2004, 11-09 Permit: 94012167 Notice of Hazardous Conditions..--1-iiV/STAF
Utilities NOTICE OF HAZARDOUS CONDITIONS
Customer Name J)Fk' .l \, jrr,L-1 Ae, Phone Number k9 ) / /
Address j 14A/ City .C1c
TYPE OF
NOTIFICATION:
Equipment Type:
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.
r('jri1 63 47��� r"" Location. r • -T- �c -xi —`
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
k f L4 it
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent \�
Customer Signature ❑ Refused to Sign
/
Service Representative Y`'/5 Date //".%
' o Time 'd 7 am/Om
White Copy - Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy- Appliance