NC0025534_ComplianceReportDentalDischarger_20230224

ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS
As Required by 40 CFR Part 441 Effective Date: July 14, 2017
Effluent Limitations Guidelines and Standards for the Dental Category
General Information
2FEB to
Water Quality Regional Operations
Name of Facility:
Autumn Dental
Physical Address:
685 Blythe Street Court Suite A
Hendersonville, NC 28739
Mailing Address:
1200 Network Center Drive Suite 2
Effingham, IL 62401
Facility Cuntact Name and Title:
Molly Rogers - Business Assistant
Phone:
828-697-6000
Email
[e-mail]
Owner/
S.Gibree, D.M.D, P.0
Operator(s)
Facility Signatory Official (per 40 CFR Part 441.50(a)(2)) Name and Title
Colleen Allen - Dentist
Phone_
828-697-6000 1
Email
[e-mail]
F Names of Licensed Dentists currently in this practice
Colleen Allen
Please select one of the following
C�
This practice is a dental discharger subject to this rule and does place and/or remove dental amalgam.
Complete sections A, 8, C, D, E and F
❑
This practice is a dental discharger that exclusively practices one or more of the following dental
specialties exempted in 40 CFR Part 441.10(c): oral pathology, oral and maxillofacial radiology, oral
and maxillofacial surgery, orthodontics, periodontics, or prosthodontics.
Complete section F only
❑
This practice is a dental discharger that does not place dental amalgam, and does not remove amalgam
except in limited emergency or unplanned, unanticipated circumstances (per 40 CFR Part 441.10(f))
Complete section F only
❑
This practice is a dental discharger that does not discharge dental amalgam wastewater to a Publicly
Owned Treatment Works (POTW) because:
❑ The practice discharges dental process wastewater to a septic tank
❑ The practice collects dental process wastewater for transfer to a Centralized Waste
Treatment Facility (CWT).
❑ Other
Complete section F only

Section A
nocerin+inn of fnrili+v
Total number of chairs:
5
Total number of chairs at which amalgam placement or removal occurs:
13
Narrative description (optional)
Section B
nncrrintinn of amalgam cPnaratnrnr Pnidvalent device
My facility has installed one or more ISO 11143 compliant amalgam separators (or equivalent devices) since June
14, 2017that captures all amalgam containing waste from the above identified chairs (in Section A) where
amalgam is placed or removed.
My facility has one or more existing amalgam separators installed prior to June 14, 2017that capture amalgam
containing waste from the above identified chairs (in Section A) where amalgam is placed or removed. I understand
that the separator(s) must be replaced with one or more ISO 11143 compliant amalgam separators (or equivalent
devices), after its lifetime has ended, and no later than June 14, 2027.
Make
Model
Serial Number
Year of
installation
Solmetex
Hg5
NXTCC-A-066768
2019
My facility operates an equivalent device.
Make
Model
Average removal efficiency
of equivalent device, as
determined per 40 CFR
441.30(a)(2) (i- iii).
Serial Number
Year of
installation

Section C
Design, Operation and Maintenance of Amalgam Separator/Equivalent Device
Please select and complete one of the following:
0
The amalgam separator (or equivalent device) is designed and is operated and maintained to
meet the requirements in §441.30 or a third -party service provider is under contract with this
facility to ensure proper operation and maintenance in accordance with § 441.30 or § 441,40.
Provide name & address of service provider:
Henry Schein
4330 Matthews -Indian Trail Road
Indian Trails, NC 28079
The amalgam separator (or equivalent device) is operated and maintained by the dental facility staff
to meet the requirements in 40 CFR Part 441.30 or Part 441.40.
Provide a description of the practices employed by the dental facility to ensure the proper operation and
maintenance in accordance with 40 CFR Part 441.30 or 441.40:
Staff inspect the unit weekly and monthly.
Change the collection canister when needed according to manufacturer directions.
Section D
DCb1. IVIQ 11d9U I I l tl l l l r l CILLII.CD, DIYIr I %.CI U1ILQLIU113
The above named dental discharger is implementing the following BMPs as specified in
40 CFR Part 441 30(b) or 40 CFR Part 441.40(b) and will continue to do so.
Waste amalgam including, but not limited to, dental amalgam from chair -side traps, screens,
vacuum pump filters, dental tools, cuspidors, or collection devices, is not 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 POTW must not be cleaned with oxidizing or acidic cleaners that may increase the
leaching of solid mercury. Prohibited cleaners include but are not limited to: bleach, chlorine,
iodine and peroxide that have a pH lower than 6.0 or greater than 8.0.

Section E
Recordkeeping and Record Retention
J I have read and understand the Recordkeeping and Record Retention requirements for dental
dischargers in 40 CFR Pat 441.50 (a) and (b).
Section F
r'Prtification Statement
"1 am a duly authorized signatory official of the above named dental facility, and certify under penalty of low 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 Signatory Official Name (print)
Authorized Signatory Official Signature and Date
ONE-TIME COMPLIANCE REPORT DEADLINES:
■ For "existing source" dental practice (began discharge to POTW prior to July 14, 2017).
o No amalgam separator DEADLINE: October 12, 2020.
o With ISO amalgam separator DEADLINE: October 12, 2020.
o With non -ISO amalgam separator DEADLINE: Install new ISO separator by July 14, 2027 or within 10
days of separator no longer effective and submit One -Time Compliance Report by October 12, 2020.
For "new source" dental practice (first discharge to POTW occurs after July 14, 2017).
o DEADLINE: No later than 90 days following introduction of wastewater into a POTW.
For "transfer of ownership".
o DEADLINE: New owner must submit report no later than 90 days after transfer.
SUBMIT REPORT TO:
Control Authority — Local Publicly Owned Treatment Works (POTW)
Control Authority — North Carolina Department of Environmental Quality (If no POTW)
CONTACT INFORMATION:
40 CFR Part 441 "Effluent Limitations Guidelines and Standards for the Dental Category" can be found at
www.epa.gov/eg/dental-effluent-guidelines