### 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 Di strict for mercury discharge minimization. Satisfactory completion and submittal would constitute compliance with Administrative Order Part Three, Reporting Requirement A. Att ach additional pages if necessary.

Items denoted with an (*) are required

.

* Administrative Order No. 8021- _ _ _ _

* Office Address Mailing Addres s 

### ( 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 pl an 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 avai lable, that indicates compliance from January 1, 2007 through December 31, 2007 , such as hazardous waste hauling mani fests or bills of lading, must be

attached to this form. If this correspondence is not avai lable, 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 rema inder 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 assi stants or hygienists, cu rrently 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:20 0 7 An n u al R e po rt F o rm fo r De ntal Care Practices - Pa ge 2

The practice at this office doe s not handle dental amalgam.

The practice at this office handles dental am algam (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 amal gam, 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 id entified 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 longe r in the office):

Any monitoring results, includi ng 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 49 th 

### Street Cuyahoga Heights, OH 44125-1011
Attention: Mercury Program

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