2004, 10-09 Notice of Hazardous ConditionsAlIv'STA'
Utilitie NOTICE OF HAZARDOUS CONDITIONS
Customer Name
Address
W oc
,-; Yet
TYPE OF
NOTIFICATION:
i AZARD The conditions noted below constitute an immediate hazard and may result in property damage; personal injury, or loss
Phone Number 9
S-0308 (08-01)
City —
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 usq this equipment 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
O Damaged appliance connector with all known appliances off
O Damaged or disconnected vent 0 Insufficient combustion/ventilation air
O Gas leak at gas equipment 0.Sther
CFH
Zed
X;'14
rr, /1 /
; s '"
Meter Left 0 Off fik, On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice.
Customer Signature
CI Owner 0 Tenant
Service Representative
❑ Agent
0 Refused to Sign
Time
3
White Copy - Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy- Appliance