Dental Amalgam One Time Compliance Report

One-Time Compliance Report for Dental Dischargers (Required By 40 CFR-Part 441)

BE ADVISED, you are required to implement Best Management Practices as follows:

Waste amalgam including, but not limited to, dental amalgam from chair-side traps, screens, vacuum pump filters, dental tools, cuspidors, or collection devices, must not be discharged to the sewer.
Dental unit water lines, chair-side traps, and vacuum lines that discharge amalgam process wastewater to the sewer must not be cleaned with oxidizing or acidic cleaners, including but not limited to bleach, chlorine, iodine and peroxide that have a pH lower than 6 or greater than 8 S.U.

BE ADVISED, you are required to keep the following records, and make them available for inspection:

While in operation or until ownership is transferred, a copy of this One-Time Compliance Report.
The date and person conducting the inspection and the results of each inspection of the amalgam separators(s) or equivalent device(s), and a summary of follow-up action, if needed.
Date of retaining or equivalent container replacement.
Dates that collected amalgam was picked up or shipped for proper disposal in accordance with 40 CFR 261.5(g)(3), and the name of the permitted or licensed treatment, storage or disposal facility.
Documentation of any repair or replacement of an amalgam separator or equivalent device, including the date, person making the repair or replacement, and a description of the work performed (including make and model).

Facility Name*

Facility Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is there a different mailing address?*

Yes No

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Facility Phone*

Owner's Name*

First Name

Last Name

Owner's Title*

Owner's Email*

Owner's Phone*

Is there a different operator or contact person than the owner?*

Yes No

Operator or Contact Person Information

This is information for the*

Operator Contact person

Operator / Contact Name*

First Name

Last Name

Operator / Contact Phone*

Operator / Contact Email*

Exemption Information

Are you seeking an exemption?*

Yes No

Check all that apply for the criteria for an exemption*

Exclusively practice one or more: oral pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics, periodontics, or prosthodontics. Only operate a mobile dentistry unit. Do not discharge any amalgam process wastewater (APWW) to the sewer. The office is not connected to the sewer system, or all APWW is collected and transferred to a Centralized Waste Treatment Facility. Do not place or remove amalgam except in limited emergency, unanticipated or unplanned circumstances.

Is all APWW collected and transferred to a Centralized Waste Treatment Facility*

Yes No

Centralized Waste Treatment Facility Name*

Information Required if Not Claiming an Exemption

Total number of chairs*

Number of chairs where dental amalgam may be generated*

Which maintenance practice applies*

Use a third-party maintenance provider We perform our own maintenance practices to ensure proper operation of device

Name of Third-Party Maintenance Provider*

Describe maintenance practices to ensure proper operation of device*

Does your facility use amalgam separator devices or amalgam removal devices*

We only use amalgam separator devices We only use amalgam removal devices We use both amalgam separator and removal devices We

How many amalgam separator devices does the faciltiy have?*

1 2 3 or more

How many amalgam removal devices does the faciltiy have*

1 2 3 or more

Amalgam Separator Device and/or Removal Device Information (3 or more devices)

If you have three or more amalgam separator or removal devices please upload a document, spreadsheet or PDF with the following information for each device:

Separator and/or Removal device information:

Type of device
Make
Model
Year installed
Documentation that the device meets Part 441.30(2) (i), (ii) and (iii) (1 separate upload for documentation for all devices)
Verify the following statements for all devices:
- The manufacturer’s operation manual is onsite and provides instruction for use including the frequency for inspection and collection container replacement such that the unit is replaced once it has reached the maximum filling level at which the device can perform to the specified efficiency.
- The device is being inspected in accordance with the operation manual, including confirmation that amalgam process wastewater is flowing through the amalgam separating portion of the device.
- In the event that the device is not functioning properly, it will be repaired or replaced with a unit that meets the requirements of paragraphs 441.30(a) (2) (i) through (iii) as soon as possible, but no later than 10 business days after the malfunction is discovered.
- The amalgam retaining unit(s) will be replaced as specified in the manufacturer’s operating manual, or when the collecting container has reached the maximum filling level, as specified in the operation manual, at which the device can perform to the specified efficiency, whichever comes first.

Upload amalgam separator and/or removal device information for three or more devices*

No File Chosen

File uploads may not work on some mobile devices.

All documentation for all devices that the devices meets Part 441.30(2) (i), (ii) and (iii)*

No File Chosen

File uploads may not work on some mobile devices.

Amalgam Separator Information - #1

Type of amalgam separator - #1*

Amalgam separator make - #1*

Amalgam separator model - #1*

Year amalgam separator installed - #1*

Amalgam Separator Information - #2

Type of amalgam separator - #2*

Amalgam separator make - #2*

Amalgam separator model - #2*

Year amalgam separator installed - #2*

Amalgam Removal Device Information - #1

Type of amalgam removal device- #1*

Amalgam removal device make - #1*

Amalgam removal devicemodel - #1*

Year amalgam revoval device installed - #1*

Documentation that the device #1 meets Part 441.30(2) (i), (ii) and (iii).*

No File Chosen

File uploads may not work on some mobile devices.

The manufacturer’s operation manual is onsite and provides instruction for use including the frequency for inspection and collection container replacement such that the unit is replaced once it has reached the maximum filling level at which the device can perform to the specified efficiency. - #1*

I certify this is true

The device is being inspected in accordance with the operation manual, including confirmation that amalgam process wastewater is flowing through the amalgam separating portion of the device. - #1*

I certify this is true

In the event that the device is not functioning properly, it will be repaired or replaced with a unit that meets the requirements of paragraphs 441.30(a) (2) (i) through (iii) as soon as possible, but no later than 10 business days after the malfunction is discovered. - #1*

I certify this is true

The amalgam retaining unit(s) will be replaced as specified in the manufacturer’s operating manual, or when the collecting container has reached the maximum filling level, as specified in the operation manual, at which the device can perform to the specified efficiency, whichever comes first. - #1*

I certify this is true

Amalgam Removal Device Information - #2

Type of amalgam removal device- #2*

Amalgam removal device make - #2*

Amalgam removal devicemodel - #2*

Year amalgam revoval device installed - #2*

Documentation that the device #2 meets Part 441.30(2) (i), (ii) and (iii).*

No File Chosen

File uploads may not work on some mobile devices.

The manufacturer’s operation manual is onsite and provides instruction for use including the frequency for inspection and collection container replacement such that the unit is replaced once it has reached the maximum filling level at which the device can perform to the specified efficiency. - #2*

I certify this is true

The device is being inspected in accordance with the operation manual, including confirmation that amalgam process wastewater is flowing through the amalgam separating portion of the device. - #2*

I certify this is true

In the event that the device is not functioning properly, it will be repaired or replaced with a unit that meets the requirements of paragraphs 441.30(a) (2) (i) through (iii) as soon as possible, but no later than 10 business days after the malfunction is discovered. - #2*

I certify this is true

The amalgam retaining unit(s) will be replaced as specified in the manufacturer’s operating manual, or when the collecting container has reached the maximum filling level, as specified in the operation manual, at which the device can perform to the specified efficiency, whichever comes first. - #2*

I certify this is true

Certification Statement

The following certification must be affirmed by either a responsible corporate officer, a general partner, proprietor or a duly authorized representative in accordance with 40 CFR 403.12(1).

I hereby certify that the above dentistry is exempt based on one of the above criteria for exemption*

I agree

I hereby certify that the amalgam separator(s) or equivalent device(s) listed above and on the attachment is designed and will be operated and maintained to meet the requirements specified in §441.30 or §441.40, and that Best Management Practices in §441.30 or §441.40 have been implemented and will be followed.*

I agree

Name of the person affirming the certification statement*

First Name

Last Name

Title of the person affirming the certification statement*

Date/Time*