Amalgam-Separator-Installation-Notice-Form-fillable

Page 1 of 2 Notice of Dental Amalgam Separator Installation (August 2015) A. Instructions Purpose and Use of this Form: State of Wisconsin DNR requires that publicly owned wastewater treatment facilities discharging effluent into State waters implement “Best Management Practices”(BMP) for minimizing mercury in those effluents. BMP for dental facilities generating amalgam waste necessitates the use of amalgam separator(s) to minimize the level of mercury discharged to the City wastewater facility. This form will satisfy the one-time reporting requirement. Follow up reporting will be required only if additional or replacement amalgam separators are installed in the future. Dentists, or their agents, may complete and submit a copy of this form to satisfy the reporting requirements. If discharge from the dental office is not to the City of Waupaca or Chain o Lakes wastewater collection system, e.g., if the wastewater is discharged to a septic or other on-site treatment system, then notification of the separator installation is not required by the City. This form is not a permit and the dental facility owner/operator is responsible for compliance with al l other federal, state, and local regulations. Due Dates: For existing dental offices – The amalgam separator(s) must be placed in service no later than November 1, 2015. For dental facilities that begin operations after April 21, 2015 – The amalgam separators must be placed in operation prior to beginning of dental services and notification shall be submitted no later than 30 days following first operation. Replacement of amalgam separators - If an amalgam separator fails or is taken out of service, there can be no legal discharge to the City sewer system. Form Submission: Sections B through D of this notice must be completed and submitted to the City of Waupaca. Failure to install acceptable separators or to provide the required notification by the applicable due dates will result in noncomplianc e with the City ordinance. Please maintain a completed copy of this form with your records. Additional information pertaining to choosing an amalgam separator, recycling the amalgam waste, and best management practices is available from the Wisconsin Dental Association website at http://www.wda.org/dental-professionals/members- only/business-of-dentistry/regulatory/amalgam-dental-waste Return completed form to: CCiittyy ooff WWaauuppaaccaa Dental Amalgam Management Program 111 S. Main St. Waupaca, WI 54981 Page 2 of 2 Notice of Dental Amalgam Separator Installation (August 2015) B. Dental Facility Identification and Information Dental Practice or Facility Name _____________________________________________ Mailing Address__________________________________________________________ ________________________________________________________________________ Contact Name_________________________________ Phone _____________________ E-mail Address___________________________________________________________ ________________________________________________________________________ C. Amalgam Separator System Installation – Provide information for each separator: Date In Rated % Max Rated # of Dental Service Manufacturer Model Name/Number Removal Flow (gpm) Chairs Served ______ ____________ ________________ _______ __________ __________ ______ ____________ ________________ _______ __________ __________ ______ ____________ ________________ _______ __________ __________ ______ ____________ ________________ _______ __________ __________ ______ ____________ ________________ _______ __________ __________ Total number of separators at this facility _____ Total number of dental chairs at this facility______ D. Certification This facility has installed the appropriate amalgam separator(s). Separator operation, maintenance, and amalgam recycling is and will continue to be in accordance with applicable regulations. I certify under penalty of law that this document, and an y attachments, was prepared under my direction or supervision in accordance with a system designed to ensure that qualified personnel properly collected and evaluated 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, accurate and complete. _____________________________________ __________________________ _____________ Owner/Operator Name (please print or type) Owner/Operator Signature Date