2003, 04-07 Notice of Unsatisfactory ConditionsAO- VISTA*
Utilities
Customer Name
Address
TYPE OF
NOTIFICATION:
NOTICE OF UNSATISFACTORY CONDITIONS
Phone Number
S-0308 (1-99)
1. 0(0+" 6-9/ City
❑ 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 turned off pending further inspection and repairs, 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.
❑ WARNING The conditions noted below constitute a potential hazard. Although the condition does not present an immediate
threat to life or property, failure to correct the condition may lead to a hazardous condition. Please contact a qualified HVAC dealer,
contractor, or service agency to perform further inspections or to bring the equipment up to current safety standards.
Equipment Type: Location•
CONDITIONS
FOUND:
❑ Apparent cracked or restricted heat exchanger ❑ Inoperative safety system
❑ Spillage of exhaust at the draft hood after a ❑ Insufficient combustion/ventilation air
reasonable warm-up time ❑ Gas leak at gas equipment
❑ Damaged appliance connector ❑ Other
❑ Damaged or disconnected vent
❑ Defective limit control
0 A gas leak in your house piping in the amount of CFH s
with all known appliances off
I have read, understood and acknowledge receipt of this notice.
v�fof 4 . f •1
Jio
+ —
❑ Owner ❑ Tenant 0 Agent
Customer Signature
Service Representative Date
4 -
Time
❑ Refused to Sign
am/pm
Equipment Disconnected? ❑ Yes ❑ No Equipment Tag Left? ❑ Yes ❑ No Authority Notification Required? ❑ Yes U No
Equipment Left ❑ On 0 Off Meter Left ❑ Off ❑ On
White Copy — Customer Yellow Copy — Attach to Service Order
Pink Copy— Authority Having Jurisdiction Hard Copy— Appliance