HomeMy WebLinkAbout2004, 10-20 Notice of Hazardous ConditionsV/STA°
Utilities
Customer Name
Address
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
NOTICE OF HAZARDOUS CONDITIONS
Phone Number Y 74
S-0308 (08-01)
City
❑ 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 eauipmenttuntil it hays been repaired.
� J " It'' .)
Itf 11.1
Location
E` t
❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
CFH
Meter Left ❑ Off ❑ On
Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice.
Customer Signature L11
Service Representative
❑ Owner ❑ Tenant
D ate
❑ Agent
❑ Refused to Sign
s.; Ii'c',s: Time
9\'L"
r
/ am/pm)
White Copy — Customer Yellow Copy— Attach to Service Order Pink Copy— Authority Having Jurisdiction Hard Copy — Appliance