2004, 11-11 Notice of Hazardous Conditions1 _ _
m' ` Utilities NOTICE OF HAZARDOUS CONDITIONS S-0308 (08-01)
Customer Name
"[.� Phone Number
Address ; City. '50 /sem. '
r �
r
TYPE OF
\G HAZARD The conditions noted below constitute an imme 1iate hazard and may result in property damage, personal injury, or loss
NOTIFICATION: /;of llife. 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: la-'�"�� Location:
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment d"'' Other
Meter Left 0 Off ,E On Meter Number
I have read, understood and acknowledge receipt of this notice.
y�j,� r
Customer Signature fid —10114r
Service Representative
WhiteCopy— Customer!. . YellowCopy- AttachtoSery
Meter Read
❑ Owner i ❑ Tenant ,®'eAgent
❑ Refused to Sign
Date Time /Z f;; mipm .
Order Pink,Copy.— Authority Having Jurisdiction Hard Copy.—Appliance ��"'