2004, 03-10 Notice of Hazardous Conditionswrit'/STA'
Utilities
NOTICE OF HAZARDOUS CONDITIONS
Customer Name
Address
TYPE OF
NOTIFICATION:
S-0308 (08-01)
Phone Number
City
❑IHAZARD 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 this eauioment until it has been repaired.
Equipment Type:
CONDITIONS
FOUND:
Location•
❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
❑ Damaged appliance connector
D Damaged or disconnected vent
❑ Gas leak at gas equipment
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
CFH
Meter Left ❑ Off CB..On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. ❑ Owner 0 Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative =1 Date Time
White Copy— Customer Yellow Copy — Attach to Service Order
Pink Copy — Authority Having Jurisdiction Hard Copy — Appliance