11-71-T32

De-commissioning or removal of a high risk manufactured water system (HRMWS)

South Australian Public Health (Legionella) Regulations 2013

The South Australian Public Health (Legionella) Regulations 2013 requires the owner of the premises on which a high risk manufactured water system is located to notify the relevant authority (City of Port Lincoln) within one (1) month of the decommissioning or removal of the high risk manufactured system.

Please complete the details below to confirm de-commissioning or removal of a High Risk Manufactured Water System on your premises.

Business Details

Registered Business Name *

Business Address *

Street address *

City *

State *

Postcode *

Phone Number *

Email *

Person De-Registering HRMWS *

System(s) being de-registered *

Cooling TowerWarm Water System

System(s) Identification *

Reason for de-registration *

Removal De-Commissioned

Date of removal or de-commissioning of system(s) *

Details of removal or de-commissioning *

Notification submitted by *

Signature *

Draw signature|Type signatureClear

Date of Signature *

I declare that all the information I have supplied is true and correct. I acknowledge that personal information provided may be used by the City of Port Lincoln for the purpose of Council business, as specified in Council's Privacy Policy.

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