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HomeMy WebLinkAbout#5045_2023_0413_MC_FINAL NC Department of Environmental Quality | Division of Water Resources | Laboratory Certification Branch 4405 Reedy Creek Road | 1623 Mail Service Center | Raleigh, North Carolina 27699-1623 919-733-3908 May 30, 2023 5045 Mr. Kent Scott Town of Pilot Mountain WWTP 124 W. Main St. Box 1 Pilot Mountain, NC 27041- Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Scott: Enclosed is a report for the inspection performed on April 13, 2023 by Michael Cumbus. 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, 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 02H .0800. A copy of the laboratory’s Certified Parameter List at the time of the audit is attached. This list will not 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 have questions or need additional information, please contact me at (919) 733- 3908 Ext. 259. Sincerely, Beth Swanson Technical Assistance & Compliance Specialist Division of Water Resources Attachment cc: Todd Crawford, Michael Cumbus, #5045 On-Site Inspection Report LABORATORY NAME: Town of Pilot Mountain WWTP NPDES PERMIT #: NC0026646 ADDRESS: 701 Lynchburg Road Pilot Mountain, NC 27041 CERTIFICATE #: 5045 DATE OF INSPECTION: April 13, 2023 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR: Michael Cumbus LOCAL PERSON(S) CONTACTED: Kent Scott and Mark King I. INTRODUCTION: This laboratory was inspected by a representative of the North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) to verify its compliance with the requirements of 15A NCAC 02H .0800 for the analysis of compliance monitoring samples. II. GENERAL COMMENTS: The facility is neat and well organized and has all the equipment necessary to perform the analyses. Staff were forthcoming and responded well to suggestions from the auditor. All required Proficiency Testing (PT) Samples for the 2023 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, 2023. Any time changes are made to laboratory procedures, Quality Assurance (QA) and/or Standard Operating Procedure (SOP) documents must be updated and relevant staff retrained. Staff must acknowledge that they have read and understand the changes as part of the documented training program. The same requirements apply when changes are made in response to Findings, Recommendations or Comments listed in this report, to ensure the methods are being performed as stated, references to methods are accurate, and the QA and SOP documents are 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 an SOP to document how new functions or policies will be implemented. Revisions to the SOPs, based on the Findings, Comments and Recommendations within this report must be submitted to this office by November 30, 2023. The laboratory is reminded that SOPs are required to be reviewed at least every two years and 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., Quality Control (QC) frequency, acceptance criteria, etc.). Evaluate all SOPs for the proper use of the word “should”. Page 2 #5045 Town of Pilot Mountain WWTP Contracted analyses are performed by Meritech Inc. (Certification #165). 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: Several instances were noted where analytical results were documented solely on the laboratory’s eDMR worksheet, rather than on both the laboratory benchsheet and the eDMR worksheet. It is recommended that the laboratory review their procedures for where data is first recorded in order to facilitate data retrieval and review, and reduce the possibility of transcription errors. The laboratory is reminded that as part of the record retention requirements, the laboratory must retain the first place data is recorded for 5 years, even if that first place is not the laboratory benchsheet. Additionally, all documentation requirements apply to the first place compliance data is recorded, whether that is the laboratory benchsheet, the eDMR worksheet or somewhere else. Recommendation: The laboratory is documenting the correction factor of 0°C for the compliance Temperature Measuring Device (TMD) on the benchsheet each day that analyses are performed. Temperature corrections are not applicable to compliance temperature-measuring devices. It is recommended that the laboratory remove this from the benchsheet to avoid confusion about whether a correction factor is being applied. A. Finding: Error corrections are not properly performed. Requirement: All documentation errors shall 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; instead the correction shall be written adjacent to the error. The correction shall be initialed by the responsible individual and the date of change documented. Ref: 15A NCAC 02H .0805 (g) (1). Comment: Multiple instances were noted where changes were written over the original entry. The date of correction and the initials of the responsible individual were not recorded. B. Finding: The laboratory is not documenting the Date Opened (in use) for purchased reagents and standards. Requirement: 15A NCAC 02H .0805 (a) (7) (K) and (g) (7) requires laboratories to have a documented system of traceability for the purchase, preparation, and use of all chemicals, reagents, standards, and consumables. That system must include documentation of the following information: 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 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: NC WW/GW LCB Traceability Documentation Requirements for Chemicals, Reagents, Standards and Consumables Policy. Page 3 #5045 Town of Pilot Mountain WWTP C. Finding: Chemical containers are not consistently dated when received and when opened. Requirement: Chemical containers shall be dated when received and when opened. Ref: 15A NCAC 02H .0805 (g) (7). D. Finding: The laboratory benchsheet is lacking required documentation: the sample collector and the sample identification. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the sample collector and the sample identification. Each item shall be recorded each time samples are analyzed. Analyses shall conform to methodologies found in Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (2) (D) and (I). Comment: A blanket statement that the sample collector and the analyst are the same person would meet the requirement for documenting the sample collector. E. Finding: The laboratory does not document QC assessments. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the quality control assessments. Ref: 15A NCAC 02H .0805 (g) (2) (O). Comment: The gel-type standard used as the daily QC check for TRC has an assigned value of 202 µg/L. The acceptance criterion is ± 10% of the assigned value, but this is missing from the benchsheet. If the criterion is listed as a concentration range, a checkbox on the benchsheet may be used to acknowledge that the acceptance criterion has been met. Otherwise, the percent recovery criterion and the calculation showing the computed percent recovery must be documented. No data were observed where the QC results were outside the acceptance criteria. Comment: The acceptance criterion for the 7.0 S.U. buffer used as the daily QC check in pH analyses is ± 0.1 S.U., but this is missing from the benchsheet. A checkbox on the benchsheet indicating that the acceptance criterion has been met would satisfy the requirement. No data were observed where the QC results were outside the acceptance criteria. F. Finding: The laboratory is not documenting the temperature used to calibrate the Dissolved Oxygen (DO) meter. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Calibration variables (temperature, elevation or barometric pressure [in mmHg], and salinity). Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen (DO). G. Finding: Only one time for sample collection and analysis is documented for DO without noting samples are analyzed in situ. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Page 4 #5045 Town of Pilot Mountain WWTP Requirement: Date and time of sample analysis must be documented to verify the 15-minute holding time is being met. Alternatively, one time may be documented for collection and analysis with the notation that samples are measured in situ or immediately at the sampling site. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Dissolved Oxygen. Comment: The laboratory uses the DO meter for compliance temperature monitoring. The Temperature section of the benchsheet notes that collection and analysis time are the same, but this statement is missing from the DO section of the benchsheet. H. Finding: The laboratory benchsheet for TRC is lacking required documentation: Date of most recent TRC calibration curve verification. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: The following must be documented in indelible ink whenever sample analysis is performed: Date of most recent calibration curve generation or calibration curve verification. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Proficiency Testing I. Finding: The laboratory is not documenting PT Sample analyses. Requirement: All PT Sample analyses must be recorded in the same daily analysis records (e.g., benchsheets) as for any Compliance Sample. This serves as the permanent laboratory record. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. 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 02H .0805 (a) (7) (E) and (g) (1)] all of the raw data, including benchsheets, instrument printouts and calibration data, for all PT Sample analyses and the associated QC analyses conducted by all Parameter Methods. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 4.0. Comment: The laboratory’s current practice is to record the instrument reading directly into the PT Vendor’s electronic submission form. No record of the analysis is maintained. J. Finding: The laboratory is not documenting the preparation of PT Samples. Requirement: PT Samples received as ampules are diluted according to the Accredited PT Sample Provider’s instructions. It is important to remember to document the preparation of PT Samples in a traceable log or other traceable format. The diluted PT Sample then becomes a routine Compliance Sample and is added to a routine sample batch for analysis. No documentation is needed for whole volume PT Samples which require no preparation, however the instructions must be maintained. Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.6. Comment: Dating and initialing the instruction sheet for each prepared PT Sample would satisfy the documentation requirement. K. Finding: PT Samples are not being distributed among all analysts from year to year. Page 5 #5045 Town of Pilot Mountain WWTP 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, January 1, 2023, Revision 6, Section 3.6. Quality Assurance/Quality Control (QA/QC) L. Finding: SOPs have not been updated for all of the methods included on the laboratory’s Certified Parameters Listing (CPL). Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. A copy of each analytical method or Approved Procedure and Standard Operating Procedure shall be available to each analyst and available for review upon request by the State Laboratory. Standard Operating Procedure documentation shall state the effective date of the document and shall be reviewed every two years and updated if changes in procedures are made. Each laboratory shall have a formal process to track and document review dates and any revisions made in all Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. Ref: 15A NCAC 02H .0805 (g) (4). Comment: The laboratory SOP for Temperature has an effective date of March 26, 2011. Staff were informed of the requirement for reviewing SOPs at least every two years and to document the review date in the revision history even when no changes are made. Chlorine, Total Residual – Standard Methods, 4500 Cl G-2011 (Aqueous) M. Finding: The laboratory is not analyzing a Method Blank when using laboratory-prepared standards. Requirement: Laboratory procedures shall comply with Subparagraph (a)(1) of this Rule. Ref: 15A NCAC 02H .0805 (g) (4). Requirement: Method Blanks would be required when using laboratory-prepared standards [including Proficiency Testing (PT) Samples] and anytime sample dilutions are performed. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Requirement: The Method Blank is deionized or distilled water from the same source used to prepare the calibration verification standards or the PT Sample, and is analyzed like a sample (i.e., with DPD/buffer added). The concentration of the Method Blank must not exceed 50% of the reporting limit (i.e., the lowest calibration verification standard concentration) or corrective action must be taken. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). N. Finding: The laboratory is performing analyses using the incorrect meter program. Requirement: Calibration curve verification checks must be performed with the calibration curve and/or program used for sample analysis. All compliance monitoring and PT Samples must be analyzed on the prepared or verified calibration curve and/or program. Ref: NC WW/GW LCB Approved Procedure for the Analysis of Total Residual Chlorine (DPD Colorimetric by SM 4500 Cl G-2011). Page 6 #5045 Town of Pilot Mountain WWTP Comment: The laboratory is analyzing samples using program #89, which is for high range samples with values between .09 and 5.0 mg/L. The annual calibration curve verification is performed using program #86, which is for low level samples with values between 2 and 500 µg/L. The laboratory’s reporting limit of 28 µg/L necessitates the use of program #86. Comment: The laboratory benchsheet documents the true values of the gel-type standards in units of mg/L. When the laboratory begins analyzing samples on the low-level TRC program, the benchsheet must be updated with the assigned True Value for Standard #1 (i.e., 202 µg/L in the most recent assignment). The other standards are above the range of the calibration curve and will not be used. Temperature – Standard Methods, 2550 B-2010 (Aqueous) Comment: Temperature is being reported to 0.1°C on the DMR. Recommendation: Unless greater precision is required by the permit or data receiving agency, it is recommended that all temperatures reported for compliance monitoring, be reported in whole numbers as recommended by the Division of Water Resource’s Precision in Discharge Monitoring Reports document. IV. PAPER TRAIL INVESTIGATION: The paper trail consisted of comparing original records (e.g., laboratory benchsheets, logbooks, etc.) and contract laboratory reports to DMRs submitted to the North Carolina Division of Water Resources. Data were reviewed for Town of Pilot Mountain WWTP (NPDES permit # NC0026646) for March, April, July, August and December 2022. The following errors were noted: Date Parameter Location Value on Benchsheet Value on DMR 03/10/2022 Temperature Effluent 10.0°C 10.2°C 07/12/2022 pH Effluent 6.6 S.U. 6.7 S.U. To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether amended DMRs 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 Recommendations 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, implementation dates and steps taken to prevent recurrence for each corrective action. Report prepared by: Michael Cumbus Date: April 19, 2023 Report reviewed by: Tonja Springer Date: April 20, 2023 Certificate Number:5045 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Town of Pilot Mountain WWTP Address:701 Lynchburg Road Pilot Mountain, NC 27041- North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:9/16/2021 The above named laboratory, having duly met the requirements of 15A NCAC 2H.0800, is hereby certified for the measurement of the parameters listed below. CERTIFIED PARAMETERS INORGANIC CHLORINE, TOTAL RESIDUAL SM 4500 Cl G-2011 (Aqueous) DISSOLVED OXYGEN SM 4500 O H-2016 (Aqueous) pH SM 4500 H+B-2011 (Aqueous) TEMPERATURE SM 2550 B-2010 (Aqueous) This certification requires maintance of an acceptable quality assurance program, use of approved methodology, and satisfactory performance on evaluation samples. Laboratories are subject to civil penalties and/or decertification for infractions as set forth in 15A NCAC 2H.0807.