QES Management System Issue Date: 19/09/2014 Recycled Water Standpipe Permit Application or Renewal City West Water Address Locked Bag 350, Sunshine 3020 Email connections@citywestwater.csdfom.au Phone 9313 8379 To apply for a permit to use a Recycled Water Standpipe within City West Water’s operating area, please read and complete this form, sign and submit by mail to Connections & Metering Services, City West Water, Locked Bag 350, Sunshine Vic 3020. In addition to the posted copy if filled in electronically this form can be emailed to the address below to quicken processing of your application. However, a Permit will not be issued until the signed hard copy is received. **For queries regarding permits – phone 9313 8379 or email connections@citywestwater.com.au OFFICE USE ONLY Permit No: Usage: Applicant details Company name: Company address: ABN/ACN: Owner/CEO name: Company contact: Office phone: Fax: Mobile: Email: Upon approval of a permit application, the terms and conditions set out in this document (including the Conditions of Permit set out below) apply to the permit that is issued. Usage information A. Number of vehicles that will be used to connect to Standpipe: B. Approx. number of times standpipe will be used (per vehicle): C. Have you stated the Intended End Uses of the recycled water you supply? D. Have the Conditions of Permit been read and signed, and do you understand that all sites receiving recycled water must be declared to CWW & must have an approved End User Permit/EIP? Yes E. No Yes No If no, please contact City West Water to discuss. Please provide the following information for all vehicles – see next page (if more than 3 vehicles require a permit, please complete “Application for Additional Vehicles” form. Document FOR-261 Rev 2 Page 1/6 QES Management System Issue Date: 19/09/2014 Vehicles to Register Vehicle 1 Vehicle Reg. no: Tanker Reg. No: Do you currently hold a hydrant permit for this vehicle?: If yes, provide details below Size (kL): Yes No With which Water Authority does this vehicle have a hydrant permit? CWW SEW YVW Other (please detail) Name of permit holder: Hydrant permit number: Backflow prevention device: Registered Air Gap Registered Pressure Zone Device (RPZ) Provide latest test results of Registered Air Gap or RPZ device Test results included Do you currently hold a recycled water (RW) permit for this vehicle from another Water Authority? If yes, provide details below. Yes No With which Water Authority does this vehicle have a hydrant permit? CWW SEW YVW Other (please detail) Name of permit holder: Recycled water permit number: Recycled water class: Bottom filling tankers only (top filling not permitted) Type of air release: Manual Auto None on roof Describe method of opening/closing roof hatch including detail of release mechanism as an attachment. Vehicle 2 Vehicle Reg. no: Tanker Reg. No: Do you currently hold a hydrant permit for this vehicle?: If yes, provide details below Size (kL): Yes No With which Water Authority does this vehicle have a hydrant permit? CWW SEW YVW Other (please detail) Name of permit holder: Hydrant permit number: Backflow prevention device: Registered Air Gap Registered Pressure Zone Device (RPZ) Provide latest test results of Registered Air Gap or RPZ device Test results included Do you currently hold a recycled water (RW) permit for this vehicle from another Water Authority? If yes, provide details below. Yes No With which Water Authority does this vehicle have a hydrant permit? CWW SEW YVW Other (please detail) Name of permit holder: Recycled water permit number: Recycled water class: Bottom filling tankers only (top filling not permitted) Type of air release: Document FOR-261 Manual Auto Rev 2 None on roof Page 2/6 QES Management System Issue Date: 19/09/2014 Vehicle 3 Vehicle Reg. no: Tanker Reg. No: Do you currently hold a hydrant permit for this vehicle?: If yes, provide details below Size (kL): Yes No With which Water Authority does this vehicle have a hydrant permit? CWW SEW YVW Other (please detail) Name of permit holder: Hydrant permit number: Backflow prevention device: Registered Air Gap Registered Pressure Zone Device (RPZ) Provide latest test results of Registered Air Gap or RPZ device Test results included Do you currently hold a recycled water (RW) permit for this vehicle from another Water Authority? If yes, provide details below. Yes No With which Water Authority does this vehicle have a hydrant permit? CWW SEW YVW Other (please detail) Name of permit holder: Recycled water permit number: Recycled water class: Bottom filling tankers only (top filling not permitted) Type of air release: Manual Auto None on roof Intended End Uses Please state the intended End Use of the recycled water you will be supplying. You may nominate more than one intended use. Permitted uses of Class A recycled water: Irrigation of lawns, trees and garden beds External pressure cleaning Irrigation of sports grounds and parklands Fire fighting Washing vehicles Irrigation of food and non-food crops Dust suppression Other (please describe): Livestock drinking water IMPORTANT: A vehicle that has been used to supply recycled water must not be used to supply potable water for human consumption, food preparation, swimming pools or ice making. For more information on food safety requirements and the carting of drinking water, see the Environmental Health section of the Department of Human Services website (http://www.health.vic.gov.au/environment/). If at any time the Permit holder becomes aware of an incident which may involve a contamination of the drinking water supply system or recycled water supply, the Permit holder must immediately contact City West Water on 131 642. What is the End User (EU) Permit number of the end user(s) you are intending to supply? EU EU EU EU Applying separately for own EU permit Intended end user is applying separately for own EU permit (company name) (http://www.citywestwater.com.au) Not yet know – details intentions: Document FOR-261 Rev 2 Page 3/6 QES Management System Issue Date: 19/09/2014 Conditions of permit Cartage of Recycled Water Training 1. Only those vehicles listed on this permit are authorised to access and take water from the recycled water standpipe. If there are additional vehicles that the applicant wishes to register the permit holder must make application in respect of these vehicles and obtain written confirmation from CWW that these vehicles are covered by this permit. 1. 2. All vehicles used to cart recycled water must have a Recycled Water Permit Holder sticker displayed at all times as issued by City West Water. 1. The Permit holder: Use of Recycled Water (a) acknowledges and agrees that the recycled water is only to be used for Intended End Uses that have been approved by City West Water; 3. All vehicles used to cart recycled water must have signage permanently located on all outlets displaying Prohibition Sign No. 404 and the words “Recycled Water Do Not Drink” visible from 5m (minimum height of lettering 25mm). (b) without limiting 1: i. acknowledges that recycled water must be used in accordance with applicable legal and regulatory requirements, including Department of Human Services (DHS) requirements and Environment Protection Authority (EPA) requirements set out in Publication 464.2 Guidelines for Use of Reclaimed Water; 4. The Permit holder acknowledges that unauthorised connection of a recycled water vehicle to the potable water system presents a significant risk to public health and must not be undertaken under any circumstances. 5. A vehicle that has been used to supply recycled water must not be used to supply potable water for human consumption, food preparation or ice making. For more information on food safety requirements and the carting of drinking water, see the Environmental Health section of the Department of Human Services website (http://www.health.vic.gov.au/environment/). ii. must ensure that all sites receiving recycled water are registered with City West Water and have an approved Environment Improvement Plan (EIP) or End Use Protocol/Permit which specifies the conditions of use of recycled water use on that site (c) acknowledges and agrees that it is responsible for the recycled water during transit and will deal with any spillage or discharge of recycled water in accordance with EPA Publication 464.2 Guidelines for Use of Reclaimed Water Guidelines 6. A vehicle that has been used to collect, transport or deliver Class A recycled water must not subsequently be used to collect, transport or deliver potable water (for any purpose) unless a registered air gap or reduced pressure zone device as depicted in AS/NZS 3500.1:2003 Page 8 diagrams a) or b) is permanently installed on the vehicle, and testing results/ certification of registered air gap or backflow prevention device is supplied to City West Water on an annual basis. 2. The Permit holder must keep records of all sites receiving recycled water and of volumes supplied to all sites. General Conditions 1. Recycled water is a limited resource and CWW is entitled to revoke this Permit by notice to the Permit holder at any time in its unlimited discretion in order to ensure that the resource is directed towards the most appropriate uses. Without limiting this right, where the Permit holder is in breach of one or more of these Conditions of Permit CWW will be entitled to revoke the Permit immediately by notice. 7. The Permit holder must only collect recycled water that is of a Class A quality and must not use the vehicle to collect, transport or deliver water that is of a quality inferior to Class A. 8. Recycled Water Permit holders who also hold a Permit to access fire hydrants and fire plugs must act in accordance with the terms of the Hydrant Permit. 2. The Permit holder must provide City West Water with access to any property or information reasonably required by CWW in order to allow CWW to audit compliance with these Conditions of Permit, or to perform audits required by the Environment Protection Authority or under applicable laws/regulations. 9. If at any time the Permit holder becomes aware of an incident which may involve a contamination of the drinking water supply system or recycled water supply, the Permit holder must immediately contact City West Water on 9313 8379. Occupational Health & Safety 3. CWW may suspend the supply of recycled water under this permit if the water quality does not meet the Class A requirements. 1. The Permit holder must ensure that any person involved in accessing the standpipe and drawing water under the authority of this permit attends a site induction at the Western Treatment Plant (WTP) to become familiar with site protocols and access arrangements to the standpipe prior to accessing the standpipe, and they must be available to attend safety meetings if requested by Melbourne Water. The site induction can be arranged by contacting WTP on Phone: 9742 9211 or Mobile: 0419 553 821. Document FOR-261 The Permit holder is responsible for ensuring all drivers and recycled water operators are aware of and comply with all Conditions of Permit and are trained to handle recycled water accordingly. 4. The Permit holder will not be entitled to any compensation, costs, loss or damages arising from or in any way related to the revocation of this Permit or the suspension of supply of recycled water. 5. The Permit holder agrees to indemnify CWW from and against any claims, costs, loss or damage suffered or incurred by CWW as a direct result of any breach of these Permit Conditions by the Permit Holder. Rev 2 Page 4/6 QES Management System Issue Date: 19/09/2014 Applicant to sign: I have read and agree in full with terms and conditions of this Permit including the Conditions of Permit: Signature: Title & name of signatory: Date: Important privacy notice By completing this form you are providing personal information to City West Water for the primary purpose of City West Water providing you with a water or sewerage supply. To read City West Water's complete privacy statement, please visit citywestwater.com.au. CWW to complete This permit application has been approved by: Signature: Date: Metering & Compliance Coordinator Signature: Date: Manager Connections and Metering Comments: Information for Recycled Water Standpipe Permit Holders Ongoing Requirements Standpipes Hours of Operation Western Treatment Plant Monday - Sunday 6am - 9pm Hoppers Lane 24 hrs - access key required Signage on Vehicles All vehicles used to cart recycled water must have Recycled Water Permit Holder stickers displayed at all times. Stickers will be mailed to the recycled water permit holder with the recycled water standpipe approval letter. Accessing Recycled Water through the Electronic System Upon approval of your permit, a recycled standpipe permit card will be issued to each vehicle. Card must be kept in your corresponding vehicle at all times as it displays your PIN to access recycled water. Carters must also have an End User PIN provided by the end user to enter into the system. Ongoing Requirements of Permit Holders All sites that receive recycled water must be registered with City West Water and must have an approved Environmental Improvement Plan (EIP) or End Use Protocol which specifies the conditions of recycled water use at that site. Permit holders must ensure that all end users are registered with City West Water prior to supplying recycled water. Ongoing Auditing by City West Water City West Water has an ongoing monitoring program to ensure that Standpipe Permit Holders and Recycled Water End Users are fulfilling their requirements. The Permit Holder must provide City West Water with access to any property or information reasonably required by CWW in order to allow CWW to audit compliance with the Conditions of Permit, or to perform audits required by the Environment Protection Authority or under applicable laws/regulations. Document FOR-261 Rev 2 Page 5/6 QES Management System Issue Date: 19/09/2014 Information for Recycled Water Standpipe Permit Holders who also hold a Hydrant Permit Persons holding a Recycled Water Standpipe Permit who also hold a Hydrant Permit must read and understand the following. Vehicles that have been used to collect recycled water MUST NOT be used to cart water that is intended for drinking. City West Water permits a truck to access both Class A recycled water and potable water under the following strict conditions. Failure to comply with these conditions will result in immediate annulment of both permits. UNAUTHORISED ACCESS TO THE POTABLE WATER SYSTEM IS A PUBLIC HEALTH RISK AND IS CONSIDERED A SERIOUS OFFENCE. A vehicle that wishes to be a dual permit holder: 1. Should NOT supply potable water for human consumption/drinking 2. Should only collect recycled water that is of a Class A standard supplied by City West Water 3. Should have one of the following filling arrangements permanently installed on the vehicle: i. A permanent registered air-gap as depicted in Figure A. ii. A reduced pressure zone device as shown in Figure B. 4. Certification of the registered air gap or the reduced pressure zone must be provided to City West Water on an annual basis. 5. Should have prohibition sign 404 with the words ‘Recycled Water Do Not Drink” permanently displayed on all outlets of the truck (See Figure C) 6. Should have both permit stickers displayed at all times. 7. Must be approved by City West Water. Arrangements can be made by contacting City West Water’s Water Connections and Technical Officer on 9313 8379. City West Water has an auditing program in place to ensure the ongoing compliance of all recycled water permit holders. City West Water ABN 70 066 902 467 Locked Bag 350 Sunshine Victoria 3020 Australia Document FOR-261 Account and general enquiries: 131 691 Faults and emergencies: 132 642 Interpreter service: 131 450 Internet: citywestwater.com.au Email: connections@citywestwater.com.au Rev 2 Page 6/6