Dental Compliance Form

For more information please visit: www.epa.gov/eg/dental-effluent-guidelines

General Information
XXX-XXX-XXXX format
Applicability: Please Select One of the Following
Complete Sections A, B, C, D, and E
Complete Section E only
SECTION A: Description of Facility
SECTION B: Description of Amalgam Separator or Equivalent Device
Make Model Year of Installation
Make Model Year of Installation Average Removal Efficiency of Equivalent Device, as Determined Per § 441.30(a)(2)i-iii
SECTION C: Design, Operation and Maintenance of Amalgam Separator/Equivalent Device
SECTION D: Best Management Practices (BMP) Certifications
SECTION E: 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.”

Sign above
XXX-XXX-XXXX format

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.