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HomeMy WebLinkAbout#5397_2023_0622_TS_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 July 21, 2023 5397 Mr. Paul Phillips Person County Board of Education Person County B.O.E 304 South Morgan St. Room #25 Roxboro, NC 27573- Subject: North Carolina Wastewater/Groundwater Laboratory Certification Branch (NC WW/GW LCB) Maintenance Inspection Dear Mr. Phillips: Enclosed is a report for the inspection performed on June 22, 2023 by Tonja Springer. 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, Tonja Springer, #5397 On-Site Inspection Report LABORATORY NAME: Person County Board of Education NPDES PERMIT #: NC0036536 WATER QUALITY PERMIT #: WQ0004750 WQ0005150 ADDRESS: 420 Leasburg Road Roxboro, NC 27573 CERTIFICATE #: 5397 DATE OF INSPECTION: June 22, 2023 TYPE OF INSPECTION: Field Municipal Maintenance AUDITOR(S): Tonja Springer LOCAL PERSON(S) CONTACTED: Paul Phillips 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. The analyst was 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. The laboratory did not have Quality Assurance (QA) and/or Standard Operating Procedure (SOP) document(s) in place for all currently certified parameters. These documents must be submitted for review as specified in Finding A. 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”. Contracted analyses are performed by Pace Analytical Services LLC - Eden NC (Certification # 633). Approved Procedure documents for the analysis of the facility’s currently certified Field Parameters were provided at the time of the inspection. Page 2 #5397 Person County Board of Education III. FINDINGS, REQUIREMENTS, COMMENTS AND RECOMMENDATIONS: Documentation A. Finding: SOPs have not been developed for 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 must have QC/SOP documents for pH and Temperature by October 31, 2023 and November 30, 2023, respectively. These must be submitted for review upon completion. SOP templates have been developed and are available for download on the NC WW/GW LCB website. B. Finding: The laboratory is lacking a documented training program. Requirement: Each laboratory shall develop and implement a documented training program that includes the following: that staff have the education, training, experience, or demonstrated skills needed to generate quality control results within method-specified limits and that meet the requirements of these Rules; that staff have read the laboratory quality assurance manual or applicable Standard Operating Procedures; that staff have obtained acceptable results on Proficiency Testing Samples pursuant to Rule .0803(1) of this Section or other demonstrations of proficiency (e.g., side-by-side comparison with a trained analyst, acceptable results on a single- blind performance evaluation sample, an initial demonstration of capability study prescribed by the reference method). Ref: 15A NCAC 02H .0805 (g) (5). C. Finding: Chemical containers are not 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 benchsheets are lacking required documentation: the method or Standard Operation Procedure reference, the instrument identification, the sample collector, the signature or initials of the analyst, the date and time of sample collection, the date of sample analyses, the time of sample analyses (when required to document a required holding time or when time-critical steps are imposed by the method, a federal regulation, or this Rule), sample identification and the proper units of measure. Requirement: All laboratories shall use printable laboratory benchsheets. Certified Data shall be traceable to the associated sample analyses and shall consist of: the method or Standard Operating Procedure, the instrument identification, the sample collector, the signature or initials of the analyst, the date and time of sample collection, the date of sample analyses, the time of sample analyses (when required to document a required holding time or when time-critical steps are imposed by the method, a federal regulation, or this Rule), sample identification and the proper units of measure.. 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) (A), (C), (D), (E), (F), (G), (H), (I), and (L). Page 3 #5397 Person County Board of Education Comment: The memo notepad that Temperature is documented on does not include the method or Standard Operation Procedure reference, the laboratory identification, the instrument identification, the sample collector, the signature or initials of the analyst, the date of sample analyses, the time of sample analyses (when required to document a required holding time or when time-critical steps are imposed by the method, a federal regulation, or this Rule), sample identification and the proper units of measure. The sample analysis time and sample result are documented but are not labeled so they are not identifiable as such. The method reference, sample identification, instrument identification and parameter analyzed can be documented on the front inside cover of the memo notepad. Comment: The “Woodland Field Test Log” where pH and DO analyses are documented does not include the method reference and instrument identification. Units of measure are not documented in the DO “Reading” column. The units for Barometric pressure (i.e., mm/Hg) are not documented on the LDO verification log. E. Finding: The laboratory is not documenting traceability information for pH buffers. 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. 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. Proficiency Testing F. 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. G. Finding: The laboratory does not have a documented plan for PT procedures. Requirement: Each laboratory shall develop documentation outlining the analytical quality control practices used for the Parameter Methods included in its Certification, including Standard Operating Procedures for each certified Parameter Method. Quality assurance, quality control, and Standard Operating Procedure documentation shall indicate the effective date of the document and 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 quality assurance, quality control, and Standard Operating Procedure documents. Supporting Records shall be maintained as evidence that these practices are implemented. The quality assurance, quality control, and Standard Operating Procedure documents shall be available for inspection by the State Laboratory. Ref: 15A NCAC 02H .0805 (a) (7). Requirement: Laboratories must have a documented plan [this is usually detailed in the laboratory’s Quality Assurance Manual or may be a separate Standard Operating Procedure Page 4 #5397 Person County Board of Education (SOP)] 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 PT Samples and any inter-laboratory organized studies, as applicable. The plan must also address the laboratory’s process for submission of PT Sample results and related Corrective Action Reports (CARs). Ref: Proficiency Testing Requirements, January 1, 2023, Revision 6, Section 3.0. Comment: The laboratory’s PT procedure may be outlined in each of the applicable parameter SOPs. The NC WW/GW LCB SOP Templates include a section for the PT procedure. Reporting H. Finding: The laboratory is not correctly transcribing analytical results from the contract laboratory report to the Discharge Monitoring Report (DMR). Requirement: Daily analyses must be performed using EPA-approved methods that are capable of producing results less than or equal to the corresponding permit limits, where such methods exist. In the case of ‘non-detect’ values, permittees (or their laboratories) are expected to report daily values to the Practical Quantitation Level (PQL) for each parameter (or “<[PQL] for values less than the PQL). Ref: Precision in Discharge Monitoring Reports, Section 3.1. Comment: Values below the detection limit were consistently reported as “0” instead of the listed detection limit preceded by the “less than” (<) symbol. I. Finding: Data qualifiers from the contract laboratory reports are not being transferred to the DMR. Requirement: Each certified Field Laboratory shall be in accordance with Paragraph (e) of this Rule. Ref: 15A NCAC 02H .0805 (g) (17). Requirement: Reported data associated with quality control failures, improper sample collection, holding time exceedances, or improper preservation shall be qualified as such. Ref: 15A NCAC 02H .0805 (e) (5). Dissolved Oxygen – Standard Methods, 4500 O G-2016 (Aqueous) J. Finding: The laboratory is producing Uncertified Data without reporting it as such. Requirement: “Uncertified Data" means any analytical result, including the Supporting Records, obtained using a method or procedure that is not acceptable to the State Laboratory pursuant to these Rules; analytical results produced by a laboratory for an analysis not within the scope of the rules of this Section; or analytical results produced by a laboratory without proper Certification. Ref: 15A NCAC 02H .0803 (35). Requirement: All Uncertified Data shall be documented as such on the benchsheet and on the final report. Ref: 15A NCAC 02H .0805 (e) (3). Comment: At the time of the inspection, the laboratory was not certified for the parameter method in use. They were certified for SM 4500 O G-2016, which is a membrane sensor technology. In practice, they were using luminescence sensor technology, which is a separate parameter method (i.e., SM 4500 O H-2016). An Amendment Application was completed at the time of the inspection. An SOP will need to be submitted in order for the laboratory to get certified for the method. Until certification is obtained, all DO results are to be reported as uncertified data. pH - Standard Methods, 4500 H+ B-2011 (Aqueous) Recommendation: It is recommended to remove “After” from the Calibration header. K. Finding: Values were reported that exceed the method specified accuracy of 0.1 units. Page 5 #5397 Person County Board of Education Requirement: By careful use of a laboratory pH meter with good electrodes, a precision of ±0.02 unit and an accuracy of ±0.05 unit can be achieved. However, ± 0.1 pH unit represents the limit of accuracy under normal conditions, especially for measurement of water and poorly buffered solutions. For this reason, report pH values to the nearest 0.1 pH unit. Ref: Standard Methods, 4500 H+ B-2011. (6). Comment: Per PT Vendor instructions, the PT Sample results should be reported to two decimal places, which is an exception to the requirement for Compliance Samples. L. Finding: The laboratory benchsheet does not clearly label which buffer is used to check the meter calibration. 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: True value for the check standard buffer. Ref: NC WW/GW LCB Approved Procedure for the Analysis of pH. M. 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 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 criterion. 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. Total Residual Chlorine – Standard Methods, 4500 Cl G-2011 (Aqueous) N. Finding: The laboratory is producing Uncertified Data without reporting it as such. Requirement: “Uncertified Data" means any analytical result, including the Supporting Records, obtained using a method or procedure that is not acceptable to the State Laboratory pursuant to these Rules; analytical results produced by a laboratory for an analysis not within the scope of the rules of this Section; or analytical results produced by a laboratory without proper Certification. Ref: 15A NCAC 02H .0803 (35). Requirement: All Uncertified Data shall be documented as such on the benchsheet and on the final report. Ref: 15A NCAC 02H .0805 (e) (3). Comment: At the time of the inspection, the laboratory was not certified for Total Residual Chlorine (TRC). Until certification is obtained, all TRC results are to be reported as uncertified data. Page 6 #5397 Person County Board of Education 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 Person County Board of Education (NPDES permit # NC0036536) for February, March and April 2023. See Findings H and I. To avoid questions of legality, it is recommended that you contact the appropriate Regional Office for guidance as to whether an amended DMR(s) 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(s) 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: Tonja Springer Date: July 11, 2023 Report reviewed by: Jill Puff Date: July 12, 2023 Certificate Number:5397 Effective Date:1/1/2023 Expiration Date:12/31/2023 Lab Name:Person County Board of Education Address:Person County B.O.E 304 South Morgan St. Room #25 Roxboro, NC 27573 North Carolina Wastewater/Groundwater Laboratory Certification Certified Parameters Listing Date of Last Amendment:10/11/2021 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 DISSOLVED OXYGEN SM 4500 O G-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.