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2003, 04-03 Notice of Hazardous Conditionow_ Utilities NOTICE OF HAZARDOUS CONDITIONS Customer Name ( /1.4. C? (-._3 . ! /, .. d) Phone Number Address / 1 `1/ [+, TYPE OF NOTIFICATION: Equipment Type: CONDITIONS FOUND: 8-0338 (06-011 City -. U HAZARD 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 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. Location. ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of ❑ Damaged appliance connector with all known appliances off ❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air Gas leak at gas equipment ❑ Other ICS .•-L (3 - S CFH Meter Left ❑ Off ❑ On Meter Number Meter Read I have read, understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent Customer Signature ❑ Refused to Sign Service Representative Date Time �`' am/pm White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance ©