2004, 12-07 Hazardous Conditions Noticeul inSTA'
Utilities NOTICE OF HAZARDOUS CONDITIONS
Customer Name •T`" Z. /VI 3' > 4 -0/ Phone Number
�+F l%-
City52.4,":/
Address
f(l 28/, _ Gam':
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
S-0308 (08-01)
- $I),_HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or Toss
%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 eauioment until it haas been repaired.
4,111.
,1 Location• �Loi3Oe
❑ Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
❑ Insufficient combustion/ventilation air
0 er
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read, understood and acknowledge
receipt of this notice. Owner ❑ Tenant
Customer Signature 1f7r.,�
Service Representative
White Copy- Customer Yellow Copy - Attach to Service Order
Date
❑ Agent
❑ Refused to Sign
Time
Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance