This facility is submitting a new One Time Compliance Report because of a transfer of ownership as required by § 441.50(a)(4)
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.
(One line per chair)
“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.”
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.
This field is not part of the form submission.
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