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Dental Amalgam Survey

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ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS

To Comply with 40 CFR 441.50


The United States Environmental Protection Agency (EPA) has promulgated pretreatment standards to reduce discharges of mercury from dental offices into publicly owned treatment works {POTWs}. The Dental Office Category regulation is codified in 40 CFR Part 441. Dental offices that place or remove amalgam must operate and maintain an amalgam separator and must not discharge scrap amalgam or use certain kinds of line cleaners. The effective date of the rule is July 14th, 2017. Some dental facilities are not required to submit a one­time compliance report.  See the applicability section (§ 441.10) to determine if your facility is required to submit a one-time compliance report.

The City of Fort Lauderdale provides wastewater services to the City of Wilton Manors, portions of the Town of Davie, City of Oakland Park, Port Everglades, Township of Lauderdale by the Sea, City of Tamarac, and some sections of Unincorporated Broward County. If you are a Dental office/facility, the City of Fort Lauderdale kindly requests your full cooperation in completing and submitting this form promptly.
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General Information
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General Information
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Mailing Address
Mailing Address
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Facility Contact
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Facility Contact

Applicability: Please Select One of the Following

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1. 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
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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

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

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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).
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).