Water Cooling Tower and Warm Water System Notification Form System Details Please select Cooling water system Warm water system Cooling and warm water system Occupier Details Occupier Full Name* - required Occupier Unit/Street Number* - required Occupier Street Name* - required Occupier Suburb/Town* - required Occupier phone number* - required Postal Address Is the postal address the same as the business address above?* - required Yes No Postal Address Address or PO Box Suburb/Town* - required State* - required Select ACT NSW NT QLD SA TAS VIC WA Postcode* - required Buidling Manager details Building Manager Full Name* - required Building Manager phone number* - required Building Manager Email Address* - required System site details Unit/Street Number* - required Street Name* - required Suburb* - required Postcode* - required Site Phone Number* - required Email Address* - required Location of system within premise* - required Cooling System details (no. of towers, make and model)* - required Water Treatment Company* - required Reason for notification Type of Notification* - required Installation Change of Occupier Change of Particulars/Decommissioning Installation date Date System Installed Change of Occupier New Occupier Residential Address* - required New Occupier ABN/CAN* - required Date Change of Occupier Occured Change of Particulars or Decommissioning Please select any that are relevant* - required Change in occupier contact details Change in building manager's contact details Water cooling tower/s added to system Water cooling tower/s removed from system Warm water system type changed/modified Existing cooling tower unique ID System has been decommissioned Declaration Name of person completing form* - required Role of person completing form* - required Email Address* - required Employer* - required I can confirm that I am an authorised person from the company* - required Signature Type It Draw It Clear Print your name Please type your signature Please sign here Privacy Statement Personal information supplied to or collected by Tamworth Regional Council will only be stored and processed by Council for lawful purposes directly related to the functions and activities of Council. Any personal information supplied will only be disclosed to a third party for the purpose of performing a lawful function or activity and for no other purpose. Disclosure of personal information to a third party will be in accordance with Tamworth Regional Council's Privacy Management Plan (PDF 331.7KB). Mandatory field(s) marked with *