2003, 05-20 Notice of Hazardous Conditions �iuVISTA
NOTICE OF HAZARDOUS CONDITIONS s-0308(0611)
Utilities i
Customer Name/' Phone Number
Address / ' Ce. x (7 City 9.99-I/(-6'" — 0 5-.7
TYPE OF ErHAZARD 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.
rier-
-, ''Equipment Type: Location:
CONDITIONS -0 Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
FOUND: 0 Damaged appliance connector with all known appliances off
0 Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
0 Gas leak at gas equipment 0 Other
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4 ....- ..c ..4 . r — ''''''".,41"., 7..ty le \,..)——
Meter Left ❑ Offn Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. 0 Owner ❑ Tenant 0 Agent
Customer Signature 'i 0 Refused to Sign
Service Representative Date '- - " Time am/pm
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance 0