Devonport City Council 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*
Applicant Email*

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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
Untitled
- First Choice
- Second Choice
- Third Choice
* 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
Fee Payment
Application ID*
Product Name*
Price:
How would you like to pay?
- Invoice me
- Pay by Credit Card
Person who will receiving an invoice*
Email where invoice needs to be sent*
Hidden
Narration
Hidden
RecordType
Credit Card
Card Details
Cardholder Name

Save and Continue Later ^[1]

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

Fee Payment