2004, 02-13 Notice of Hazardous ConditionsAPIII W/STA°
Utilities
Customer Name u t ri bLt3 t i
Address 1i%72.iS /AZ_ City /(4,6--!./
NOTICE OF HAZARDOUS CONDITIONS
S-0308 (08-01)
Phone Number . :)(3c)
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
U HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
of life. The equipment has been disconnected or left inoperable, and shall not be turned back on until such repairs have been completed
by a qualified HVAC dealer, contractor, or service agency, and the equipment has been brought up to current safety standards. Do not
attempt to use thisse`ouipmenntt until it has been repaired.
Yr'(1 '/Y.
Location.
❑ Apparent cracked or restricted heat exchanger 0 A gas leak in your house piping in the amount of CFH
❑ Damaged appliance connector with all known appliances off
El_Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
O Gas leak at gas equipment ❑ Other
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Meter Left Off ❑ On Meter Number Meter Read
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I have read, understood and acknowledge receipt of this notice.
Customer Signature 1*
Service Representative
VP)
0 Ownerl p@' Tenant 0 Agent
White Copy - Customer Yellow Copy - Attach to Service Order
❑ Refused to Sign
Date .2 _1 3 Time
Pink Copy - Authority Having Jurisdiction Herd Copy - Appliance