[{"@context":"https:\/\/schema.org\/","@type":"Article","@id":"https:\/\/iaomt.org\/one-time-compliance-form-for-dental-dischargers-appendix-iii\/#Article","mainEntityOfPage":"https:\/\/iaomt.org\/one-time-compliance-form-for-dental-dischargers-appendix-iii\/","headline":"One Time Compliance Form for Dental Dischargers – Appendix III","name":"One Time Compliance Form for Dental Dischargers – Appendix III","description":"SAMPLE 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 sample 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  [...]","datePublished":"2025-08-06","dateModified":"2025-08-06","author":{"@type":"Person","@id":"https:\/\/iaomt.org\/author\/moore\/#Person","name":"International Academy of Oral Medicine & Toxicology","url":"https:\/\/iaomt.org\/author\/moore\/","identifier":1240,"image":{"@type":"ImageObject","@id":"https:\/\/iaomt.org\/wp-content\/litespeed\/avatar\/bfc92e3fae46f1c852ba2a2990470c47.jpg?ver=1776187415","url":"https:\/\/iaomt.org\/wp-content\/litespeed\/avatar\/bfc92e3fae46f1c852ba2a2990470c47.jpg?ver=1776187415","height":96,"width":96}},"publisher":{"@type":"Organization","name":"The International Academy of Oral Medicine & Toxicology","logo":{"@type":"ImageObject","@id":"https:\/\/iaomt.org\/wp-content\/uploads\/IAOMT-Schema-app-logo.jpg","url":"https:\/\/iaomt.org\/wp-content\/uploads\/IAOMT-Schema-app-logo.jpg","width":120,"height":60}},"image":{"@type":"ImageObject","@id":"https:\/\/iaomt.org\/wp-content\/uploads\/iaomt-logo2.jpg","url":"https:\/\/iaomt.org\/wp-content\/uploads\/iaomt-logo2.jpg","width":100,"height":100},"url":"https:\/\/iaomt.org\/one-time-compliance-form-for-dental-dischargers-appendix-iii\/","about":["Articles"],"wordCount":1023,"keywords":["Dental Mercury Regulatory"],"articleBody":"SAMPLEONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERSto Comply with 40 CFR 441.50Effluent Limitations Guidelines and Standards for the Dental Office CategoryInstructions:The following is a sample 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 (\u201cDental Amalgam Rule\u201d). Some dental facilities are not required to submit a one-time compliance report. See the applicability section (\u00a7 441.10) to determine if your facility is required to submit a one-time compliance report.Note to dental facilities: Do not fill out and submit this form unless directed to do so by your Control Authority. Please contact your Control Authority to determine what form to use. Your Control Authority may be your wastewater utility, your state wastewater agency, or the U.S. EPA Regional Office. For assistance in determining your Control Authority, please see EPA\u2019s website: www.epa.gov\/eg\/dental-effluent-guidelines.General Information Name of FacilityPhysical Address of Dental FacilityCity:State:Zip:Mailing AddressCity:State:Zip:Facility ContactPhone:Email:Names of Owner(s):Names of Operator(s) if different from Owner(s):Applicability: Please Select One of the Following\u2610This 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\u2610This 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 (\u00a7 441.50(a)(4))\u2610This 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 \u00a7 441.50(a)(4).Section ADescription of FacilityTotal 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 \u2610NO \u2610The facility discharged amalgam process wastewater prior to July 14th, 2017 under any ownership.Section BDescription of Amalgam Separator or Equivalent Device \u00a0\u2610The 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:\u00a0\u2610The dental facility installed prior to June 14, 2017 one or more existing amalgam separators that do not meet the requirements of \u00a7 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 \u00a7 441.30(a)(1) or \u00a7 441.30(a)(2), after their useful life has ended, and no later than June 14, 2027, whichever is sooner.MakeModelYear of installation            \u00a0\u2610My facility operates an equivalent device.MakeModelYear of installationAverage removal efficiency of equivalent device, as determined per \u00a7 441.30(a)(2)i- iii.            Section CDesign, Operation and Maintenance of Amalgam Separator\/Equivalent Device \u2610YESI certify that the amalgam separator (or equivalent device) is designed and will be operated and maintained to meet the requirements in \u00a7 441.30 or \u00a7 441.40.A third-party service provider is under contract with this facility to ensure proper operation and maintenance in accordance with \u00a7 441.30 or \u00a7 441.40.\u2610YESName of third-party service provider (e.g. Company Name) that maintains the amalgam separator or equivalent device (if applicable): \u2610NOIf none, provide a description of the practices employed by the facility to ensure proper operation and maintenance in accordance with \u00a7 441.30 or \u00a7 441.40.\u00a0Describe practices:Section D Best Management Practices (BMP) Certifications\u2610The above named dental discharger is implementing the following BMPs as specified in \u00a7\u00a0441.30(b) or \u00a7 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 ECertification StatementPer \u00a7 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 \u00a7\u00a0403.12(l).\u201cI 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 \u00a7\u00a0403.12(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.\u201dAuthorized Representative Name (print name):Phone:Email:Authorized Representative SignatureDateRetention Period; per \u00a7 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."},{"@context":"https:\/\/schema.org\/","@type":"BreadcrumbList","itemListElement":[{"@type":"ListItem","position":1,"name":"One Time Compliance Form for Dental Dischargers – Appendix III","item":"https:\/\/iaomt.org\/one-time-compliance-form-for-dental-dischargers-appendix-iii\/#breadcrumbitem"}]}]