Page 1 of 2 

### New York State Department of Environmental Conservation 

# Notice Of Dental Amalgam Separator Installation (May 2006)



### _________________________________________________________________________________ 

# A. Instructions Purpose and Use of this Form: State regulation requires that all dental facility wa ters likely to come into contact with amalgam waste must be treated prior to discharge by an amalgam separato r meeting certain specifications. If the discharge is to a sewa ge treatment works, written notification must be provided to th e 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 pl aced 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 th e wastewater is discharged to an on-site septic tank/leachfield, then notification of separator installation is not required by this re gulation. Please note that this form is not a permit and that the dental facility owner/operator is responsible for compliance w ith 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 s ubmitted 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 discharg e from the affected portion of the facility until the separator is replaced. Notification for replacement separators must be s ubmitted 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 acceptabl e separators or to provide the required notification by the app licable due dates will result in noncompliance with the regulation and po ssible 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 wo rks or who to send the notification to, search the telephone boo k blue pages for the municipality (city/town/village/county) wher e the dental facility is located under headings such as “Environment”, “Public Utilities”, “Sanitation”, “Sewer”, or “Wat er 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 re quirements 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 informati on on mercury are available on the NYSDEC website at www.dec.state.ny.us/website/dow/mercury.html
.



### ___________________________________________________________________________________ 

# B. Reason For Submission FNotification for a dental facility operating on May 12, 2006 FNotification 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 __________________________________

___________________________________________________________________________________Page 2 of 2 

### 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 sepa rator(s). Separator design, in stallation, maintenance, and amalgam recycling is and will continue to be in accordance with applicable regulations. I certify under penalty of law that thi s document, and any attachments, was prepared under my direc tion 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, accu rate, and complete. I am aware that there are significant penalties for submitting false information, including the possi bility of fine and imprisonment for knowing violations.



### ________________________________ _______________________________ _______________ Owner/Operator Name (please print or type) Owner/Operator Signature Date