2005, 05-25 Notice of Hazardous Conditionsju liir/STA'
Utilities , /
Customer Name 1/114L I- AA Ili /4//$$
NOTICE OF HAZARDOUS CONDITIONS
Address /1 7 0 r A1Ap lce_!�
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
Phone Number
City
S-0308 (08-01)
j.0 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
attemot to use this eouioment until it has been repaired.
Location• /6044Q A
❑ Apparent cracked or restricted heat exchanger> . A gas leak in your house piping in the amount of
❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
CFH
4 I., it. 42342:4L+.1 r,.. _ —
/ G 7 Arl .tip
l /e, 4../ a- -r -
Meter Left ❑ Off On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. Owner
Customer Signature
Service Representative f e L
❑ Tenant 0 Agent
White Copy - Customer Yellow Copy - Attach to Service Order
0 Refused to Sign
Date.— S —itS>S Time ZaWE)
Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance