2003, 11-14 Notice of Hazardous ConditionsAm_
Utilities
Customer Name
Address
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
NOTICE OF HAZARDOUS CONDITIONS
Phone Number
''/1A AL> .,1E City t
S-0308 (08-01)
❑ HAZARD 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 equipment until it has been repaired.
Location -
• ;.v( -e AGM
❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
❑ Damaged appliance connector
O Damaged or disconnected vent
O Gas leak at gas equipment
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Meter Left ❑ Off
❑ On
Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. 0 Owner 0 Tenant 0 Agent
Customer Signature 0 Refused co Sign
Service Representative Date II - 6 Time am/pm
White Copy - Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance