Cooling Tower – Elevated Legionella/ Heterotrophic Plate Count Notification Form

Purpose of Form

The Public Health Regulation 2012 (the Regulation) requires occupiers to ensure that the cooling water system is tested for Legionella count and heterotrophic colony count (HCC), on a monthly basis. Occupiers must notify the local government authority within 24 hours of receiving a reportable test result of Legionella count ≥1,000 colony forming units per millilitre (cfu/mL) or HCC ≥5,000,000 cfu/mL.

This approved form must be completed in accordance with clause 13R of the Regulation. Further information on the process of notification and responding to elevated microbial levels is provided in the NSW Guidelines for Legionella Control in Cooling Water Systems, available at www.health.nsw.gov.au/environment/legionellacontrol.

Site and Contact Details

Site Address *

Cooling Water System Details *(number of cooling towers, and unique identification number for each cooling tower)

Local Government Authority *(where this system is located)

Provide the name, phone numbers (business hours, after hours and mobile numbers), email address, and postal address for each of the contact persons listed below.

Occupier Contact Details

Occupier Name *(the person or entity who owns the system)

Phone Number *

Email Address *

Duly Qualified Person Contact Details

(Person managing the system on a day to day basis, and attended the site during this month).

Name *(Duly Qualified Person)

Employer *

Phone Number *

Email Address *

Laboratory

Laboratory Name *

NATA Accreditation Details *

Reportable Test Results

Type of Test (Legionella or heterotrophic colony count) *

Test Result (in cfu/mL) *

Description of Sampling Point *(type of sampling point, and location on cooling water system)

Date and Time of Sampling by Duly Qualified Person *

Date and Time of Testing by Laboratory *

Date and Time of Result Receipt by Occupier *

Laboratory Report(s) *

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The Regulation requires certain results and records to be kept on the premises and made available immediately, or kept electronically and made available within 4 hours of request. These include: operating and maintenance manuals; RMPs; results of microbial testing and chemical analysis; and maintenance records (in accordance with section 3.7 of AS/NZS 3666.3:2011).

Details of Person Completing the Form

Name *

Role *

Employer *(name of company or organisation)

Postal Address *

Email Address *

Phone Number *

Signature *

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Date *

Local government authority use:

Date Received

Name of Receiving Officer

Position of Receiving Officer

Notification received within 24 hours of occupier receiving a reportable test result from laboratory.

Unique identification numbers confirmed.

Register of cooling water systems updated with reportable test result.

Contacted occupier or duly qualified person (DQP) to confirm control strategies put in place in accordance with the Risk Management Plan (RMP) and AS/NZS 3666.3:2011.

Contacted occupier or DQP to obtain second and third microbial test results.

Flagged for follow up.

Desktop (off site) follow up.

Site investigation and inspection.

Improvement notice issued.

Prohibition order issued.

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