ADEM Form 570 "On-Time Compliance Report for Dental Discharges" - Alabama

What Is ADEM Form 570?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ADEM Form 570 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 570 "On-Time Compliance Report for Dental Discharges" - Alabama

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A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
O
-
C
R
D
D
NE
TIME
OMPLIANCE
EPORT FOR
ENTAL
ISCHARGERS
Instructions: This form 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. For instance, if the wastewater discharge is not to a
sewage treatment works (e.g. if the wastewater is discharged to an on-site septic tak/leach field, without subsequent pickup and
discharge to a public sewer), the one-time compliance report is not required. See
the applicability section (§ 441.10)
to determine
if your facility is required to submit a one-time compliance report. Dental facilities that are required to submit a one-time
compliance report to the Alabama Department of Environmental Management should mail this form to the following address:
ADEM-Water Division
Industrial Section
PO Box 301463
Montgomery, Alabama 36130-1463
G
I
ENERAL
NFORMATION
Name of Dental Facility
Physical Address of Dental Facility
Mailing Address of Dental Facility
City
State
Zip Code
City
State
Zip Code
Dental Facility Contact Name
Phone No.
Email Address
Name(s) of Owner(s):
Name(s) of Operator(s), if different from Owner(s):
A
:
PPLICABILITY
Please indicate which of the following apply to this dental facility by checking the appropriate box:
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 E
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 E only
Please indicate if this is Transfer of Ownership
(§ 441.50(a)(4))
by checking the box below:
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).
ADEM Form 570 02/2021
Page 1 of 3
A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
O
-
C
R
D
D
NE
TIME
OMPLIANCE
EPORT FOR
ENTAL
ISCHARGERS
Instructions: This form 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. For instance, if the wastewater discharge is not to a
sewage treatment works (e.g. if the wastewater is discharged to an on-site septic tak/leach field, without subsequent pickup and
discharge to a public sewer), the one-time compliance report is not required. See
the applicability section (§ 441.10)
to determine
if your facility is required to submit a one-time compliance report. Dental facilities that are required to submit a one-time
compliance report to the Alabama Department of Environmental Management should mail this form to the following address:
ADEM-Water Division
Industrial Section
PO Box 301463
Montgomery, Alabama 36130-1463
G
I
ENERAL
NFORMATION
Name of Dental Facility
Physical Address of Dental Facility
Mailing Address of Dental Facility
City
State
Zip Code
City
State
Zip Code
Dental Facility Contact Name
Phone No.
Email Address
Name(s) of Owner(s):
Name(s) of Operator(s), if different from Owner(s):
A
:
PPLICABILITY
Please indicate which of the following apply to this dental facility by checking the appropriate box:
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 E
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 E only
Please indicate if this is Transfer of Ownership
(§ 441.50(a)(4))
by checking the box below:
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).
ADEM Form 570 02/2021
Page 1 of 3
S
A: D
D
F
ECTION
ESCRIPTION OF
ENTAL
ACILITY
Total number of chairs at which amalgam may be present in the resulting wastewater
Total number of chairs
(i.e., chairs where amalgam may be placed or removed)
Description of any amalgam separator(s) or equivalent device(s) currently operated:
Yes
No
This dental facility discharged amalgam process wastewater prior to July 14th, 2017, under any
ownership.
S
B: D
A
S
E
D
ECTION
ESCRIPTION OF
MALGAM
EPARATOR OR
QUIVALENT
EVICE
Please indicate which statement(s) below are applicable by checking the appropriate box(es):
This 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.
Indicate the number of chairs at which amalgam placement or removal may occur that are serviced
by a compliant amalgam separator (or equivalent device):
Prior to June 14, 2017, this dental facility installed one or more existing amalgam separators that do NOT
meet the requirements of
§ 441.30(a)(1)(i) and (ii)
Indicate the number of chairs at which amalgam placement or removal may occur that are NOT
serviced by a compliant amalgam separator (or equivalent device):
By checking this box, I am affirming that 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.
Please list the ISO 11143 (or ANSI/ADA 108-2009) compliant amalgam separators in service at this dental facility:
Year of
Make
Model
installation
Please indicate if this dental facility operates one or more equivalent devices by checking the box and listing the
devices below:
Yes, this dental facility operates one or more equivalent devices.
Average removal efficiency of
Year of
Make
Model
equivalent device, as determined per
installation
§441.30(a)(2)i-
iii.
ADEM Form 570 02/2021
Page 2 of 3
S
C: D
, O
M
A
S
/E
D
ECTION
ESIGN
PERATION AND
AINTENANCE OF
MALGAM
EPARATOR
QUIVALENT
EVICE
Please indicate which of the following statements are true by checking the appropriate box:
I certify that the amalgam separator (or equivalent device) is designed and will be operated and maintained to meet
the requirements in
§ 441.30
or
§
441.40.
I certify that a third-party service provider is under contract with this dental facility to ensure proper operation and
maintenance in accordance with
§ 441.30
or
§
441.40.
Provide the name of third-party service provider (e.g. Company Name) that maintains the amalgam separator
or equivalent device (if applicable):
I can NOT certify that the either of the above statements are true.
Provide a description of the practices employed by this dental facility to ensure proper operation and
maintenance in accordance with
§ 441.30
or
§ 441.40
in the space below:
S
D: B
M
P
(BMP) C
ECTION
EST
ANAGEMENT
RACTICES
ERTIFICATIONS
Please indicate that this dental facility is implementing the required BMPs by checking the box below:
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).
S
E: C
S
ECTION
ERTIFICATION
TATEMENT
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 this 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.”
Name of Authorized Agent
Authorized Agent’s Signature
Date Signed
Agent’s Phone Number:
Agent’s Email Address:
Retention Period; per
§ 441.50(a)(5)
As long as a dental facility subject to this part is in operation, or until ownership is transferred, this dental facility or an agent or
representative of this dental facility must maintain this One-time Compliance Report and make it available for inspection in either
physical or electronic form.
ADEM Form 570 02/2021
Page 3 of 3
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