2005, 01-04 Notice of Hazardous Conditionstr...w4,10Qp,11,,
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Utilities NOTICE OF HAZARDOUS. CONDITIONS
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Customer Name 6"'a'1'34N
Phone Number
S-0308 (08-01
Address /kat" /L . ,Ct G Tom, /_ `".- City `' -s-fl)/E. /'P
TYPE OF
NOTIFICATION:
Equipment Type
CONDITIONS
FOUND:
"D•HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
iof 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.
ha_ 1,4 Sfro r/
>CI—Apparent cracked or restricted heat
❑ Damaged appliance connector
❑ Damaged or disconnected vent
U Gas leak at gas equipment
Location.
e esipe.e4
exchanger ❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
4
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Meter Left ❑ Off "tli.On Meter Number
1 have read, understood and acknowledge receipt of this notice.
Customer Signature y� fir
Service Representative
Meter Read
Owner jO Tenant
0 Agent
❑ Refused to Sign
Date //::— tit
e0-1-
QS Time
•
White Copy -Customer Yellow Copy- Attach to Service Order Pink Copy- Authority Having Jurisdiction Hard Copy -Appliance