2003, 05-08 Notice of Hazardous ConditionsA l IST
Utilities
NOTICE OF HAZARDOUS CONDITIONS
Customer Name `7- , h h n %i 7e77r'`� T -i i Phone Numb
Address City
S-0308 (06-01)
ectZ-z4/54/
TYPE OF HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
NOTIFICATION: /of Iife. 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.
Equipment Type: Location:
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑
FOUND: ❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
0
A gas leak in your house piping in the amount of CFH
with all known appliances off
Insufficient combustion/ventilation air
_Other
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Meter Left I( Off ❑ On Meter Number
I have read, understood and acknowledge receipt of this notice. L�
Customer Signature °) // % 6-
(Owner ❑ Tenant ❑ Agent
Meter Read
■ Refused to Sign
Service Representative Date 6 3 Time
White Copy—Customer Yellow Copy—Attach to Service Order
Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance
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