REGULATED PREMISES INSPECTION REPORT

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

System details

• System type / serial number

• System Location

• System photo

  Media

Contact details

• Contact name

• Contact number

• 24hour emergency contact name/number

Compliance with Public Health (Microbial Control) Regulation

• Operation and maintenance manual provided

  Yes

  No

  N/A

• Manuals comply with AN/NZS 3666

  Yes

  No

  N/A

• Maintenance records up to date

  Yes

  No

  N/A

• Maintenance records kept on site

  Yes

  No

  N/A

• System equipped with an automatic process to control microbial growth

  Yes

  No

  N/A

• process of disinfection is in operation at all times

  Yes

  No

  N/A

• process of disinfection is certified by a competent person

  Yes

  No

  N/A

• Certificate of microbial control expires on

  Date

• Any sample exceeds specified levels of 1 000 000 CPU HPC or 10 CPU TL in past 12 months

  Yes

  No

  N/A

Maintenance

• Tower connected to sewer

  Yes

  No

  N/A

• Chemicals stored satisfcatorily

  Yes

  No

  N/A

• Access for maintenance is satisfictory

  Yes

  No

  N/A

• Provisions made for maintenance

  Yes

  No

  N/A

• System inspected monthly for past 12 months

  Yes

  No

  N/A

• Cleaning interval does not exceed 6 months

  Yes

  No

  N/A

• System cleaned after seasonal shut down

  Yes

  No

  N/A

Contractor details

• Maintenance contractor name

• Maintenance contractor contact number

Comments

• Additional information / comments

• Re-inspection required

  Yes

  No

  N/A

Signature

• Owner / employee

  Sign

• Environmental Health Officer

  Sign