S): LOCAL PERSON(S) CONTACTED: INTRODUCTION: Robeson County Water Department 265 McGirt Road Maxton, NC 28364 NC0048577, NC0086991, NC0086894, NC0085685, and NCO084204 5628 March 31, 2015 Field Maintenance Tonja Springer Debbie Locklear 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. Proficiency Testing Proficiency Testing (PT) samples for the 2015 proficiency testing calendar year have not yet been analyzed. The laboratory is reminded that these results must be submitted to this office directly from the vendor by September 30, 2015. Contracted analyses are performed by TBL Environmental Laboratory, Inc. (Certification #37) and Environment 1, Inc. (#10). Current quality assurance policies for Field Laboratories, an example benchsheet and approved procedures for the analysis of the facility's currently certified parameters were provided at the time of the inspection. The requirements associated with Findings D, E, F and G have been implemented by our program since the last inspection. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: Several instances of writing over a number as a means of error correction were observed that were also not initialed or dated. Page 2 #5628 Robeson County Water Dept. 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. Wite-Out®, correction tape or similar products designed to obliterate documentation are not to be used. Write the correction adjacent to the error. The correction must be initialed by the responsible individual and the date of change documented. All data and log entries must be written in indelible ink. Pencil entries are not acceptable. Ref: Quality Assurance Policies for Field Laboratories. Total Residual Chlorine — Standard Methods, 4500 Cl G-2000 RH — Standard Methods, 4500 H+ B-2000 Comment: The laboratory benchsheets for pH and Total Residual Chlorine (TRC) were lacking pertinent data: Instrument identification. The NC WW/GW LC Approved Procedure for Analysis of pH and the NC WW/GW LC Approved Procedure for Analysis of Total Residual Chlorine documents state: The following must be documented in indelible ink whenever sample analysis is performed: Instrument identification. This requirement is a new policy that has been implemented by our program since the last inspection. Demonstration of acceptable corrective action (i.e., an updated completed benchsheet with instrument identification and an implementation date of 4/1/2015) was received by email on 4/8/2015. No further response is necessary for this finding. Total Residual Chlorine — Standard Methods, 4500 Cl G-2000 Comment: The Gel standard when verified against the annual calibration curve was analyzed on the wrong program. The annual verification curve performed in 2014 was analyzed on (program 86) but the gel standard was verified on (program 88). The NC WW/GW LC Approved Procedure for Analysis of Total Residual Chlorine states: Purchased "Gel -type" or sealed liquid ampoule standards may be used for daily standard curve verification only. These standards must be verified initially and every 12 months thereafter, with the standard curve. When this is done, these standards may be used after the manufacturer's expiration date. It is only necessary to verify the gel or sealed liquid standard which falls within the concentration range of the curve used to measure sample concentrations. Demonstration of acceptable corrective action (i.e., the gel standard was read on program (86) 3 times and the average taken to obtain a true value of 191 pg/L at the time of the inspection, and an updated completed benchsheet that included the true value of the gel standard and with an implementation date of 4/1/2015,) was received by email on 4/8/2015 An additional notification of acceptable corrective action (i.e., a statement that the gel standard verification will be read on the same program as samples) was received by email on 4/28/2015. No further response is necessary for this finding. Comment: The post analysis calibration verification check standard(s) is not being documented on laboratory benchsheets. The NC WW/GW LC Approved Procedure for Total Residual Chlorine states: The following must be documented in indelible ink whenever sample analysis is performed. True value and value obtained for the post analysis calibration verifications) where applicable. Demonstration of acceptable corrective action (i.e., an updated completed benchsheet with the post analysis calibration verification check standard(s) documented and an implementation date of 4/8/2015) was received by email on 5/4/2015. Comment: The laboratory is analyzing a post analysis calibration verification standard after each sample, which is not required. When performing analyses away from the certified laboratory's primary location, a post analysis calibration verification must be analyzed at the end of the run. The post analysis calibration verification standard concentration must be at mid -range. It is recommended that a mid -day calibration verification be performed when samples are analyzed over an extended period of time. The value obtained for the post analysis calibration verification check standard must read within 10% of the true value of the post analysis calibration verification check standard. If the obtained value is Page 3 #5628 Robeson County Water Dept, outside of the ±10% range, corrective action must be taken. Recommendation: It is recommended the lab document the time the post analysis calibration verification standard(s) is/are analyzed to verify that they are done mid -day and/or after the last sample. B. Finding: The laboratory is not verifying the factory -set curve at a concentration equal to or less than the permit limit for all permitted locations. Requirement: The concentrations of the calibration standards must bracket the concentrations of the samples analyzed. One of the standards must have a concentration equal to or below the lower reporting concentration for Total Residual Chlorine. The lower reporting limit must be less than or equal to the permit limit. Ref: The NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Please submit a copy of a new annual verification curve that meets the multiple permit limit requirements. Comment: The following permits analyzed under Robeson County Water Department's certification have permit limits of 17 pg/L: NC0086991, NC0086894, NC0085685 and NC0084204. Permit NC0048577 has a permit limit of 28 pg/L. The 2014 annual verification lowest standard concentration was 20 pg/L. Recommendation: It is recommended that the laboratory verify the internal calibration using the following concentrations: 10 (or 15), 20, 50, 200 and 400 pg/L. C. Finding: Values less than the established reporting limit are being reported on the Discharge Monitoring Report (DMR). Requirement: The concentrations of the calibration standards must bracket the concentrations of the samples analyzed. One of the standards must have a concentration equal to or below the lower reportinq concentration for Total Residual Chlorine The lower reporting limit must be less than or equal to the permit limit. Ref: NC WW/GW LC Approved Procedure for the Analysis of Total Residual Chlorine. Please submit copies of at least three weeks of completed DMRs exhibiting the proper reporting protocol with the response to this report. Comment: The laboratory established a lower reporting limit of 20 pg/L in 2014. Values with concentrations less than that must be reported as <20 pg/L on the DMR. The laboratory has been reporting <10 pg/L on the DMR based on the established lower reporting limit of the 2013 annual verification curve. In order to meet permit and reporting requirements, the laboratory must establish a lower reporting limit that is less than or equal to the permit limit by verifying the factory -set calibration with a standard concentration equal to or below the lowest permit limit as cited in Finding B and report less than values as < the established permit limit, which should be equal to or less than 17 pg/L, the lowest permit limit. D. Finding: A reagent blank was not analyzed with the prepared annual 5-point calibration curve verification. Requirement: 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. A reagent blank would only be analyzed when preparing the annual 5-point calibration curve or 5 annual calibration curve verification standards. A reagent blank is made from the same laboratory water source used to make quality control 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 Page 4 #5628 Robeson County Water Dept. reference method, or corrective action must be taken. Ref: NC WW/GW LC Approved Procedure for Analysis of Total Residual Chlorine. PH — Standard Methods, 4500 H+ B-2000 Comment: The laboratory is analyzing a post analysis calibration verification standard after each sample, which is not required. When performing analyses away from the certified laboratory's primary location, a post analysis calibration verification using the check standard buffer must be analyzed at the end of the run. The post analysis calibration verification standard concentration must be at mid- range. It is recommended that a mid -day calibration verification be performed when samples are analyzed over an extended period of time. Recommendation: It is recommended the lab document the time the post analysis calibration verification standard(s) is/are analyzed to verify that they are done mid -day and/or after the last sample. Proficiency Testing E. Finding: The preparation of TRC Proficiency Testing (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: The 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. F. Finding: The laboratory is not documenting 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: PT samples are not being documented on the benchsheets. Results were only documented on the vendor reporting form then submitted to the vendor by fax. G. Finding: The laboratory is not analyzing Proficiency Testing (PT) samples in the same manner as environmental 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. H. Finding: The hard copy of the PT results that are faxed is not retained. Page 5 #5628 Robeson County Water Dept. Requirement: The laboratory shall retain all records necessary to facilitate historical reconstruction of the analysis and reporting of analytical results for PT samples. This means the laboratory must have available and retain for five years [pursuant to 15A NCAC 2H .0805 (a) (7) (G)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT analyses and the associated quality control analyses conducted by all method technologies. These records shall include a copy of the reporting forms used by the laboratory to report the analytical results to the PT provider. If the analytical results for the PT samples were entered or uploaded electronically to a provider website, the laboratory shall retain a copy of the on-line data entry summary or similar documentation of entry of the PT results from the PT provider website. The laboratory shall make these records available for review upon request by the NC WW/GW LC program. Auditors will review PT records during on -site evaluations. Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Requirement: Data pertinent to each analysis must be maintained for five years. Ref: 15A NCAC 2H .0805 (g) (1). 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 Maxton Water Plant (NPDES #NC0048577), Sanchez Dr. WTP (NPDES #NC0086991), Raemon Well WTP (NPDES #NC0086894), Lumber Bridge WTP (NPDES #NC0085685), and Kenric Rd. WTP (NPDES #NC0084204) for August and December, 2014 and February, 2015. The following error was noted. Date Parameter Location Value on Value on Benchsheet DMR 2/11/2015 pH (NPDES #NC0084204) Kenric Rd. WTP 7.3 s.u. 7.1 s.u. Effluent In order to avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether an amended Discharge Monitoring Report will be required. A copy of this report will be made available to the Regional Office. V. CONCLUSIONS: Correcting the above -cited findings 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 an implementation date for each corrective action. Report prepared by: Tonja Springer Date: April 24, 2015 Report reviewed by: Nick Jones Date: April 27, 2015