Dental Amalgam Form

Name of Facility(Required)

Address of Dental Facility(Required)

Street Address City State ZIP Code

Mailing address is the same as above

Yes

Mailing Address(Required)

Street Address City State ZIP Code

Name of owner(s)(Required)

Name of operator(s) if different from owner(s)

Applicability

Please Select One of the Following:(Required)

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

(Also, select if applicable) Transfer of Ownership (§ 441.50(a)(4))

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:(Required)

Total number of chairs at which amalgam may be present in the resulting wastewater (i.e., chairs where amalgam may be placed or removed):(Required)

Description of any amalgam separator(s) or equivalent device(s) currently operated:(Required)

The facility discharged amalgam process wastewater prior to July 14th, 2017 under any ownership.(Required)

Yes

Section B

Description of Amalgam Separator or Equivalent Device:

Link to section § 441.30

The 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 at the following number of chairs at which amalgam placement or removal may occur.(Required)

Yes

If yes, please indicate how many chairs in the space provided below.

Number of chairs(Required)

Make

Model

Year of installation

The dental facility installed prior to June 14, 2017 one or more existing amalgam separators that do not meet the requirements of § 441.30(a)(1)(i) and (ii) at the following number of chairs (provided below) 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.(Required)

Yes

If yes, please indicate how many chairs in the space provided below.

Number of chairs(Required)

My facility operates an equivalent device.

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:

Links to sections § 441.30 and § 441.40

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.(Required)

Yes

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.(Required)

Yes

Name of third-party service provider (e.g. Company Name) that maintains the amalgam separator or equivalent device (if applicable):

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.

Describe practices. (Links to § 441.30 or § 441.40)

Section D

Best Management Practices (BMP) Certifications:

The above named dental discharger is implementing the following BMPs as specified in § 441.30 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).

Acknowledgement(Required)

By checking this box, I verify the above information is correct.

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.”

Authorized Representative Signature(Required)

By printing your name here, you acknowledge that all the above information is correct.

Phone(Required)

Email(Required)

A copy of the completed form will be emailed to you.

04/26/2026

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, 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.

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For Downers Grove Sanitary District Use Only

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Sewer Problems? Call (630) 969-0664
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DGSD Dental Amalgam Form

Applicability

Section A

Section B

Section C

Section D

Section E

For Downers Grove Sanitary District Use Only

Dental Amalgam Form

Sewer Problems? Call (630) 969-0664Our technicians are available at all hours to help you.

DGSD Dental Amalgam Form

Applicability

Section A

Section B

Section C

Section D

Section E

For Downers Grove Sanitary District Use Only

Sewer Problems? Call (630) 969-0664
Our technicians are available at all hours to help you.