Form 5 Notice – Fluoridated Water Quarterly Report

Water Fluoridation Regulation 2020
Part 5 section 23(1)

Purpose of form
This form may be used by a public potable water supplier to give a Fluoridated Water Quarterly Report per calendar quarter.

Required fields are marked with an asterisk (*).

Public potable water supplier *

ABN/ACN *

DRDMW Service Provider ID *

Street address of potable water supplier *

Town/suburb *

Postcode *

Postal address (if different to street address) *

Name of treatment plant *

Location of treatment plant *

Report Details

Reporting period (Quarter – calendar year) e.g. Q1 2020 *

Number of samples of water taken for prescribed testing *

Prescribed concentration for local government area *

Average fluoride concentration of fluoridated water as measured by prescribed tests *

Maximum fluoride concentration of fluoridated water as measured by prescribed tests *

Minimum fluoride concentration of fluoridated water as measured by prescribed tests *

Number of samples exceeding 1.5mg fluoride/L *

Explanation where average measured fluoride concentration is not within 0.1mg/L of prescribed concentration for local government area *

Details of person submitting Notice

Principal contact name *

Principal contact position *

Telephone number *

Email *

Print

All sections of this form must be completed to meet the requirements of section 23 of the Water Fluoridation Regulation 2020.

Version 2.0 -  November 2021