Annual Report Form for Dental Care Practices 

This form may be completed and submitted by each dental care practice issued an administrative 

order by the Northeast Ohio Regional Sewer District for mercury discharge minimization. 

Satisfactory completion and submittal would constitute compliance with Administrative Order Part 

Three, Reporting Requirement A. Attach additional pages if necessary. 

Items denoted with an (*) are required.

*Administrative Order No. 8021- _ _ _ _ 

 *Office Address Mailing Address (if different from Office Address) 

*Number, Street Number, Street 

*City, Zip City, State, Zip 

*Telephone Number Email 

Fax Number (if applicable) Other contact information 

* Has this office installed an Amalgam Separator?  Yes  No 

If yes, when was it installed: ________________________________________________ 

Specify model and vendor: _________________________________________________ 

If no, does facility plan to install one?  Yes  No  Maybe 

* Name and Address of amalgam waste recycler and/or hazardous waste hauler through which 

amalgam waste is disposed________________________________________________________ 

______________________________________________________________________________ 

* Copies of any correspondence, if available, that indicates compliance from January 1, 2007

through December 31, 2007, such as hazardous waste hauling manifests or bills of lading, must be 

attached to this form. If this correspondence is not available, please indicate why _________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

* Have changes been made at this facility since December 31, 2006?  Yes  No 

 If yes, you must complete the remainder of this form. 

If no, it is not necessary to complete the remainder of this form, please sign and date the 

back of this form and send it to the address provided.

Names of all dental care practitioners, not including assistants or hygienists, currently or expected 

to be practicing at this office: 

 

Specify the days of the week and hours each day that this office is in operation: 

Please make a check mark in each appropriate box below and provide, where appropriate, the 

requested information to the best of your ability: 
2007 Annual Report Form for Dental Care Practices - Page 2 

 The practice at this office does not handle dental amalgam. 

 The practice at this office handles dental amalgam (such as extracting amalgam or teeth 

containing amalgam) and is implementing all best management practices (BMPs) specified in 

its BMP Plan submitted to the Northeast Ohio Regional Sewer District. 

 The practice at this office handles dental amalgam, but the following BMPs specified in its 

BMP Plan are not being implemented for the following reason(s): 

 

 

 The practice at this office is implementing the following additional BMPs that were not 

specified in its BMP plan: 

 Other changes in the information previously provided in this practice’s BMP Plan are 

described below and/or attached to this form: 

___________________________________________________________________________ 

 Potential sources of mercury have been identified in this office. These include:

Wastes from evacuation system Fluorescent bulbs 

Extracted amalgam Mercury-containing switches 

Extracted teeth containing amalgam Mercury-containing thermostats 

Amalgam capsules (including scrap) Thermometers 

Liquid mercury Sphygmomanometers 

Other:___________________________________________________________

 The following potential sources of mercury have been eliminated from this office (including 

any from above that are no longer in the office): 

 

 Any monitoring results, including any information indicating the effectiveness of implemented 

BMPs, are summarized below and/or attached to this form: 

 

* Your Name (printed): 

* Your Signature: Date: 

The annual report for the practice at this office is due no later than March 1, 2008 and should 

be sent to the address below: 

Northeast Ohio Regional Sewer District 

4747 East 49th Street 

Cuyahoga Heights, OH 44125-1011 

Attention: Mercury Program

Please attach any other information pertinent to mercury reduction efforts at this facility.