Fillable City of Bethlehem Industrial Pretreatment Program One-Time Compliance (City of Bethlehem)

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City of Bethlehem Industrial Pretreatment Program One-Time Compliance (City of Bethlehem)

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City of Bethlehem Industrial Pretreatment Program
One-Time Compliance Report for Dental Dischargers
to Comply with 40 CFR 441.50
Effluent Limitations Guidelines and Standards for the Dental Office Category
1
General Information
Name of Dental Facility
Physical Address of Dental Facility
City:
State:
Zip:
Mailing Address of Dental Facility
City:
State:
Zip:
Facility Contact
Phone:
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 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
Transfer of Ownership (select if applicable)
☐
This facility is a dental discharger subject to 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).
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.
City of Bethlehem Industrial Pretreatment Program
One-Time Compliance Report for Dental Dischargers
to Comply with 40 CFR 441.50
Effluent Limitations Guidelines and Standards for the Dental Office Category
2
Section 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:
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.
Make
Model
Year of installation
☐
This 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
Company name, address, and phone number
of third-party service provider that maintains the
amalgam separator or equivalent device (if
applicable):
☐
NO
If a third-party service provider is not used, 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:
City of Bethlehem Industrial Pretreatment Program
One-Time Compliance Report for Dental Dischargers
to Comply with 40 CFR 441.50
Effluent Limitations Guidelines and Standards for the Dental Office Category
3
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).
Section 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
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.
Return a signed copy of this One-Time Compliance Report to:
Christian Torres
MIPP/QC Coordinator
City of Bethlehem WWTP
144 Shimersville Rd.
Bethlehem, PA 18015
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Completed 2 August 2020

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