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2. This form contains the minimum information dental facilities must submit in a one-time compliance report as required by the EPA in the Effluent Limitations Guidelines and Standards for the Dental Office Category (“Dental Amalgam Rule”). Dental offices that discharge to POTWs that do not place or remove amalgam need only submit this one-time certification. Dental offices that place or remove amalgam must operate and maintain an amalgam separator and must not discharge scrap amalgam or use certain kinds of line cleaners. They must also submit this One-Time Compliance Report.
4. See the applicability section (§ 441.10) to determine if your facility is required to submit a one-time compliance report.
   PART 441—DENTAL OFFICE POINT SOURCE CATEGORY
6. Name of Dental Facility
8. Physical Address of Dental Facility
10. City
11. State
12. Zip Code
14. Mailing Address
16. City
17. State
18. Zip Code
20. Facility Contact First Name
21. Facility Contact Last Name
23. Phone Number
24. Email Address
26. Owner First Name(if different from facility contact)
27. Last Name
31. Applicability: Please Select One of the Following

    1. Facility is a dental discharger subject to this rule (40 CFR Part 441) and it places or removes dental amalgam. Complete sections A, B, C, D, and E
    2. Facility is a dental discharger subject to this rule and (1) does not place amalgam, and (2) does not remove amalgam except limited emergency or unplanned, unanticipated circumstances. Complete E only
33. (Select if applicable) Transfer of Ownership (§ 441.50(a)(4))

    This facility is submitting a new One Time Compliance Report because of a transfer of ownership as required by § 441.50(a)(4)

    1. This facility is a dental discharger subject to this rule (40 CFR Part 441), and it has previously submitted a one-time compliance report. This facility is submitting a new One Time Compliance Report
35. Transfer of Ownership
    § 441.50(a)(4)
39. Section A: Description of Facility
41. Total number of chairs:
43. Total number of chairs at which amalgam may be present in the resulting wastewater (i.e., chairs where amalgam may be placed or removed):
45. Description of any amalgam separator(s) or equivalent device(s) currently operated:
47. The facility discharged amalgam process wastewater prior to July 14th, 2017 under any ownership.*

    1. Yes

    1. No
51. Section B: Description of Amalgam Separator or Equivalent Device
53. The dental facility has installed one or more ISO 11143 (or ANSI/ADA 108-2009) compliant amalgam separators (or equivalent devices) that captures all amalgam containing waste at the following number of chairs at which amalgam placement or removal may occur:

    1. Yes

    1. No
55. If Yes, How many chairs?
57. The dental facility installed prior to June 14, 2017 one or more existing amalgam separators that do not meet the requirements of § 441.30(a)(1)(i) and (ii) at the following number of chairs at which amalgam placement or removal may occur:

    1. Yes

    1. No

    
    

    I understand that such separators must be replaced with one or more amalgam separators (or equivalent devices) that meet the requirements of 441.30(a)(1) or 441.30(a)(2), after their useful life has ended, and no later than June 14, 2027, whichever is sooner.

59. Requirements:
    § 441.30(a)(1) and § 441.30(a)(2)
61. If Yes, How many chairs?
63. Type of chairs:

    (One line per chair)

65. Make / Model / Year of Installation
67. Equivalent devices:

    1. My facility operates an equivalent device.
69. Type of chair using equivalent device:

    (One line per chair)

71. Make / Model / Year of Installation / Average removal efficiency of equivalent device, as determined per § 441.30(a)(2)i- iii.
73. Average removal efficiency determination:
    § 441.30(a)(2)i- iii.
77. Section C: Design, Operation and Maintenance of Amalgam Separator/Equivalent Device
79. I certify that the amalgam separator (or equivalent device) is designed and will be operated and maintained to meet the requirements in § 441.30 or § 441.40.

    1. Yes
81. A third-party service provider is under contract with this facility to ensure proper operation and maintenance in accordance with § 441.30 or § 441.40.

    1. Yes

    1. No
83. Requirements:
    § 441.30 or § 441.40
85. Name of third-party service provider (e.g. Company Name) that maintains the amalgam separator or equivalent device (if applicable):
87. If none, provide a description of the practices employed by the facility to ensure proper operation and maintenance in accordance with § 441.30 or § 441.40.
91. Section D: Best Management Practices (BMP) Certifications
93. The above named dental discharger is implementing the following BMPs as specified in § 441.30(b) or § 441.40 and will continue to do so.

    1. Yes

    1. No

    
    

    • 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 a publicly owned treatment works (e.g., municipal sewage system)
    • Dental unit water lines, chair-side traps, and vacuum lines that discharge amalgam process wastewater to a publicly owned treatment works (e.g., municipal sewage system) 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 (i.e. cleaners that may increase the dissolution of mercury).
95. BMPs
    § 441.30(b) or § 441.40
99. Section E: Certification Statement
101. Authorized Representative Name *
102. Email Address*
103. Phone Number*
105. Per § 441.50(a)(2), the One-Time Compliance Report must be signed and certified by a responsible corporate officer, a general partner or proprietor if the dental facility is a partnership or sole proprietorship, or a duly authorized representative in accordance with the requirements of § 403.12(l).

     “I am a responsible corporate officer, a general partner or proprietor (if the facility is a partnership or sole proprietorship), or a duly authorized representative in accordance with the requirements of  § 403.12(l) of the above named dental facility, and certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.”

107. Certification:
     § 441.50(a)(2)
109. By checking "Yes" you attest to the declaration above

     1. Yes
111. Retention Period; per § 441.50(a)(5)

     As long as a Dental facility subject to this part is in operation, or until ownership is transferred, the Dental facility or an agent or representative of the dental facility must maintain this One Time Compliance Report and make it available for inspection in either physical or electronic form.

112. Retention Period
     § 441.50(a)(5)
Leave This Blank:


114. 1. Receive an email copy of this form.
115. Email address

     This field is not part of the form submission.

116. Submit

* indicates a required field