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									                                 Appendix 3 - Legionella Management Plan

The Control of Legionella Bacteria in Water Systems

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  1. Introduction

  2. Legislation

  3. Policy Application

  4. Management Structure

  5. Investigation in the Case of a Suspected Outbreak

  6. Legionella Management Procedures

  7. Useful Numbers

  8. Appendices

     1. Action in the Event of an Outbreak

     2. Legionella Risk Assessment

     3. Guidance Note – Monitoring and treatments for Hot and Cold Water Systems

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The Legionella Management Plan (LMP) clearly details the duties & responsibilities of those
council officers who are responsible for the management & control of legionella bacteria
within council buildings.


The Health and Safety at Work Act 1974 extends to the risk from legionella bacteria,
which may arise from, work activities. Apart from the Health and Safety at Work etc Act
1974, there are two sets of Regulations and on Approved Code of Practice that apply to
the control of legionella bacteria in water systems.

These are:-

             The Control of Substances Hazardous to Health Regulations (COSHH)
             The Notification of Cooling Towers and Evaporative Condensers Regulations
             The HSE Approved Code of Practice ACOP L8 (rev) – “The control of
              legionella bacteria in water systems”.

2.1 The Control of Substances Hazardous to Health Regulations (COSHH)

Harmful bacteria such as legionella pneumophila (biological agents) are subject to the
requirements of the Control of Substances Hazardous to Health Regulations (COSHH). The
COHSHH framework provides actions designed to control the risk and requires that:

             Risk assessments are carried out;
             Steps are taken to prevent exposure where total removal of the hazardous
              substance is not reasonably practicable;
             Maintenance, examination and testing of control measures, e.g. automatic
              dosing equipment for delivery of biocides and other treatment chemicals;
             Provision of information, instruction and training for employees
             Where it is appropriate that, health surveillance is carried out.

2.2 The Notification of Cooling Towers and Evaporative Condensers Regulations

Any one who controls a premise which has equipment that includes a cooling tower and/or
evaporative condensers must inform the local authority in writing with details of the
‘notifiable devises’ on the appropriate forms which are available from Local Authorities or
the Health and Safety Executive.

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  2.3 The HSE Approved Code of Practice ACOP L8 (rev) – “The control of legionella
  bacteria in water systems”.

  The Approved Code of Practice applies to the control of legionella bacteria in any
  undertaking involving work activity and to premises controlled in connection with trade or
  business, whose activity gives rise to a risk of harmful exposure to legionella bacteria.
  Also where there is a reasonable foreseeable risk of harmful exposure to legionella
  bacteria in any premise where water is used or stored and where there is a means of
  creating and transmitting water droplets, which may be inhaled. These include the

               Water systems incorporating a cooling tower
               Water systems incorporating an evaporative condenser
               All hot water and certain cold water systems
               Other plant and systems containing water which is likely to exceed 20°C and
                which may release a spray or aerosol during operation or maintenance such
                as vehicle washers, humidifiers and spa baths.

  The Approved Code of Practice provides a basic framework for preventing further
  outbreaks of the disease, giving advice on how to comply with the requirements of the
  Heath and Safety at Work etc Act 1974 and the Control of Substances Hazardous to Health.
  It places responsibility on employers and others to:

               Identify and assess risks of legionellosis
               Avoid the use of systems that give rise to a foreseeable risk of legionellosis
                or, where this is not reasonably practicable, prepare a written scheme for
                minimising the risk from exposure
               Implement and manage the scheme of precautions including the appointment
                of a person / persons to take managerial responsibility and to provide
                supervision; and keep appropriate records
               Advise on the management, selection, training and competence of personnel


  Gateshead Council recognise the need to protect its employees and others from the
  harmful effects of legionella by:-

               Complying with the above Regulations and the requirements of this policy;
               Providing standards not less than those set out in the Approved Codes of
               Appoint a person or persons, to take managerial responsibility and to provide
               Taking all reasonable steps to prevent its employees and others from
                breathing in droplets of water containing harmful levels of legionella.
               Keeping the appropriate records
               Providing appropriate training

  In support of this Gateshead Council will instigate the following practical steps:-

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3.1.0 Organisation and Responsibilities (See Appendix 1)

The ACoP identifies 2 distinct roles, each having specific responsibilities, namely;

   1.      The Duty Holder
   2.      Responsible person

3.1.1 Duty Holder: Chief Executive

The Chief Executive, as Duty Holder must appoint in writing a responsible person or
persons to take managerial responsibility for controlling legionella in premises under their
control and ensuring that the Council meets it’s statutory obligations.

3.1.2 Responsible Person(s): Group Directors

Group Directors have responsibility for ensuring the Control of Legionella in premises
under their control. This requires the Group Directors to:

              Appoint a legionella Co-ordinator(s) to act as a point of contact between
               their Services and Property Services
              Identify necessary resources to take remedial action to reduce the risks
               presented by Legionella bacteria within their premises

4.1.0 Service Management Structure

In addition to the Duty Holder & Responsible Persons detailed above Gateshead Council
have implemented the following management structure to ensure that the Legionella
Management Plan is adhered to.

4.1.1 Legionella Co-ordinators e.g. Heads of Service or Deputies, Headteachers

The role of the legionella co-ordinator is to:

       Co-ordinate the efforts within the Service to ensure that suitable action is taken to
        implement the findings of premises risk assessments.
       Liaise with Property Services and Human Resources (Health & Safety) on the
        management of Legionella Bacteria within the Services premises and the
        commissioning of remedial works or when Legionella risks have been identified.
       Advise their Senior Management Team where additional funding is required to
        comply with the ACoP L8 or where risk assessments have identified potential areas
        of concern.
       Ensure that all facilities managers and those in control of buildings comply with the

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4.1.2 Facilities Managers and those in control of buildings e.g. Librarian, Leisure
Centre Manager

Those Officers who are responsible for the day-to-day management of the risk from
Legionella bacteria on-site must:

      Allow reasonable access to enable the risk assessment and any remedial works to
       take place.
      Ensure that no repair, maintenance or alteration work takes place on hot and cold
       water systems within the building(s) they are responsible for without notifying
       Property Services of the planned changes so an assessment can be made as to the
       potential water hygiene impact on the system.
      Appoint and identify any individuals(s) who will be responsible for completing the
       routine water hygiene tasks and checks on the premises.
      Ensure that the necessary routine water hygiene tasks and checks as described in
       the water hygiene logbook are completed at the required frequencies and recorded
       in the site logbook.

4.1.3 Head of Property Services

The Head of Property Services is responsible for managing technical aspects of the
management of the risk from Legionella bacteria in Council premises. This requires the
Head of Property Services to:-

      Lead on and manage the corporate Legionella risk assessment process and oversee
       the LMP.
      Arrange for annual risk assessment reviews.
      Arrange for and monitor the effectiveness of necessary remedial works following
       risk assessments and laboratory testing.
      Provide training, advice and assistance on the implementation of these procedures
       to managers commissioning or managing any works in connection with hot and cold
       water systems (and other related systems regarded as at risk from Legionella
      Maintain suitable records of the findings of risk assessments and completion of
       remedial works.
      Report on implementation of risk assessment programmes, the completion of
       remedial works and the results of monitoring the conduct of on-site routine water
       hygiene tasks and checks.

4.1.4 Local Environmental Services

As directed by the Council’s ‘Responsible Person(s)’ they will undertake the following;

      Carry out tests, as required, on water systems.
      Carry out investigations and remedial works as instructed.
      Carry out all weekly/monthly inspection/monitoring /maintenance tasks as
       indicated by site logbooks.

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      Ensure all necessary documentation is completed and returned to the Legionella
       Control Officer in Property Services.
      Inform the Responsible Persons (or their nominated Deputies) of any immediate
       concerns in relation to Legionella and the Council’s water systems as soon as
      Ensure compliance with the LMP and laid down specifications.

4.1.5 Employees

   All employees will need to ensure that they comply with the Council’s policy and the
   LMP and any instructions from the Responsible Persons and their Deputies.

5.1.0 Investigation in the Case of a Suspected Outbreak

The Environmental Health and Trading Standards, are empowered under the
Environmental Protection Act 1990 to investigate, in conjunction with the Heath
Protection Agency, all confirmed cases of Legionnaires’ disease in order to identify the
source of infection.

However, should the investigation indicate a possible implication of Council premises as a
source of the infection, the relevant information will be forwarded to the Health and
Safety Executive for enforcement purposes.

All suspected outbreaks would also need to be reported to Duty Holder and the
Responsible Person. Action would be taken in line with Appendix 2.

6.1.0 Risk Assessments (see appendix 3)

A suitable and sufficient assessment is required to identify and assess the risk of exposure
to Legionella Bacteria from work activities and the water systems on the premises and any
necessary precautionary measures. The assessment should include identification and
evaluation of potential sources of risk and:

             The particular means by which exposure to legionella is to be prevented; or
             If prevention is not reasonable practicable, the particular means by which
              the risk from exposure to legionella bacteria is controlled.

Where the assessment demonstrates that there is no reasonably foreseeable risk or that
risks are insignificant and unlikely to increase, no further assessments or measures are
necessary. All risk assessments should be reviewed annually and when the situation
changes or if for any other reason it is believed that the original assessment may no longer
be valid.

6.2.0 Control Measures

Where the risk assessment shows that there is a reasonable foreseeable risk and this
cannot be totally eliminated, there should be a written scheme for controlling the risk

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from exposure. This scheme should specify measures to be taken to ensure that it remains
effective and should include:

            An up-to-date plan showing layout of the plant or system, including any part
             temporarily out of use;
            A description of the correct and safe operation of the system;
            The precautions to be taken;
            Checks to be carried out to ensure efficacy of the scheme and the frequency
             of such checks;
            Remedial action to be taken in the event that the scheme is shown not to be

There are many ways in which exposure to legionella bacteria can be controlled and the
complexity of controls will vary depending on the risks posed by any one system. The risk
from exposure will normally be controlled by measures, which do not allow the
proliferation of legionella bacteria in the system and reduce exposure to water droplets
and aerosol. Control measures will generally include the following precautions where

            Controlling the release of water spray;
            Avoidance of water with temperatures between 20°C and 45°C;
            Avoiding water stagnation, which may encourage the growth of biofilm;
            Avoiding the possibility of materials which provide a harbour for nutrients
             which encourages the multiplication of bacteria e.g. dead animals, wood
             etc., which can fall into open water tanks;
            Avoid use of materials in systems that can harbour or provide nutrients for
             bacteria and other organisms;
            Keeping systems clean to avoid the build-up of sediments which may harbour
            The use of suitable and safe water treatment programmes;
            Effective monitoring and management systems, which ensure correct and
             safe operation together with effective maintenance of the water system.

Any written scheme, which includes the use of chemicals, must contain manufactures
details on the effectiveness, the required concentrations and contact time required for
effective treatment. They should also contain the heath and safety information for the
storage, handling, use and disposal of the chemical.

The cleaning and disinfection procedures should be clearly stated. Where monitoring
procedures are required the scheme must clearly state the required frequency, sampling
locations and procedures to ensure consistency. It must make clear the acceptable
physical and chemical parameters together with allowable tolerances. There must also be
guidance on the remedial action to be taken in case the control limits are exceed,
including lines of communication, which should include all appropriate appointed persons.

It is essential that the risks are adequately controlled therefore written schemes must
state what arrangements have been made to ensure they are properly implemented and
managed. Anyone who is responsible for managing the scheme or undertaking monitoring

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of the control measures needs to be identified in the written scheme by name. All written
schemes must also contain a Normal Operating Procedure together with an Emergency
Action Plan.
The primary objective should be to avoid conditions, which permit Legionella Bacteria
to proliferate and to avoid creating a spray or aerosol.

6.3.0 Monitoring and routine inspection

Where there is a significant risk there is a need to ensure that the control measures
remain effective. This should be the duty of the responsible person or where appropriate,
a Council appointed external contractor and should involve:

             Checking the performance of the system and it’s component parts:
             Inspecting the accessible parts of the system for damage and signs of
              contamination; and
             Monitoring to ensure that the treatment regime continues to control to the
              required standard

The frequency and extent of the routine monitoring will depend on the operating
characteristics of the system (see appendix 4)

6.4.0 Records

Records of risk assessments and surveys of water systems carried out in accordance with
the Approved Code of Practice will be documented. The resulting information is to be
held by the appointed person or persons, together with the appropriate site manager as
follows: -
            Property Services Database
            Local Environmental Services Database
            Water Hygiene Logbook (Held on each site)

These records will contain:

             The findings of the risk assessment;
             Written schemes and details of it’s implementation; and
             The results of monitoring, inspection, tests or checks carried out and the
              dates. This should include the details of the state of operation i.e. after a
              period of infrequent use or not in use; and
             Training records of all personnel with responsibilities connected to the
              control of legionella bacteria in water systems; and

To ensure that precautions continue to be carried out, adequate information in available
and that records required to be kept are done so far at least two years after that period.
All records should be signed by those performing the various tasks assigned to them.
These records shall be retained for five years.

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6.5.0 Notification to the Local Authority

The Head of Property Services must be informed using the correct documentation of any
equipment, which includes cooling towers and evaporate condensers, unless the system
contains water that is not exposed to the air and the water and electricity supply are not
connected. If new equipment is being installed this notification should be carried out
before the equipment is brought into use. Head of Property Services should also be
informed of any notifiable device which becomes redundant and is decommissioned or

5.6.0 Information for Employees

All staff who are involved in the running and maintenance of water systems must be given
information to ensure they are aware of the risks associated with the equipment. They
should have access to the written scheme and risk assessments. Poor communication has
been indicated in previous outbreaks as a contributory factor, therefore all lines of
communication should be clear, unambiguous and audited regularly to ensure they are and
remain effective.

This also applies to communications to external contractors and consultants who may be
responsible for parts of the control regime. All responsible persons should be identified in
the written scheme, which clearly states their duties. For systems, which operate
automatically, there may be a need to write in a call out procedure.

If outside contractors are used, steps should be taken to ensure they are competent and
that the work is undertaken in a way, which minimises risks.

6.7.0 Training

All key personnel must be identified and provided with specialist training and regular
refresher training, which will be recorded on their personal training records.

7.0.0 Useful Contact Numbers

Property Services                    (TBA)

Local Environmental Services         (TBA)

Human Resources                      (TBA)

Environmental Health                 (TBA)

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8.0.0 Appendices

     1. Action in the Event of an Outbreak

     2. Legionella Risk Assessment

     3. Guidance Note – Monitoring and treatments for Hot and Cold Water Systems

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                                                                              Appendix 1

In the Unlikely Event of a Legionellosis Outbreak

         This corporate policy is a preventative one and therefore does not address service
          continuity and other issues in relation to the unlikely event of a legionellosis
          outbreak which either has been confirmed as, or implicated as possibly, originating
          from a Council operational building.

         In handling such an event, groups responsible for the building will need to seek
          immediate advice from:

                       Property Services of Development and Enterprise
                       Human Resources (Health and Safety Section)
                       Communications Section of Chief Executives Office
                       Health Protection Agency North East
                        Floor E, Milburn House
                        Dean Street, Newcastle-Upon-Tyne
                        NE1 2LF – (Tel: 0191 261 2577)

   Service continuity issues resulting from denial of access to Council operational buildings in
   such circumstances should be covered by generic plans to deal with denial of access to

Action in the event of an outbreak

          1) Legionnaires’ disease is not notifiable under public health legislation in England
             and Wales.

          2) An outbreak is defined by the Public Health Laboratory Service (PHLS) as two or
             more confirmed cases of legionellosis occurring in the same locality within a six-
             month period. Location is defined in terms of the geographical proximity of the
             cases and requires a degree of judgement. It is the responsibility of the Proper
             Officer for the declaration of an outbreak. The Proper Officer is appointed by
             the Local Authority under public health legislation and is usually a Consultant in
             Communicable Disease Control (CCDC).

          3) Gateshead Council has an established incident plan to investigate major
             outbreaks of infectious disease including legionellosis. These are activated by
             the Proper Officer who invokes an Outbreak Committee, whose primary purpose
             is to protect public health and prevent further infection. This will normally be
             set up to manage the incident and will involve representatives of all the
             agencies involved. HSE or the Local Authority EHO may be involved in the
             investigation of outbreaks, their aim being to pursue compliance with health and
             safety legislation.

          4) CCDC or the Council’s EHO may make a site visit.

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5) As part of the outbreak investigation and control, the enforcing authority may
   make the following requests and recommendations.

           a) To shut down any processes that are capable of generation and
              disseminating airborne water droplets and keep them shut down
              until sampling procedures and any remedial cleaning or other work
              has been done. Final clearance to restart the system may be

           b) To take water samples from the system before any emergency
              disinfection being undertaken. This will help the investigation of the
              cause of the illness. The investigating officers from the Council may
              take samples or require them to be taken.

           c) To provide staff health records to discern whether there are any
              further undiagnosed cases of illness, and to help prepare case
              histories of the people affected.

           d) To co-operate fully in an investigation of any plant that may be
              suspected of being involved in the cause of the outbreak. This may
              involve, for example:

                         i. Tracing of all pipework runs;

                        ii. Detailed scrutiny of all operational records;

                       iii. Statements from plant operatives and managers;

                        iv. Statements from water treatment contractors or

6) Any infringements of relevant legislation, may be subject to a formal
   investigation by the appropriate enforcing authority.

Emergency cleaning and disinfection procedure for cooling towers

7) If a cooling water system has been implicated in an outbreak of Legionnaires’
   disease emergency cleaning of that system has to take place as soon as possible.
   The following actions should be taken, where appropriate:

                       a. Switch off the fan immediately;

                       b. Take samples for laboratory investigation before any
                          further action;

                       c. Switch off the circulation pump as soon as it is
                          practicable and the system decommissioned;

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                       d. Consult the enforcing authority before proceeding

                       e. Keep all personnel clear of the tower area;

                       f. When cleared by the enforcing authority, add sodium
                          hypochlorite to the system water to obtain a measured
                          concentration of 50 mg/l of free chlorine;

                       g. Circulate the system water with the fans off for a period
                          of at least six hours;

                       h. Maintain the free chlorine level at an absolute minimum
                          of 20 mg/l at all times;

                       i. Use a suitable biodispersant;

                       j. After six hours, de-chlorinate and drain the system;

                       k. Undertake manual cleaning of the tower, sump and
                          distribution system with cleaning staff wearing fully
                          pressurized respirators;

                       l. Refill with fresh water, add sodium hypochloride;

                       m. Recirculate without using the fan, at 20 mg/l of free
                          available chlorine for six hours;

                       n. De-chlorinate and drain the system

                       o. Refill, recirculate and take samples for testing;

                       p. Re-commission system when test results detect no
                          legionella and/or permission is granted by the enforcing

8) If a water system other than a cooling system is implicated in an outbreak of
   Legionnaires’ disease, emergency treatment of that system should be carried
   out as soon as possible.

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                                                                            Appendix 2


Risk assessments are carried out by specialists appointed by the Head of Property Services;

A typical Risk Assessment will need to consider these basic issues:

             The source of system supply water, for example, whether from a mains
              supply or not;
             Possible sources of contamination of the supply water within the premises
              before it reaches the cold water storage cistern, calorifer, cooling tower or
              any other system using water that may present a risk of exposure to
              Legionella Bacteria;
             The normal plant operating characteristics; and
             Usually, but not reasonably foreseeable operating conditions, for example
             Recommendations
             Schematics/Drawings showing the system and its characteristics.

The assessment should be reviewed regularly (at least annually) and, whenever there is
reason to suspect that it is no longer valid. An indication of when to review the
assessment and what needs to be reviewed should be recorded. This may result from, for

             Changes to the water system or its use;
             Changes to the use of the building in which the water system is installed;
             The availability of new information about risks or control measures;
             The results of checks indicating that control measures are no longer
             A case of Legionnaires’ disease/legionellosis is associated with the system


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                                                                                 Appendix 3

     Monitoring of treatments for All Hot and Certain Cold Water Systems

   There are various hot and cold water systems within buildings, which may give rise to a
   risk of legionnaires disease. In the past hot and cold water systems were associated with
   more reported outbreaks than cooling towers. In recent years however the frequency of
   outbreaks from hot and cold water systems has dropped probably due to better
   maintenance and care of these systems.

   Cooling towers pose the greatest risk and the levels of treatment and monitoring required
   for these systems reflect this risk. However since the hot and cold water systems are so
   widespread and can be very complex in design they still pose a foreseeable risk and so
   some level of treatment and monitoring may still be necessary.

   This document summarises the recommended minimum inspection frequencies for
   different types of water systems. Each system should however be looked at individually
   after assessing the risks it poses and an appropriate inspection regime put into place:

System / Service   Task                                                   Frequency
Cooling towers     Monitor water quality, water use and                   Weekly to three
and evaporative    biocide/chemical use to assess and ensure              Monthly
condensers         effectiveness of water treatment regime,
                   including key chemical and microbiological
                   parameters, and observations of internal condition
                   of pond, pack and water.
                   Central control function, conductivity sensor          Monthly to three
                   calibration, lowdown function, uniformity of           monthly, according to
                   water distribution, condition of sprays/troughs,       risk
                   eliminators, pack, pond, immersion heater, fans
                   and sound attenuators.
                   Clean and disinfect cooling towers/evaporative         Six monthly
                   condensers, make-up tanks and associated
                   systems, including all wetted surfaces, descaling
                   as necessary. Packs should be removed and
                   cleaned where practicable.
Hot water          Arrange for samples to be taken from hot water         Annually
services           calorifiers, in order to note condition of drain
                   Check temperatures in flow and return at               Monthly
                   Check water temperature up to one minute to see        Monthly
                   if it has reached 50°C in the sentinel taps
                   Visual check on internal surfaces of calorifiers for   Annually
                   scale and sludge. Check representative taps for
                   temperature as above on a rotational basis
                   Check tank water temperature remote from ball          Six Monthly
Cold water         valve and mains temperature at ball valve. Note
services           maximum temperatures recorded by fixed max /
                   min thermometers where fitted

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                   Check that temperature is below 20°C after            Monthly
                   running the water for up to two minutes in the
                   sentinel taps
                   Visually inspect cold water storage tanks and carry   Annually
                   out remedial work where necessary. Check
                   representative taps for temperature as above on
                   rotational basis
Shower heads       Dismantle, clean and descale shower heads and         At least Quarterly or
                   hoses                                                 as deemed necessary
Little-used        Flush through and purge to drain, or purge to         Weekly
outlets            drain immediately before use, without release of
Spray              Clean and disinfect spray humidifiers / air washers   Six monthly
humidifiers, air   and make-up tanks including all wetted surfaces,
washers and wet    descaling as necessary
scrubbers          Confirm the operation of non-chemical water           Weekly
                   treatment (if present)
Water softeners    Clean and disinfect resin and brine tank – check      As recommended by
                   with manufacturer what chemicals can be used to       manufacturer
                   disinfect resin bed
Emergency          Flush through and purge to drain                      Six monthly or more
showers and eye                                                          frequently if
wash sprays                                                              recommended by
Sprinkler and      When witnessing tests of sprinkler blow down and      As directed
hose reel          hose reels ensure that there is minimum risk of
systems            exposure to aerosols
Spa baths          Check filters – sand filters should be back washed    Daily
                   Check water treatment – pools should be               Three times daily
                   continuously treated with an oxidizing biocide
                   Clean and disinfect entire system                     Weekly
Car/bus washes     Check filtration and treatment system, clean and      See manufacturers’
                   disinfect system                                      instructions
Indoor fountains   Clean and disinfect ponds, spray heads and make-      Interval depending on
and water          up tanks including all wetted surfaces, descaling     condition
features           as necessary

   NB: This list is not exhaustive it merely illustrates some of the systems that we may
   have in operation within the Council.

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