2004, 04-15 Notice of Hazardous ConditionsATVISTA' NOTICE OF HAZARDOUS CONDITIONS
Utilities p
Customer Name IS?... id[..c' W . JAI Phone Number (5o q �t') 2 1'7 " 5"6. 2 -7
Address M i_ ` c 1 . r` /, City '' .:4",. "' . e
U HAZARD The conditions Noted below constitute an immediate hazard and may result in property dambge, 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
attemot to use this eauioment until it has been repaired.
S-0308 (08-01)
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
❑ Apparent cracked or restricted
❑ Damaged appliance connector
LI Damaged or disconnected vent
❑ Gas leak at gas equipment
Location. tom%t
eat exchanger ❑ A gas leak in your house piping in the amount of CFH
with ail known appliances off
❑ Insufficient combustion/ventilation air
',Other
s 1441,
Meter Left ❑ Off
Meter Number
Meter Read
I have read, understood and acknowledge receipt,of this notice. Owner ❑ Tenant ❑ Agent
Customer Signature�'``,.� ❑ Refused to Sign CJ
Date 1.. e Time I f t
Service Representative
White Copy - Customer
Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance