Submit a One-Time Dental Discharger Report

1. Check to make sure your office is required to submit this form

Some dental facilities are not required to submit a one-time compliance report. See the applicability section (§ 441.10) to determine if your facility is required to submit a one-time compliance report.

2. Download and fill out the compliance report

The form contains the minimum information dental facilities must submit in a one-time compliance report. This report is required by the Effluent Limitations Guidelines and Standards for the Dental Office Category (“Dental Amalgam Rule”).

You may print the form and fill it in by hand or you may fill in the form and print it after completion.

Download the Form(PDF)

3. Contact us if you have questions

Call the City of Grand Rapids Industrial Pretreatment Program at 616-456-3633.

4. Return your completed form to us

You can send your completed report by fax or mail. Due to federal requirements we currently cannot accept completed reports by email.

Fax
616-456-4423

Mail
Environmental Services
Industrial Pretreatment Program
1300 Markets Ave SW
Grand Rapids, MI 49503