Application/Renewal for registration of regulated systems and premises where cooling towers are operated Form

1Applicants Details

2Details of Premises

3Regulated Systems Details

Regulated Systems Public Health Act 1997 | Section 114
PART A TO BE COMPLETED BY APPLICANT (OWNER/OCCUPIER)
Applicant Details
Who is the Owner/Occupier*
Name of applicant*
First Last
Name of the company*
Authorised Officer*
First Last
ACN*
Address for correspondence*
Street Address City State Post Code
Address of registered office*
Street Address City State Post Code
Telephone*
Mobile Phone*
Email*

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Details of premises where regulated system is located or cooling tower is operated
Business Name
Address of premises*
Street Address City State Postal Code
Telephone*
Mobile Phone*
Email*
Daytime contact person*
First Last
Telephone*
Mobile Phone*
After hours contact person for access to the premises*
First Last
Telephone*
Mobile Phone*
Is the business aware of the requirements for operation of certain regulated systems under the guidelines for Legionella 2012?*
Consent*
I agree to the privacy policy of the Devonport City Council.
Click Here to view our Privacy Policy (Opens in a new tab)a
Date
MM slash DD slash YYYY

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PART B TO BE COMPLETED BY APPLICANT

A separated Part B must be completed for EACH regulated system/cooling tower at the premises.
How many regulated heating systems/cooling towers would you like to renew/register?*
Please enter a number less than or equal to 12.
Regulated Heating System/Cooling Tower 1
Description of where system is located at registered address:*
NOTE: The Director of Public Health considers that for warm water systems and cooling towers
to be operated without posing a threat to public health, operation and maintenance must
comply with AS/NZS 3666.2.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload risk assessment previously provided remains current and there have been no significant modifications to the system*
Drop files here or

Max. file size: 50 MB.
Upload Water testing results*
Drop files here or

Max. file size: 50 MB.
Upload maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 2
Description of where system is located at registered address:*
NOTE: The Director of Public Health considers that for warm water systems and cooling towers
to be operated without posing a threat to public health, operation and maintenance must
comply with AS/NZS 3666.2.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 3
Description of where system is located at registered address:*
NOTE: The Director of Public Health considers that for warm water systems and cooling towers
to be operated without posing a threat to public health, operation and maintenance must
comply with AS/NZS 3666.2.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload Certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 4
Description of where system is located at registered address:*
NOTE: The Director of Public Health considers that for warm water systems and cooling towers
to be operated without posing a threat to public health, operation and maintenance must
comply with AS/NZS 3666.2.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload Certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 5
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 6
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 7
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 8
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 9
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower*
Regulated Heating System/Cooling Tower 10
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 11
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower
Regulated Heating System/Cooling Tower 12
Description of where system is located at registered address:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
System details:*
- Warm water system
- Cooling tower associated with air conditioning
- Cooling tower associated with refrigeration plant or freezer
- Cooling tower associated with other industrial process or equipment cooling
System make/model:*
Serial number:*
Owner’s identifying number:*
Maintenance Details
Are maintenance records available?*
- Yes
- No
Are some aspects of operation or maintenance carried out by an external person or organisation?*
- Yes
- No
If yes, indicate which aspects have been assigned and state the person/organisation responsible below:*
The following documentation must be attached to this application for each regulated
system/cooling tower.
Tick the appropriate boxes and include the documents with the application.*
- Risk assessment for the system* OR
- Risk assessment previously provided remains current and there have been no significant modifications to the system*
- Water testing results, if carried out.
- Maintenance specifications and certification of completion
- Certification of the disinfection process*
- Details of water treatment processes*
- Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation
* Does not apply to warm water systems
Upload Risk assessment for the system*
Drop files here or

Max. file size: 50 MB.
Upload Risk assessment previously provided remains current and there have been no significant modifications to the system
Drop files here or

Max. file size: 50 MB.
Upload Water testing results, if carried out.*
Drop files here or

Max. file size: 50 MB.
Upload Maintenance specifications and certification of completion*
Drop files here or

Max. file size: 50 MB.
Upload certification of the disinfection process*
Drop files here or

Max. file size: 50 MB.
Upload Details of water treatment processes*
Drop files here or

Max. file size: 50 MB.
Upload Documentation of Corrective Action that has been taken after non-compliance with standards/issues with operation*
Drop files here or

Max. file size: 50 MB.
Additional comments for the Regulated Heating System/Cooling Tower

Save and Continue Later

Application/Renewal for registration of regulated systems and premises where cooling towers are operated Form

Applicant Details

Details of premises where regulated system is located or cooling tower is operated

Regulated Heating System/Cooling Tower 1

Maintenance Details

Regulated Heating System/Cooling Tower 2

Maintenance Details

Regulated Heating System/Cooling Tower 3

Maintenance Details

Regulated Heating System/Cooling Tower 4

Maintenance Details

Regulated Heating System/Cooling Tower 5

Maintenance Details

Regulated Heating System/Cooling Tower 6

Maintenance Details

Regulated Heating System/Cooling Tower 7

Maintenance Details

Regulated Heating System/Cooling Tower 8

Maintenance Details

Regulated Heating System/Cooling Tower 9

Maintenance Details

Regulated Heating System/Cooling Tower 10

Maintenance Details

Regulated Heating System/Cooling Tower 11

Maintenance Details

Regulated Heating System/Cooling Tower 12

Maintenance Details

Acknowledgment

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