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