Dental Office Point Source Category

Section A: Facility Information
Facility Name
Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Facility Contact - Name

First NameLast Name
Facility Contact - Phone Number

Area CodePhone Number
Facility Contact - Email
example@example.com
Name(s) of Owner(s)
Name(s) of Operators(s); if different from owner(s)
Name of Authorized Signature Authorities

First NameLast Name
Date business was established at this location

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this a transfer of ownership?

Section C: Description of Dental Office Practice
Description of the operations at this dental facility
Number of chairs
Total number of chairs at which dental amalgam may be present in the resulting wastewater
Do you have more than one amalgam separator?
How many amalgam separators are operated on site?
number of separators
Please enter the details for each amalgam separator(s) or equivalent device(s) currently operated on site; one per line.
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:
Number of 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: 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.

Section D: Maintenance and Operation of Amalgam Separator(s) or Equivalent Device(s)
Name of the third-party service provider that maintains the amalgam separator(s) or equivalent device(s) operated at the dental office (if applicable):
If a third-party service provider is not used, please give a brief description of the practices employed by the facility to ensure proper operation and maintenance of the amalgam separator(s) or equivalent device(s) in accordance with 441.30 or 441.40.

Section E: Certification
I certify:
I certify:
I 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, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for known violations.
Electronic Signature
Printed Name

First NameLast Name
Title
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
As long as a Dental facility subject to 40 CFR 441 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. (441.50 (a)(5))
Should be Empty:

ONE-TIME COMPLIANCE REPORT