Approved form AF2002-244

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 CT4
(see s56L)
Australian Capital Territory

Cooling Tower and Warm Water Registration Change of Information Form

(See attached Cooling Tower and Warm Water Registration Change of Information Form)

Regist. No:			File No:			
Please complete this form, sign it and return it.
Section 1	Conditions of Information Change
•	This application must be signed by the current registered person; and
•	The original registration certificate must be submitted with this change of information application.
If these conditions cannot be met, please complete a new application form.
Section 2	Type of Change
Registered Person	  Section 3	System Location	  Section 4	Contact Details	  Section 5
Postal Details	  Section 6	Equipment Details	  Section 7	Premises Owner	  Section 8
Premises Manager	  Section 9	Equipment Owner	  Section 10	Equipment Manager	  Section 11
Section 3	Registered Person/Company Details

You cannot vary the Registered Person using this form.  Please complete a Transfer Form or a new Application.  These forms are available from the Health Protection Service.

Section 4	Location of Registered System

You cannot vary the location of the cooling tower or warm water storage system.  You must complete a new Application.  This form is available from the Health Protection Service.

Section 5	Contact Details
1	Contact Details for the Registered Person/Company		
Contact Person			
After Hrs		Phone		Mobile			
Fax		Email			
Section 6	Postal Details
2	Postal Address for Registration Correspondence		

Suburb		State		Postcode			
Section 7	Equipment Details
3	Cooling tower or warm water storage system details		
Name of Manufacturer		Model No.			
Year of Manufacture		Serial No.			
4	Have you made any other significant modification to the cooling tower or warm water storage system?	Yes  No 		
Note:
(a)	A cooling tower that comprises a water loop may be considered to be more than one cooling tower.
(b)	On making a significant modification to the cooling tower or warm water storage system, you must submit a practicing engineer’s certificate certifying the cooling towers or warm water storage systems compliance to the ACT Cooling Tower and Warm Water Storage System Code of Practice with this Change of Information Form.	

Section 8	Premises Owner
5	Person/Company who owns the premises where the cooling tower or warm water system is located	
Name			
6	Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
7	Physical Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
8	Postal Address 		

Suburb		State		Postcode			
9	Does a Commonwealth Agency own the Cooling Tower or Warm Water Storage System?	Yes  No 		
Section 9	Premises Manager
10	Person/Company who managers the premises where the cooling tower or warm water system is located	
Company			
Name			
11	Premises Manager's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
12	Premises Manager's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
13	Premises Manager's Postal Address 		

Suburb		State		Postcode			
Section 10	Equipment Owner
14	Person/Company who owns the cooling tower or warm water system	
Company			
Name			
15	Equipment Owner's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
16	Equipment Owner's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
17	Equipment Owner's Postal Address 		

Suburb		State		Postcode			
Section 11	Equipment Manager
18	Person/Company who manages the cooling tower or warm water system	
Company			
Name			
19	Equipment Manager's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
20	Equipment Manager's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
21	Equipment Manager's Postal Address		

Suburb		State		Postcode			
Section 12	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	
Change of Information Approved	Yes  No  	Conditions	Yes  No 				
Officer's Signature		Date