Amalgam Materials
6. Does this office “place” Yes No OR “remove” Yes No amalgam fillings?
Disposed of in the trash
7. How does this office dispose of amalgam particles?
Hazardous waste, Provider Name_________________________ __________________
Stored on-site for future disposal
Returned to vendor, Vendor Name_________________________ _________________
Disposed of as a bio hazard material
Recycled, Provider
Name__________________________________________________
8. How does this office dispose of the unused portion of amalgam capsules?
Disposed of in the trash
Hazardous waste, Provider Name____________________________________________
Stored on-site for future disposal
Returned to vendor, Vendor Name___________________________________________
Disposed of as a bio hazard material
Recycled, Provider name___________________________________________________
Mercury Spill Kit? Yes No Not Applicable
Spill Control Plan for chemical spills? Yes No
Certification Statement
I hereby certify that my office complies with the Best Management Practices for the recycling and
disposal of amalgam, mercury, silver (X-ray fixer), and X-ray lead foil as indicated above.
_______________________________________________ ___________________________
Responsible Person's signature Date
Please print name signed above ___________________________________________________
Please return this survey to:
Public Works
Water Resources Division, Industrial
Monitoring 7472 Cochran Road, College Park,
GA 30349
Or fax it to 404-612-2931
9. Does this office have an amalgam separator as required by 40 CFR 441 which went into effect on July
2017? Yes No Year Installed ___________ Brand Name_________________________
9a. If no, indicate month and year you plan to install amalgam separator in order to meet 40 CFR 411
compliance date: ________________________________
10. How often do you clean and service the amalgam separator? ________________________ Who cleans
and/or services the amalgam separator? ______________________________________________________
11. Does your office have:
