LISTING OF EXISTING SEPARATORS OR EQUIVALENT DEVICES CURRENTLY IN USE AT FACILITY MY FACILITY OPERATES AN AMALGAM SEPARATOR Manufacturer/Make Model Vendor/Supplier Installation Date 1. 2. 3. 4. MY FACILITY OPERATES AN EQUIVALENT DEVICE Description of any amalgam removal device(s) currently operated with amalgam removal percentage equivalent to ISO 11143 compliant amalgam separators: Manufacturer/Make Model Vendor/Supplier Installation Date 1. 2. 3. 4. Documentation of amalgam solids removal percentage performance test results compliant with specifications of § 441.30(a)(2)(i) (iii) is attached to this Report – DESIGN, AND MAINTENANCE OF AMALGAM SEPARATOR/EQUIVALENT DEVICE I certify that the amalgam separator(s) or equivalent device(s) in use at this dental facility is (are) designed and will be operated and maintained to meet the requirements in § 441.30 or § 441.40. THIRD PARTY SERVICE PROVIDER INFORMATION Name of third-party service provider that maintains the amalgam separator(s) or equivalent device(s), if applicable: If no third-party provides service, give a brief description of the practices employed by the facility to ensure proper operation and maintenance or amalgam separators in accordance with § 441.30 or § 441.40: BEST MANAGEMENT PRACTICES (BMPS) I certify that this dental facility is implementing BMPs specified in section §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 chair 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).
LISTING OF EXISTING SEPARATORS OR EQUIVALENT DEVICES CURRENTLY IN USE AT FACILITY MY FACILITY OPERATES AN AMALGAM SEPARATOR Manufacturer/Make Model Vendor/Supplier Installation Date 1. 2. 3. 4. MY FACILITY OPERATES AN EQUIVALENT DEVICE Description of any amalgam removal device(s) currently operated with amalgam removal percentage equivalent to ISO 11143 compliant amalgam separators: Manufacturer/Make Model Vendor/Supplier Installation Date 1. 2. 3. 4. Documentation of amalgam solids removal percentage performance test results compliant with specifications of § 441.30(a)(2)(i) – (iii) is attached to this Report DESIGN, AND MAINTENANCE OF AMALGAM SEPARATOR/EQUIVALENT DEVICE I certify that the amalgam separator(s) or equivalent device(s) in use at this dental facility is (are) designed and will be operated and maintained to meet the requirements in § 441.30 or § 441.40. THIRD PARTY SERVICE PROVIDER INFORMATION Name of third-party service provider that maintains the amalgam separator(s) or equivalent device(s), if applicable: If no third-party provides service, give a brief description of the practices employed by the facility to ensure proper operation and maintenance or amalgam separators in accordance with § 441.30 or § 441.40: BEST MANAGEMENT PRACTICES (BMPS) I certify that this dental facility is implementing BMPs specified in section §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 chair 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).
WPCP-FCD-0086.docx