2005, 01-02 Notice of Hazardous Conditions"4
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r� ISTA NOTICE OF HAZARDOUS CONDITIONS S-0308(DB-01)
Utilities ,. -----
t tt /✓tot/ Phone Number `972 5'7C4'
Customer Name
'I V' /3' r. t- City "C>...."
i In Yl "13 -44.tr
Address
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TYPE OF ,� H� AZARD The conditions noted below constitute an immediate hazard and mayresult in property damage, personal injury, or loss
NOTIFICATION: .�"of'lite'.Theequipment has been disconnected orleftinoperable, and shalfnotbeturned back onuntil such repairs have been completed
has been brought up to current safety standards. Do not
by a qualified HVAC dealer, contractor, or service agency, and the equipment
attempt to use this equipment until it has been repaired. •
Type. r/4 le Location. / ter ,
Equipment
-Apparent house in the amount of CFH
CONDITIONS, F' ;CC cracked or restricted heat exchanger ❑ A gas leak in your piping
FOUND: ❑ Damaged appliance connector with all known appliances off •
F ❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air•
0 - ❑ Gas leak at gas equipment ❑ Other
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Meter Number / ~V` _ Meter Read
Meter Left 0 Off -On
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/have read, understood and acknowledge'rec'elp`t of fhts'noLce.._,._..�-b Owner ❑Tenant ❑Agent
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Signature ..1 0 Refused to Sign
Customer
417 . -P.
LC//>4L a Date / Z-CCJ�'i . Time ��aram/pm
Service Representative 'eq fi / , ,
White Copy -Customer Yellow Copy - Attach to Service Order Pink Copy- Authority Having Jurisdiction Hard Copy - Appliance