2005, 05-11 Notice of Hazardous Conditions4(STA'
Utilities
Customer Name
NOTICE OF HAZARDOUS CONDITIONS
Address
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
S-0308 (08-01)
Phone Number
�7''-J /VC /L .v. -i e....City / %4-. /
/
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.
❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
O Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipmentsji
ith all known appliances off
❑ nsufficient combustion/ventilation air
Other
e
, r 7/4 -
r ,L! .c/4- / E /1/.. - f'`: �i.+, J./ .��. .L/f / // •) /
Meter Left ❑ Off f� On Meter Number
I have read, understood d acknowledge receipt of this notice. ❑ Owner
Customer Signature
Service Representative d6(;
Meter Read
'Tenant ❑ Agent
0 Refused to Sign
Date J///G {Time fth �C' am/ mj
White Copy - Customer yellow Copy - Attach to Service Order
Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance