Fillable ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS to Comply (City of Hendersonville)

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ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS to Comply (City of Hendersonville)

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November 2017 Form approved
OMB No. 2040-0287
Approval expires 11/30/2020
ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS
to Comply with 40 CFR 441.50
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”). Some dental facilities are not required to submit a one-time compliance report. See the applicability section (§
441.10) to determine if your facility is required to submit a one-time compliance report.
Note to dental facilities: Please contact your Control Authority to determine what form to use. The City of Hendersonville
is the Control Authority for its wastewater utility. For assistance, please see the City’s website: www.hvlnc.gov/water-
sewer/applications-and-forms. Please complete form and submit to lsmith@hvlnc.gov.
General Information
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))
November 2017
Page 2 of 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).
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.
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
☐
My facility operates an equivalent device.
November 2017
Page 3 of 4
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
November 2017
Page 4 of 4
☐
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.
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ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS to Comply (City of Hendersonville)

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Completed 3 August 2020

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