2004, 01-03 Hazardous Condition NoticeVISTA"
Utilities
NOTICE OF HAZARDOUS CONDITIONS
Customer Name,r�\/1/-/s1/ 4A- 57 /2 i 'f 1 f' t-� Phone Number ?2 7. ,:9 /'
Address ^ /• 'tel.A/''S City -/ C
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
S-0308 (08-01)
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.
❑ Apparent cracked or restricted heat exchanger ❑
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
Location.
A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
CFH
l L•
1/
Meter Left ❑ Off ❑ On Meter Number
I have read, understood and acknowledge receipt of this notice.
Customer Signature
Service Representative
Meter Read
❑ Owner ❑ Tenant ❑ Agent
❑ Refused to Sign
White Copy — Customer Yellow Copy — Attach to Service Order
Date / Time /1-4.-' ^-� i am/
esi
Pink Copy— Authority Having Jurisdiction Hard Copy — Appliance