Escondido, CA · San Diego County
Dental Amalgam Rule One-Time Certification
Dental facilities use this one-time compliance report to provide information about amalgam discharge, separators, maintenance, and best management practices when directed by their Control Authority.
What this form is
This report collects facility details, amalgam separator information, maintenance practices, and best management practices for compliance with the Dental Amalgam Rule. The form says some facilities are not required to submit it and instructs dental facilities not to submit it unless directed by their Control Authority. Depending on the facility’s applicability, complete sections A through E or section E only.
Who needs it
A dental facility should use this report only if its Control Authority directs it to submit a one-time compliance report.
How to submit it
Contact your Control Authority to determine whether to submit this form and which form to use; do not submit it unless directed.
About notarization
This document is signed without a notary; the authorized representative signs and dates a certification under penalty of law.
How to submit this form
- 1
Download the Form
Download the Dental Amalgam Rule One-Time Certification form.
- 2
Check Applicability
Contact your Control Authority to determine whether your facility must submit a one-time compliance report and which form to use.
- 3
Complete the Applicable Sections
If directed to use this form, provide the facility, separator, maintenance, and certification information required for your facility.
- 4
Submit Only When Directed
Do not submit the form unless directed by your Control Authority.
Frequently asked questions
- Do I need a notary for the Dental Amalgam Rule One-Time Certification?
- No. The authorized representative signs and dates the certification under penalty of law, but the document does not require a notary.
- Who should submit this one-time compliance report?
- A dental facility should submit it only if directed by its Control Authority. The form says some facilities are not required to submit a report.
- How do I submit the Dental Amalgam Rule One-Time Certification?
- Contact your Control Authority to determine whether to submit the report and which form to use. Do not submit this form unless directed.
Need something notarized?
This Dental Amalgam Rule One-Time Certification doesn’t need a notary — but if you have another Escondido form that does, a commissioned online notary can help.