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HomeMy WebLinkAbout#5117_2014_final INSPECTION REPORT ROUTING SHEET To be attached to all inspection reports in-house only. Laboratory Cert. #: 5117 Laboratory Name: Town of Angier WWTP Inspection Type: Field Maintenance Inspector Name(s): Tonja Springer Inspection Date: February 11, 2014 Date Report Completed: March 6, 2014 Date Forwarded to Reviewer: March 6, 2014 Reviewed by: Nick Jones Date Review Completed: March 7, 2014 Cover Letter to use: Insp. Initial Insp. Reg. Insp. No Finding Insp. CP Corrected Unit Supervisor/Chemist III: Dana Satterwhite Date Received: March 20, 2014 Date Forwarded to Linda: April 2, 2014 Date Mailed: April 2, 2014 _____________________________________________________________________ On-Site Inspection Report LABORATORY NAME: Town of Angier WWTP WATER QUALITY PERMIT # : WQ0002638 ADDRESS: P.O. Box 278 Angier, NC 27501 CERTIFICATE #: 5117 DATE OF INSPECTION: February 11, 2014 TYPE OF INSPECTION: Field Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Jimmy Cook 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 clean and well organized. The facility has all the equipment necessary to perform the analyses. Proficiency Testing (PT) samples have been analyzed for all certified parameters for the 2013 proficiency testing calendar year and the graded results were 100% acceptable. Current quality assurance policies for Field Laboratories and approved procedures for the analysis of the facility’s currently certified parameters were provided at the time of the inspection. Contracted analyses are performed by Pace Analytical Services, Inc. (Certification #67). The requirements associated with Findings B and D have been implemented by our program since the last inspection. III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: General Comment: The laboratory is analyzing and voluntarily reporting data for Total Residual Chlorine without North Carolina Wastewater/Groundwater Laboratory Certification. This parameter is not on their W ater Quality (WQ) permit. The North Carolina Administrative Code, 15A NCAC 2H .0804 (a) states: Commercial, Municipal, Industrial and Other facilities are required to obtain certification for field parameters which will be reported by the client to comply with State surface water, groundwater, and pretreatment Rules. Demonstration of acceptable corrective action (i.e., an email stating the laboratory Page 2 #5117 Town of Angier WWTP has discontinued reporting Total Residual Chlorine as of 3/1/2014) was received on 3/5/2014. No further response is necessary for this finding. Documentation Recommendation: The laboratory’s data defensibility would be improved with the addition of an instrument maintenance log. This can be as simple as a description in a comment box on a benchsheet. One example of instrument maintenance is replacing the probe on the pH meter. Comment: Instrument identification was not documented on the benchsheet. The NC WW/GW LC Approved Procedure for the Analysis of pH document states: 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 benchsheet which included the instrument ID) was received by email on 3/5/2014. No further response is necessary for this finding. Comment: The laboratory needs to increase the documentation of purchased pH buffers. The Quality Assurance Policies for Field Laboratories 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. A system (e.g., traceable identifiers) must b e in place that links standard/reagent preparation information to analytical batches in which the solutions are used. Consumable materials such as pH buffers and lots of pre-made standards are included in this requirement. 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 benchsheet which included pH buffer traceability) was received by email on 3/5/2014. No further response is necessary for this finding. A. Finding: All original records were not on file. 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 2H .0805 (g) (1). Comment: Data omission, as noted in the Paper Trail Investigation section of this report, can be perceived as falsification of data. B. Finding: Several instances of writing over a number as a means of error correction were observed. 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. pH – Standard Methods, 4500 H+B-2000 Comment: The benchsheet did not contain all the necessary labeling information. Sample collection time, analysis time, and analyst’s initials were not documented on the benchsheet. The North Carolina Administrative Code, 15A NCAC 2H .0805 (g) (1) states: Data pertinent to each analysis must be Page 3 #5117 Town of Angier WWTP 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. Demonstration of acceptable corrective action (i.e., an updated benchsheet which included sample collection time, analysis time and analyst’s initials) was received by email on 3/5/2014. No further response is necessary for this finding. C. Finding: Data values were not always reported on the Discharge Monitoring Report (DMR) to the nearest 0.1 pH unit. Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Report all data values to the nearest 0.1 pH unit. Ref: NC WW/GW LC Approved Procedure for the Analysis of pH. Recommendation: The units of measure for pH analyses are Standard Units (S.U.). It is recommended that pH be read in one-hundredths (0.01). Values must be reported in tenths (0.1). It should be noted that many proficiency testing (PT) providers require samples be reported to one-hundredths. Comment: For the data reviewed during the inspection, there was only one instance observed where the data value was not reported to the nearest 0.1 pH unit. The laboratory personnel indicated their thoughts were that the computer program would not let them put in a zero after the decimal place (i.e., 6.0). Recommendation: It is recommended that the laboratory personnel contact the Fayetteville Regional Office to ask for guidance with reporting data values on the DMR. Proficiency Testing D. Finding: The laboratory is not designating the correct method code(s) for proficiency testing (PT) sample results. Requirement: To ensure that you are reporting the correct method, review your certificate attachment (i.e., certified parameter list). The method must include the entire method reference as is written on your certificate attachment (i.e., certified parameter list). Ref: Proficiency Testing Requirements, February 20, 2012, Revision 1.2. Comment: Designating the correct method code(s) will ensure you receive proper credit for the parameter method technologies on your current certificate attachment. When a PT provider utilizes a web-based submittal system, where the laboratory selects the analytical method from a pull-down list, it may be necessary to edit the choices given. Technical difficulties should be addressed with the PT provider. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing laboratory benchsheets and contract lab reports to Discharge Monitoring Reports (DMRs) submitted to the North Carolina Division of Water Resources. Data were reviewed for August, November, 2013 and December, 2014. The following errors were noted: Page 4 #5117 Town of Angier WWTP Date Parameter Location Value on Benchsheet Value on DMR 1/6/2014 pH Effluent No value documented 6 s.u. 1/22/2014 pH Effluent No value documented 6.2 s.u. 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 and implementing the recommendation 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. Report prepared by: Tonja Springer Date: March 6, 2014 Report reviewed by: Nick Jones Date: March 7, 2014