2004, 06-10 Notice of Hazardous Conditions(Y1: r�i.�:.uLM='•*v�,,,vf :..7w..,, r. z?.,4ny,1�'t..Wrwr..�. i._..,, r. •' , .:.
I! OTME OF HAZARDOUS CONDITIONS
S-0308(08-01)
y Utilities
Customer Name t, A! e J d d� n�Rr. Phone Number
Address %d;�rs City
TYPE OF L] 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
n+ , by aqualified.HVAC dealer, ,contractor, or service agency, and the equipment has been brought up to current safety standards. Do not
� ,. service
r. s. t F ,
r attemotfo use this equipmentuntillt.has been :repairetl°:'
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Egwpment Type: Location
Apparent cracked or re§tom heat:exchanger L3A gas leak in your house piping in the amount of CFH
CONDITIONS > �
FOUND:' 0 Damaged appliance connector with all known appliances off
L3 Damagedor disconnected vent ❑ Insufficient combustion/ventilation air
+ .❑ Gas leak' at gas equipment ❑' Other
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Meter Left ❑ Off 0n
I have read, understood.and a
Customer. Signature'
Service Representative'
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Wl'ite.Copy
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Meter 'Number Meter Read �✓
cknowledge receip.t.ofthlsnh63&e. 6O mner' 0 Tenant El Agent
tr 9 0 Refused to Sign
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Date ) ,�' Time Lm/pm
41
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Customer ' ,yellow Copy Attach to SerVice.Ordei Pink Copy --Authority Having Jurisdiction Hard Copy Appliance
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