2005, 05-24 Notice of Hazardous Conditions�ii11,/STA•
Utilities
Customer Name
Address
1
NOTICE OF HAZARDOUS CONDITIONS
f
-
1/1,41:42
TYPE OF
NOTIFICATION:
orek
S-0308 (08-01)
Phone Number --)A .
City
041AZARD The conditions noted below constitute an immediate hazard and -may result in property damage, personal injury, or loss
/of life. The equipment has been disconnected or leffinoperable, 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:
CONDITIONS
FOUND:
❑ Apparent cracked or restricted heat exchange
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
Location.
❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
'C'],Other
CFH
rl
Of
Meter Left 0 Off � 3 On Meter Number
I have read, understood and acknowledge.receipt of this notice.
Customer Signature
41(
Owner 0 Tenant
Meter Read
0 Agent
0 Refused to Sign
Service Representative
II;
White Copy - Customer Yellow Copy - Attach to Service order
Date
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4-- </Z....r Time /SO: 462
'1
Pink Copy Authority Having Jurisdiction Hard Copy Appliance