2005, 03-25 Notice of Hazardous Conditionsviii//STA' NOTICE OF HAZARDOUS CONDITIONS
Utilities'�-� ,. l�/1 � 12
/Customer Name r/YPuLt ✓'✓7-)/gD'rr"° r."..- . Phone Number n l'r' - 17 e;'2'
Address !S 3315----RASn .,AtsiL- �� City'�-as 1 /a IirL �i
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DeHAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
of lifd . 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 this eauioment until it has been repaired.
Equipment Type: re I AJSerr Location• / ;Lb; 1/• igieLl -
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
A. ••-. leak at gas equipment ❑ Other
S-0309 (08-01)
TYPE OF
NOTIFICATION:
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Meter Left ❑ Off ' I%n Meter Number Meter Read
I have read, understoodand acknowledge receipt of this notice, \:I/Owner ❑ Tenant ❑ Agent
Customer Signature %ft_2 L (-A:17i ^-)J tr,-f11V-/ - -• ❑ Refused to Sign
Service Representative /n��? ) Date ;12 /US Time
White Copy —Customer Yellow Copy — Attach to Service Order Pink Copy — Authority Having Jurisdiction Hard Copy —Appliance
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