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
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
“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):
Authorized Representative Signature
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:
City of Bethlehem WWTP
144 Shimersville Rd.
Bethlehem, PA 18015
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