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COOLING WATER SYSTEM

By Maurice Walker,2014-01-24 22:19
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4-1-507 Revised August 2010 Page 1 COOLING WATER SYSTEM REGISTRATION FORM INFORMATION TO APPLICANT About this Application Form The Public and Environmental Health Legionella Regulations 2008 require the owner of premises on which a cooling water system is installed to ensure the system is registered with the Local Council for the area ..

    COOLING WATER SYSTEM

    REGISTRATION FORM

    INFORMATION TO APPLICANT

    About this Application Form

The Public and Environmental Health Legionella Regulations 2008 require the owner of premises on which

    a cooling water system is installed to ensure the system is registered with the Local Council for the area in which the premises are situated. This form is designed for the mandatory registration of cooling water system(s) under the Public and Environmental Health (Legionella) Regulations 2008 and must be

    completed in its entirety.

Registration / Registration Renewal Fees

Registration / registration renewal fees payable to the Local Council are prescribed in Schedule 1 of the

    Public and Environmental Health (Legionella) Regulations 2008, as follows:

     For registration of 1 water system $32.00 For registration of each additional water system installed on the same premise $21.30 On application to an authority for renewal of registration of a high risk manufactured water system (per system) $16.00

    Please note: These fees do not include inspection fees; testing fees and applications to the minister.

Changes requiring notification to the Local Council

    There are a number of mandatory requirements related to the registration of cooling water system(s), including the following:

; Registration remains in force for a period of 12 months after which the applicant must renew the

    registration to the authority.

    ; The owner of premises on which a high risk manufactured water system registered with the Local

    Council is installed, must within 1 month after any change in the particulars registered in relation to the

    system, notify the authority of the change.

    ; If a high risk manufactured water system registered with the authority is decommissioned, the owner of

    the premise on which the system is installed must notify the authority of the decommissioning within 1

    month after the event.

Where to find more information

Local Council

    Should you require assistance with registration or have any questions please contact your Local Council Environmental Health Officer on 8640 3444 or email council@whyalla.sa.gov.au

    4-1-507 Revised August 2010 Page 1

    COOLING WATER SYSTEM

    REGISTRATION FORM

    REGISTRATION TYPE

New Application:

     New registration of cooling water system(s)

    Please indicate the total number of systems to be registered with this application__________________ Existing Registrations:

     Renew registration of cooling water system(s)

     Modify business ownership details and/or maintenance and operation contact details of existing registration(s) of cooling water system(s)

    Please indicate the total number of systems already registered ________________________________

SITE DETAILS

Registered Business Name ______________________________________________________

    ABN_________________________________________________________________

    Address ___________________________________________________________________________ __________________________________________________________________________________ Trading name of premises ___________________________________________________________________ Site (Street) Address ______________________________________________________________________

     ________________________________________________________________________________________ Postal Address ___________________________________________________________________________

     ________________________________________________________________________________________ Contact phone _____________________________________________ Fax ___________________________ Description of Business Activities _____________________________________________________________

     ________________________________________________________________________________________ Business Operating Hours __________________________________________________________________ 4-1-507 Revised August 2010 Page 2

BUSINESS OWNERSHIP DETAILS

    Name of Business Owner(s)

    Name of Business Owner(s) _________________________________________________________________

     ________________________________________________________________________________________ Business Address

    Street Address ___________________________________________________________________________

     ________________________________________________________________________________________ Contact phone _____________________________________________ Fax ___________________________ Name of business contact, representing business owner(s), in regards to this registration.

    Name of Contact __________________________________________________________________________ Position/Title _____________________________________________________________________________ Residential Address

    Street Address ______________________________________________________________________ __________________________________________________________________________________ Contact phone ____________________________________________ Fax ___________________________ Email Mob ___________________________________________

    Additional after hours contact: Name_____________________Phone_________________________

OPERATION & MAINTENANCE CONTACT DETAILS

    Person/company responsible for operation & maintenance In-house Contractor

    Name of Business ________________________________________________________________________ Name of the Contact Person

    Name __________________________________________________________________________________ Position/Title _____________________________________________________________________________ Business Address

    Street Address ____________________________________________________________________________

     ________________________________________________________________________________________ Contact phone ____________________________________________Fax__________________________ Email ____________________________________________________Mob_________________________ Residential Address

    Street Address ___________________________________________________________________________

     ________________________________________________________________________________________ Contact phone _____________________________________________ Fax ___________________________ Additional after hours contact: Name_____________________Phone_________________________

    4-1-507 Revised August 2010 Page 3

    PLANT IDENTIFICATION FORM

    Please Note: Where there is more than 1 cooling water system to be registered, you must photo copy this page and complete it for each system to be registered.

    1 Plant Identification

    Make/brand ______________________________________________________________________________ Model No. _______________________________________________________________________________ System common name/Identification No.(e.g system 1; cooling tower 1) ______________________________ 2 Type of Cooling Water System

     Cooling Tower Evaporative Condenser

    Other___________________________

    3 Application of Cooling Water System

    Application of cooling tower/evaporative condenser Air handling Process cooling

     Other, please specify ____________________________________________________________________ (if there are multiple systems, please detail this on the site plan (over page)) 4 Location of Cooling Water System

    Location Roof Ground Plant

    Room

     Other, please specify ____________________________________________________________________ 5 Frequency of Operation

     Annual Seasonal (please specify months)____________________

    6 Maintenance of cooling water system

    Please indicate the maintenance regime utilised for the cooling water system

     Section 2.5 of AS/NZS 3666.2; or

     Section 3 of AS/NZS 3666.3; or

     A program approved by the Minister (attach the approval as an appendix to this registration) 7 Drift Eliminators

    Is a drift eliminator fitted to the system?

     Yes

     No

    8 Automatic Biocide Dosing Devices

    Is the cooling water system fitted with an automatic biocide dosing device?

     Yes

     No

    9 Decontamination Procedure

    Please indicate the decontamination procedure utilised for the cooling water system

     Prescribed decontamination procedure set out in Schedule 3 Part 1 of the Guidelines for the Control of

    Legionella in Manufactured Water Systems in South Australia; or

     A decontamination procedure approved by the Minister (attach the approval as an appendix to this registration)

    4-1-507 Revised August 2010 Page 4

SITE PLAN

    Please draw a site plan identifying the location of all cooling water system(s). Where necessary, please attach additional pages

4-1-507 Revised August 2010 Page 5

REGISTRATION FORM CHECKLIST

To assist processing your application, please ensure that the following items have been completed and

    attached:

     Application type indicated

     Site details

     Business ownership details

     Operation/Maintenance Contacts

     Cooling water system plant identification form(s)

     Please indicate number of forms:_____

     Site plan

     (with attachment(s) where necessary)

APPLICANT DETAILS

Name of person submitting registration form

    First name_________________________________Surname__________________________________

    Position title ________________________________________________________________________

    Signature__________________________________________________________ Date____/____/_____

     Office Use Only Completed Fee received: (Receipt number and amount)__________________________________ Property Identification:________________________ ____/____/____ Date registered: ________________________ Registration expiry date: ____/____/____

4-1-507 Revised August 2010 Page 6

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