Compliance Form

(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.

As 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.

(must be signed by owner/partner listed in Section B)

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" I am a duly authorized representative 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.”

1. Complete this form; DO NOT SIGN.
2. Press SUBMIT button.
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: ocsan.gov/dental-office-point-source-form

1.  Amalgam 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 average removal efficiency of 95 percent of the mass of solids as determined per 40 CFR 441.30(a)(2)i-iii. sized to accommodate the maximum discharge rate of amalgam process wastewater. Dental facilities with separators or equivalent devices installed prior to 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.

2.  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:

    

a. Documentation of the date of each inspection of the amalgam separator(s) or equivalent device(s), name of person(s) conducting the inspection, and results of each inspection (including a summary of follow-up actions if needed).

    

b. Documentation of amalgam-retaining container or equivalent container replacement (including the date, as applicable).

    

c. Documentation of all dates that collected dental amalgam is picked up or shipped for proper disposal in accordance with 40 CFR 261.5(g)(3), and the name of the permitted or licensed treatment, storage, or disposal facility receiving the amalgam retaining containers.

    

d. Documentation of any repair or replacement of an amalgam separator or equivalent device, including the date, person(s) making the repair or replacement, and a description of the repair or replacement (including make and model).

    

e. A discharger or an agent or representative of the dental discharger must maintain and make available for inspection in either physical or electronic form the manufacturer’s operating manual(s) for the current device(s).

3.  Duly Authorized Representative

    

a. If the applicant or User is a corporation:

    

i. The president, secretary, treasurer, or a vice president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions of the corporation; or

    

ii. The manager of one or more manufacturing, production, or operation facilities, provided the manager is authorized to make management decisions that govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiate and direct other comprehensive measures to assure long-time environmental compliance with environmental laws and regulations; can ensure that the necessary systems are established or actions taken to gather complete and accurate information for individual wastewater discharge permit requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

    

b. If the applicant or User is a partnership or sole proprietorship: a general partner or proprietor, respectively.

    

c. If the applicant or User is a federal, state, or local governmental facility: a director or highest official appointed or designated to oversee the operation and performance of the activities of the government facility, or the designee.

4.  Required Best Management Practices (BMPs)
    

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).

5.  Signature Requirement
    

Per 40 CFR 441.50(a)(2), the 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 40 CFR 403.12(I).