The form will take 30-45 minutes to complete.
Initial Compliance Certification Report
All Dental Practices must submit an Initial Compliance Certification Report — even if the practice seems like it could be exempt from the required best management practices of the Dental Amalgam Rule.
Initial Report Due Dates
If your practice opened after July 15, 2017, the report is due 30 days after the practice opened. If you purchased an existing practice, the new owner must submit the report within 30 days of taking ownership.
The EPA requires an original signature on this report.
Please mail the original form to:
Water Pollution Control Lab
Attn: Dental Amalgam Program
6543 N Burlington Ave.
Portland, OR 97203
Annual Certification Report
Only dental practices that are required to implement the BMPs must submit the annual certification report. Exempt practices do not need to meet this ongoing reporting requirement.
Annual Report Due Dates
This report must be received by the City no later than November 15 of each year. The report does not require an original signature. You may return the form either by e-mail or mail.
To respond by email, please send the completed PDF form to:
To respond by mail, please send the original form to:
Water Pollution Control Lab
Attn: Dental Amalgam Program
Portland Water Pollution Control Lab
6543 N Burlington Ave.
Portland, OR 9720
Program Fee
The annual program fee is $170. The annual fee assists in recovering costs associated with permitting, inspecting, and monitoring facilities that meet the City’s ADCM requirements. The fee is billed at the start of the fiscal year in July.