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2004, 11-30 Notice of Hazardous ConditionsAV/STA Utilities Customer Name Address TYPE OF NOTIFICATION: Equipment Type: CONDITIONS FOUND: ) d� a/0/44, NOTICE OF HAZARDOUS CONDITIONS / HAZARD The conditions noted below constitute an im1 ediate hazard and may result in property damage, personal injury, or loss o ' e. The equipment has been disconnected or left inoperab , 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 eauioment until it has been repaired. Phone Number City +."+' l S-0308 (08-01) ❑ Apparent cracked or restricted heat exchanger ❑ Damaged appliance connector ❑ Damaged or disconnected vent ❑ Gas leak at gas equipment Location. PT `-`' ❑ A gas leak in your house piping in the amount of with all known appliances off ❑ Insufficient combustion/ventilation air "'Other CFH etc ‘44 (70_ /1-1 seg ,�.� s. 627 . ":",7 i. Meter Left ❑ Off On I have read, understood Customer Signature Meter Number Meter Read ckno►yledge receipt of ihis notice. wner ❑ Tenant ❑ Agent ❑ Refused to Sign Date " Time /1,� lra pm ✓ Service Representative WhiteCopy- Customer Yellow Copy - Attach to Service Order Pink Copy -Authority Having Jurisdiction Hard Copy- Appliance