Approved form AF2002-243

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 CT3
(see s56K)
Australian Capital Territory

Cooling Tower and Warm Water Registration Renewal Form

(See attached Cooling Tower and Warm Water Registration Renewal Form)

Regist. No:		Fee:		File No:		Expiry Date:		
Please complete this form, sign it and return it with the prescribed fee.  GST is not applicable under section 81-5 of the A New Tax System (Goods and Services Tax) Act 1999 (C’th).
Section 1	Registered Person/Company Details
1	Registered Person		
Title		First Name		Surname			
ABN		Company		
Please Note: To change the registered persons details you must either complete a transfer form or submit a new application
Section 2	Location of Registered System
2	Building Name where Registered System is Located		
Name			
3	Registered System’s Address		
Street No		Street			
Suburb		Postcode			
Section 3	Contact Details
4	Contact Details for the Registered Person/Company		
Contact Person			
After Hrs		Phone		Mobile			
Fax		Email			
Section 4	Postal Details
5	Postal Address for Registration Correspondence		

Suburb		State		Postcode			
Section 5	Equipment Details
6	Cooling tower or warm water storage system details		
Name of Manufacturer		Model No.			
Year of Manufacture		Serial No.			
7	Have you made a significant modification to the system and not notified the Health Protection Service	Yes  No  	
If Yes, a practicing engineer's certificate certifying the cooling tower's or warm water storage systems compliance to the ACT Cooling Tower and Warm Water Storage System Code of Practice 2000 must accompany the renewal in light of the significant modification.	

Section 6	Premises Owner
8	Has there been a change of premises owner? (If Yes, please complete this section)	Yes  No  	
9	Person/Company who owns the premises where the cooling tower or warm water system is located	
Name			
10	Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
11	Physical Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
12	Postal Address 		

Suburb		State		Postcode			
Section 7	Premises Manager
13	Has there been a change of premises manager? (If Yes, please complete this section)	Yes  No  	
14	Person/Company who managers the premises where the cooling tower or warm water system is located	
Company			
Name			
15	Premises Manager's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
16	Premises Manager's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
17	Premises Manager's Postal Address 		

Suburb		State		Postcode			

Section 8	Equipment Owner
18	Has there been a change of equipment owner? (If Yes, please complete this section)	Yes  No  	
19	Person/Company who owns the cooling tower or warm water system	
Company			
Name			
20	Equipment Owner's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
21	Equipment Owner's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
22	Equipment Owner's Postal Address 		

Suburb		State		Postcode			
Section 9	Equipment Manager
23	Has there been a change of equipment manager? (If Yes, please complete this section)	Yes  No  	
24	Person/Company who manages the cooling tower or warm water system	
Company			
Name			
25	Equipment Manager's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
26	Equipment Manager's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
27	Equipment Manager's Postal Address		

Suburb		State		Postcode			
Section 10	Declaration
I declare that all the information supplied on this form is true and correct and the necessary records and / or documentation exist to support this application.	
Signature of Registered Person/Company		Date				
Print Name		Position
Title				

OFFICE USE ONLY	
Registration Approved	Yes  No  	Conditions	Yes  No 				
Officer's Signature		Date					

Section 11	Payment
Payment Method - Please Tick ()	Cash 	Cheque 	Credit Card 	
Note: Cheques should be made payable to the Health Protection Service. 	
Type of Credit Card - Please Tick ()	Visa 	Master Card 	Bankcard 	
Credit Card No	Expiry Date	
   	/	
Cardholders' Name			
		
Fee	$		
I agree for the Health Protection Service to debit my account for the above fee.	
Card Holder's Signature		Date			
Daytime Phone No					
How to Pay		
	Phone: 6205 1700 (Please have your credit card and this notice ready when you call). 		Fax: 6205 1705 	
Note: You are still required to sign and return this form prior to the issue of your registration certificate.	
	By Mail: Health Protection Service, Locked Bag 5, Weston Creek  ACT  2611.		In Person: Health Protection Service, 25 Mulley Street, Holder ACT.	
	Online: www.canberraconnect.act.gov.au 			

OFFICE USE ONLY
File No: _________________			Registration No _____________________