2004, 02-25 Notice of Hazardous Conditions" IST
Utilities
Customer Name jµ7
Address L ' 12,-Y/
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
NOTICE OF HAZARDOUS CONDITIONS
S-0308 (08-01)
Phone Number .1 45'.r�
City o
❑ 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. p0 not
attemot to u his eauioment until it has beeJoaired.
} t o c. 4 1 4_ t"' ' R Location
Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
7.. .1` Tom'
Pal . C o .
Meter Left ❑ Off On
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[_ u.1 irci -- itia r <.; fliv,
Meter tuber Meter Read
1 have read, understood audjacknowledge receipt of this notice.
Customer Signature
Service Representative
Owner ❑ Tenant ❑ Agent
❑ Refused to Sion
Date 2 2 5'
Time /Z, 3b am)
White Copy — Customer Yellow Copy — Attach to Service Order Pink Copy — Authority Having Jurisdiction Hard Copy— Appliance