2003, 04-01 Notice of Hazardous ConditionsNOTICE OF HAZARDOUS CONDITIONS S-0308(06-01)
Utilities
Customer Name Phone Number
Address.— C2 6 XY( X_ city
TYPE OF L3 HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
NOTIFICATION: oflife. The equipment has,beeh,d,isconnected,or left inoperable, and shall not be turned back on until such repairs have been completed
by 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 Types 2,51 �-f '4 '?�7 Location: e
'
CONDITIONS pparent cracked or restricted heat, exchanger El A gas leak in your house piping CFH in the amount of
FOUND: bmaged,appliance connector with all known appliances off
El, Damaged or disconnected vent Ll Insufticient combustion/ventilation air
El. Gas leak at gas equipment L3 Other cit
Q 577
Meter Left Ell Off El
On Meter Number
Meter Read
I.have read, understood
and acknowledge receipt of this notice. El Owner, El Tenant L3 Agent
i
LI Refused to Sign
V
Customer Signature
t.
117
Date Time
A
/p
Representative
ServiceRepresent
no
w Copy—Attach tory
— .Seice Order
White Copy Customer Yello
Pink Co py—A uthority He ving Jurisdiction Hard Copy Appliance