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  1. 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.
  2. Applicability: Please Select One of the Following
  3. (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)

  4. Section A: Description of Facility
  5. The facility discharged amalgam process wastewater prior to July 14th, 2017 under any ownership.*
      1. Section B: Description of Amalgam Separator or Equivalent Device
      2. 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. 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:

                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.

              1. Type of chairs:

                (One line per chair)

              2. Equivalent devices:
              3. Type of chair using equivalent device:

                (One line per chair)

              4. Section C: Design, Operation and Maintenance of Amalgam Separator/Equivalent Device
              5. 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.
              6. 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. Section D: Best Management Practices (BMP) Certifications
                  2. 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.

                      • 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).
                    1. Section E: Certification Statement
                    2. 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.”

                    3. By checking "Yes" you attest to the declaration above
                    4. 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.

                    5. Leave This Blank:

                    6. This field is not part of the form submission.