2004, 02-12 Notice of Hazardous Conditions ..PuAim,
NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
<'" 7/, -7
Customer Name r O/t/ • Phone Number '
Address -/'c,! fi</c"Y Ali City ,
TYPE OF ❑ HAZARD The conditions noted below constitute an immediate hazard and may result in property damage,personal injury,or loss
NOTIFICATION: 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.Do not
attempt to use this eauioment until it has been repaired.
Equipment Type: ei'•4Location:
CONDITIONS 0 Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
FOUND: ❑ Damaged appliance connector with all known appliances off
0 Damaged or disconnected vent 0 Insufficient combustion/ventilation air (;�' .
'�
❑ Gas leak at gas equipment 0 Other Qa
{
,j t,l /'`e I
I S T a !" ,,.i -
ti "e i 1' Jt ..:
Meter Left ❑ Off ,R On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. CI Owner 0 Tenant Agent
Customer Signature ' � _./),,.16"'" ❑ Refused to Sign
•
Service Representative 1,0„-.2..,....,,, h/5 Date 2 '/2 el V Time /.7.5 — am/pm
L......)
WhiteCopy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance