DENTAL AMALGAM MANAGEMENT COMPLIANCE FORM

Business Address *
Business Address
Representative Name *
Representative Name
Phone *
Phone
Compliance
Best Management Practices: All dental practices are required to certify that they have implemented and are currently in compliance with best management practices (BMPs) outlined in Central Weber Sewer Improvement District’s Wastewater Control Rules and Regulations. All dental chairs are equipped with chair-side traps and all vacuum pumps are equipped with traps and filters. All equipment is cleaned, disposed of, and maintained in accordance with the manufacturer’s instructions. The dental practice uses only non-chlorine or non-oxidizing disinfectants and neutral line cleaners when cleaning lines. When cleaning filters or collecting scrap amalgam, the dental practice does not rinse filters or traps over sinks or drains. All water containing amalgam waste is washed through amalgam separator lines. The dental practice recycled all bulk mercury and recycles all amalgam wastes. All contact and non-contact scrap amalgam is salvaged and stored in structurally sound, tightly closed and appropriately labeled containers. The dental practice never disposes of amalgam wastes in, infectious waste or biohazard containers or in the garbage. All amalgam wastes are transferred to an off-site recycling facility for recycling of mercury on at least an annual basis. If the dental practice still uses amalgam, the dental practice uses only pre-capsulated, single –use amalgam and stocks a variety of sizes in order to minimize waste. Amalgam Separator: Amalgam separators shall be installed in all dental practices that place or remove amalgam. The amalgam separator shall be ISO 11143 certified and shall be designed and approved for a flow rate capable of handling the maximum volume discharged from the dental practice it serves. The amalgam separator must be tested according to the most current ISO 11143 standard. If ISO increases the acceptable standard, the dental practice must comply with the new standard within five years. All wastewater that may contain amalgam particles must pass through the amalgam separator. The amalgam separator is maintained in accordance to the manufacturer’s instructions. Waste removed from the amalgam separator is collected and handled in accordance with the manufacturer’s instructions and as described in the BMPs. Record Keeping: Dental practices must maintain records of amalgam disposal. These records shall include the date, the name and address of the facility to which any waste amalgam is shipped, and the amount shipped. The dental practice must also maintain records of all maintenance and service completed on the amalgam separator. All records must be kept on site for a minimum of three years and shall be made available to Central Weber Sewer Improvement District upon request.
Certification
“I certify that 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”.
Date *
Date
Entering your name constitutes electronic signature and agreement to compliance.