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CITY OF CUMBERLAND WASTEWA TER TREATMENT PLANT ONE-TIME (City of Cumberland)

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CITY OF CUMBERLAND WASTEWA
TER TREATMENT PLANT
ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS
to Comply with 40 CFR 441 * Effluent Limitations Guidelines and Standards for the Dental Office Category *
Instructions: The following is a form that contains the minimum information dental facilities must submit in a one-time compliance report as
required by the Effluent Limitations Guidelines and Standards for the Dental Office Category (“Dental Amalgam Rule”) 40 CFR 441.50.
I
f you have recieved a notice from the City of Cumberland; please fill out this form completely, print out and sign the Certification Statement.
Review section (§ 441.10 (a) - (f)) and check the appropriate box under Applicability, complete the required sections, sign and submit this form.
Mail the form to: City of Cumberland Engineering Division, 57 N. Liberty Street, Cumberland, MD 21502
For more information:
City of Cumberland’s website * http://www.ci.cumberland.md.us/ * Engineering Division (301-759-6604)
EPA’s website * www.epa.gov/eg/dental-effluent-guidelines
Name of Facility
Physical Address of Dental Facility
City: State: Zip:
Mailing Address
City: State: Zip:
Facility Contact
Phone: Email:
Names of Owner(s):
Names of Operator(s) if different from
Owner(s):
Applicability: Please Select One of the Following
☐
This 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
☐
This facility is a dental discharger subject to this rule and (1) it does not place dental amalgam, and (2)
it does not remove amalgam except in limited emergency or unplanned, unanticipated circumstances.
Complete section E only
(Also, select if applicable) Transfer of Ownership (§ 441.50(a)(4))
☐
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 because of a transfer of ownership as required by
§ 441.50(a)(4).
General Information
Section A
Description of Facility
Total number of chairs:
Total number of chairs at which amalgam may be present in the resulting
wastewater (i.e., chairs where amalgam may be placed or removed):
Description of any amalgam separator(s) or equivalent device(s) currently operated:
YES
☐
NO
☐
The facility discharged amalgam process wastewater prior to July 14th, 2017 under any
ownership.
S
ection B
Description of Amalgam Separator
or Equivalent Device
☐
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:
Chairs:
☐
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:
Chairs:
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.
Make Model Year of installation
☐
My facility operates an equivalent device.
Make Model
Year of
installation
Average removal
efficiency of
equivalent device,
as determined per §
441.30(a)(2)i- iii.
Section C
Design, Operation and Maintenance of Amalgam Separator/Equivalent Device
☐
YES
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.
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.
☐
YES
Name of third-party service
provider (e.g. Company
Name) that maintains the
amalgam separator or
equivalent device (if
applicable):
☐
NO
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.
Describe practices:
Section D
Best Management Practices (BMP) Certifications
☐
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).
S
ection E
Certification Statement
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.”
Authorized Representative Name (print name):
Phone: Email:
Authorized Representative Signature
Date
R
etention 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.
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CITY OF CUMBERLAND WASTEWA TER TREATMENT PLANT ONE-TIME (City of Cumberland)

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Completed 21 January 2021

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