2004, 09-13 Notice of Hazardous ConditionsuV/STA' NOTICE OF HAZARDOUS CONDITIONS
Utrl/tie�. 5-0308 (08-01)
Customer Name i A { Lie . -i S O t Phone Number . l _ 5:/
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Address /V 2 (C -c--4-7-:_rCity . 4.-i.; %/_.e.-
TYPE OF ❑ HAZARD The conditions noted below constitute an immediate hazard and may result in property daLge, 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 eauioment until it has been repaired.
Equipment Type: 4A.... rr2 .-J 4'ii-4(I' IA I/
Location
j La t r L ti:
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
FOUND: Li Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ ._Other
CFH
.11
Meter Left ❑ Off C O,n
Meter Number Meter Read
I have read, understoodan.acknowledge recei
Customer Signature V • if --
Service Representative
of thisice. Cl. Owner ❑ Tenant ❑ Agent
,.1
G
Date
❑ Refused to Sign (
(3'0 Time JS in ar�'i(pmJ
White Copy - Customer Yellow Copy Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance r)'\14()