2003, 04-04 Hazardous Conditions�uV/STA&
Utilities
Customer Name � \<42- °'°Y
Address r
TYPE OF
NOTIFICATION:
NOTICE OF HAZARDOUS CONDITIONS
9
Phone Number
City
S-0308 (06-01)
❑ 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.
Equipment Type:
Location• —�� `` ,Mc"�
CONDITIONS ❑ Apparent cracked or restricted heat exchanger D A gas leak in your house piping in the amount of
FOUND: ❑ 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. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative
Date 47
` ' 3 Time `�✓� am/pm
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance