<p>QES Management System Issue Date: 01/07/2014</p><p>Design verification form</p><p>This form must be lodged by the consultant and submitted at least ten days prior to construction starting</p><p>City West Water Email [email protected]</p><p>Service (please select)</p><p>Water supply Recycled water Sewerage Pump station</p><p>Development details</p><p>Location/estate name: </p><p>City West Water reference: </p><p>Developer: </p><p>Consultant: </p><p>Consultant nominated representative (name): </p><p>Consultant nominated representative email: </p><p>Key personnel – design: </p><p>Designer’s name: </p><p>1 Documentation to be submitted (please select):</p><p>1.1 electronic copy of final design drawings in PDF format</p><p>1.2 electronic copy of road and drainage drawings (detail plans) for the development in PDF format</p><p>1.3 details of existing and proposed services, if not indicated on the submitted plans</p><p>1.4 hydraulic computations for main and branch sewerage designs</p><p>1.5 geotechnical report and project specific backfill specification</p><p>1.6 Verification Attachment Sheet, if any of the items on this form are not applicable.</p><p>Document FOR-312 Rev 3 Page 1/2 QES Management System Issue Date: 01/07/2014</p><p>2 Consultant’s assurance</p><p>As the Consultant’s nominated representative responsible for the design of the development works detailed in the Development Deed, City West Water reference: I verify that:</p><p>The design is in accordance with the Development Deed and its referred documents and standards.</p><p>Consultant’s nominated representative</p><p>Name: Company position: </p><p>Signature: Date: </p><p>Important privacy notice</p><p>City West Water is a state owned company which provides retail water, sewerage and trade waste services to Melbourne’s central business district, inner and western suburbs.</p><p>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</p><p>Document FOR-312 Rev 3 Page 2/2</p>