HomeMy WebLinkAbout96.Item 4 Handouts LaPA 09-11-2017 - Compliance Reports.pdf ORANGE COUNTY SANITATION DISTRICT (OCSD)
LIMITED DENTAL DISCHARGER COMPLIANCE REPORT
Dental facilities that do not place dental amalgam,and do not remove dental amalgam except in limited emergency or unplanned,
unanticipated circumstances are exempt from any further requirements of the Dental Office Point Source Category if they certify
such in their Compliance Report to their Control Authority. By limited circumstances, EPA means dental offices that remove
amalgam at a frequency less than five percent of its procedures(this percent approximates to 9 removals per office per year). A
dental facility that stocks amalgam capsules clearly intends to place amalgam, and therefore does not quality for the limited
circumstance exemption. A dental office that initially certifies as a Limited Dental Discharger and subsequently begins to stock
amalgam capsules, or increases the amalgam removal frequency to more than five percent of its procedures, must install an
amalgam separator or equivalent treatment in accordance with the Dental Category Rule, and submit OCSD's comprehensive
Dental Discharger Compliance Report form.
DENTAL FACILITY INFORMATION
Exrsbng Source:"a.t New Source:aect
Date facility began operating:
Dental facility name:
Facility address:
Facility city: Zip code:
Mailing address:
Mailing city,state: Zip code:
On-site contact name:
Contact hone:
Contact email:
EXEMPTIONS
If your facility falls under one or more of these exemptions, please check all that apply. If none of these
exemptions apply to your facility,you must complete OCSD's Dental Discharger Compliance Report.
❑ 44L30(c)
The facility indicated in dental facility information above exclusively practices one or more of the following
dental specialties: Oral pathology,oral and maxillofacial radiology,oral and maxillofacial surgery,
orthodontics,periodontics,or prosthodontia.
❑ 44LIO(d)
The facility indicated in dental facility information above is a mobile unit operated by a dental discharger.
41L10(e)
The facility indicated in dental facility information above does not discharge any amalgam process
wastewater to the Orange County Sanitation District's sewer system, but collects all dental amalgam
process wastewater for transfer off-site to a facility that treats the waste(like a Centralized Treatment
Facility).
❑ "L10(f)
The facility indicated in dental facility information above is a Dental Discharger that does not place dental
amalgam,and does not remove amalgam except in limited emergency or unplanned,unanticipated
circumstances.
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OWNERSHIP INFORMATION
(owner/partner title
(owner/partner) title
(owner/partner) (title)
(owner/partner) title
(owner/partner title
(owner/partner) title
(owner/partner) (title)
(owner/partner) tide
(owner/partner) title
(owner/partner) title
CERTIFICATION STATEMENT
,of
Print Name Print Title
O am a responsible corporate officer ea z,a general partner or proprietor(if the the partnership or sole proprietorship),or
O am a duly authorized representative eel a in accordance with the requirements of 40 CFR 403.12(I),
certify under penalty of law that the above named dental facility does not place dental amalgam and does not
remove dental amalgam, except in limited emergency or unplanned, unanticipated circumstances. I
certify under penalty of law that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
information submitted. Based on my inquiry of the person or persons who manage the system, or those
persons directly responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief,true, accurate, and complete. I am aware that there are significant penalties for submitting
false information,including the possibility of fine and imprisonment for knowing violations.
Authorized Representative Signature 80..4 Date
(R".n,Gve s"anuo,)
When mmpletM,print,sign dat,make a copy 'MIDI save a cop/of this For
for your records,'^s and mail original m: and e-mail Eo:
oranxe county sanitation Dintrin pentalon¢epoma..
DBntal Amalgam Progam
10W Ellis Avenue
Fountain valley.rA 927M Page 2 of 3
REFERENCES
1. Existing Source or New Source Determination-Dental facilities operating prior to July 14,2017 are considered
an Existing Source(PSES)and must submit the compliance report by October 12,2020. New Dental Dischargers
who open for business on or after July 14, 2017 are considered a New Source(PSNS) and must submit the
compliance report to OCSD within 90 days of discharging to the sanitary sewer system(New Source does not
include an ownership change). An Existing Source that changes ownership is required to submit a new
compliance report within 90 days.(BACK)
2. Responsible Corporate Officer(Authorized Representative)
a) If the applicant or User is a corporation:
(1) The president, secretary, treasurer, or a vice president of the corporation in charge of a principal
businessfunction,oranyother person who performs similar policy or decision making functions for the
corporation;or
(2) The manager of one or more manufacturin&production, or operation facilities, provided the manager
is authorized to make management decisions that govern the operation of the regulated facility
including having the explicit or implicit duty of making major capital investment recommendations,
and initiate and direct other comprehensive measures to assure long-term environmental compliance
with environmental laws and regulations; can ensure that the necessary systems are established or
actions taken to gather complete and accurate information for individual Wastewater discharge permit
requirements;and where authority to sign documents has been assigned or delegated to the manager
in accordance with corporate procedures.
b) If the applicant or User is a partnership or sole proprietorship:a general partner or proprietor,respectively.
c) If the applicant or User is a federal, state, or local governmental facility: a director or highest official
appointed or designated to oversee the operation and performance of the activities of the government
facility,or the designee.(BACK)
3. Duly Authorized Representative(Designated Signatory)
d) The individuals described in paragraphs(a)through (c) above, as Responsible Officers, may designate an
Authorized Representative if the authorization is in writing,the authorization specifies the individual or
position responsible for the overall operation of the facility from which the discharge originates or having
overall responsibility for environmental matters for the company or organization, and the written
authorization is submitted to OCSD.
e) An applicant or User not falling within one of the above categories must designate as the Responsible Officer
an individual responsi ble for the overall operation of the facility. The Responsible Officer may designate an
Authorized Representative.(BACK)
4. Signature Requirement- Per 40 OFF 441.50(a)(2),the Compliance Report must be signed and certified by a
responsible corporate officer, a general partner or proprietor if the dental facility is a partnership or sole
proprietorship, or a duly authorized represemative in accordance with the requirements of 40 CFR 403.12(I).
(BACK)
S. Retention Period:Per 40 CFR 441.50(a)(5),as long as a dental facility subject to this part is in operation,or until
ownership is transferred, the trial facility or an agent or representative of the dental facility must maintain
this Compliance Report and make it available for inspection in either physical or electronic form.(BACK)
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ORANGE COUNTY SANITATION DISTRICT (OCSD)
DENTAL DISCHARGER COMPLIANCE REPORT
Dental facilities operating prior to July 14, 2017 are considered an Existing Source (PSES) and have until July 14,
2020 to comply with the Dental Office Point Source Category Pretreatment Standards and category requirements.
The compliance report must be submitted by October 12,2020, New Dental Dischargers who open for business on
or after July 14, 2017 are considered a New Source (PSNS) and must immediately comply with the category
requirements and submit the compliance report to OCSD within 90 days of discharging to the sanitary sewer
system (New Source does not include an ownership change). An Existing Source that changes ownership is required
to submit a new compliance report within 90 days.
DENTAL FACILITY INFORMATION
Existing Source: 0 New Source: Q
Date facility began o ratio : uek arc-see eapbmtlon aE )
Dental facility name:
Facility address:
Facility city: Zip code:
Mailing address:
Mailing city,state:. 17ip code:
On-site contact name:
Contact hone:
Contact e-mail:
OWNERSHIP INFORMATION
(owner/partner) title
(owner/partner) (title
(owner/partner) title
owner/ artner title
(owner/partner) title
(owner/partner) (title)
(owner/partner) title
(owner/partner) (title
(owner/partner) (title
owner/partner title
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DESCRIPTION OF OPERATIONS AND AMALGAM SEPARATORS
Total number of chairs: I Number of practicing dentists at this facility:
Total number of chairs at which dental amalgam placement or removal occurs:
Amalgam Separator(s)or Equivalent Device(s)
Make Model Date of Installation Complies with Requisite Standard
ANSUADA ISO ❑95%Removal ER.
ANSI/ADA []ISO ❑95%Removal Elf.
ANSVADA []ISO ❑95%Removal ER.
ANSUADA ❑ISO ❑95%Removal Eff
ANSVADA ❑ISO ❑95%Removal ER.
ANSI/ADA []ISO ❑95%Removal ER.
ANSI/ADA ❑ISO ❑95%Removal Eff.
ANSUADA ❑ISO ❑95%Removal Eff.
ANSI/ADA []ISO ❑95%Removal Eff
ANSUADA ❑ISO ❑95%Removal Eff.
ANSVADA []ISO ❑95%Removal Eff.
ANSI/ADA []ISO ❑95%Removal Eff
N applicable,name of the third-
parry service provider maintaining
the amalgam sepamtor(s): (company name(
Service providers local address:
(address,city,state,zip(
Service provider's phone:
If not using a service provider, in the space below,supply a brief description of the practices employed by the
facility to ensure proper operation and maintenance of their amalgam separators in accordance with 40 CFR
441.30 or 441.40(e.g.,employee training,written environmental policy,operation and maintenance instructions,
programmed maintenance reminders, maintenance checklist,amalgam recycling log,etc.):
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REQUIRED DOCUMENTATION
As long as the above named Dental Discharger is subject to this regulation,or until ownership is transferred,the
Dental Discharger or an agent or representative must maintain records and documentation per 40 CFR
441.50(b)"`r z
CERTIFICATION FOR DENTAL DISCHARGERS THAT PLACE OR REMOVE AMALGAM
of
Print Name Print Title
Qam a responsible corporate off icer"a-',a general partner or proprietor(if the facility is a partnership or sole proprietorship),or
Qam a duly authorized representative"",`in accordance with the requirements of 40 CFR 403.12(I)
1 certify under penalty of law that the above named dental facility is in compliance with the Dental Office Point Source
Category requirements to install, operate, and maintain one or more amalgam separators, or equivalent amalgam removal
devices, and that the separator(s)or devices) are designed and will be operated and maintained to meet the requirements
specified in 40 CFR 441.30(PSES)or 441.40(PSNS).
Furthermore,I certify that
has taken the necessary steps, including employee training,to ensure that the Best Management Practices as specified in
40 CFR 441.30(b)or 441.40`10 s,and Record Keeping and Documentation as specified in 40 CFR 441.50(b)or 441.40"`r z,are
implemented and continued.
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision
in accordance with a system designed to assure that qualified personnel properly gather and evaluate the
Information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information,the information submitted is,to the best of my knowledge and belief,true,accurate,
and complete. I am aware that there are significant penalties for submitting false information, including the
possibility of fine and imprisonment for knowing violations[40 CFR 403.6(a)(2)(11)(2016)].
Authorized Representative Signature"`r° Date
(Rewn,,Llve Signature)
When completed,print,sign,date,make a copy -AND- Save a copy of this PDF
for your records,and mail original to: and email to:
Orange County Sanitation District DentalOffice@oc d.com
Dental Amalgam Program
10844 Ellis Avenue
Fountain Valley,CA 92708
RETENTION PERIOD
Per 40 CFR 441.50(a)(5),as long as a dental facility subject to this part is in operation,or until ownership is transferred,the
dental facility or an agent or representative of the dental facility must maintain this Compliance Report and make it
available for inspection in either physical or electronic form.
Page 3 of 4
REFERENCES
1.Amalgam Separators)or Equivalent Device(s)-A dental facility coming into compliance with 40 CFR 441 must install one or more ISO 11143
(or ANSI/ADA 108-2009)compliant amalgam separators,or equivalent devices with average removal efficiency of 95 percent of the mass of
solids as determined per 40CFR 441.30(a)(2)i-iii,sized to accommodate the maximum discharge rate of amalgam process wastewater. Dental
facilities with separators or equivalent devices installed prior to June 14,2017 that do not meet the requirements of 40 CFR 441.30(a)(1)(i)and
(ii)must replace their amalgam separators(or equivalent devices)with units that meet the requirements of 40 OR 441.30(a)(1)or 441.30(a)(2),
after their useful life has ended,and no later than June 14,2027,whichever is sooner.(BACK)
2.Required Documental-Per 40 CFR 441.50(b),Dental Dischargers or an agent or representative of the dental discharger must maintain and
make available for inspection in either physical or electronic farm,for a minimum of three years:
(1) Documentation of the date of each inspection of the amalgam sepa rator(s)or equivalent device(s),name of person(s)conducting the
inspection,and results of each inspection(including a summary of follow-up actions if needed).
(2) Documentation of amalgam retaining container or equivalent container replacement(including the date,as applicable).
(3) Documentation of all dates that collected dental amalgam is picked up or shipped for proper disposal in accordance with 40 CFR
261.5(g)(3), and the name of the Permitted or licensed treatment, storage or disposal facility receiving the amalgam retaining
containers.
(4) Documentation of any repair or replacement of an amalgam separator or equivalent device,including the date,persons(s)making the
repair or replacement,and a description of the repair or replacement(including make and model).
(5) Dischargers or an agent or representative of the dental discharger must maintain and make available for inspection in either physical
or electronic form the manufacturer's operating manuals)for the current device(s). (BACK)
3.Responsible Corporate Officer(Authorized Representative)
a) If the applicant or User is a corporation:
(1) The president,secretary,treasurer,or a vice president of the corporation in charge of a principal business function,or any other
person who performs similar policy or decision making functions for the corporation;or
(2) The manager of one or more manufacturing, production, or operation facilities, provided the manager is authorized to make
management decisions that govern the operation of the regulated facility including having the explicit or implicit duty of making major
capital investment recommendations, and initiate and direct other comprehensive measures to assure long-term environmental
compliance with environmental laws and regulations;can ensure that the necessary systems are established or actions taken to gather
complete and accurate information for individual Wastewater discharge permit requirements;and where authority to sign documents
has been assigned or delegated to the manager in accordance with corporate procedures.
b) If the applicant or User is a partnership or sole proprietorship:a general partner or proprietor,respectively.
c) If the applicant or User is a federal,state,or local governmental facility:a director or highest official appointed or designated to oversee
the operation and performance of the activities of the government facility,or the designee. (BACK)
4.Duly Authorized Representative(Designated Signatory)
d) The individuals described in paragraphs(a)through(c)above,as Responsible Officers,may designate an Authorized Representative if the
authorization is in writing,the authorization specifies the individual or position responsible for the overall operation of the facility from
which the discharge originates or having overall responsibility for environmental matters for the company or organization,and the written
authorization is submitted to OCSD.
e) An applicant or User not falling within one of the above categories must designate as the Responsible Officer an individual responsible for
the overall operation of the facility. The Responsible Officer may designate an Authorized Representative. (BACK)
5.Required Bert Management Practices filli
Waste amalgam including,but net limited to,dental amalgam from chair-side traps,screens,vacuum pump filters,dental tools,cuspidors,or
collection devices must not be discharged to a publicly owned treatment works(e.g.,municipal sewage system).
Dental unit water lines,chair-side traps,and vacuum lines that discharge amalgam process wastewater to a publicly owned treatment works
(e.g.,municipal sewage system)must not be cleaned with oxidizing or acidic cleaners,including but rot limited to bleach,chlorine,iodine,and
peroxide that have a pH lower than 6 or greater than 8(i.e.,cleaners that may increase the dissolution of mercury). (BACK)
6.Signature Requirement
Per 40 CFR 441.50(a)(3).the Compliance Report must be signed and certified by a responsible corporate officer,a general partner or proprietor
if the dental facility is a partnership or sole proprietorship,or a duly authorized representative in accordance with the requirements of 40 CFR
403.12(1). (BACK)
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