Dental Facility Annual Self-Certification Form

In keeping with Vancouver’s Dental Mercury Reduction Program, all dental offices that are connected to the City’s sanitary sewer system are required to install and maintain amalgam separators and follow industry-approved best management practices (BMPs). These requirements promote sound operations, a healthy community and environment, and consistency with dental best practices and federal/state guidelines and regulations. A self-certification form must be completed and submitted by Feb. 28 each year in order to maintain compliance with the Letter of Discharge permit issued to your dental practice by the City of Vancouver. Please enter the business name of your dental practice and select the appropriate answers to best describe your activities during the past calendar year.