2005, 02-15 Notice of Hazardous Conditionso {,
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.0ii VISTA' NOTICE OF HAZARDOUS CONDITIONS s -papa 0e-04
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Customer Name Li/1''I 1 / f i �n /�1T'_C at re- Phone Number
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TYPE OF t&/HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury,
NOTIFICATION: iroflli e. 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 bought up to current safety standards
this eaqquipment untilntilit has been repaired
or loss
Do not
/
//aattempttt/to�'use
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Equipment Typec_21Let: ;L,i.o.t">.- /,f/.2.1e-r'd
heat exchanger ❑ A leak in house in the amount of CFH
CONDITIONS ❑ Apparent cracked or restricted gas your piping
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipm nt ❑ Other /......
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Ihave read, understood
er+acknowledge receipt ofthis notice. / p/;Owner ❑ Tenant ❑ Agent /1`
Customer Signature if r ,^^,) /214r^^ ^_c ..-,-3"7- ! X ❑ Refused to Sign
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\--,-4" 7 /4 I /`> ' Date 2' /Y,+! Time,,• r--461
Service Representative
White Copy -Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy -Appliance