2004, 06-01 Notice of Hazardous ConditionsAJV/STA'
Utilities
Customer Name
Address 7"Yi
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
NOTICE OF HAZARDOUS CONDITIONS
11-1
Phone Number
6 -Lt: jJA— ..a 1 city ) ji" 7V
S-0308 (08-01)
/J. —`39'62
ZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
of life.l he 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.
❑ Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
t f fr t'
Location. LP i/ ` U":5- $- Al
gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
CFH
FP
1
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vli4J
1,11,1f LA./IL
1,4
Meter Left ❑ Off Meter Number
Meter Read
I have read, understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
I' r
'• -Customer Signature ❑
I �;
Service Representative \J ( .. Date
White Copy — Customer Yellow Copy — Attach to Service Order
fusel d to Sign
Time a[ti/pm `)
Pink Copy — Authority Having Jurisdiction Hard Copy—Appliance