PWSD Form Center

2. 
4. Section 1 - Business Name and Address(es)
6. Annual Report Year:
   -- Select One --20212022202320242025
10. Name of Dental Facility:
11. Phone Number:
13. Email:
14. Fax Number:
16. Dental Facility Address:
17. Mailing Address:
19. Dental Facility City:
20. Dental Facility Zip Code:
21. Mailing City:
22. Mailing Zip Code:
24. Name of Business Owner(s) and Operator(s)
26. Name and Title of Primary Contact for Amalgam Issues:
28. Type of Dentistry (Description of Operation):
30. Section 2 - Best Management Practices (BMP's)
    A response is required for each BMP listed below.
32. Best Management Practices
34. 1. Use pre-capsulated, single-use amalgam capsules.*
    -- Select One --YesNoN/A
36. 2. All dental chairs are equipped with chair-side traps and all vacuum pumps are equipped with traps or filters.*
    -- Select One --YesNoN/A
38. 3. All equipment is cleaned and maintained in accordance with the manufacturer's instructions. *
    -- Select One --YesNoN/A
40. 4. Staff amalgam-handling training has been recently conducted and logged.*
    -- Select One --YesNoN/A
42. 5. Use non-chlorine, non-oxidizing disinfectants and neutral cleaners with a pH between 6-8 (please review your product's SDS for compliance).*
    -- Select One --YesNoN/A
44. 6. Screens, filter, traps or amalgam separators or any other amalgam-containing equipment are not rinsed over sinks or drains. *
    -- Select One --YesNoN/A
46. 7. Salvage, store, and recycle scrap amalgam (used disposable amalgam capsules, contact and non-contact amalgam scrap, and extracted teeth) in structurally sound, tightly closed and appropriately labeled containers. *
    -- Select One --YesNoN/A
48. 8. Recycle all bulk mercury and all amalgam waste by transferring the waste to an off-site recycling facility for recycling of mercury or manage and dispose of the waste in accordance with the applicable federal, state and local hazardous waste laws and regulations. AT NO TIME SHOULD AMALGAM WASTE BE DISPOSED OF OR FLUSHED DOWN THE DRAIN OR TOILET.*
    -- Select One --YesNoN/A
50. Please explain any "NO" or "N/A" responses:
52. Section 3 - Operations and Maintenance (O&M) Plan
    Each Dental Facility shall develop an O&M Plan to ensure proper operation and maintenance of all Amalgam Separators and documentation of all maintenance activities. The O&M Plan and service records must be maintained for a minimum of three (3) years and will be made available to PWSD upon request.
54. Are you in a facility with more than one dentists?
55. If yes, who is the owner of the amalgam separator? If not please type N/A.
57. Operations and Maintenance Plan: *

    Attach a copy of your Operations and Maintenance Plan. If you do not have one please attach a document stating why you do not have one. 

59. My third-party service provider maintains our separator and can readily provide a copy of our Operations and Maintenance Plan.
    -- Select One --YesNo
61. (If 3rd Party Vendor is used): Business Name of Vendor and Contact Name:
    (Please enter both the business name and the name of the best person to contact)
62. Vendor Phone:
64. Section 4 - Amalgam Separator System Installation
    Provide information for each separator
66. Separator #1
68. Manufacturer of Separator:
69. Model Name & Number:
71. Separator Serial Number:
72. Is the separator ISO 11143 certified?
    -- Select One --YesNo
74. Year of Installation:
75. Number or Chairs:
77. Separator #2
79. Manufacturer of Separator:
80. Model Name & Number:
82. Separator Serial Number:
83. Is the separator ISO 11143 certified?
    -- Select One --YesNo
85. Year of Installation:
86. Number or Chairs:
88. Section 5 - Amalgam Separator Maintenance and Operation
90. All wastewater that contains dental amalgam or other sources of mercury is discharged through the above mentioned separator(s) which is properly sized for flow. This dental facility properly maintains and operates the amalgam separator(s) in accordance with the manufacturer specifications, including necessary cleanings, cartridge of filter replacement and other required servicing. Additionally, monthly visual amalgam separator inspections are being conducted and logged. All logs including inspections and training logs, as well as detailed records of amalgam separator repair, replacement or maintenance, and amalgam recycling receipts, manifests, etc., will be maintained for a minimum of three (3) years and will be made available for review upon requests from PWSD.
    -- Select One --YesNo
92. Section 6 - Annual Dental Amalgam Report
94. "This dental facility has implemented and is complying with the required BMP's. Additionally, this dental facility has installed the necessary ISO-11143 amalgam separator(s), in accordance with requirements of PWSD's Dental Amalgam Control Program. I certify this document and all attachments were prepared under my direction or supervision to ensure that qualified personnel properly gather and evaluated the information submitted. I certify the information submitted is true, accurate and complete."
96. Authorized Representative*
    (type name of authorized representative)
97. Date*
    Date
99. Upload image, pdf, or word doc of signature*
Leave This Blank:


101. 1. Receive an email copy of this form.
102. Email address

     This field is not part of the form submission.

103. Submit

* indicates a required field