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Annual Dental Amalgam Inspection

  1. PWSD Logo - horizontal
  2. Section 1 - Business Name and Address(es)
  3. Section 2 - Best Management Practices (BMP's)
    A response is required for each BMP listed below.
  4. Best Management Practices
  5. 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.
  6. 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. 

  7. (Please enter both the business name and the name of the best person to contact)
  8. Section 4 - Amalgam Separator System Installation
    Provide information for each separator
  9. Separator #1
  10. Separator #2
  11. Section 5 - Amalgam Separator Maintenance and Operation
  12. Section 6 - Annual Dental Amalgam Report
  13. "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."
  14. (type name of authorized representative)
  15. Leave This Blank:

  16. This field is not part of the form submission.