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[null,null,null,null,null,"\nDental Facilities\n    Pollution Prevention (P2) Plan\n\n"]
["City of Toronto designated this Pollution Prevention (P2) Plan for an owner or operator of a premises from which dental amalgam may be discharged and directly or indirectly enter a municipal sewer connection or municipal sewer, pursuant to Municipal Code Chapter 681. A completed Plan must be submitted to Toronto Water by a new dental office and whenever a change in ownership, address, dental practice, number of patient chairs, brand of amalgam separator or third party maintenance of the amalgam separator changes. Subsequent to this Plan, proof of service of the amalgam separator, via copies of receipts, must be submitted each time service (i.e. maintenance/cleanings) is performed. All questions are to be answered as applicable. If you would like a copy of this form in an alternate accessible format, please contact 311 (www.toronto.ca/311)."]
[]
["1. Office Information "]
["Dental Office Name"]
["Dental Office Address (Street Number, Name, Suite/Unit Number, City, Province, Postal Code)",null,null,null,null,null,"Business Telephone Number   ",null,null,null,null,"     "]
[null,null,null,null,null,null,"Business Fax Number   "]
[null,null,null,null,"Business Email",null,null,null,null,null,null,"     "]
["Contact Name                    (First, Last)",null,null,null,null,null,"Number of Employees ",null,null,null,null,"     "]
["Position  "]
["Days of Operation ( i.e. Mon-Fri ) ",null,null,null,null,"Hours of Operation \n( i.e. 9am-7pm )",null,null,null,null,null,null,"     "]
["Type of Unit (i.e. freehold, building unit, mall unit)"]
["Does your office use and/or remove amalgam fillings and/or collect wastewater that may contain dental amalgam that may directly or indirectly enter the sewage works?  "]
["If the answer is yes, complete the form in its entirety. In all other cases, skip to Section 7 and complete the declaration. Also, indicate in the space provided below an explanation of your dental practice and why amalgam is not used in that field of practice."]
[]
["2. Existing Processes and Waste Generation"]
["How many dental and hygiene chairs does your office have?",null,null,null,null,null,"Dental",null,"Hygiene"]
["Does your office use amalgam when placing, repairing and/or replacing amalgam fillings?"]
["Does your office remove amalgam fillings?"]
["Are there cuspidors attached to the dental chairs?"]
["─ If the answer is \"yes\", are there traps attached to the cuspidors?"]
["─ If there are traps attached to the cuspidors, are they regularly inspected and cleaned?"]
[]
["What brand and model is the installed amalgam separator (e.g. Mars AmalgamBoss, Solmetex HG 5, R & D Services Amalgam Collector, Bio-Dent Metasys, MSS, etc.)? Please specify:"]
["Brand:",null,null,null,null,null,"Model:"]
["What is the efficiency rating (i.e. 99 or 95%) for the amalgam separator brand?",null,null,null,null,null,null,null,"%"]
[]
[]
["15-0037 2016-11 ",null,null,null,null,null,null,null,null,"Page 1 of 4"]
[null,null,null,null,null,"\nDental Facilities\n    Pollution Prevention (P2) Plan\n\n"]
["How many units of amalgam separators are installed?",null,null,null,null,null,null,"Unit(s)"]
["What is the amalgam separators manufacturer's maintenance schedule for the number of patient chairs at your office?"]
["Does your office have a contractor to regularly inspect and maintain the amalgam separator or does your office conduct self-inspection and maintenance of the amalgam separator?"]
["If serviced by a contractor:\n"]
["- Which contractor performs the work (e.g. Mars, Octagon, Greenflow, Sinclair, Henry Schein, Bio-Dent, Stericycle, ECS, Patterson, etc.)? Please specify"]
["-  How often is your contractor called to service the amalgam separator (e.g. annually,  once every six months, etc.)? Please specify:\n"]
["If self inspected and maintained:"]
["- How often is the self-inspection and maintenance conducted and how is it conducted?"]
[]
[]
["- How is the amalgam waste removed from  the amalgam separator disposed?",null,null,null,null,null,null,null,null,null,null,"     "]
[null,null,null,null,null,null,null,null,null,null,null,"     "]
["Please provide the dates your amalgam separator was serviced (i.e. maintenance/cartridge replacement), by a contractor or your office, over the last 2 years.",null,null,null,null,null,null,null,null,null,null,"     "]
["4. Waste Management "]
["Does your office have silver recovery equipment to recover silver from silver-bearing solution before discharging into the sanitary sewer?"]
["Does your office's cuspidors and traps connect to the amalgam separator?"]
["    ─ If the answer is “no”, how does amalgam get collected from the cuspidors and traps?"]
[]
["Is your office's vacuum pump filter installed before or after the amalgam separator? (Toronto Water recommends the vacuum pump filter be installed AFTER to capture amalgam within the amalgam separator.) If the vacuum pump filter is installed BEFORE, the filter and its contents shall be disposed as hazardous waste."]
["Does your office have a waste carrier with an Environmental Compliance Approval (ECA) from the Ministry of the Environment and Climate Change (MOECC) to collect and dispose (or recycle where appropriate) the below waste? (Check all that apply)"]
[]
["    ─ If you have checked any of the above waste, please specify the waste carrier's name (if more than one is used, please     \n        provide all waste carrier names)?\n"]
[]
["15-0037 2016-11 ",null,null,null,null,null,null,null,null,"Page 2 of 4"]
[null,null,null,null,null,"\nDental Facilities\n    Pollution Prevention (P2) Plan\n\n"]
["5. Pollution Prevention Checklist \n(This list does not limit any other requirements in Chapter 681)"]
["A. The concentration of mercury in wastewater that is discharged into the sanitary sewer shall not exceed 0.01 mg/L."]
["B. Whenever possible, adopt digital radiography to substitute usage of x-ray films (containing lead and chemicals)."]
["C. Amalgam separator shall be regularly inspected and maintained and cartridge shall be properly replaced, to maintain its efficiency, when separating amalgam waste from wastewater before discharging into the sanitary sewer."]
["D. Amalgam by-pass from cuspidors or sinks is prohibited (all cuspidors must be connected to amalgam separator except those beside hygienist-only chairs)."]
["E. Separate contacted amalgam and non-contacted amalgam waste as much as possible as non-contacted amalgam can be recycled more easily."]
["F. Avoid overstocking chemicals, such as amalgam capsules, x-ray film processing fixers and developers to reduce the risks of a chemical spill, leakage, and disposal due to expired/off-specification products."]
["G. When collecting and storing wastes, properly label waste containers for easy identification and disposal."]
["H. Do not pour chemicals or silver-bearing processing solutions into the drain, sink, sewer grates, maintenance access hole/manholes or natural environment (e.g. lawn)."]
["I. All wastes including amalgam waste, silver-bearing x-ray film processing solution and biomedical waste (e.g. used sharps, blood-soaked materials) should be stored in sealed labelled containers when temporarily stored onsite and transported for appropriate disposal."]
["J. Amalgam waste, lead foils and biomedical waste, should be segregated for proper offsite disposal / recycling. Do not mix these together as their disposal/recycling methods are different."]
["K. No dental clinic shall dispose amalgam waste, lead foils, used lead vests or biomedical waste into regular garbage."]
["L. All hazardous waste, including waste amalgam, silver-bearing x-ray film processing solution, lead foils and biomedical waste, shall be disposed by a waste carrier with an Environmental Compliance Approval (ECA) from the MOECC. This is required by the “General – Waste Management R.R.O. Reg. 347” of the MOECC."]
["M. When a waste storage container is filled, it should be properly sealed and labelled. Within 90 days, the waste container shall be shipped out to a waste carrier with an ECA from the MOECC for offsite disposal. This is required by the “General – Waste Management R.R.O. Reg. 347” of the MOECC."]
["N. If a septic tank is used onsite, a waste hauler/disposal company with an ECA from the MOECC shall be used to empty the septic tank and haul away sludge for proper offsite treatment/disposal."]
["Have you read and understood the above pollution prevention requirements?"]
["By signing this form you undertake to educate yourself and your staff with the above pollution prevention requirements to help protect our municipal sewage works and natural environment."]
["15-0037 2016-11 ",null,null,null,null,null,null,null,null,"Page 3 of 4"]
[null,null,null,null,null,"\nDental Facilities\n    Pollution Prevention (P2) Plan\n\n"]
["6. List of Dentists and Associates"]
["Please list all the dentists and associates at your office."]
["Dentist/Associate Name",null,null,"Position",null,null,"Dentist/Associate Name",null,null,"Position"]
[]
[]
[]
[]
["7. Declaration"]
["As owner or operator, or legal representative of same, of premises from which dental amalgam may be discharged and \ndirectly or indirectly enter a municipal sewer connection or municipal sewer, I                                                                                    represent and declare that this Pollution Prevention (P2) Plan and all information and supporting documentation contained in or with this Plan comply with Chapter 681 and are accurate and complete to the best of my knowledge. I undertake to comply with this Plan and make it readily available for inspection at the subject premises by the representatives of the City of Toronto."]
[]
["Signature:      ",null,null,null,null,null,"Date (yyyy-mm-dd):      "]
[]
["Submit the Completed Pollution Prevention Plan"]
["by Mail",null,null,null,null,null,"by Fax",null,null,"by Email"]
["Manager",null,null,null,null,null,"416-696-3727",null,"P3Help@toronto.ca"]
["Environmental Monitoring & Protection"]
["Toronto Water"]
["30 Dee Avenue,"]
["Toronto, Ontario M9N 1S9"]
["Supporting Documentation"]
["Please submit copies of all amalgam separator service receipts (i.e. maintenance/cartridge replacement) for the service dates listed in this Pollution Prevention (P2) Plan. "]
[" "]
[]
["15-0037 2016-11 ",null,null,null,null,null,null,null,null,"Page 4 of 4"]

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[]
["Yes",null,null,"Yes","Monthly",null,"Self Serviced and Maintained"]
["No, Have Strong Suction",null,null,"No","Quarterly",null,"Contractor Serviced and Maintained"]
[null,null,null,"N/A","Annually"]
[null,null,null,null,"Every Six Months"]
[null,null,null,null,"Once Every Two Years"]
[null,null,null,null,"Others (Specify)"]

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[]
["Yes","Monthly","Self Serviced and Maintained","Before","Yes"]
["No","Quarterly","Contractor Serviced and Maintained","After","No, Strong Suction"]
[null,"Every Six Months"]
[null,"Annually"]
[null,"Once every two years"]
[null,"Other (Please Specify)"]