HomeMy WebLinkAbout2008, 07-23 Notice of Hazardous ConditionsX111Aust1 tSTA
Utilities
Customer Name
NOTICE OF HAZARDOUS CONDITIONS
Address 12, I l '`c l J? ? t {'l'.
TYPE OF
NOTIFICATION:
Phone Number
S-0308 (11-05)
City i ; Q., 4A
❑ 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
this equipment until it has been repaired.
Equipment Type:` Location:
CONDITIONS
FOUND:
❑ Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
CFH
Meter Left ❑ Off ❑ On Meter Number
I have read, understood and acknowledge receipt of this notice.
Customer Signature ---- 1
Service Representative
Meter Read
❑ Owner ❑ Tenant
❑ Agent
€-')M '.4, (1
•
White Copy- Customer
Yellow Copy -Attach to Service Order
WMS #
❑ Refused to Sign
Date -7 / - -:� 1 I Time am/pm
Pink Copy- Authority Having Jurisdiction Hard Copy- Appliance