2004, 02-05 Notice of Hazardous ConditionsAuld
Utilities NOTICE OF HAZARDOUS CONDITIONS 60308(08-01)
Customer Name ��` �A AP T&i AJ � Phone Number
ityTYAddress" ev 14 l !i c City—
TYPE
PE OF '®`HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
NOTIFICATION: 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 dznd Location✓ m;
CONDITIONS { �i] =Apparent cracked` r �restncted heat exchanger p q gas ,leak in your house piping in the amount of CFH
FOUND:. 40 Damaged appliance iconnector with all known appliances.off
❑ Damaged or"disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
I have read, understood and acknowledge receiptiof this notice. 'ElAvvner ❑ Tenant ❑ Agent `vl
Customer Signature Lr r jl?' } t•.�„..f.. ,;..�:. L3 Refused to Sign
0,
Service Representative Date 4 Time 0Carn/pm
}yx White Copy - Customer • i Yellow Copy Attach to Service Order Pmk Copy Authority Havnig Ju��sdlchon Hard Copy . Apphance ,,ti , : {.
,.... „