250 R.I. Code R. 250-RICR-140-20-3.20

Current through October 15, 2024

Section 250-RICR-140-20-3.20 - Appendix A - Certification Statement for the Sale or Distribution of Elemental Mercury

RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 235 Promenade Street Providence, RI 02908
Applicant's full legal name and address, and contact information (printed)
Name/Organization:	Telephone #:
Mailing Address:
City/Town:	State:	Zip code:
Contact Person:	Telephone #:
Mailing Address:
City/Town:	State:	Zip code:
Contact Person:	Telephone #:
Email Address:

Product manufacturer's name, address and contact information (if different from above):
Name:	Telephone #:
Mailing Address:
City/Town:	State:	Zip code:
Contact Person:	Telephone #:
Mailing Address:
City/Town:	State:	Zip code:
Email Address:

Amount of Mercury transferred (pounds):
Date transferred:

Use of Elemental Mercury (check all that apply):
Medical	Dental Amalgam
Research	Other:

Certification: As the recipient of Elemental Mercury, I certify that:
The elemental mercury is to be used only for medical, dental amalgam dispose-caps, or research purposes;
I understand that mercury is toxic and must be stored and used appropriately so that no person is exposed to the mercury; and,
I will not place or allow anyone else under my or my organization's control to place the mercury or cause the mercury to be placed in solid waste for disposal or in a wastewater disposal system.

Signature (of an Authorized Senior Management Official for Recipient) and Date.
Print or type name and Title of the Authorized Senior Management Official.
A copy of § 3.20 of this Part, Appendix A, must be sent to above noted address to the ATTN: OTCA / Mercury Transfer Certification. Recipient should receive a Material Data Safety Sheet (MSDS) with delivery.