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New York State Department of Environmental Conservation 

Notice Of Dental Amalgam Separator Installation (May 2006) 

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A. Instructions 

Purpose and Use of this Form: State regulation requires that all dental facility waters likely to come into contact with amalgam

waste must be treated prior to discharge by an amalgam separator meeting certain specifications. If the discharge is to a sewage

treatment works, written notification must be provided to the appropriate sewage treatment works or sewer authority. 

This form is intended to provide a consistent format for dentists to satisfy this one-time reporting requirement. Follow-up

reporting by dentists is only required when new separators are placed in service. Dentists may complete and submit a copy of

this form to satisfy the reporting requirement. Alternatively, dentists may use another format which is consistent with the

requirements specified in 6NYCRR 374-4. 

If the discharge is not to a sewage treatment works, e.g. if the wastewater is discharged to an on-site septic tank/leachfield, then

notification of separator installation is not required by this regulation. Please note that this form is not a permit and that the dental

facility owner/operator is responsible for compliance with all other federal, state, and local regulations. 

Due Dates: For dental facilities operating on May 12, 2006 - The amalgam separator(s) must be placed in service no later than

May 12, 2008 and notification must be submitted no later than June 11, 2008. For dental facilities that begin operations after

May 12, 2006 - The amalgam separator(s) must be placed in service prior to beginning operation and notification must be

submitted no later than 30 days following first operation. Replacement of separators - If an amalgam separator fails or is

otherwise taken out of service then there may be no discharge from the affected portion of the facility until the separator is

replaced. Notification for replacement separators must be submitted no later than 30 days following their installation. 

Form Submission: All sections must be completed and submitted to the sewage treatment works or sewer authority that the

dental wastewater is tributary to. Failure to install acceptable separators or to provide the required notification by the applicable

due dates will result in noncompliance with the regulation and possible enforcement action. Please maintain a completed copy

of this form with your records. Please do not submit a copy of this form to NYSDEC unless directed to do so by NYSDEC

staff. 

If you are unsure if your discharge is to a sewage treatment works or who to send the notification to, search the telephone book

blue pages for the municipality (city/town/village/county) where the dental facility is located under headings such as

“Environment”, “Public Utilities”, “Sanitation”, “Sewer”, or “Water Pollution Control”. Call them and based on your location

their staff should be able to assist you. 

Additional Information: Please note that there are also other regulatory requirements applicable to dentists including, but not

limited to: dental amalgam waste storage; recycling of dental amalgam waste and elemental mercury; record keeping and

inspection; and, prohibitions on certain activities. A copy of this form, the dental amalgam regulations, and general information

on mercury are available on the NYSDEC website at www.dec.state.ny.us/website/dow/mercury.html .

___________________________________________________________________________________

B. Reason For Submission

F Notification for a dental facility operating on May 12, 2006 

F Notification for a dental facility that began operating after May 12, 2006 

Specify date that dental facility operation began ______________________

Name of applicable sewage treatment works/sewer authority __________________________________

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New York State Department of Environmental Conservation 

Notice Of Dental Amalgam Separator Installation (May 2006) 

__________________________________________________________________________________

C. Dental Facility Identification and Information

Dental Practice or Facility Name _________________________________________________________

Mailing Address ______________________________________________________________________

City _______________________________ State______________________ Zip__________-_______

Facility Street Address (Not P.O. Box) ___________________________________________________

Municipality (City/Town/Village) ___________________________ County _____________________ 

Contact Name ___________________________________________ Phone ______________________ 

Email Address ___________________________________________ 

___________________________________________________________________________________

D. 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_____

________________________________________________________________________________

E. Certification

This practice/facility has installed an appropriate amalgam separator(s). Separator design, installation, 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 any attachments, was prepared under my direction or supervision in accordance with a system designed to

assure that qualified personnel properly gathered 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 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.

________________________________ _______________________________ _______________

Owner/Operator Name (please print or type) Owner/Operator Signature Date