2010 - 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)

*Dentist’s Name

Dentist’s Name

*Number, Street

Number, Street

*City, Zip

City, State, Zip

*Telephone Number

Telephone Number

Fax Number (if applicable) Email

Email Other contact information

* Has this office installed an Amalgam Separator? Yes No

If yes, when was it installed:_________________________________________________

Specify model and vendor: __________________________________________________

* 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, 2010

through December 31, 2010, 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, 2009?

• 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:

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, 2011 and should be

sent to the address below:

Northeast Ohio Regional Sewer District

4747 East 49

th

Street

Cuyahoga Heights, OH 44125-1011

216-641-6000

Attention: Mercury Program

Mercuryprogram@neorsd.org

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