FORM: WC03
Water Carrier Registration
Renewal
Water Carrier Registration Renewal
Health (Drinking Water) Amendment Act 2007, Section 69L
The Drinking Water Assessor (DWA) in your district can assist you with filling out this form.
Water carrier trading as:
Water carrier owner:
(may be a company name)
Name of person responsible:
(must be a named individual)
Position:
Address:
Phone:
Date form completed:
Fax:
Email:
/
/
Office use only
Date registration entered:
1.
/
/
Please enter details of all vehicles, vessels, rail wagons and associated equipment (such as
demountable tanks, hoses and fittings) used in association with the carriage of water in the
tables below.
Vehicle / Vessel / Rail Wagon / Tanks
(Enter separately all vehicles, trailers, demountable tanks. If registration number is not applicable,
generate a permanent identification number that can be checked on the equipment)
Description
Identification / registration #
Description
Identification / registration #
Description
Identification / registration #
Description
Identification / registration #
Guidelines for the Safe Carriage and Delivery of Drinking-water
23
Hoses and Fittings
Notes:
1. Identify the type of hoses and fittings used, eg, solid moulded hose, lay-flat hose. Enter each type of hose or fitting
on a new line.
2. Circle either ‘yes’ or ‘no’ to state whether the type of hose or fitting is suitable for the purpose of delivering potable
water.
Type of hose or fitting used
Suitable for delivering potable water?
Yes
No
Type of hose or fitting used
Suitable for delivering potable water?
Yes
No
Type of hose or fitting used
Suitable for delivering potable water?
Yes
No
Type of hose or fitting used
Suitable for delivering potable water?
Yes
No
Type of hose or fitting used
Suitable for delivering potable water?
Yes
No
2.
Have there been any changes or additions to water sources used, vehicle(s) or equipment since
your registration was last renewed?
Please tick
(9)
Yes
No
If yes, describe below.
If no, do you certify that all registration details relevant to the water carrier in the current version of the
Drinking-Water Supply register are true and correct?
Please tick
(9)
Yes
No
Renewal of water carrier registration requires a compliance certificate from a Drinking Water Assessor, no
more than three months old. Please attach a copy of this certificate.
Signed
(person responsible)
If you require help completing this form, please contact the drinking water assessor at your local District Health
Board.
24
Guidelines for the Safe Carriage and Delivery of Drinking-water