Leichhardt Municipal Council Regulated Premises Inspection Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Business Details

• Date / Time

  Date

• Cooling tower / Warm water system

  Cooling Tower

  Warm Water Systems

• Water Sample collected for Analysis

  Yes

  No

  N/A

• Maintenance Contractor Name

• Maintenance Contractor Phone Number

• Emergency Contact

• Emergency Contact Number

Compliance with Public Health Act 2010 and Public Health Regulation 2012

• Operation & maintenance manual provided

  Yes

  No

  N/A

• Manuals comply with AZ/NZS 3666.2:2011

  Yes

  No

  N/A

• Maintenance records up to date

  Yes

  No

  N/A

• Maintenance records located on site

  Yes

  No

  N/A

• Equipped with an automatic process of disinfection

  Yes

  No

  N/A

• Is the system/s connected to sewer?

  Yes

  No

  N/A

• Certified by a competent person

  Yes

  No

  N/A

• Expiry date of Certificate of Disinfection

• System inspected monthly for past 12 months

  Yes

  No

  N/A

• Cleaning interval not exceeding 6 months

  Yes

  No

  N/A

General Mantenance

• Appearance of internal wetted surfaces of the cooling tower

  Clean

  Mildly Dirty

  Very Dirty

  Unable to determine

  N/A

• Appearance of water in the sump

  Clean

  Mildly Dirty

  Very Dirty

  Unable to determine

  N/A

• Chemicals stored satisfactory

  Yes

  No

  N/A

• Access to the tower appears safe and easy

  Yes

  No

  N/A

Comments

• Re-Inspection Required

  Select Nil - Satisfactory No Reinspection required - Ensure all above mentioned non compliances are attended prior to next routine inspection Reinspection 24 hours Reinspection 7 days Reinspection 14 days Reinspection 28 days Improvement Notice Prohibition Order Penalty Notice

  • Nil - Satisfactory
  • No Reinspection required - Ensure all above mentioned non compliances are attended prior to next routine inspection
  • Reinspection 24 hours
  • Reinspection 7 days
  • Reinspection 14 days
  • Reinspection 28 days
  • Improvement Notice
  • Prohibition Order
  • Penalty Notice

• Owner / Employee Signature

  Sign

• Authorised Council Officers Name

  Kursty Delmas

  Michael Hendry

  Donna Clement

• Authorised Council Officer Signature

  Sign

• Authorised Council Officer Phone Number

  9367 9068

  9367 9076

  9367 9073