Program Action: Require Dental Facilities to Follow Mercury BMPs

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1 Program Action: Require Dental Facilities to Follow Mercury BMPs Your city can help to decrease levels of toxic mercury entering the Bay, its habitats, and its wildlife. Mercury is a toxic, bioaccumulating heavy metal found in dangerous concentrations in San Francisco Bay. Mercury threatens water quality and has led to local fish consumption advisories. While there are many sources of mercury that find their way to the Bay through sewage effluent, several local and regional studies have shown that dental facilities discharge a large amount of the mercury intentionally and accidentally to the sanitary sewer system each year. Due to mercury and other pollutant levels, the Bay is currently on the 303d list of impaired water bodies under the Clean Water Act. 1 Many regulations limit the amount of mercury that can be present in the Bay, including the NPDES permit, EPA Sludge Regulations, and the mercury TMDL. However, heavy metals, including mercury, are not completely removed from wastewater through conventional treatment methods. Wastewater discharged into the Bay as well as biosolids placed in landfills (which often find their way into the Bay) therefore contain significant levels of mercury. Dental facilities are large consumers of mercury in fact, the third largest in the United States. In 1997 alone, 40 metric tons of mercury was used for dental purposes. 2 In the Bay Area, studies have estimated that 61 percent of the mercury entering the San José/Santa Clara Water Pollution Control Plant comes from dental practices. 3 Studies in Palo Alto determined that 30 grams of mercury per dentist are discharged to the sanitary sewer each year. 4 These levels are achieved even with the use of chair-side traps and vacuum pump filters, which trap some, but not all, dental mercury waste. In addition to mercury reaching the Bay through sewage effluent, some dental facilities also improperly dispose of mercury in the red medical waste bags. The contents of these bags are often incinerated, which releases mercury into the atmosphere, leading to deposition on land and in the Bay. 5 Bay Area municipalities can help dischargers meet the requirements of the mercury TMDL and prevent dental mercury from moving through the sanitary sewage system by encouraging the use of mercury Best Management Practices (BMPs) by dental facilities. These BMPs have been implemented locally by the cities of San Francisco, Palo Alto, San Jose, and others and are encouraged by the EPA and the ADA. Nationally, 11 states have established mandatory state-wide dental mercury programs. 6 Dental mercury BMPs include: Installing an amalgam separator Not using bulk mercury Cleaning and maintaining vacuum filters on a regular basis CWA Section 303(d) List of Water Quality Limited Segments. USEPA approval date 6/28/ Hughes, Stephanie. May Dental Amalgam Recovery Program for East Palo Alto, Palo Alto, Los Altos, Los Altos Hills, and Mountain View. 3 City of San Jose Environmental Services. Dental Amalgam Program Frequently Asked Questions. Last modified 11/12/ Hughes, Stephanie. May Dental Amalgam Recovery Program for East Palo Alto, Palo Alto, Los Altos, Los Altos Hills, and Mountain View. 5 City of San Jose Environmental Services. Dental Amalgam Program Frequently Asked Questions. Last modified 11/12/ United States Environmental Protection Agency. August Health Services Industry Detailed Study: Dental Amalgam

2 Avoiding the use of chlorine-containing disinfectants, as these chemicals can cause build-ups of mercury to be released more readily into wastewater Not washing tools or equipment that come into contact with amalgam in the sink or other link to the sanitary sewer system Keeping accurate records of amalgam use Having a certified hazardous waste facility properly dispose of amalgam waste Storing amalgam in air-tight containers Storing amalgam waste according to recycler instructions Case study: Palo Alto The ordinance (attached) developed for Palo Alto is also used by the cities of Mountain View and Los Altos. The amalgam program is in effect locally for Palo Alto, East Palo Alto, Los Altos, Los Altos Hills, and Mountain View. Some dental practices, including periodontists, orthodontists, and oral pathologists, are exempt from the requirement to install an amalgam separator if the removal or placement of amalgam fillings occurs no more than three days per year. Facilities can also be exempt if several other conditions apply, such as having a vacuum system that was installed before 2003 or if the facility can show evidence of regular pump outs. The following are the requirements for complying with the Palo Alto Dental Amalgam Recovery Program: 7 1. Comply with Best Management Practices - This is the first mandatory action dental facilities are required to implement. Palo Alto s BMPs include most of those listed above. - The fact sheet also directs facilities to implement ADA BMPs. 2. Install an amalgam separator that meets ISO Standards - Certified separators remove at least 95% of amalgam from wastewater. - Facilities were told to install a separator within roughly one year. 3. Submit documentation that shows your office is complying - This is done by permittees through self-certification of implementation of BMPs and installation of a separator. 4. Keep staff training, mercury disposal, and separator installation and maintenance records onsite for three years. Before implementing its Dental Amalgam Recovery Program, Palo Alto worked directly with dental facilities in the city to introduce them to the dental amalgam program, identify efforts facilities have voluntarily taken to reduce the amount of mercury going down the drain, and to ask for their assistance in developing the program. City staff visited 43 percent of dental facilities in the city to determine baseline BMP and amalgam separator use. 8 Following implementation of the program, staff has been visiting about 20 percent of the city s dental facilities annually to verify compliance with the amalgam program. 9 Estimated costs to dental facilities: Expense Estimated Cost Range Low High Amalgam separators (one time) $150 $2,000 Installation of separators (one time) $50 $1,000 Maintenance and mercury waste disposal (annual) $250 $600 Table 1. Costs to dental facilities identified by the City of Palo Alto, based on 2004 estimates Hughes, Stephanie. May Dental Amalgam Recovery Program for East Palo Alto, Palo Alto, Los Altos, Los Altos Hills, and Mountain View. 8 United States Environmental Protection Agency. August Health Services Industry Detailed Study: Dental Amalgam 9 Personal communication with Brad Eggleston, City of Palo Alto 10 Hughes, Stephanie. May Dental Amalgam Recovery Program for East Palo Alto, Palo Alto, Los Altos, Los Altos Hills, and Mountain View.

3 Program contact: Karin North Case study: San Jose The San Jose/Santa Clara Water Pollution Control Plant established a mandatory dental mercury permitting program in The permit requirement applies to San Jose, Santa Clara, Campbell, Cupertino, Los Gatos, Milpitas, Monte Sereno, Saratoga, and adjacent unincorporated areas all cities under the jurisdiction of the Water Pollution Control Plant. The requirements for complying with San Jose s program are very similar to Palo Alto, the main difference being that San Jose requires dental facilities to obtain a permit (see the attached program brochure): 1. Apply for a Dental Wastewater Discharge Permit. - Permits are effective for five years. - Like Palo Alto, permit exemptions only apply to certain dental practices (including periodontists, orthodontists, oral pathology/oral medicine, and others) that remove or place amalgam fillings three days per year or less. 2. Implement Required Best Management Practices. 3. Install an ISO certified amalgam separator. - See the attached list of approved amalgam separator manufacturers from the Bay Area Pollution Prevention Group (BAPPG). 4. Certify Compliance by completing the BMP Certification and Amalgam Separator Installation Certification. 5. Keep Records of training, disposal, and equipment onsite for five years. 6. Submit an annual Dental Wastewater Discharge Permit Annual Report. Estimated costs to dental facilities: In San Jose, there are no costs to obtain the permit itself. Equipment and mercury disposal costs are listed in table 2 below. Costs for the equipment can be split among practices with a shared vacuum line (one separator is required per vacuum system). Extra plumbing costs may also apply to the installation of the separator. Expense Estimated Cost Range Low High Amalgam separators (one time) $600 $2,000 Hazardous waste collection service (annual) $200 $200 Table 2. Estimated costs of complying with the dental amalgam program in San Jose. 11 Program contact: Roberta Dunlap Roberta.Dunlap@sanjoseca.gov 11 City of San Jose Environmental Services. Dental Amalgam Program Frequently Asked Questions. Last modified 11/12/

4 Additional items to consider The EPA conducted a study in August 2008 examining a variety of dental amalgam programs around the country. They researched the costs of purchasing an amalgam separator as well as operation and maintenance costs (table 3). The study drew both from manufacturer estimates of cost and calculated average costs based on similar information from nine regional studies. The results confirm the wide price ranges quoted by Palo Alto and San Jose, especially in the cost of separators. Average Cost According to manufacturers Amalgam Separator Operation and Maintenance $2320 $657 According to regional studies $283-$3170 $388-$1160 Table 3. Average costs of amalgam separator purchase, operation, and maintenance, estimated from manufacturers and regional studies. 12 The EPA report also includes information on the costs to municipalities and state governments of implementing and enforcing dental amalgam programs (table 4). Costs involve actions such as the development and distribution of program materials, outreach, and site visits. Program Cost of BMP Program to State and Local Agencies Description Total Cost ($2008) Number of Participants Cost per Participant Source San Francisco, Brochure/fact sheets + CA distribution $80, $89.56 AMSA, 2002 San Francisco, CA Site visits $16, visits $ AMSA, 2002 Palo Alto, CA Brochure/fact sheets + distribution $16, $32.20 AMSA, 2002 Palo Alto, CA Outreach/advisory group $13, $26.80 AMSA, 2002 Western Lake Superior District, Outreach $40, $ AMSA, 2002 MN Salem, OR Staff labor $8, $76.42 ACWA, 2007 Salem, OR Inspection or other form of contact $4, $44.77 ACWA, 2007 Oregon State All costs in 2004 $3, $74.53 ACWA, 2007 Oregon State All costs in 2005 $1, $54.62 ACWA, 2007 Oregon State All costs in 2006 $6, $ ACWA, 2007 Table 4. Cost of dental amalgam BMP programs to state and local agencies 13. While it appears that San Francisco s brochure efforts are the most expensive and Oregon s 2006 program was the least expensive, examining the cost per participant shows different results. The lowest costs per participant were borne by the City of Palo Alto, which actually had the second highest number of participants. The most expensive actions were the site visits conducted by the City of San Francisco and the outreach efforts by Western Lake Superior District in Minnesota. Deciding on the best dental amalgam program design for your 12 United States Environmental Protection Agency. August Health Services Industry Detailed Study: Dental Amalgam 13 United States Environmental Protection Agency. August Health Services Industry Detailed Study: Dental Amalgam

5 municipality should therefore take into account the number of participants you intend to target and the types of actions you feel are important to engage in for an effective program. Please contact Save The Bay s Clean Bay Project program staff for additional resources. Policy Department x118 cleanbay@savesfbay.org Partial funding for this project comes from the USEPA San Francisco Bay Water Quality Improvement Fund (2009) in collaboration with the San Francisco Estuary Partnership and ABAG.

6 Sewer Use Ordinance Mandating Amalgam Separators and Best Management Practices [The text presented below is excerpted from the city of Palo Alto ordinance. Ordinance language for the cities of Mountain View and Los Altos is identical.] Requirements for dental facilities that remove or place amalgam fillings. (a) Definitions. For the purposes of this section the following words and phrases shall be as defined herein. (1) Amalgam separator is a device that employs filtration, settlement, centrifugation, or ion exchange to remove amalgam and its metal constituents from a dental office vacuum system before it discharges to the sewer. (2) Amalgam waste means and includes non-contact amalgam (amalgam scrap that has not been in contact with the patient); contact amalgam (including, but not limited to, extracted teeth containing amalgam); amalgam sludge captured by chairside traps, vacuum pump filters, screens, and other amalgam trapping devices; used amalgam capsules; and leaking or unusable amalgam capsules. (3) ISO is the International Organization for Standardization s standard for amalgam separators. (b) All owners and operators of dental facilities that remove or place amalgam fillings shall comply with the following waste management practices: (1) No person shall rinse chairside traps, vacuum screens, or amalgam separators equipment in a sink or other connection to the sanitary sewer. (2) Owners and operators of dental facilities shall ensure that all staff members who handle amalgam waste are trained in the proper handling, management and disposal of mercury-containing material and fixer-containing solutions, and shall maintain training records that shall be available for inspection by the superintendent or designee during normal business hours. (3) Amalgam waste shall be stored and managed in accordance with the instructions of the recycler or hauler of such materials. (4) Bleach and other chlorine-containing disinfectants shall not be used to disinfect the vacuum line system. (5) The use of bulk mercury is prohibited. Only precapsulated dental amalgam is permitted. (c) All owners and operators of dental vacuum suction systems, except as set forth in subsections (d) and (e) of this section, shall comply with the following: (1) An ISO certified amalgam separator device shall be installed for each dental vacuum suction system on or before March 31, 2005; provided, however, that all dental facilities that are newly constructed on and after the effective date of this ordinance shall include an installed ISO certified amalgam separator device. The installed device must be ISO certified as capable of removing a minimum of 95 percent of amalgam. The amalgam separator system shall be certified at flow rates comparable to the flow rate of the actual vacuum suction system operation. Neither the separator device nor the related plumbing shall include an automatic flow bypass. For facilities that require an amalgam separator that exceeds the practical capacity of ISO test methodology, a non-certified separator will be accepted, provided that smaller units from the same manufacturer and

7 of the same technology are ISO-certified. Alternative materials and methods may be proposed to the superintendent for approval, pursuant to (2) Proof of certification and installation records shall be submitted to the superintendent within 30 days of installation. (3) Amalgam separators shall be maintained in accordance with manufacturer recommendations. Installation, certification, and maintenance records shall be available for immediate inspection upon request therefor by the superintendent or designee during normal business hours. (d) Facilities with vacuum suction systems that meet all of the following conditions may apply to the superintendent for an exemption to the requirements of subsection (c) of this section: (1) The systems was installed before October 1, (2) The system is a dry vacuum pump system with an air-water separator. (3) The sedimentation tank is non-bottom draining, with the drain above the anticipated maximum level of accumulated sludge. (4) Evidence of regular pump outs (a minimum of once a year, or more often if either directed by the manufacturer or necessary to keep solids from exiting through the drain) is maintained and open to inspection by the superintendent during normal business hours. (5) The system has no direct discharge pipe to the sewer on the bottom of the sedimentation tank. An owner or operator whose facility meets conditions (1) through (5) may apply for this exemption by written letter to the superintendent. The superintendent or designee will review the system and, if the exemption is approved, shall provide a written letter of exemption. An exemption obtained pursuant to this subsection (d) shall expire upon installation of a new vacuum system. Upon expiration of the exemption, the facility shall comply with subsection (c) of this section before commencing further operation. (e) The following types of dental practice are exempt from this section , provided that removal or placement of amalgam fillings occurs at the facility no more than 3 days per year: (1) Orthodontics; (2) Periodontics; (3) Oral and maxillofacial surgery; (4) Radiology; (5) Oral pathology or oral medicine; (6) Endodontistry and prosthodontistry.

8 A Dentist s Guide to the Keep mercury out of our waterways Dental Amalgam Program & Permit Who is required to participate? Dentists who remove or place amalgam fillings and who practice in the San Jose/ Santa Clara Water Pollution Control Plant service area are required to obtain a Dental Wastewater Discharge Permit and follow Best Management Practices. Dental wastewater may contain mercury, a toxin that can affect the health of waterways, wildlife, and people. The San Francisco Bay the jewel of our region has been designated as impaired by the Regional Water Quality Control Board (Water Board) due to high levels of mercury in fish, water, and sediment. The Water Board requires Bay Area wastewater treatment facilities, including the San Jose/Santa Clara Water Pollution Control Plant (Plant), to implement programs that control mercury at its source. Capturing mercury at its source and before it reaches the sewer system is the best way to reduce mercury pollution in both water and air. The Dental Amalgam Program for the eight cities and unincorporated areas served by the Plant requires dentists to implement practices aimed at keeping dental-related mercury out of the sanitary sewer system and out of our Bay. How does a dental practice comply? STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Apply for a Dental Wastewater Discharge Permit. Visit our Web site or call for an application. Follow Best Management Practices (see inside). Install an approved amalgam separator. Visit our Web site for a list. Submit documentation certifying your compliance with the requirements (see checklist on back page). Keep training, disposal, and equipment records on site and available for inspection. For more information, visit or call (408)

9 Dentists help reduce mercury pollution with these Best Management Practices (BMPs) These practices are required as part of your discharge permit. Amalgam waste must NEVER be placed in the regular trash, placed with infectious waste (red bag), or flushed down the drain or toilet. The American Dental Association strongly recommends recycling amalgam waste as a best management practice for dental offices. Amalgam waste includes contact amalgam such as extracted teeth containing amalgam restorations; noncontact or scrap amalgam; used, leaking, or unusable amalgam capsules; and amalgam captured by chair-side traps, vacuum pump screens, and other devices, including the traps, filters, and screens themselves. ➓ ➊ Eliminate all use of bulk elemental mercury. Bulk elemental mercury, also referred to as liquid or raw mercury, must be recycled or disposed of as hazardous waste. Use only pre-capsulated dental amalgam in the smallest appropriate size. Train staff and document training. Train staff in proper handling, management, and disposal of mercury-containing material and fixer solutions. Maintain a training log and keep this log for at least five years. This log must be made available to authorized inspectors. ➋ Properly manage chair-side traps. Change or empty chairside traps frequently and store the trap and its contents with amalgam waste. Never rinse traps in the sink. If you have reusable traps, make sure any material you use to clean the trap is disposed of with amalgam waste. ➌ Do not use chlorine-based products to clean vacuum lines. Do not use sodium hypochlorite (bleach) or other chlorine containing products to cleanse vacuum lines, as these products have been shown to release the mercury in the amalgam. Information on line cleaners and their effect on amalgam waste can be found on our Web site. ➍ Properly maintain and dispose of screens. Change vacuum pump filters and screens as needed or as directed by the manufacturer and store with amalgam waste. Seal and store filters and screens as well as their contents (including any water that may be present) with amalgam waste in an airtight container. ➎ Maintain the vacuum system. For dry vacuum turbine units, have a qualified maintenance technician, amalgam recycler, or hazardous waste disposal service pump out and clean the air-water separator tank. ➒ Properly dispose of fixer solution. Use a licensed hauler to transport spent fixer solution to be recycled or managed as a hazardous waste, or personally deliver it to the Santa Clara County Conditionally Exempt Small Quantity Generators Program ( Never pour fixer solution down the drain. ➑ Store amalgam waste in airtight containers. Follow recycler s or hauler s instructions for disinfection of waste and separation of contact and non-contact amalgam. Do not use disinfectant solutions with oxidizers, such as bleach, to disinfect the amalgam. A healthy dental practice will incorporate these BMPs. Following them is one more way that you can promote the health of your patients and the general public. It can be good for your bottom line, too, as many of today s consumers want to support businesses that use green practices. BMPS are: Good for the environment Good for patients Good for business ➐ Document amalgam waste. Maintain written or computerized logs of amalgam waste generated and removed from the vacuum system or plumbing. In addition, obtain receipts or other certified documentation from your recycler or hauler for all amalgam waste recycling or disposal shipments. Keep these receipts on file for at least five years and available to authorized inspectors. ➏ Properly discard amalgam waste. Recycling is the preferred method for discarding amalgam waste. Have a licensed recycling contractor, mail-in-service, or hazardous waste hauler remove your amalgam waste, or personally deliver your amalgam waste to the Santa Clara County Conditionally Exempt Small Quantity Generators Program ( For more information, visit or call (408)

10 Questions Frequently Asked What is amalgam waste? Amalgam waste means and includes non-contact dental amalgam (dental amalgam scrap that has not been in contact with the patient); contact dental amalgam (including, but not limited to, extracted teeth containing amalgam); dental amalgam sludge captured by chairside traps, vacuum pump filters, screens, and other dental amalgam trapping devices including the traps, filters and screens; used, leaking or unusable dental amalgam capsules; and used amalgam separator canisters. Is any dental practice exempt from this requirement? A practice is exempt from this requirement if amalgam fillings are removed or placed three or fewer days per year and the facility serves one of the following primary functions: Radiology Oral and maxillofacial surgery Oral pathology or oral medicine Orthodontics Periodontics Endodontics Prosthodontics Will separators installed before the program requirements take effect be acceptable for compliance? Yes, but only if the unit is an approved ISO certified amalgam separator. Will chairside traps and vacuum filters meet the requirement? No, chairside traps and vacuum filters are separate devices that do not meet the amalgam removal requirement. Will dental practices be charged permit fees like large industries? No, there is no permit fee at this time. What is the duration of my permit? Dental Wastewater Discharge Permits are effective for a period of five (5) years. The effective and renewal dates are indicated in your permit. Will my practice be inspected for compliance with my permit? Yes, a scheduled inspection will be performed at least once during the five year permit period. If your practice is out of compliance, additional inspections may be scheduled. Compliance Checklist All required forms and a list of approved amalgam separators can be found on our Web site. Submit complete Dental Wastewater Discharge Permit Application. Receive Dental Wastewater Discharge Permit with effective date. Implement Best Management Practices (BMPs). Submit Best Management Practices (BMPs) Certification Form within 90 days of permit s effective date. Install approved ISO certified amalgam separator. Submit Amalgam Separator Installation Certification within 180 days of effective date of permit. Keep training, disposal, and equipment records on-site and available for inspection. Submit Dental Wastewater Discharge Permit Annual Report according to the deadline listed in the permit. Environmental Services A Certified Green Business Serving the cities of San José, Santa Clara, and Milpitas; Cupertino Sanitary District; West Valley Sanitation District (including Campbell, Los Gatos, Monte Sereno, and Saratoga); County Sanitation District No. 2-3; and Burbank Sanitary District. Printed on recycled paper using soy-based inks. 0509/Q3000:xxxx/RB/JMc/IX For more information, visit or call (408)

11 BAPPG List of Accepted Amalgam Separators (May 2009) This listing is in alphabetical order by business name. In order to be included here a manufacturer has submitted current technical information about its amalgam separator equipment to the Bay Area Pollution Prevention Group (BAPPG) [1]. The submitted information includes a current laboratory test report of equipment effectiveness [2], and a quality assurance document [3] indicating that units currently being manufactured are the same as what was tested. BAPPG only accepts laboratory tests that have been performed by an accredited laboratory according to the 1999 or later edition of Standard No. ISO of the International Organization for Standardization. Dental practices contemplating the purchase of an amalgam separator are encouraged to contact the manufacturers directly to determine whether a specific unit on this list meets their needs (e.g., type of vacuum system, number of operatories, space requirements, etc.). Some units are available through local distributors in the San Francisco area. BAPPG intends to periodically update this list. Manufacturers that wish to have their amalgam separators considered for inclusion on the list should contact: Meg Gale, SF-PUC, (415) MGale@sfwater.org Page 1 May 2009

12 BAPPG Accepted Amalgam Separator List Business Info Make Model Separation Technology AB Dental Trends 211 Grover Street Lynden, WA Roger Weiss (800) FAX (800) Rasch Filtration Rasch Rasch Settlement Ion Exchange Rasch American Dental Accessories 7310 Oxford Street Minneapolis, MN Rasch AD-1000 ( ) Filtration Settlement Richard Zeiska (800) FAX (888) Rasch AD-1500 ( ) Ion Exchange Dental Recycling North America 145 West 58th Street New York, NY Marc Sussman (800) FAX (866) BU Settlement BU Settlement Purewater Development, Inc 5001 SW 74th Court Miami, FL Metasys ECO II Settlement Walter Ruffini (305) FAX Continued on next page... Page 2 May 2009

13 BAPPG Accepted Amalgam Separator List Business Info Make Model Separation Technology R & D Services, Inc 8116 Green Lake Dr. N. Seattle, WA Deanna Borden (800) (206) FAX dbfraker@comcast.net Amalgam Collector Amalgam Collector Amalgam Collector CE 24 Settlement / Sedimentation CE12 CH 9 or CH12 Amalgam Collector CE18 RAMVAC Dental Products, Inc 3100 First Avenue Spearfish, SD Marian Alderman (605) FAX malderman@dentalez.com Ramvac Hg Settlement Rebec LLC Catch Hg 400 Settlement P.O. Box 658 Edmonds, WA Catch Hg 400 Plus Tim Reber (800) FAX (800) tim@rebecsolutions.com Catch Hg 1000 Catch Hg 1000 Plus Catch Hg 9000 Solmetex, Inc 50 Bearfoot Rd. Northborough, MA Al Dube (508) FAX (508) adube@solmetex.com Hg-5 Original Settlement Hg-5 Mini Page 3 May 2009

14 BAPPG Accepted Amalgam Separator List Footnotes [1] This list takes the place of earlier editions published by the City and County of San Francisco. Manufacturers wishing to submit an amalgam separator for consideration should download a copy of the Amalgam Separator Information Form available on the BAPPG website < or contact Meg Gale of San Francisco Public Utilities at (415) <MGale@sfwater.org>. [2] Information about the International Organization for Standardization (ISO) and its testing standards is available at: < Standard No. ISO pertains to tests on amalgam separator units to determine their removal efficiency under laboratory conditions. Tests based upon the 1999 standard are acceptable until the issued test certificate expires (typically after 5 years). At that point the current ISO will be required. Inclusion on the BAPPG list requires that a separator has been tested within the previous 5 years, and that the amalgam removal efficiency under both empty and full conditions is 95% or greater. These tests must be performed by a laboratory that is independently accredited as being capable of performing ISO tests. [3] As part of the ISO process, manufacturers may arrange a periodic third-party quality assurance review to determine that their current separator units are the same as were tested. The independent reviewing authority may be the ISO testing laboratory, a quality assurance service, or a professional engineer registered in the United States, who issues a letter, report, or other document to certify its findings. [4] The next update to the BAPPG amalgam separator list is tentatively planned for mid Page 4 May 2009