Compliance Form Home » Dental Office Point Source Form » Compliance Form Compliance Report Form DENTAL DISCHARGER COMPLIANCE REPORT EPA 40 CFR 441 Step 1 of 4 25% SECTION A – FACILITY INFORMATION (All Fields Required)FACILITY NAME: First PHONE NUMBER:EMAIL ADDRESS: PHYSICAL ADDRESS: PHYSICAL ADDRESS MAILING ADDRESS: MAILING ADDRESS: ON-SITE CONTACT NAME: First Please select ONE of the following RED boxes:Red Boxes This Dental Facility Must complete Sections B and C is a dental discharger that does not place or remove amalgam except in limited emergency or unplanned, unanticipated circumstances (limited circumstances is the removal of amalgam at a frequency of less than 5% of the Dental Facility’s procedures (this percent approximates to 9 removals per office per year)). Must complete Sections B and C This Dental Facility is a mobile unit operated by a dentist or licensed health care facility. Must complete Sections B and C This Dental Facility does not discharge any amalgam process wastewater to Orange County Sanitation District’s sewer system, but collects dental amalgam process wastewater for transfer off-site to a Centralized Waste Treatment Facility as defined in 40 CFR part 437. Must complete Sections B and C This Dental Facility is a dental discharger subject to this Rule, as it places OR removes dental amalgam. Must complete Sections B and C This Dental Facility is a dental discharger that serves the following primary function(s): Please check all ☐ that apply. Must complete Sections B, C, and E Orthodontics Orthodontics Prosthodontics Prosthodontics Oral Pathology or Oral Medicine Oral and Maxillofacial Surgery Periodontics Periodontics Oral and Maxillofacial Radiology Oral and Maxillofacial Radiology Oral Pathology or Oral Medicine Oral Pathology or Oral Medicine SECTION B – OWNERSHIP INFORMATION(If only one owner, please record “N/A” on line 2; title is “CEO“, “President“, “Owner“, “Director“, etc. Please do not record “Dentist” for title.) Next element.Name OWNER/PARTNER: TITLE: Name OWNER/PARTNER: TITLE: SECTION C – DESCRIPTION OF OPERATIONS AND AMALGAM SEPARATORSNumber of practicing dentists at this facility:Total number of chairs:Total number of chairs at which dental amalgam placement or removal occurs:Amalgam Separator(s) or Equivalent Device(s)Make Model Installation Date Complies with Requisite Std Ref.1 ANSI/ADA ISO 95% Removal Eff. Make Model Installation Date Complies with Requisite Std Ref.1 ANSI/ADA ISO 95% Removal Eff. Make Model Installation Date Complies with Requisite Std Ref.1 ANSI/ADA ISO 95% Removal Eff. Untitled This Dental Facility has contracted a third-party service provider to maintain the amalgam separator(s) Service Provider Name: First Service Provider Phone No:Service Provider Address: Street Address Untitled This Dental Facility maintains its amalgam separator(s), and spent amalgam separators are shipped to: Processing Facility Name: First Processing Facility Phone No:Processing Facility Address: Street Address Practices employed by the Dental Facility to ensure the proper operation and maintenance of the amalgam separators in accordance with 40 CFR §441.30, or §441.40 and §441.50 are below; check all that apply.Multi check Manufacturer’s operation manual is available for inspection in either physical or electronic form. Amalgam separator is inspected weekly, monthly, when the vacuum drops, or other, to ensure proper operation according to the manufacturer’s operation manual. The amalgam retaining unit is replaced according to the manufacturer’s standards. Office documents the amalgam separator inspection results including the date, person conducting the inspection, and any follow-up actions including amalgam separator or retaining unit replacement. Documentation is maintained for inspection for no less than three years. In the event the amalgam retaining unit has reached the maximum level or the amalgam separator is not working properly, unit will be repaired or replaced with a separator or equivalent device that meets the regulation’s requirements no later than 10 business days after the malfunction is discovered. Dental unit water lines, chair-side traps and vacuum lines that discharge into the Orange County Sanitation District’s sewer lines, are not cleaned with oxidizing, acidic cleaners, including but not limited to bleach, chlorine, iodine and peroxide that have a pH lower than 6 or greater than 8Ref. 4 (i.e., cleaners that may increase the dissolution of mercury). SECTION D – REQUIRED DOCUMENTATIONAs long as the above-named Dental Facility is subject to this regulation, or until ownership is transferred, the Dental Discharger or an agent or representative must maintain records and documentation per 40 CFR 441.50(b)Ref. 2.SECTION E – CERTIFICATION STATEMENT (must be signed by owner/partner listed in Section A)I am a duly authorized representativeRef.3 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 Signatory Name (please print): First Signature and Date First Date MM slash DD slash YYYY HOW TO SUBMIT THE COMPLETED FORM1. Complete this form; DO NOT SIGN. 2. Save the completed, unsigned form (or all data will be lost) and email it as an attachment to: lmckinley@ocsan.gov 3. Once received and confirmed complete by OC San, you will be notified by email to print two copies, sign and date both, keep one copy for your records, and mail the other to: Orange County Sanitation District ATTN: Lori McKinley Dental Amalgam Program 18480 Bandilier Circle, Fountain Valley, CA 92708 If you have questions, please refer to OC San’s website at: ocsandev.ntc-us.com/dental-office-point-source-form REFERENCESAmalgam Separator(s) or Equivalent Device(s) A dental facility coming into compliance with 40 CFR 441 must install one or more ISO 11143 (or ANSI/ADA 108-2009) compliant amalgam separators, or equivalent devices with an average removal efficiency of 95 percent of the mass of solids as determined per 40 CFR 441.30(a)(2)i-iii. These devices must be sized to accommodate the maximum discharge rate of amalgam process wastewater. Dental facilities with separators or equivalent devices installed before June 14, 2017, that do not meet the requirements of 40 CFR 441.30(a)(1)(i) and (ii) must replace their amalgam separators (or equivalent devices) with units that meet the requirements of 40 CFR 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. Required Documentation Per 40 CFR 441.50(b), dental dischargers, or an agent or representative of the dental discharger, must maintain and make available for inspection in either physical or electronic form for a minimum of three years:
