2004, 05-28 Notice of Hazardous Conditions111- TA'
Utilities
Customer Nam _
Address I�
TYPE OF
NOTIFICATION:
NOTICE OF HAZARDOUS CONDITIONS
OVE
S-0308 (08-07)
Phone Number S 7/ 7
"-
City C 0- /2
❑ HAZARD .The conditions noted below constitute an immediate haiard 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 cauipment until it has been repaired,
Equipment Type!
CONDITIONS
FOUND!
Location,.
❑ Apparent cracked or restricted heat exchanger U A gas leak in your house piping in the amount of CFH
❑ Damaged appliance connector with all known appliances off
LJ Damaged or disconnected vent 0 Insufficient combustion/ventilation air
L' Gas leak at gas equipment ❑ Other
La kmptf
M f' ofpE- if F ATR1 X
iv riff -se__ (1 A `s
Meter Left 0 Off
On Meter Number
Meter Read
I have read, understrd and acknowledge receipt of this notice. 0 Owner 0 Tenant 0 Agent
•
Customer Signature
{t ', // )1' If Y LI Refused to Sign
t
C
Service Representative _ Date _ Time f L " /pm
White Copy - Customer Yellow Copy - Attach to Service Order
Pink Copy - Authority.Having Jurisdiction Hard Copy - Appliance