2005, 01-12 Notice of Hazardous Conditions#7vISTA
Utilities
Customer Name
Address
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
l , '
NOTICE OF HAZARDOUS CONDITIONS ,r
Phone Number riJ `'/ 605
' Z3
C - 4-q
,AgNAZARD 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 thisriseauioment until it�has been repaired.
t r Location. ` A %C-
S -0308 (08-01)
City
.0@.Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
1f
❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
CFH
CL
!e'
MeteiLeft ❑ Off AOn Meter Number Meter Read
I have read, understood and•acknowledge receipf of this notice. ` ',Owner ❑ Tenant ❑ Agent
Customer Signature �J ❑ Refused to Sign
/Fr r '
Service Representative ,r Date !—'°r' ' —(°') Time
White Copy — Customer
Yellow Copy — Attach to Service Order Pink Copy — Authority Having Jurisdiction Hard Copy — Appliance
pm