Dental Facility Annual Self-Certification Form

In keeping with Vancouver’s Dental Mercury Reduction Program, all dental offices that are connected to the City’s sanitary sewer system are required to install and maintain amalgam separators and follow industry-approved best management practices (BMPs).These requirements promote sound operations, a healthy community and environment, and consistency with dental best practices and federal/state guidelines and regulations. The form below must be completed and submitted by Feb. 28 each year in order to maintain compliance with the Letter of Discharge permit issued to your dental practice by the City of Vancouver. Please enter the business name of your dental practice and select the appropriate answer from the drop-box menus to best describe your activities during the past calendar year (2022).

Business Name(Required)

Email(Required)

Email address provided will be used only by the City’s Dental Mercury Reduction and Wastewater Pretreatment programs if needed to contact your practice.

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1. Has the dental practice ownership or address changed within the last year?(Required)

2. Does this dental practice place or remove dental amalgam?(Required)

3. Does this dental practice place or remove dental amalgam only in limited emergency or unplanned circumstances?(Required)

4. Does this dental practice have an amalgam separator?(Required)

5. Was a new or replacement amalgam separator installed within the past year?(Required)

6. If you use an amalgam separator, is it ISO 11143 or ANSI/ADA 108-2009 compliant?(Required)

7. Was the amalgam separator operated and maintained in accordance with manufacturer specifications over the past year?(Required)

8. Does this dental practice contract with a third-party service provider to maintain the amalgam separator?(Required)

9. Are all dental unit water lines, chair-side traps and vacuum lines that may receive amalgam connected to an amalgam separator?(Required)

10. Are all dental unit water lines, chair-side traps and vacuum lines that may receive amalgam cleaned with non-oxidizing, non-bleach solutions that have a pH between 6 SU and 8 SU?(Required)

11. Is waste amalgam from chair-side traps, screens, vacuum pump filters, dental tools, cuspidors or other collection devices properly disposed of and NOT discharged to the sanitary sewer system?(Required)

12. Was scrap amalgam stored for recycling in a tightly capped container, away from all sinks and drains?(Required)

13. Were chair-side traps, vacuum filters and other amalgam containing equipment cleaned away from sinks/drains that are connected directly to sanitary sewer?(Required)

14. Were amalgam and mercury-bearing wastes managed for off-site recycling and NOT disposed into the trash, infection waste or biohazard containers?(Required)

15. Were x-ray developer and fixer solutions properly pretreated prior to discharge to the sanitary sewer?(Required)

16. Were x-ray developer and fixer solutions managed off site for disposal?(Required)

17. Were glutaraldehyde or ortho-phthalaldehyde (OPA) sterilant solutions properly pretreated prior to discharge to the sanitary sewer?(Required)

18. Were glutaraldehyde or ortho-phthalaldehyde (OPA) sterilant solutions properly managed for off-site disposal?(Required)

19. Are maintenance and service records for the amalgam separator maintained at the practice site and available for inspection?(Required)

20. Are records for disposal of mercury, amalgam, silver/fixer and other hazardous wastes maintained at the practice site and available for inspection?(Required)

21. I certify that the information submitted is true and accurate to the best of my knowledge and belief. *(Required)

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