New York State regulations require that all dental facility waters likely to come in contact with amalgam waste must be treated prior to discharge by an amalgam separator. This form is intended to provide a consistent format for dentists to satisfy this one-time reporting requirement. Follow-up reporting by dentists is only required when new separators are placed in service. Dentists may complete and submit a copy of this form to satisfy the reporting requirement. Alternatively, dentists may use another format which is consistent with the requirements specified in 6NYCRR 374-4.
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