This form is to be completed by Property Owner or Authorised Agent

Property owner

Name:______

Address:______

CompanyACN number:______

Name of authorised representative:______

Premises address

Property ID no: ______

Address:______

Town: ______State:______Postcode: ______

Type of Business: (description of property’s use)______

Postal address (tick if same as property address)

Address: ______

Town: ______State:______Postcode: ______

Name of contact person responsible for site management:

First name: ______Surname: ______

Work phone: ______Mobile: ______

Email address:______

Type of Backflow Prevention Device(BPD) (This table must be completed)

Type of BPD / Make / Size (mm) / Number of Devices
& Serial Number / Level of Hazard
Reduced Pressure Zone Device / High
Double Check-Valve / Medium
Dual Check-Valve / Low

CONDITIONS

The Owner must comply with each of the following conditions:

Laws & Standards

(a)The Owner must comply with all relevant laws and Australian Standards, including:

  • Water Industry Act 1994
  • Water Act 1989
  • Plumbing Standards Regulations 1998 (Vic)

AS/NZ 3500.1.2003 – Plumbing and drainage – Water services;

AS 2845 – Water Supply – Mechanical Backflow Prevention devices

(b)The Owner must ensure that any BPD installed at the property boundary complies with, and is marked as complying with AS 2845.

(c)The Owner must not use any fire service installed at the Property for any purpose other than fighting fire.

Installation

The Owner must ensure that any BPD is:

(d)Installed:

  • By a person accredited to install, commission and test BPDs (‘an accredited person’);
  • At or near the property’s boundary;
  • In a place which is easily accessible and which will prevent water in the BPD from freezing;
  • In accordance with the manufacturer’s instructions

(e)Commissioned by an accredited person, when the BPD is installed

Annual Testing

Where appropriate the owner must ensure that any BPD which is being installed is tested annually by an accredited person, in accordance with the manufacturer’s instructions and AS 2845.

Reporting and Records

(f)The Owner must ensure that:

  • a report on commissioning the BPD: and
  • the results of each annual test,
  • are promptly sent to:Trade Waste Officer

Coliban Water

PO Box 2770

BENDIGO DC VIC 3554

(g)The Owner must also:

  • keep a record of the date and details of any maintenance work and each annual tests; and
  • make that record available for inspection at the request of a representative of Coliban Water

Acceptance

To be signed as an agreement by the Owner or Authorised Agent. The Authorised Agent will be a person with authority to commit the Business/Company to agreements.

Signature of Owner / Authorised Agent:

Signature:______

Name (please print):______

Date: ______

Return via email:

Fax: (03) 5434 1315

Postage: Coliban Water, PO Box 2770, Bendigo DC VIC 3554

For information on our Privacy Policy visit our website or call 1300 363 200.