2005, 05-17 Notice of Hazardous ConditionsM �yhrfi�r'xYtt.
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Utilities
Customer Name
Address In
TYPE
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
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NOTICE OF HAZARDOUS CONDITIONS
Z6e./ vitimetti
Phone Number.
City
'4,
(t,hei i et 11- &,3C
0-0303 (08-01)
Cil HAZARD The conditions noted below co sn iitute-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 this eomprnent until it has been repaired.
Location
Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
IEICOther
Damaged appliance connector
Damaged or disconnected vent
Gas leak at gas equipment
CFH
•,i•
/`l'// / S //L✓`4/
Meter Left ❑ Off Cr.Can Meter Number
r
I have read, understood and acknowledge receiptof this notice
Customer Signature
\ Meter Read
;Owner
❑ Tenant
Service Representative� • 0 Dr
Date
❑ Agent
Li Refused to Sign
Sof/%/:C Time An d c-,�
a /pm
-/ -
White Copy -Customer Yellow Copy -Attach to Service Order P,nA Copy - Authority Ha ving Jurisdiction Hard Copy -Appliance