"One-Time Compliance Report for Dental Dischargers" - Oregon

One-Time Compliance Report for Dental Dischargers is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

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Download "One-Time Compliance Report for Dental Dischargers" - Oregon

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Oregon Department of Environmental Quality
One-Time Compliance Report for Dental Dischargers
DEQ Headquarters Office
Attn: Industrial Pretreatment Program
700 NE Multnomah St, Suite 600
Portland, Or 97232
503-229-5696
For complying 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 Dental Office
Category (“Dental Amalgam Rule”). Some dental facilities are not required to submit a one-time compliance
report. See
the applicability section (§ 441.10)
to determine if your facility is required to submit a one-time
compliance report.
General Information
Name of facility:
Physical address of the dental facility:
City:
State:
Zip:
Mailing address:
City:
State:
Zip:
Facility contact:
Phone:
Email:
Names of owner(s):
Names of operator(s) if
different from owner(s):
Oregon Department of Environmental Quality
1
Oregon Department of Environmental Quality
One-Time Compliance Report for Dental Dischargers
DEQ Headquarters Office
Attn: Industrial Pretreatment Program
700 NE Multnomah St, Suite 600
Portland, Or 97232
503-229-5696
For complying 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 Dental Office
Category (“Dental Amalgam Rule”). Some dental facilities are not required to submit a one-time compliance
report. See
the applicability section (§ 441.10)
to determine if your facility is required to submit a one-time
compliance report.
General Information
Name of facility:
Physical address of the dental facility:
City:
State:
Zip:
Mailing address:
City:
State:
Zip:
Facility contact:
Phone:
Email:
Names of owner(s):
Names of operator(s) if
different from owner(s):
Oregon Department of Environmental Quality
1
Applicability: Please select one of the following
This 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 F
This 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 F only
Transfer of ownership
(§ 441.50(a)(4))
(Select if applicable)
This 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
§
441.50(a)(4).
Section A
Description of facility
Total 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:
The facility discharged amalgam process wastewater prior to July 14th, 2017 under any
YES
NO
ownership.
Section B
Description of amalgam separator or equivalent device
The dental facility has installed one or more ISO 11143 (or ANSI/ADA 108-2009) compliant
Chairs:
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:
The dental facility installed prior to June 14, 2017 one or more existing amalgam separators
Chairs:
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.
Make
Model
Year of installation
My facility operates an equivalent device.
Oregon Department of Environmental Quality
2
Average removal
efficiency of
Year of
Make
Model
equivalent device, as
installation
determined per
§ 441.30(a)(2)i-
iii.
Section C
Design, operation and maintenance of amalgam separator/equivalent device
I certify that the amalgam separator (or equivalent device) is designed and will
YES
be operated and maintained to meet the requirements in
§ 441.30
or
§
441.40.
A third-party service provider is under contract with this facility to ensure proper operation and maintenance
in accordance with
§ 441.30
or
§
441.40.
Name of third-party service
provider (e.g. Company
Name) that maintains the
YES
amalgam separator or
equivalent device (if
applicable):
If none, provide a description of the practices employed by the facility to ensure
NO
proper operation and maintenance in accordance with
§ 441.30
or
§
441.40.
Describe practices:
Section D
Best Management Practices (BMP) certifications
The above named dental discharger is implementing the following BMPs as specified in
§ 441.30(b)
or
§ 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).
Oregon Department of Environmental Quality
3
Section E
Retention Period; per § 441.50(a)(5) & 441.50(b)
One Time Compliance Report: 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.
Other Records: The Dental facility subject to this rule must maintain documents and make available for
inspection in either physical or electronic form for a minimum of three years.
1. Documents related to inspection of amalgam separators and follow-up actions;
2. Documentation of amalgam retaining container or replacement, including date, if applicable;
3. Documents related to dental amalgam pickup or shipment for proper disposal by a licensed storage
or disposal facility;
4. Documentation of any repair or replacement of an amalgam separator or device;
5. Manufacturer’s Current operating manual for the device in place.
Section F
Certification Statement
Per
§
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
§
403.12(l).
“I 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 § 403.12(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.”
Authorized Representative name (print name):
Phone:
Email:
Authorized Representative signature
Date
Oregon Department of Environmental Quality
4
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