2005, 04-01 Notice of Hazardous Conditions.a _.w..✓+\r..r..v..-
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.' rInSTA NOTICE OF HAZARDOUS CONDITIONS S-oao8 (08"01)
Utilities /
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Customer Name ...It in
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Address
TYPE OF ❑ HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
NOTIFICATION: of life. The equipment has been disconnected or left inoperable, and shall not be turned back on until such repairs have been completed
has been brought up to current safety standards. Do not
by a qualified HVAC dealer, contractor, or service agency, and the equipment
use this equipment until itthh/as been renaired.
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Type. (94t tiI.Ari=c-7 1rel_ Location. P/ti'cal. '?nn4r
Equipment
house in the amount of CFH
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your piping •
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
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I have read, understoodand acknowledge receipt of this notice., t caner "❑ Tenant �, ❑Agent CI
( ) a., / `• Refused to Sign �\
• Customer Signature
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/ /jfl"tZ lie "(a Date �C/•�"�.3� Time /6/,31 am/pm
Service Representative •
White Copy -Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy -Appliance