2004, 03-25 Notice of Hazardous ConditionsUtilities
Customer Name
Address
TYPE OF
NOTIFICATION:
NOTICE OF HAZARDOUS CONDITIONS
Phone Number 47 • J
CityL,
S-0308 (08-01)
HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
of li e. 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 eouioment until it has been repaired.
Equipment Type:
CONDITIONS
FOUND:
Location
U Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
❑ 'Damaged appliance connector
O Damaged or disconnected vent
O Gas leak at gas equipment
CFH
C•'4,(L
• I
Meter Left 0 Off ❑ On Meter Number
I have read, understood and acknowledge receipt of this notice.
Customer Signature
Meter Read
caner 0 Tenant 0 Agent
0 Refused to Sign
./2.</e</ Time_ -i 9 60,M
Service Representative
L1
White Copy - Customer Yellow Copy - Attach to Service Order
D ate
Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance
‘Nr)