Westlake, TX · Tarrant County
One-Time Compliance Report for Dental Dischargers
Dental facilities use this report to provide the Town of Westlake and Trinity River Authority with facility information, amalgam controls, and required certifications.
What this form is
This report provides the minimum information dental facilities must submit for a One-Time Compliance Report under the Dental Amalgam Rule. Facilities that place or remove dental amalgam complete Sections 4 through 8, while facilities that do not do so except in limited circumstances complete Section 8 only; a transfer of ownership also requires a new report. The form asks about facility contacts, equipment, maintenance practices, certifications, and an authorized representative’s wet signature.
Who needs it
A dental facility submits this report if it falls under the form’s applicability instructions or is filing a new report because of a transfer of ownership.
How to submit it
Mail the original wet-signature form to Trinity River Authority, Pretreatment Department, 6500 W. Singleton Blvd., Dallas, Texas 76212.
About notarization
This document is signed without a notary; the authorized representative must sign in wet ink and date the form.
How to submit this form
- 1
Download The Report
Download the One-Time Compliance Report for Dental Dischargers.
- 2
Complete The Applicable Sections
Follow the applicability instructions and answer the questions for the sections required for your dental facility.
- 3
Gather Any Attachments
Attach additional sheets if you have more than four different amalgam separators or equivalent devices.
- 4
Sign And Date The Form
Have an authorized representative sign and date the report using wet ink.
- 5
Mail The Original
Mail the original wet-signature form to the Trinity River Authority Pretreatment Department at the address listed in the instructions.
Frequently asked questions
- What is the One-Time Compliance Report for Dental Dischargers?
- It collects dental facility details, information about amalgam separators or equivalent devices, operating practices, and certifications for submission to the Town of Westlake and Trinity River Authority.
- Who needs to complete this report?
- Dental facilities follow the form’s applicability section: facilities that place or remove amalgam complete Sections 4–8, while facilities that do not, except in limited circumstances, complete Section 8 only.
- Do I need a notary for the One-Time Compliance Report for Dental Dischargers?
- No. The authorized representative must sign and date the form using wet ink; the document does not require notarization.
- How do I submit the One-Time Compliance Report?
- Mail the original wet-signature form to Trinity River Authority, Pretreatment Department, 6500 W. Singleton Blvd., Dallas, Texas 76212.
Need something notarized?
This One-Time Compliance Report for Dental Dischargers doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.