Dental Office Point Source Category

Section B: Exemptions
These exemptions apply to my facility *

441.10 (c) - The facility indicated in Section A above exclusively practices one or more of the following dental specialties: Oral pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics,periodontics, or prosthodontics. 441.10 (d) - The facility indicated in Section A above is a mobile unit operated by a dental discharger. 441.10 (e) - The facility indicated in Section A above does not discharge any amalgam process wastewater to the CWL sewer system, but collects all dental amalgam process wastewater for transfer off-site to a facility that treats the waste (like a Centralized Waste Treatment Facility). 441.10 (f) - The facility indicated in Section A above is a Dental Discharger that does not place dental amalgam, and does not remove amalgam except in limited emergency or unplanned, unanticipated circumstances, and I certify to City Water & Light (the Control Authority) that this facility is exempt from any further requirements of 40 CFR 441, other than this One Time Compliance Report.
No Exemptions *

There are no exemptions that apply to my facility. If you have marked this box, please complete Sections C through E.

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? *

No Yes
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: *

Yes No
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. *

Yes No

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: *

that the amalgam separator(s) or equivalent device(s) is designed and will be operated and maintained to meet the requirements specified in 40 CFR 441.30 or 441.40.
I certify: *

that the facility identified in Section A is implementing Best Management Practices specified in 441.30 (b) or 441.40 (b) and will continue to do so.
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 *

Clear
Printed Name *

First Name Last Name
Title *
Date

Month Day Year
Date
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:

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ONE-TIME COMPLIANCE REPORT