Cooling tower and warm water system (Regulated systems) application form

COOLING TOWER AND WARM WATER SYSTEM (REGULATED SYSTEMS)

APPLICATION FORM

NSW Public Heath Act 2010

In accordance with the requirements of the NSW Public Health Act 2010 the following regulated systems must be registered with Council:

All water cooling systems
Warm water systems installed within a hospital or nursing home

For further information or questions regarding this form, please contact Council via 9911 6555.

Address of cooling tower/ warm water system

Trading/premise name: *

Address of premise: *

Postcode of premise: *

Location of system/s: *e.g. roof top

Premises owner's details

Premises owner business name *

Premises owner ABN *

Premises owner Address *

Premises owner Postcode *

Premises owner contact surname *

Premises owner contact first name *

Premises owner contact home address *

Premises owner contact postcode *

Premises owner contact phone (h)

Premises owner contact phone (w)

Premises owner contact phone (m) *

Premises owner contact email *

Occupier/s details

Who will be responsible for maintenance? *

OwnerOccupier

Please complete where the owner does not have access to the regulated system or the occupier is responsible for its maintenance. Where more than one (1) occupier is responsible please attach relevant details.

Business name: *

Proprietor: *

ABN: *

Address: *

Postcode: *

Contact surname: *

Contact first name: *

Contact home address: *

Contact suburb: *

Contact postcode: *

Contact phone (m): *

Contact phone (w): *

Contact phone (h): *

Contact email: *

Building Manager (Where applicable)

Is there a Building Manager who manages this cooling tower on behalf of the owner/occupier? *

YesNo

Company name: *

Company ABN: *

Building manager first name *

Building manager surname *

Position title: *

Company mailing address: *

Company mailing postcode: *

Company mailing suburb: *

Home address: *

Home postcode: *

Building Manager contact (h): *

Building Manager contact (w): *

Building Manager contact (m): *

Emergency contact phone (w): *

Emergency contact email: *

Particulars of cooling tower/ warm water system

Type of system: *

Cooling towerWarm water

Number of towers in system 1 *

Number of towers in system 2 *

Number of towers in system 3 *

Number of towers in system 4 *

Number of towers in system 5 *

Name of Water treatment company: *

ABN of Water treatment company: *

Water treatment company address: *

Water treatment company suburb: *

Water treatment company postcode: *

Water treatment company contact surname: *

Water treatment company contact firstname: *

Water treatment company phone (h):

Water treatment company phone (w):

Water treatment company phone (m): *

Water treatment company email: *

PLEASE NOTE

Council may inspect the system without prior notice to assess the system for compliance with legislative requirements. An inspection fee will be charged. Any change to the information provided in this form, must be notified to Council within one month of the change being made.

To view the Public Health Act 2010 and Public Health Regulation 2022, please refer to the NSW Health website.

Applicant Signature *

Draw signature|Type signatureClear

Date signed *