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2. ATTENTION: After completing this survey, print it as a PDF and save it to your computer. Then, make sure to attach it to the appropriate field in the Pre Treatment Questionnaire
4. General Information
6. Name of Facility*
8. Physical Address of Dental Facility*
10. City*
11. State*
12. Zip Code*
14. Mailing Address*
16. City*
17. State*
18. Zip Code*
20. Facility Contact*
21. Phone Number*
22. Email Address*
24. Name(s) of Owner(s)*
26. Contact information for All Practicing Dentists
28. Name*
29. Phone Number*
30. Email Address*
32. Name
33. Phone Number
34. Email Address
36. Name
37. Phone Number
38. Email Address
40. Name
41. Phone Number
42. Email Address
44. Name
45. Phone Number
46. Email Address
48. Applicability — Please select one of the following:*

    1. This facility is a dental discharger subject to this rule by Federal Regulation 40 CRF Part 441 as it places or removes dental amalgam. Complete Sections A, B, C, D, and E.
    2. 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.
50. Also select if applicable: Transfer of Ownership (§ 441.50(a)(4))

    1. This facility is a dental discharger subject to this rule (40CRF Part 441) and has previously submitted a Dental Survey. This facility is submitting a new One Time Compliance Report because of a transfer of ownership as required by Federal Regulation 441.50(a)(4).
52. Section A: Description of Facility
54. Total Number of Chairs*
55. Number of chairs at which amalgam may be present in resulting wastewater (chairs where amalgam may be placed or removed):*
57. Descriptions of any amalgam separator(s) or equivalent devices(s) currently operated: *
58. Did this facility discharge amalgam process wastewater prior to July 14, 2017, under any ownership? *

    1. Yes
    2. No
60. Section B: Description of Amalgam Separator or Equivalent Device
62. 1. The dental facility has installed one or more ISO 11143 (or ANSI/ADA 108-209) compliant amalgam separators (or equivalent devices) that captures all amalgam placement or removal may occur:
63. Chairs:
65. 1. The dental facility prior to June 14, 2017, installed one or more existing amalgam separators that do not meet the requirements of Reg 441.30(a)(1)(i) and (ii) at the following number of chairs at which amalgam placement or removal occur: I understand that such separators must be replaced with one or more amalgam separators (or equivalent devices) that meet the requirements of Regulation 441.30(a)(1) or 441.30(a)(2), after their useful life has ended, and no later than June 14, 2027, whichever
66. Chairs:
68. Make
69. Model
70. Year of Installation
84. 1. My facility operates an equivalent device.
86. Make
87. Model
88. Year of Installation
89. Average removal efficiency of equivalent device, as determined per Reg. 441.30(a)(2)i- iii.
106. Section C: Design, Operation and Maintenance of Amalgam Separator/Equivalent Device
108. 1. I certify that the amalgam separator (or equivalent device) is designed and will be operated and maintained to meet the requirements in Regulation 441.30 or 441.40.
110. Is a third-party service provider under contract with this facility to ensure proper operation and maintenance in accordance with § 441.30 or § 441.40?
112. 1. Yes, List name of the third-party service provider (e.g., Company Name) that maintains the amalgam separator or equivalent device (if applicable):
116. 1. No. If none, provide a description of the practices employed by the facility to ensure proper operation and maintenance in accordance with § 441.30 or § 441.40:

      

120. Section D: Certification Statement
122. The undersigned is a principle or managerial agent for the survey respondent with authority concerning requirements for wastewater discharge from the facility.

     I hereby certify, under penalty of law, that this document and all of its attachments were prepared under my direction or supervision according to a process designed to ensure that qualified personnel properly gather and evaluate the information submitted. The information is, to the best of my knowledge and belief, true, accurate, and complete. 

124. Title*
125. First Name*
126. Last Name*
128. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
130. Electronic Signature*
131. Date*
133. Authorized Representative

     1. I am an Authorized Representative (AR)
134. AR Phone Number
135. AR Email Address
137. ATTENTION: After completing this survey, print it as a PDF and save it to your computer. Then, make sure to attach it to the appropriate field in the Pre Treatment Questionnaire
Leave This Blank:


138. Print Only

* indicates a required field