2005, 01-27 Notice of Hazardous Conditions Air_
NOTICE OF HAZARDOUS CONDITIONS s-°3°8(°8-°')
Utilities
Customer Name t Phone Number
Address -ski 4: City
TYPE OFHAZARD 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 equipment until it has been repaired.
Equipment Type: Pill' '/` Location: 77->11-:> ._,ke e<. ..
CONDITIONS ❑ 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
❑ Damaged or disconnected vent U Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
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Meter Left ❑ Off ❑ On Meter Number Meter Read 9)o
I have read,understood and acknowledge receipt of this notice. ❑ Owner U Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
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Service Representative r�, ` Date l' Time ,`` a m
WhiteCopy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance