SAMPLE: Amalgam Separator Inspection Form

In accordance with the Best Management Practices (BMPs) for dental practices or clinics, established by the Department of Energy and Environmental Protection (DEEP), this form is to be maintained at each dental office which stores, uses or otherwise handles mercury amalgam and made available to the Department of Energy and Environmental Protection upon request. To refer to the BMPs and additional information visit the DEEP website at www.ct.gov/deep/mercury.

Please complete one form for each amalgam separator used in the dental practice or clinic.

Separator Brand Model Serial No. Date Installed

Cartridge Below Above Change Y/N Date of Comment (include description of routine/non-routine maintenance activities) Initials Fill Line Fill Line If Yes, include Service the date

Note: All records and receipts of all contact and non-contact amalgam sent to recycling or disposal facilities must also be maintained on site. SAMPLE: Chair-Side Trap Inspection Form

In accordance with the Best Management Practices (BMPs) for dental practices or clinics, established by the Department of Energy and Environmental Protection (DEEP), this form is to be maintained at each dental office which stores, uses or otherwise handles mercury amalgam and made available to the Department of Energy and Environmental Protection upon request. To refer to the BMPs and additional information visit the DEEP website at www.ct.gov/deep/mercury.

Please complete one form for each chair-side trap used in the dental practice or clinic.

Chair-Side Trap # Model Serial No. Date Installed

Comment (include description of routine/non-routine Type of Service Date of Service Initials maintenance activities)