1 

Madison Metropolitan Sewerage District 

Mercury Pollutant Minimization Program (PMP) 

A) Summary 

The surface water quality criterion for mercury as specified in NR 106 is 1.3 ng/l (ppt). In 2002, 

DNR determined that utilizing wastewater treatment technology to achieve discharge 

concentrations necessary to meet the 1.3 ppt water quality standard would result in substantial 

and widespread adverse social and economic impacts. DNR further concluded that appropriate 

mercury source reduction activities are environmentally preferable to wastewater treatment 

technology, in many cases. Provisions in NR 106 allow DNR to establish alternative mercury 

effluent limitations, conditioned in part on the permittee agreeing to develop and implement a 

mercury pollutant minimization program (PMP). 

The District’s WPDES permit anticipates that the District will not meet the 1.3 ng/l criterion and 

that an alternate mercury effluent limitation would be necessary. The permit requires that a draft 

PMP be submitted to DNR by March 31, 2007. PMP implementation must begin by September 

30, 2007. In accordance with NR 106 and WPDES provisions, the District has developed and 

will implement a mercury pollutant minimization program. 

B) Background 

The District’s PMP recognizes and builds upon the significant voluntary efforts already 

undertaken by the District to address mercury contributions to the collection system. These 

efforts began in 1997, when the District was one of three wastewater treatment facilities that 

agreed to work with DNR to perform community outreach and education. Their goal was to 

minimize mercury use. During this time, District staff members worked cooperatively with 

POTW and recycling staff throughout Wisconsin and the Midwest to reduce mercury product 

usage and to encourage recycling of existing products. Today, District staff members uphold the 

minimization efforts by continually providing assistance to POTW staff and others as they are 

able. 

Prior to 1997, District staff members were aware of activities and devices within the treatment 

plant that were actual or potential sources of mercury to wastewater. Since 1997, the District has 

taken efforts to minimize the use of these sources. Staff members eliminated the use of a 

mercury compound as a catalyst in Kjeldahl nitrogen analysis and as the Nessler’s ammonia 

reagent. The electrical department collected mercury containing tilt switches and float balls for 

proper disposal and have removed thermometers and manometers from plant equipment 

wherever possible. In 1998, a recycling program was established for recycling fluorescent 

lamps, and District staff members also assisted in the clean up of a comminuter water seal 

mercury spill in recent years. 

The mass of mercury in the District’s influent has decreased significantly since the late 1980’s 

(Figure 1 and Appendix A). Factors contributing to this decrease include: product substitution, 

ordinance changes, mercury collection activities such as the Clean Sweep Program, and the 

additional outreach and education activities described in Appendix B. Biosolids mercury 

concentrations peaked in the mid 1980’s and have significantly decreased since then (Figure 2). 
2 

Figure 1: Influent Hg Mass Loads 

0

20

40

60

80

100

120

140

160

180

1987198919911993199519971999200120032005

Year

Hg Mass (grams/day)

Figure 2: GBT Biosolids Mercury Concentration

(Yearly Average)

0

2

4

6

8

10

12

14

19791981198319851987198919911993199519971999200120032005

Year

Hg concentration 

(mg/kg dry weight)

The average biosolids mercury concentration for 2006 (through September) is 1.1 mg/kg, well 

below the 17 mg/kg concentration limit used by the Wisconsin Department of Natural Resources 

to define “High Quality” biosolids. Efforts to reduce influent mercury concentrations have also 

impacted effluent mercury concentrations. 

 

The average effluent mercury concentration since testing began in March, 2004 using the EPA 

low level mercury method (Method 1631) is 2.3 ng/l (See Appendix C). While effluent 

concentrations are low, monthly grab samples have exceeded the 1.3 ng/l surface water criterion 

in all but one case since March, 2004. For comparison purposes, Appendix C also presents the 

monthly influent, effluent and biosolids mercury concentrations for the past 3 years and shows 

the average percent removal from the effluent. 

C) Current sources of mercury to collection system 

The daily influent mercury load to the Nine Springs Wastewater Treatment Plant in 2005 was 

24.4 grams, based on an average flow of 39.3 MGD and an average influent mercury 

concentration of 164 ppt. Using analytical data when available, along with values found in the 

literature, mercury loads have been estimated from residential, commercial, industrial and 

infiltration contributions and these estimations are given in Table 1. The commercial category 
3 

accounts for about 81 percent of the daily influent mercury load. The commercial load includes 

contributions from dentists, hospitals, schools and other sources. The mercury load from hauled 

wastes (e.g. septage, holding tanks, grease traps) was estimated at 1.3 grams per day, but was not 

included in Table 1 since septage enters the treatment plant after the influent sampling point. 

Table 1: Mercury Loads to MMSD influent 

Sector 

Flow 

(MGD) % of Total Hg conc. (ppt) (grams/day) % of base load

Residential 23.1 58.9 49 4.3 17.6 

Commercial 11.3 28.7 461a 19.7a 80.7 

Industrial 3.0 7.5 26 0.3 1.2 

Infiltration 1.9 4.8 20 0.1 0.6 

 

Subtotal 39.3 99.9 24.4 100.0 

 a Grams by difference, from known contributions. Hg concentration back calculated. 

D) PMP Focus 

DNR has developed a guidance manual to assist agencies with PMP development. DNR states 

that the manual is “intended solely as guidance and does not contain any mandatory 

requirements except where requirements found in statute or administrative rule are mentioned.” 

The guidance document specifically identifies dental clinics, hospitals, schools (primarily post 

secondary schools) and industry as sectors that should be addressed in a PMP. The District’s 

PMP focuses on controlling mercury contributions from all four of these sectors. The level of 

effort spent in addressing each of these sectors is commensurate with the magnitude of the 

contributions and the degree to which control can be accomplished using reasonable approaches. 

The PMP builds upon the considerable effort that the District has already voluntarily invested to 

control mercury contributions from these sectors. The District has also identified residential 

contributions as an additional targeted sector. The approach used to address mercury 

contributions from each of the above sectors is identified below: 

(i) Dental Sector 

The dental sector represents the largest controllable source of mercury to the District’s collection 

system, and therefore will receive the greatest focus in the initial PMP. Detailed sampling to 

characterize dental contributions has not been conducted, given the difficulties associated with 

sample collection and analysis. However, the District estimates that 45% to 68% of the total 

influent mercury load (56% to 84% of the commercial load) in 2005 was contributed by the 

dental sector (See Figures 3 and 4). 

This estimate is based on data from a variety of sources, including the District’s 2005/2006 

dental survey, information on “per dentist” mercury discharges reported in studies conducted by 

other agencies, and information on the mercury capture efficiencies of chair side traps and 

amalgam separators (60% and 98%, respectively). Actual contributions could be higher or 

lower, but the range is in reasonable agreement with figures cited by DNR and WDA. 
4 

Figure 3. Figure 4. 

 

Breakdown of Commercial Contributions 

(Based on low estimate of dental contribution)

Other=

8.6

grams/day

or 

44%

Dental=

11.1

grams/day

or 

56%

Other

Dentists

Breakdown of Commercial Contributions

 (Based on high estimate of dental contribution)

Other=

3.1 

grams/day

or 16%

Dental=

16.6

grams/day

or 84%

Other

Dentists

The District will address mercury contributions from the dental sector through four approaches: 

1. Require clinics that place or remove amalgam to follow WDA best management practices 

for amalgam wastes 

2. Require clinics that place or remove amalgam to install and maintain amalgam separators 

3. Conduct on-site inspections to evaluate BMP implementation and waste handling at 

dental facilities. Target will be 20% inspection rate of the dental clinics/year (100% 

during the five year WPDES permit cycle) 

4. Require clinics to complete and submit an annual form summarizing the status of 

amalgam separator installation/maintenance and implementation of BMP.

Data from the District’s 2005/2006 survey of dental clinics shows that there are 103 clinics in the 

service area that can be expected to place and/or remove significant amount of amalgam. These 

clinics are either general or pediatric clinics. Twenty three (23) of these clinics have already 

installed amalgam separators. 

Prior to PMP implementation, the District will revise its Sewer Use Ordinance to require dental 

clinics that place or remove amalgam to properly install and maintain ISO 11143 certified 

amalgam separators by December 31, 2008. The SUO will also require that these dental clinics 

implement WDA best management practices by December 31, 2008. A copy of the draft SUO is 

given in Appendix D. On-site inspections and annual reporting by the dental clinics will be used 

to document compliance with these requirements. Annual reporting by the dental clinics will be 

accomplished by completing a form developed by the District (Appendix E). The District 

reserves the right to revise this form as necessary to ensure that relevant and useful information 

will be obtained from the dental clinics. District staff will work cooperatively with the Dane 

County Dental Society to accomplish the above initiatives. 

(ii) Hospitals/Medical Sector 

Limited sampling data from 2006 at three hospitals in the District’s service area showed mean 

and median mercury concentrations of 394 ppt and 114 ppt, respectively. The median 

concentration is about 3.4 times higher than the median concentration from residential sources. 

There have been efforts within the medical sector to reduce mercury use. The District approach 

to addressing mercury contributions from the medical sector will focus primarily on information 
5 

and education efforts. District staff will initially meet with representatives from each of the four 

hospitals to determine each facility’s current status relative to mercury minimization activities. 

Each facility will be asked to provide a brief initial report summarizing steps already taken to 

address mercury contributions to the collection system and any additional steps (if any) that they 

anticipate taking. As part of this initial report, they will be asked to complete a best management 

practices checklist. At least one meeting will be held each subsequent year with appropriate 

hospital staff. Each hospital will also be asked to submit a letter or report on an annual basis 

summarizing mercury related activities and initiatives which have been undertaken during the 

previous year. 

(iii) School Sector 

School sector related activities will focus primarily on the post-secondary schools within the 

District’s service area. An emphasis will be placed on information and education activities, with 

the goal of minimizing mercury contributions to the collection system from these schools. 

District staff will initially meet with representatives from each of the three post-secondary 

schools in 2007 to discuss mercury related issues. Each facility will be asked to submit a brief 

report summarizing steps already taken to address mercury contributions to the collection system 

and any additional steps (if any) that they anticipate taking. Meetings will then be held with 

appropriate school staff on an annual basis. Each post-secondary school will be asked to submit 

a letter or report on an annual basis summarizing mercury related initiatives that they have taken 

during the past year. 

Elementary, middle and high schools within the District’s service area will initially be sent 

information on best management practices for mercury. Fact sheets to be sent to key staff 

members in public school districts will include: information on WDNR’s “Green and Healthy 

Schools” criteria, potential hazards of mercury, possible sources of mercury, and how to safely 

dispose of and recycle mercury. The targeted audiences will include maintenance or buildings 

and grounds managers (spill response, demolition of science rooms, inspection of drains and 

traps), lead nursing staff (fever thermometers and sphygmomanometers), and science curriculum 

coordinators (elimination of mercury-containing devices and chemicals). Additional information 

and education activities for these schools will be conducted on an “as needed” basis as 

determined by District staff. 

(iv) Industrial Sector 

Analytical testing over the last several years (since low level testing was initiated at MMSD) has 

shown no significant mercury discharges from the industrial community in our service area. 

Contributions from this sector are estimated to be approximately 1% of the total mass of mercury 

entering the wastewater system (Table 1). At no point over the last 10 years has any regulated 

industry violated the mercury limit in the District’s Sewer Use Ordinance. The District will 

continue to monitor the industrial sector as required by NR 211 for industrial pretreatment 

purposes. Permitted industries are inspected annually by the pretreatment coordinator. District 

staff will distribute informational materials to the industries during the annual inspection process. 

New industries/businesses that may be potential sources of mercury will be identified and 

addressed consistent with existing procedures in the District’s pretreatment program. 

(v) Residential Sector 

Testing during 2005-2006 of residential only wastewater type samples indicates a contribution of 

mercury from this sector that could account for nearly 18% of mass loadings to our treatment 

plant (Table 1). Given the diffuse nature of contributions from this sector, PMP control 
6 

strategies will focus on information and education activities. The District will continue to take 

advantage of partnerships with Clean Sweep and the EnAct (Environmental Action Teams) 

program, which is organized by the Madison Environmental Group. EnAct teams are formed on 

a neighborhood basis, with a key objective of encouraging and empowering team members to 

take actions in their daily lives to reduce the environmental impact of their households. In 

accordance with NR106, District information and education activities will alert the sectors, 

particularly the public, to mercury recycling opportunities via Clean Sweep, vendors, and special 

programs (e.g. TRC-Thermostat Recycling Corporation) for lamps, thermostats, and other 

mercury-containing products. 

Information and education activities deemed reasonable and appropriate will be undertaken by 

the District. Options include: 

• Bill insert to customers 

• Informational page insert in local newspapers 

• Informational meetings 

• Displays at Home Shows 

• Interview with local TV 

• Brochures provided at plant tours 

• Participate in mobile collection events 

• Establish informational web-site 

• Partner with Dane County Department of Public Works and Recycling 

The Wisconsin PMP guidance document identifies fluorescent bulbs, auto switches and 

thermostats as known sources of mercury. Fluorescent bulb recycling is already addressed in a 

Dane County ordinance and will not be addressed in the District’s PMP other than as part of the 

publication of information on recycling opportunities. Auto switches and thermostats will be 

addressed through information and education activities. 

Planned collection system monitoring is not being considered for the first years of the District 

mercury PMP. The PMP, as presented herein targets known major sources; collection system 

monitoring can be performed, as situations present themselves, for identifying general loadings 

from residential areas or perhaps from targeted business/industrial developments. 

E) Data Management 

A database developed in-house dedicated to the mercury PMP is functional and will be further 

developed to manage contact data, facility identification and practices, survey data, and report 

generation. Relevant summary data may be provided in annual reports submitted to DNR. 

Detailed information will be available upon request. 

F) Resources 

The District will allocate resources as necessary to effectively implement this PMP. PMP efforts 

will be led by the District’s Pretreatment and Waste Acceptance Coordinator. Laboratory staff 

will play a key role in multiple areas, including sample collection/analysis, inspection of dental 

clinics, and information/education activities with other sectors. Database development to 

support PMP activities will be led by Information Services staff. Administrative Services staff 

will be responsible for administrative tasks including preparation of informational materials, plan 

evaluation, record keeping and annual reporting. Other staff will be involved in PMP related 
7 

activities on an as needed basis. Monetary needs will be identified during the District’s annual 

budgeting process and allocations will be made as appropriate.

G) PMP Goals 

Sector specific initial goals for the PMP are given below. The goals may be revised as 

experience is gained in implementing the PMP. 

1) Dental Sector 

a. 100% compliance with WDA BMPs by December 31, 2008 

b. 100% compliance with the amalgam separator installation requirement by 

December 31, 2008 

c. 20% inspection rate annually 

2) Hospitals/Medical Sector 

a. Hold annual meetings with hospital personnel 

b. Receipt of Hg PMP and/or annual report received from all hospitals by December 

31, 2007 

c. Scheduled inspection rate of 25% 

3) Schools 

a. Hold annual meetings with each post-secondary facility 

b. Receipt of Hg PMP and/or annual report received from all post-secondary schools 

by December 31, 2007 

c. Send mercury fact sheets 

4) Industrial 

a. Distribute a mercury fact sheet to permitted industries during annual inspections 

5) Residential 

a. Provide mercury reduction resource information to ENACT on an annual basis for 

publication/distribution in newsletters 

b. Cooperate in mercury reduction activities with the Clean Sweep Program 

c. Participate in information and education activities as appropriate throughout the 

year. Examples could include posting information on the District’s web site and 

providing mercury reduction information to District customers for inclusion in 

water and sewer bills 

The timeline for key milestones (through December, 2008) of the PMP is given below. The 

dates shown for PMP submittal by the District, subsequent approval by DNR, and submittal of 

the first annual report are consistent with dates specified in the District’s WPDES permit. 
8 

H) Timeline 

I) Annual Report to DNR 

An annual report summarizing PMP activities conducted by the District during the previous 

twelve (12) month period will be submitted to DNR by March 31st of each year. The first report 

will be submitted by March 31, 2008. Annual reports will include the following information: 

 

1) Analytical data for effluent, influent and biosolids 

2) Staffing and other resources allocated to the mercury PMP effort 

3) Progress made towards reaching the goals within the specific sectors (See Section F) 

4) New and/or revised PMP goals 

5) District contact information 

Where reasonable and appropriate, forms provided in DNR Mercury PMP Guidance Document 

or the functional equivalent will be used when submitting information in the annual report. 

Revisions/adjustment to the approaches identified in previous sections of this PMP may be 

necessary based on experience gained during implementation of the PMP. Revisions, if 

necessary, will also be identified in the annual reports. 

3/31/07 6/30/07 9/30/07 12/31/07 3/31/08 6/30/08 9/30/08 12/31/2008

WDA BMP’s Compliance 

Date 

100% Separator Installation 

Newsletters out to Dental, 

Hospital, & School Sectors. 

Request 

Annual Reports 

from Hospitals 

and Schools 

Educational 

Mailer Sent 

Out to Sectors 

Acceptance of PMP by DNR 

& Implementation of BMP’s 

Meet with 

Hospitals & Schools 

PMP 

Submitted to 

DNR for 

Review and 

Approval 

Hold 1st Dental 

Assessments 

Run a preliminary 

audit of BMP status 

in different sectors 

Dental 

Sector 

Reminder 
9 

Appendix A 

Nine Springs Wastewater Treatment Plant 

Influent Mercury Loadings (1987-2005) 

Year Flow (MGD) Average 

Mercury 

Concentration 

(ppb)

Influent 

Mercury 

Loading 

(grams/day)

1987 35.86 1.13 153 

1988 34.94 0.99 131 

1989 34.49 0.85 111 

1990 34.92 0.92 122 

1991 36.83 0.93 130 

1992 36.77 0.93 85 

1993 42.69 0.36 58 

1994 39.53 0.34 51 

1995 39.18 0.27 40 

1996 39.56 0.26 39 

1997 38.03 0.41 59 

1998 41.16 0.25 39 

1999 41.53 0.25 39 

2000 42.10 0.33 53 

2001 41.76 0.33 52 

2002 40.14 0.44 67 

2003 38.56 0.29 42 

2004 42.96 0.27 43 

2005 39.32 0.16 24 
10 

Appendix B 

Summary of District Efforts to Reduce Influent Mercury Loadings 

The following is a list of mercury reduction activities that the District has been involved 

in over the last fifteen years, in an effort to bring about reductions in the level of mercury 

entering wastewater. 

 

• “Charter Member” DNR Community Mercury Reduction Group 

• Informational insert distributed to Madison area residents (70,000+) 

• Thermometer exchanges. (4900 collected). Included groundbreaking work at 

pharmacies 

• Safety Saturday (collected 274 thermometers, 33 thermostats, 20 other) 

• Dane County, and local ordinances to ban sale of thermometers, 2000 

• Local ordinance requiring acceptance of fluorescent lamps and Hg thermostats at 

retailers 

• 1997 Wisconsin Mercury Round Up 

• P2 week 

• Sierra Club letter 

• NARI Home Remodeling Expo 2001 

• 3/23/01 news conference at MMSD 

• Informational newsletters 

• Educational plant tours to UW and Edgewood Nursing students 

• Talks given at elementary schools 

• Brochures 

• Cooperative work Clean Sweep 

• WORT radio interview held 

• Mailings distributed to schools 

• Mailings distributed to medical facilities 

• Several informational meetings with Dane County Dental Society (DCDS) 

• Letters and other outreach published in DCDS monthly newsletter 

• Surveys distributed to dental facilities in our treatment area, summer 2005 

• Alternative laboratory method developed, eliminating use of mercury in our lab 

• Elimination of mercury from chemical storage areas in lab 

• MMSD electrical department identifying and recycling pressure and temperature 

gauges and tilt switches 
11 

Appendix C 

Nine Springs Wastewater Treatment Plant 

Influent, Effluent and Biosolids Mercury Concentrations 

 (March 2004* to September 2006) 

 

Month Year 

Influent 

(ppt) 

Effluent 

(ppt) 

% 

Removal 

GBT Biosolids 

(mg/kg dry wt.) 

March 2004 253 2.16 99.1 1.0 

April 2004 211 1.58 99.3 1.1 

May 2004 314 2.89 99.1 1.2 

June 2004 210 1.55 99.3 1.9 

July 2004 213 2.64 98.8 1.7 

August 2004 209 1.72 99.2 1.5 

September 2004 164 1.54 99.1 1.5 

October 2004 1.4 

November 2004 176 2.80 98.4 1.6 

December 2004 142 1.92 98.6 1.2 

 2004-Ave 209 2.11 99.0 1.4 

 

January 2005 227 1.95 99.1 1.5 

February 2005 173 2.20 98.7 1.1 

March 2005 149 2.04 98.6 1.1 

April 2005 75 2.32 96.9 2.2 

May 2005 246 1.97 99.2 1.1 

June 2005 136 1.10 99.2 1.8 

July 2005 161 2.17 98.7 2.5 

August 2005 149 1.98 98.7 1.5 

September 2005 236 1.89 99.2 1.5 

October 2005 133 6.54 95.1 1.3 

November 2005 160 2.68 98.3 1.5 

December 2005 126 2.28 98.2 1.4 

 2005-Ave 164 2.43 98.4 1.5 

 

January 2006 110 4.96 95.5 1.0 

February 2006 209 1.86 99.1 1.0 

March 2006 136 1.86 98.6 1.0 

April 2006 117 1.47 98.7 1.1 

May 2006 98 2.42 97.5 0.9 

June 2006 192 2.65 98.6 1.1 

July 2006 128 1.82 98.6 1.3 

August 2006 276 1.37 99.5 1.0 

September 2006 181 2.93 98.4 1.1 

2006-Ave 161 2.37 98.3 1.1 

* Low level testing of effluent by EPA Method 1631 began in March, 2004 
12 

Appendix D 

Sewer Use Ordinance Language Regarding Amalgam Separator 

Installation/Maintenance and Implementation of Wisconsin Dental Association 

BMPs for Amalgam Waste 

Section 5.1.6 Discharges from dental clinics 

(a) This section applies to discharges from dental clinics where amalgam is placed or 

removed. This section does not apply to the specialties orthodontics, periodontics, oral 

and maxillo-facial surgery, endodontics, prosthodontics or to other clinics that do not 

place or remove amalgam, or which are identified by the District as de-minimus 

contributors. For the purpose of this section, a dental clinic is defined as a non-mobile 

facility dedicated to the examination and treatment of patients by healthcare professionals 

specializing in the care of teeth, gums, and oral tissues. 

(b) Within the shortest reasonable time, but no later than (INSERT DATE if not December 

31, 2008), dental clinics that place or remove amalgam shall implement best management 

practices for amalgam as established by the Wisconsin Dental Association. 

(c) Within the shortest reasonable time, but no later than (INSERT DATE if not December 

31, 2008), dental clinics shall install, operate and maintain an amalgam separator meeting 

the criteria of the International Standards Organization (ISO 11143) for every vacuum 

system receiving amalgam waste. Amalgam separators shall be installed, operated, and 

maintained according to instructions provided by the manufacturer. The amalgam 

separator shall have a design and capacity appropriate for the size and type of vacuum 

system. 

(d) If a dental clinic is implementing the requirements in 5.2.5(b) and 5.2.5(c), any numerical 

discharge limit for mercury established in this chapter does not apply.

(e) Starting (INSERT DATE if not June 1, 2007) and annually thereafter, dental clinics will 

submit reporting information to the District using forms provided by the District. 

Reporting information will include: 

1. The date the amalgam separator was installed 

2. The manufacturer name and model number of the separator 

3. Certification that the amalgam separator was installed and is being operated and 

maintained in accordance with instructions provided by the manufacturer. 

4. Certification that best management practices for amalgam as established by the 

Wisconsin Dental Association are being implemented. 

5. The person responsible for assuring compliance with the Amalgam Separator 

requirements in the District’s Sewer Use Ordinance. 

(f) Dental clinics shall obtain records from the contractors used to remove amalgam waste 

for each shipment. The records shall show the volume or mass of amalgam waste 

shipped, the name and address of the destination, and the name and address of the 

contractor. Dental clinics shall maintain these records for a minimum of three years. 
13 

(g) Dental clinics shall allow the District to inspect the vacuum system, amalgam separator, 

amalgam waste storage areas, and other areas deemed necessary by the District to 

determine compliance with this section. Inspections shall occur by appointment during 

the normal operating hours of the dental clinic as long as advance notice does not impede 

enforcement of this section. 
14 

Appendix E 

Dental Facility Mercury Checklist 

Best Management Practices are those defined by the WDA and Installation, Operation, and Maintenance of an 

Amalgam Separator meeting ISO 11143 Standards. 

Facilities complying with the WDA Criteria and the installation/maintenance of an amalgam separator meeting ISO 11143 

standards shall be considered in compliance with the local sewer use ordinance limit for mercury. It is the intention of the 

Mercury Pollutant Minimization Program to encourage implementation of mercury BMPs. 

If you do not place or remove amalgam fillings, check here_____ sign the bottom of the form, and return it to the following 

address: 

Directions: Please check either YES or NO, and fill in the date field for each question. When answering YES fill in the date 

when the BMP was fully implemented in the DATE column. When answering NO (a BMP is not fully implemented) fill in the 

date anticipated in the DATE column. 

 YES NO DATE 

 mm/dd/year 1. Has all bulk mercury been eliminated from your stock at your 

 dental clinic? 

 2. Does your dental clinic use precapsulated alloys? 

 3. Does your dental clinic recycle disposable amalgam capsules? 

 4. Does your dental clinic capture and recycle non-contact scrap 

 amalgam? 

 5. Does your dental clinic capture and recycle contact amalgam 

 including the contents of chair-side traps? 

 6. Does your dental clinic recycle contact amalgam retained by 

 the vacuum pump filter? 

 7. Does your dental clinic disinfect and recycle extracted teeth 

 with amalgam fillings? 

 8. Does your dental clinic use non-chlorine, non-bleach line 

 cleaners that minimize the dissolution of amalgam? 

 9. Does your dental clinic have and maintain an amalgam 

 separator meeting ISO standards? 

9a. If you currently have an amalgam separator, please provide us with the following information. 

 

Manufacturer: 

______________________________________________Model:___________________________ 

Date Installed: 

9b. Name and address of vendor where amalgam is recycled: 

Comments: 

I have personally examined and am familiar with the information submitted in this document and attachments. Based upon 

my inquiry of the individuals immediately responsible for obtaining the information reported herein, I believe that the 

submitted information is true, accurate and complete. 

Name of Facility _______________________________________________________________________ 

Address _______________________________________________________________________ 

Phone _________________________________Fax___________________________________ 

Email of Contact Person _______________________________________________________________________ 

_____________________________________________________________________________________________

Printed Name Signature Title Date 

MMSD 

Attn: Pretreatment Dept. 

1610 Moorland Rd. 

Madison, WI 53713