Audit Report

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procedures and expectations are described in OP-13. OCWA’s QEMS and QEMS Policy are communicated to the Public through OCWA’s website (refer to Element 2). The QEMS Policy is also to be posted at the Lambton Area Water Supply System in the Administration Area.

DWQMS Reference: 13 Essential Supplies and Services

Client Reference: LAWSS Operational Plan OP-13 (rev. 0, 26-Feb-2018)

Details: OP-13 documents the requirements for procuring essential supplies and services for the Lambton Area Water Supply System which are contained in the Facility Emergency Plan, Emergency Contact/Essential Supplies and Services List. The list is reviewed and updated at least once every calendar year by the QEMS Representative. As part of the Corporate procurement process, potential suppliers/service providers are informed of relevant aspects of OCWA’s QEMS through the tendering process and through specific terms and conditions set out in all agreements and purchase orders. New suppliers and service providers are to be sent a letter identifying their status as an essential supplier/service provider and is to include a copy of the QEMS Policy; letters are to be sent every 5 years. Contractors are selected based on their qualifications and ability to meet the facility’s needs and may be requested or required to participate in additional relevant training/orientation activities to ensure conformance with facility procedures and to become familiar with OCWA workplaces. All third-party drinking water testing services are provided by accredited and licensed laboratories and internal/external calibration procedures are outlined in OP-13.

DWQMS Reference: 14 Review and Provision of Infrastructure

Client Reference: LAWSS Operational Plan OP-14 (rev. 1, 14-Dec-2018)

Details: OP-14 outlines the requirements for the review and provision of infrastructure that is consistent with the DWQMS standard. The Operations Manager, with Operations personnel, is responsible for conducting an annual review of the subject system’s infrastructure to assess its adequacy for the operation and maintenance of the system. Items reviewed may include maintenance activities, age of infrastructure and available technologies, as well as the outcomes of the risk assessment. As an output, a summary of capital and major maintenance recommendations review is a rolling 6 Year Major Maintenance Plan and an OCWA Major Maintenance and Capital Project List that is used to assist the Owner and OCWA with planning infrastructure needs for the short and long-term. This report is submitted, at least once every calendar year by Operations Management, to the Owner for review. The final approved LAWSS 10 Year Capital Plan forms the long term forecast for any major infrastructure maintenance, rehabilitation and renewal activities as per OP-15.

DWQMS Reference: 15 Infrastructure Maintenance, Rehabilitation and Renewal

Client Reference: LAWSS Operational Plan OP-15 (rev. 0, 26-Feb-2018), 2018 LAWSS 6-Year Major Maintenance Plan (2016-2022)

Details: The OP documents an infrastructure maintenance, rehabilitation, and renewal procedure that meets the requirements of the DWQMS. OCWA, under contract with the Owner, maintains a computerized Work Management System (WMS) to manage maintenance, rehabilitation and renewal of infrastructure for which it is operationally responsible. The major components of the WMS consist of planned maintenance, unplanned maintenance, rehabilitation, renewal and program monitoring and reporting. Operations Management ensures that the inventory of equipment in WMS is maintained and ensures that appropriate maintenance plans are in place. OCWA’s infrastructure maintenance, rehabilitation and renewal program is initially communicated to the Owner through the operating agreement. OCWA’s program is communicated to the Owner on a monthly basis through the reports titled ‘Monthly Operations Report’ and the ‘Work Order Summary Report’ and through the results of the Management Review. The 6-Year Major

Audit Report

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Maintenance Plan provides a long-term (rolling 6-year from 2016-2022) list of major maintenance recommendations including 2016/2017 completed projects.

DWQMS Reference: 16 Sampling, Testing and Monitoring

Client Reference: LAWSS Operational Plan OP-16 (rev. 1, 19-Jul-2018), 2019 Sample Schedules (rev.0, 5-Nov-2018) for Water Treatment Plant, Warwick-Watford, Point Edward, St. Clair, Plympton-Wyoming, Lambton Shores, and Sarnia

Details: OP-16 documents a sampling, testing, and monitoring procedure that meets the requirements of the DWQMS. Sampling, testing, and monitoring is conducted in accordance with regulatory requirements. Sampling requirements for the facility are defined in the facility’s sampling schedule which is available to operations personnel, at the location(s) noted in OP-05, is maintained by the Operations and Compliance Lead and is updated as required. Test results from continuous monitoring equipment are captured by the SCADA system and are reviewed by a certified Operator in accordance with regulatory requirements. Adverse water quality incidents are responded to and reported as per SOP for Reporting Adverse Water Quality. In-house process control activities are conducted twice per shift (4 times total per day) by the certified Operator(s) on duty and in-house samples are analysed following approved laboratory procedures. There are no relevant upstream sampling, testing and monitoring activities that take place for this facility/system. Sampling, testing and monitoring results are readily accessible to the Owner on a monthly basis via the Monthly PDM Report available on the shared and on the Cloud. At a minimum, Owners are provided with an annual summary of sampling, testing and monitoring results through the SDWA O. Reg. 170/03 Section 11 Annual Report, the Schedule 22 Municipal Summary Report and through the Management Review process outlined in OP-20 Management Review.

DWQMS Reference: 17 Measurement and Recording Equipment Calibration and Maintenance

Client Reference: LAWSS Operational Plan OP-17 (rev. 0, 27-Feb-2018)

Details: OP-17 documents a measurement and recording equipment calibration and maintenance procedure that meets the requirements of the DWQMS. The Senior Operations Manager together with the Utility Plant Instrumentation Tech establishes and maintains a list of measurement and recording devices and associated calibration and/or verification schedules using the automated Work Management System (WMS). All measurement and recording equipment calibration and maintenance activities must be performed by appropriately trained and qualified personnel or by a qualified third-party calibration service provider (refer to OP-13 Essential Supplies and Services). Any measurement device which does not meet its specified performance requirements during calibration and/or verification must be removed from service and the failure is reported to the Senior Operations Manager as soon as possible so that immediate measures can be taken to ensure that drinking water quality has not been compromised by the malfunctioning device. Any actions taken as a result of the failure are recorded in the facility logbook.

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DWQMS Reference: 18 Emergency Management

Client Reference: LAWSS Operational Plan OP-18 (rev. 0, 27-Feb-2018), CP-01 Spill Response (rev.8), -02 Critical Injury (rev.7), -04 Loss of Service (rev.6), -05 Unsafe Water (rev.7), -06 Security Breach (rev.4), and -07 SCADA/PLC Failure (rev.4, all 14-Dec-2018), CP-03 Critical Shortage of Staff (rev.3, 23-Jan-2014)

Details: OP-18 documents a list of potential emergency situations or service interruptions (e.g. unsafe water, loss of service, SCADA/PLC failure, etc.). Facility Emergency Plan (FEP) is the Corporate standard for emergency management at OCWA-operated facilities. The FEP supports the facility-level response to and recovery from Level 1, 2 and 3 events related to water and wastewater operations and Operations Management is responsible for establishing a site-specific FEP that meets the Corporate standard for this drinking water system. The processes for responding to and recovering from each potential emergency situation/service disruption are documented within a site-specific contingency plan (CP). The CPs and related standard operating procedures (SOPs) are contained within the FEP. At least one CP must be tested each calendar year and each CP must be reviewed at least once in a five-calendar year period. The reviews and tests are recorded on the FEP-01 Contingency Plan Review/Test Summary Form and in WMS as appropriate; CP-04 was tested 11-Dec-2018 (and 2018-06-07) and also documented on Training Form (SCADA updates were required) with additional testing 6-Jun-2018 for CP-02 and -06 (no actions resulted) as well as -07, -05, -03 and -01 (requiring update of SOPs).

DWQMS Reference: 19 Internal Audits

Client Reference: LAWSS Operational Plan OP-19 (rev. 0, 27-Feb-2018), Internal QEMS Audit Report (conducted 17-Jul with report issued 18-Jul-2018), Internal QEMS Audit Protocol (rev.2, 2018-01-12)

Details: OP-19 documents an Internal Audit procedure that meets the requirements of the DWQMS. QEMS representative is responsible for maintaining the internal audit schedule, which ensures that all elements of the DWQMS are audited at least once every calendar year, last completed 17-Jul-2018 as per the Internal Audit Report and according to DWQMS v2 as per the QEMS Audit Protocol with 11 OFIs identified. The Lead Auditor reviews the audit findings and conclusions with the QEMS Representative and Top Management. The QEMS Representative distributes the audit results to Top Management and others as appropriate and ensures that results of internal QEMS audits are included as inputs to the Management Review as per OP-20 Management Review. Corrective actions are initiated when non-conformances are identified through internal QEMS audits and are documented and monitored as per OP-21 Continual Improvement.

DWQMS Reference: 20 Management Review

Client Reference: LAWSS Operational Plan OP-20 (rev. 1, 14-Dec-2018), LAWSS Board Meeting Minutes (28-Sep-2018), Management Review Minutes (rev. 1, 29-Aug-2018), LAWSS 2018 Management Review Tracking Spreadsheet

Details: OP-20 documents a Management Review procedure that meets the requirements of the DWQMS. At a minimum, the QEMS Representative, at least one member of Top Management and the LAWSS Representative must attend the Management Review meeting (most recently completed on 29-Aug-2018 and signed off by Owner and OA representatives 30-Aug-2018 with all actions shown as complete on the 2018 Management Review Tracking Spreadsheet). The Management Review participants review the data presented and make recommendations and/or initiate action to address identified deficiencies as appropriate as per OP-21. Management review actions may be proposed by any of the participants and QEMS Representative ensures that minutes of and actions resulting from the Management Review meeting are prepared and

Audit Report

Doc ID: 8298 / Issue Date: Mar. 2018 © SAI Global Pty Limited Copyright 2018 - ABN 67 050 611 642 Page 12 of 12

distributed to the appropriate OCWA Top Management, personnel and the LAWSS Representative. The results of the Management Review were communicated to the Owner via the LAWSS Board Meeting held on 28-Sep-2018.

DWQMS Reference: 21 Continual Improvement

Client Reference: LAWSS Operational Plan OP-21 (rev. 0, 27-Feb-2018), 2018 Internal Audit OFI/NC Spreadsheet (rev.0, 18-Jul-18), LAWSS 2018 Management Review Tracking Spreadsheet

Details: The OA continues to continually improve the QEMS through the tracking and implementation of internal/external audit findings (including detailing OFIs that have not been implemented as per the 2018 Internal Audit OFI/NC Spreadsheet) and Management Review Action items via the Tracking Spreadsheet. The QEMS Representative (in consultation with Operations Management and/or the SPC Manager) investigates the need for a corrective action to eliminate the root cause(s) so as to prevent the non-conformance from recurring and determines the corrective action needed based on this consultation. The Operations Management (or designate) assigns responsibility and a target date for resolution. The implementation of preventive actions are tracked by the QEMS Representative using tracking spreadsheets from external/internal audits and the management review. If there is evidence that the action taken was not effective, the Operations Management (or designate) may consider further preventive actions and assigns resources as appropriate. The QEMS Representative and/or Operations Management, in consultation with the SPC Manager, will review and consider applicable internal and/or external BMPs identified by internal and/or external sources as part of the Management Review (refer to element 20, no BMPs were identified during the 2018 Management Review) and in the corrective and preventive action processes described above and all applicable BMPs must be reviewed and considered once every 36 months.

Details regarding the personnel interviewed and objective evidence reviewed are maintained on file at SAI Global.

This report was prepared by:

Sandra Tavares, B.Sc., M.Sc., EP(EMSLA), EP-Sustainability SAI Global Management Systems Auditor

The audit report is distributed as follows: • SAI Global

• Operating Authority

• Owner

• MECP

Notes

Copies of this report distributed outside the organization must include all pages.