250-RICR-140-20-3
250-RICR-140-20-3. Rules and Regulations Governing the Administration and Enforcement of the Rhode Island Mercury Education and Reduction Act (version Adoption, 05/11/2004 to 12/28/2005)
State of Rhode Island and Providence Plantations
Department of Environmental Management
Office of Waste Management
Rules and Regulations Governing the Administration and Enforcement
of the Rhode Island Mercury Education and Reduction Act
May 2004
Authority:
These rules and regulations are promulgated pursuant to the Mercury Education
and Reduction Act of 2001, R.I. General Law Chapter 23-24.9 (1956) and the
Department of Environmental Management, R.I. General Laws Chapter 42-17.1
(1956), in accordance with § 42-35, and the Administrative Procedures of the R. I.
General Laws of 1956, as amended.
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State of Rhode Island and Providence Plantations
Department of Environmental Management
Rules and Regulations Governing the Administration and Enforcement of the
Rhode Island Mercury Education and Reduction Act
Table of Contents
1.
PURPOSE ...........................................................................................................................................................3
2.
AUTHORITY......................................................................................................................................................3
3.
APPLICATION ..................................................................................................................................................3
4.
DEFINITIONS....................................................................................................................................................3
5.
NOTIFICATION................................................................................................................................................6
6.
RESTRICTIONS ON MERCURY-ADDED NOVELTIES..........................................................................11
7.
LIMITATIONS ON THE USE OF ELEMENTAL MERCURY.................................................................12
8.
APPLICATION TO PRODUCTS REGULATED BY FOOD AND DRUG ADMINISTRATION ..........14
9.
DISCLOSURE PROVISION...........................................................................................................................14
10. ENFORCEMENT/PENALTIES .....................................................................................................................14
11. APPEALS..........................................................................................................................................................14
12. SEVERABILITY..............................................................................................................................................15
13. EFFECTIVE DATE .........................................................................................................................................15
APPENDIX A- CERTIFICATION STATEMENT FOR THE SALE OR DISTRIBUTION OF ELEMENTAL
MERCURY ................................................................................................................................................................16
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1.
Purpose
In accordance with the Mercury Education and Reduction Act of 2001, R.I. General Laws
Chapter 23-24.9 (1956), the purpose of these regulations is to improve public and ecosystem
health by achieving significant reductions in environmental mercury by encouraging the
establishment of effective waste reduction, recycling, management and education programs.
2.
Authority
These rules and regulations are promulgated pursuant to the Mercury Education and Reduction
Act of 2001, R.I. General Law Chapter 23-24.9 (1956) and the Department of Environmental
Management, R.I. General Laws Chapter 42-17.1(1956), in accordance with § 42-35, and the
Administrative Procedures of the R. I. General Laws of 1956, as amended.
3.
Application
The terms and provisions of these rules and regulations shall be liberally construed to permit the
Department to effectuate the purposes of state law, goals, and policies.
4.
Definitions
For the purposes of these regulations, the following terms shall have the following
meanings:
4.1 “Authorized senior management official” means a corporate official or the
individual responsible for the overall operation of a facility (or designated
authorized agent of the facility) or an operational unit of a facility, such as a plant
manager, superintendent, manager of environmental programs, or person of
equivalent responsibility.
4.2 "Component" means a mercury-added product that is incorporated into another
product to form a fabricated mercury-added product, including, but not limited to,
electrical switches and lamps.
4.3 “Component manufacturer” means any person who produces a mercury-added
product that is incorporated into another product, including but not limited to
electrical switches, relays, and lamps.
4.4 “Department” means the Rhode Island Department of Environmental Management.
4.5 “Director" means the Director of the Rhode Island Department of Environmental
Management or his or her designee.
4.6 “Elemental mercury” means a heavy, silvery-white metal that is liquid at room
temperature and is represented by the chemical symbol “Hg” with an atomic
number of 80 and an atomic mass of 200.59.
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4.7 “Fabricated mercury-added product" means a product that consists of a
combination of individual components that combine to make a single unit,
including, but not limited to, mercury-added measuring devices, lamps and switches
to which mercury or a mercury compound is intentionally added in order to provide
a specific characteristic, appearance, or quality, or to perform a specific function or
for any other reason.
4.8 “Fluorescent lamp” means a low-pressure mercury electric-discharge lamp in
which a fluorescing coating (phosphor) transforms some of the ultraviolet energy
generated by the discharge into light.
4.9 "Formulated mercury-added product" means a product that includes, but is not
limited to, laboratory chemicals, cleaning products, cosmetics, pharmaceuticals and
coating materials that are sold as a consistent mixture of chemicals to which
mercury or a mercury compound is intentionally added in order to provide a
specific characteristic, appearance, or quality, or to perform a specific function or
for any other reason.
4.10 "Healthcare facility" means any hospital, nursing home, extended care facility,
long-term care facility, clinical or medical laboratory, state or private health or
mental institution, clinic, physician's office or health maintenance organization.
4.11 “Interstate Mercury Education and Reduction Clearinghouse (IMERC)” is a
program established under the auspices of the Northeast Waste Management
Officials’ Association (NEWMOA). It was established to facilitate tasks and serve
as a single point of contact for the manufacturers, distributors, or importers of
mercury-added products to facilitate compliance with state requirements for these
products.
4.12 “Manufacturer” means manufacturer as defined in R.I. General Laws Chapter 23-
24.9, namely any person, firm, association, partnership, corporation, governmental
entity, organization, combination, or joint venture that produces a mercury-added
product or an importer or domestic distributor of a mercury-added product produced
in a foreign country. In the case of a multi-component mercury-added product, the
manufacturer is the last manufacturer to produce or assemble the product. If the
multi-component product is produced in a foreign country, the manufacturer is the
importer or domestic distributor.
4.13 "Mercury-added button cell battery" means a button cell battery to which the
manufacturer intentionally introduces mercury for the operation of the battery.
4.14 "Mercury-added novelty" means a mercury-added product intended mainly for
personal or household enjoyment or adornment. Mercury-added novelties include,
but are not limited to, items intended for use as figurines, adornments, toys, games,
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cards, ornaments, yard statues and figures, candles, jewelry, holiday decorations,
items of apparel (including footwear), or similar products.
4.15 “Mercury-added product" means a product, commodity, chemical or a product with
a component that contains mercury or a mercury compound intentionally added to
the product, commodity, chemical or component in order to provide a specific
characteristic, appearance, or quality, or to perform a specific function or for any
other reason. These products include formulated mercury-added products and
fabricated mercury-added products.
4.16 “Mercury compound” means a substance composed of elemental mercury and one
or more other chemical elements in fixed proportions.
4.17 "Mercury fever thermometer" means a mercury-added product that is used for
measuring body temperature.
4.18 “Offer for sale or use" means any presentation for acceptance or rejection made by
any means, including those that are electronically conveyed.
4.19 "Person" means any individual, group of individuals, firm, joint stock company,
association, partnership, private or municipal corporation, government or quasi-
governmental corporation, state, commission, political subdivision of the state, any
interstate body, or the federal government or any agency or subdivision thereof.
4.20 “Prescription” means a verbal or written order for drugs, medicines and devices by
a licensed practitioner, to be compounded or dispensed by licensed pharmacists in
a duly registered pharmacy, and to be kept on file for a period of four (4) years.
Prescriptions may also apply to the finished products dispensed by the licensed
pharmacists in the registered pharmacy, on order of a licensed practitioner.
4.21 “Product category” means a group of mercury-added products that have the same
purpose for having the mercury in each unit, the same consumer or commercial use,
and an amount of mercury per unit for all products that fall within the category.
4.22 “Provider of elemental mercury” means any person that offers elemental mercury
for sale or use or otherwise distributes elemental mercury.
4.23 “Recipient of elemental mercury” means any person who purchases or otherwise
receives elemental mercury.
4.24 “School” means any public or private kindergarten, elementary, secondary, or
secondary vocation-technical school or Head Start facility or other institution for
the teaching of children in Rhode Island.
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5.
Notification
Notification Requirements In Accordance with §23-24.9-5: Reporting by Manufacturers or
Industry/Trade Groups
5.1 Initial Notification
5.1.1
The notification for a mercury-added product(s) required by R.I. General
Laws § 23-24.9-5, shall include, at a minimum, the following information
for the manufacturer of the product(s):
5.1.1.1
The manufacturer’s full legal name and mailing address;
5.1.1.2
The name, address, and telephone number of a contact person for the
manufacturer;
5.1.1.3
If the manufacturer corresponds via e-mail or otherwise has a presence
on the Internet, the contact person’s e-mail address and/or
manufacturer’s web address, as applicable; and
5.1.2
If the notification, including information required under 5.1.1, for a
mercury-added product(s) is submitted by a manufacturer’s designated
industry or trade group, the notification shall include the following
information:
5.1.2.1
The company or organization’s full legal name and mailing address;
5.1.2.2
The name, address, and telephone number of a contact person for the
company or organization; and
5.1.2.3
If the company or organization corresponds via e-mail or otherwise
has a presence on the Internet, the contact person’s e-mail address
and/or organization’s web address, as applicable.
5.1.3
The notification for a mercury-added product(s), shall include the following
information on the mercury-added product(s):
5.1.3.1
A description of the product or product category;
5.1.3.2
The amount of mercury in each unit of the product, reported in
milligrams (mg) or parts-per-million (ppm) either as an exact number,
as an average per unit with an upper and lower limit, or as falling
within one (1) of the ranges specified in Section 5.1.4 of these
regulations;
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5.1.3.3
The purpose of mercury in each unit of the product;
5.1.3.4
If the mercury-added product or product category contains one (1) or
more mercury-added components in the product, the information
required under Section 5.1.3.1 through 5.1.3.3 above shall be provided
for each mercury-added component contained in the product; and
5.1.3.5
If the mercury-added product or product category contains one (1) or
more mercury-added components in the product, the notification shall
indicate how many units of each component are contained in each unit
of the product.
5.1.4
The manufacturer shall use the following ranges when reporting
mercury content of mercury-added products by range and for
classifying products according to the mercury content in each unit of
the mercury-added product:
5.1.4.1
Greater than 0 but less than or equal to 5 milligrams (mg);
5.1.4.2
Greater than 5 mg but less than or equal to 10 mg;
5.1.4.3
Greater than 10 mg but less than or equal to 50 mg;
5.1.4.4
Greater than 50 mg but less than or equal to 100 mg;
5.1.4.5
Greater than 100 mg but less than or equal to 1000 mg; or
5.1.4.6
Greater than 1000 mg.
5.1.5
If a manufacturer of a mercury-added formulated product elects to use the
specified ranges in Section 5.1.4, they shall report the milligrams of mercury
per one (1) liter of the mercury-added formulated product.
5.1.6
The notification shall provide the name and title of the authorized senior
management official signing the notification on behalf of the manufacturer.
5.1.7
An authorized senior management official shall:
5.1.7.1
Sign and date the notification form; and
5.1.7.2
Certify by the individual’s signature that the information submitted on
the form(s) is true and accurate to the best of their knowledge and
belief, subject to a penalty for making false statements.
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5.1.8
The notification information required under Section 5.1 shall be submitted
on a form obtained from the Interstate Mercury Education and Reduction
Clearinghouse (IMERC).
5.1.9
The notification shall be submitted to the Interstate Mercury Education and
Reduction Clearinghouse (IMERC). If information is submitted to the
Department, in accordance with these regulations, it is assumed to be a
public record unless exempt under R.I. General Laws § 38-2-2 (R.I. Access
to Public Records Act).
5.1.10
The manufacturer of a product containing a mercury-added button cell
battery(ies) shall comply with all the requirements of Section 5.1.1 through
Section 5.1.9 above, even if the battery is the only mercury or mercury-
added component in their product.
5.2
Updated Notification
5.2.1
As required by R.I. General Laws § 23-24.9-5(c), the manufacturer, or the
manufacturer’s designated industry or trade group, shall update and revise
the information in the notification whenever there is a significant change in
the information or when requested by the Director.
5.2.2
A significant change that triggers the requirement to provide an updated
notification shall be deemed to have occurred whenever:
5.2.2.1
Any of the following contact information has changed for the
manufacturer or the manufacturer’s industry or trade group: (i)
company or organization name, (ii) name of the company’s or
organization’s contact person, and (iii) mailing address or phone
number for the contact person;
5.2.2.2
The mercury has been eliminated from the product or product
category;
5.2.2.3
The manufacturer stops manufacturing the mercury-added product or
product category;
5.2.2.4
The mercury-added product or product category is no longer sold in
Rhode Island; or
5.2.2.5
It has been 3 years since the previous notification was approved.
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5.2.3
The updated notification shall include the following:
5.2.3.1
All the information required by R.I. General Laws § 23-24.9-5; and
5.2.3.2
The reason for the update.
5.2.4
An authorized senior management official shall:
5.2.4.1
Sign and date the updated notification form; and
5.2.4.2
Certify by the individual’s signature that the information submitted on
the form(s) is true and accurate to the best of their knowledge and
belief, subject to a penalty for making false statements.
5.2.5
The updated notification shall be submitted on a form obtained from the
Interstate Mercury Education and Reduction Clearinghouse (IMERC).
5.2.6
The updated notification shall be submitted to the Interstate Mercury
Education and Reduction Clearinghouse (IMERC). If information is
submitted to the Department, in accordance with these regulations, it is
assumed to be a public record unless exempt under R.I. General Laws § 38-
2-2 (R.I. Access to Public Records Act).
5.3
Reporting by Product Category
5.3.1
Two or more mercury-added products may be reported as a product category
under the following conditions:
5.3.1.1
All products included in the product category have the same purpose
for having mercury in the product and have the same mercury-added
components; and
5.3.1.2
For products with mercury-added or with one mercury-added
component, all the products included in the product category contain a
total amount of mercury per unit, on average, that falls within one of
the ranges defined in Section 5.1.4; or
5.3.1.3
For products with multiple mercury-added components, all like
components of the products included in the product category contain a
total amount of mercury per unit, on average, that falls within one of
the ranges defined in Section 5.1.4.
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5.4
Reporting Total Mercury in All Mercury-Added Products
5.4.1
A manufacturer of a mercury-added product(s), or the manufacturer’s
designated industry or trade group, shall submit a notification providing
information on the total amount of mercury in all products required by R.I
General Laws § 23-24.9-5.
5.4.2
The information on the total amount of mercury in all mercury-added
products sold in the United States for a calendar year shall be reported by
product or product category.
5.4.3
If the information on the total amount of mercury contained in all mercury-
added products sold in the United States over the last calendar year is to be
submitted by an industry or trade group, the manufacturer shall provide the
following information in a separate notification:
5.4.3.1
The name and address of the designated industry or trade group;
5.4.3.2
The name, address, and telephone number for a contact person for the
industry or trade group; and
5.4.3.3
A statement that the information will be provided by an industry or
trade group.
5.4.4
The notification of the total amount of mercury in all mercury-added
products shall include the following information:
5.4.4.1
The manufacturer’s or industry or trade group’s name and address;
5.4.4.2
The name, address, and telephone number of a contact person for the
manufacturer or industry or trade group;
5.4.4.3
If the manufacturer or industry or trade group corresponds via e-mail
or otherwise has a presence on the Internet, the contact person’s e-mail
address and/or manufacturer’s web address, as applicable;
5.4.4.4
If the information on the total amount of mercury contained in all
mercury-added products sold in the United States over the last
calendar year is submitted by an industry or trade group, the industry
or trade group shall specify the manufacturers for whom it is reporting;
and
5.4.4.5
The total amount of mercury in all mercury-added products sold in the
United States for the previous calendar year.
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5.4.5
Information on the total amount of mercury contained in all mercury-added
products sold in the United States shall be submitted to the Department by
April 1st for the previous calendar year.
5.4.6
The manufacturer or industry or trade group shall submit information on the
total amount of mercury in all mercury-added products sold in the United
States for a calendar year every 3 years thereafter.
6.
Restrictions on Mercury-Added Novelties
6.1
Mercury-Added Novelties: After January 1, 2003, no mercury-added novelty
shall be offered for final sale or use or distributed for promotional purposes in
Rhode Island. This ban on sale, use or distribution does not apply to a novelty
incorporating one or more mercury-added button cell batteries as its only
mercury-added component.
6.2
A mercury-added product which meets the definition of a mercury-added novelty
in Section 4.14 and meets one or more of the following criteria (6.2.1 through
6.2.3) is a mercury-added novelty and subject to the January 1, 2003 deadline:
6.2.1
Mass produced and distributed for promotional or advertisement purposes;
6.2.2
Easily or regularly discarded into the waste-stream;
6.2.3
Reasonably understood to be a non-essential product.
Not all criteria (Section 6.2.1 through 6.2.3) need to be met for a mercury-added
product to be a mercury-added novelty for the purposes of these regulations.
6.3
Product Specific Determination: Manufacturers may request that the Department
evaluate a specific mercury-added product to determine if it is a mercury-added
novelty under these regulations. In evaluating these products, the Department
shall consider the criteria in Section 6.2 and may take into consideration whether
an alternative non-mercury-added product, similar in function, size and price,
exists. The Department is authorized to request any additional written information
it deems necessary to make an appropriate determination.
6.4
Manufacturers that produce and sell mercury-added novelties shall notify retailers
about the provisions of this product ban (Section 6, Restrictions on Mercury-
Added Novelties). The notification by manufacturers to retailers of mercury-
added novelty items required by R.I. General Laws § 23-24.9-6, shall include the
following information:
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6.4.1
A statement that pursuant to R.I. General Laws § 23-24.9-6, no mercury-
added novelty shall be offered for final sale or use or distributed for
promotional purposes in Rhode Island after January 1, 2003;
6.4.2
The specific product(s) from the manufacturer covered under the
notification; and
6.4.3
Information on how to properly dispose of the remaining inventory,
including at a minimum that any remaining stock of mercury-added
novelties must be recycled or disposed as hazardous waste in accordance
with regulations promulgated pursuant to R.I. General Laws § 23-19.1 (The
Rhode Island Hazardous Waste Management Act).
6.5
The restrictions on the sale and distribution of mercury-added novelty items under
R.I. General Laws § 23-24.9-6, shall not apply to novelty items containing a
mercury-added button cell battery if the battery is the only mercury or mercury-
added component in the item.
7.
Limitations on the Use of Elemental Mercury
7.1
After January 1, 2003, a provider of elemental mercury in Rhode Island, including
intermediate distributors and distillers, shall distribute elemental mercury to end-
users in Rhode Island only for the allowable uses specified under R.I. General
Laws § 23-24.9-12 namely for medical, dental, or research purposes.
7.2
The provider of the elemental mercury shall provide the recipient of the elemental
mercury with the Material Safety Data Sheet (MSDS) for elemental mercury, as
defined in 42 U.S.C. Section 11049 with each delivery of elemental mercury.
7.3
The purchaser or recipient of elemental mercury shall sign a statement (Appendix
A), which includes, in accordance with R.I. General Laws § 23-24.9-12, the
following information:
7.3.1
Name and address of the provider of elemental mercury;
7.3.2
Name, address, and telephone number, of a contact person for the provider
of elemental mercury;
7.3.3
If the provider corresponds via e-mail or otherwise has a presence on the
Internet, the contact person’s e-mail address and/or provider’s web address,
as applicable;
7.3.4
Name and address of the recipient of elemental mercury;
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7.3.5
Name, address, and telephone number of a contact person for the recipient
of elemental mercury;
7.3.6
If the recipient corresponds via e-mail or otherwise has a presence on the
Internet, the contact person’s e-mail address and/or recipient’s web address,
as applicable;
7.3.7
Amount of mercury provided to the recipient in that delivery;
7.3.8
Date of the transfer;
7.3.9
A statement indicating that the recipient of the elemental mercury
understands and agrees to the following restrictions specified in R.I. General
Laws § 23-24.9-12:
7.3.9.1
The recipient of the elemental mercury shall use the mercury only for
medical, dental amalgam dispose-caps, or research purposes;
7.3.9.2
The recipient of the elemental mercury understands that mercury is
toxic and shall store and use it appropriately so that no person is
exposed to the mercury; and
7.3.9.3
The recipient of the elemental mercury shall not place or allow anyone
under the purchaser's control to place the mercury or cause the
mercury to be placed in solid waste or red bag regulated medical waste
for disposal or in a wastewater treatment and disposal system except in
accordance with all applicable federal, state and local requirements.
7.3.10
The intended allowable use of the mercury by the recipient, namely whether
it is to be used for medical, dental, research purposes, or for further
distribution for these intended uses; and
7.3.11
Name and title of the authorized senior management official for the recipient
of the elemental mercury signing the certification statement.
7.4
The information required pursuant to Section 7.3 shall be submitted on the form
included in Appendix A of these regulations.
7.5
An authorized senior management official for the recipient of the elemental
mercury shall:
7.5.1
Sign and date the completed certification statement form; and
7.5.2
Certify by the individual’s signature that the information submitted on the
form is true and accurate to the best of the individual’s knowledge and
belief, subject to a penalty for making false statements.
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7.6
The recipient of elemental mercury shall complete and sign a separate
certification statement for each delivery of elemental mercury.
7.7
The provider of the elemental mercury shall forward each completed certification
statement to the Department.
7.8
The provider shall forward completed certification statements to the Department
at least monthly, unless no elemental mercury was offered for sale or use during
the previous month.
8. Application to Products Regulated by Food and Drug Administration
Nothing in these regulations shall apply to prescription drugs regulated by the Food and Drug
Administration (FDA) under the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 301 et. seq.,
to biological products regulated by the Food and Drug Administration under the Public Health
Service Act, 42 U.S.C. § 262 et. seq., or to any substance that may be lawfully sold over the
counter without a prescription under the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 301
et. seq.
9.
Disclosure Provision
Information provided to the Department, in accordance with these regulations, is assumed to be a
public record unless exempt under R.I. General Laws § 38-2-2 (R.I. Access to Public Records
Act).
10. Enforcement/Penalties
The Director shall assess all penalties for violation of these regulations in accordance with the
provisions of R.I. General Laws Chapter 23-24.9 (The 2001 Mercury Education and Reduction
Act), R.I. General Laws Chapter 42-17.1 (The Department of Environmental Management), R.I.
General Laws 42-17.6 (Administrative Penalties for Environmental Violations) and the "Rules
and Regulations for Assessment of Administrative Penalties".
Effective July 1, 2005, a violation of any of the provisions of R.I. General Laws 23-24.9 or any
rule or regulation promulgated pursuant thereto, shall be punishable, in the case of a first
violation, by a civil penalty not to exceed one thousand dollars ($1,000). In the case of a second
and any further violations, the liability shall be for a civil penalty not to exceed five thousand
dollars ($5,000) for each violation.
11. Appeals
Any person affected by a decision of the Director pursuant to these regulations may, in
accordance with Administrative Rules of Practice and Procedure for the Department of
Environmental Management, file a claim for an adjudicatory hearing to review the decision. The
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party contesting a Department decision bears the burden of proof that their application(s) or
action(s) comply with all requirements of the rules and regulations herein. All requests for a
hearing regarding a decision of the Director must be in writing and filed with the clerk of the
Department's Administrative Adjudication Division (AAD) within thirty (30) days of receipt of
the Director's decision. All requests for a hearing regarding an enforcement action issued by the
Department must be in writing and filed with the clerk of the Department's Administrative
Adjudication Division (AAD) within twenty (20) days of receipt of the enforcement action.
12. Severability
If any provision of these Rules and Regulations, or the application thereof to any person or
circumstances, is held invalid by a court of competent jurisdiction, the validity of the remainder
of the Rules and Regulations shall not be affected thereby.
13. Effective Date
The foregoing Rules and Regulations Governing the Administration and Enforcement of the
Mercury Education and Reduction Act, after due notice, are hereby adopted and filed with the
Secretary of State this ______day of ________, 2004 to become effective twenty (20) days
thereafter, in accordance with the provisions of Chapters 23-24.9, 42-35, 42-17.1, 42-17.6 of the
General Laws of Rhode Island of 1956, as amended.
Frederick J. Vincent
Interim Director, RI Department of Environmental Management
Notice Given on:
1/12/04
Public Hearing held:
2/11/04
Filing Date:
4/21/04
Effective Date:
5/11/04
15
RHODE ISLAND
DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
235 Promenade Street, Providence, RI 02908-5767
TDD 401-831-5508
Appendix A- Certification Statement for the Sale or Distribution of Elemental Mercury
I.
APPLICANT'S FULL LEGAL NAME AND ADDRESS, ADDRESS, AND CONTACT INFORMATION (PRINT):
Name/Organization:
Telephone #:
Mailing Address:
City/Town:
State:
Zip Code:
Contact Person:
Telephone #:
Mailing Address:
City/Town:
State:
Zip Code:
E-mail Address:
II.
PRODUCT MANUFACTURERS 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:
E-mail Address:
III.
AMOUNT OF MERCURY TRANSFERRED (POUNDS):
DATE TRANSFERRED:
IV.
USE OF ELEMENTAL MERCURY (CHECK ALL THAT APPLY):
! Medical
! Dental Amalgam
! Research
! Other___________________
V.
CERTIFICATION: AS THE RECIPIENT OF ELEMENTAL MERCURY, I CERTIFY THAT:
(1) The elemental mercury is to be used only for medical, dental amalgam dispose-caps,
or research purposes;
(2) I understand that mercury is toxic and must be stored and used appropriately so that
no person is exposed to the mercury; and
(3) 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)
Date
Print or Type Name and Title of the Authorized Senior Management Official
APPENDIX A :A copy of this document should be sent to above noted address.
ATTN: OTCA/Mercury Transfer Certification
Recipient should receive a Material Data Safety Sheet (MSDS) with delivery.