Approved form AF2002-242

Approved by the General Manager of the Health Protection Service on 6.12.2002 under the

Public Health Act 1997, s137A

Public Health Act 1997—Form CT2
(see s56H)
Australian Capital Territory

Cooling Tower and Warm Water Storage System Registration Certificate

(See attached Cooling Tower and Warm Water Storage System Registration Certificate)

Cooling Tower and Warm Water Storage System Registration Certificate
«Premises_PropertyName»
«Premises_StreetNo» «Premises_Street»
«Premises_Suburb»  «Premises_Postcode»
Registration No: «Registration_Number»
This licence authorises «Proprietor_FullName» to carry on the location specific registrable public health risk activity of the operation of Cooling Towers and Warm Water Storage Systems at the premises mentioned above for the period starting from {{Date_Granted}} to «Due_for_Renewal».
Precise Location of System
{{Precise_Location}}
Owner of Registered Premises
{{Owner_Name}} - {{Owner_Address}}
Manager of the Registered Premises
{{Manager_Name}} - {{Manager_Address}}
Equipment Owner
{{Equipment_Owner}} - {{Owner_Address}}
Equipment Manager
{{Equipment_Manager}} - {{Manager_Address}}
Special Conditions
«Conditions»

<Signatory>