2004, 09-22 Notice of Hazardous Conditions Ank
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NOTICE OF HAZARDOUS CONDITIONS s-osos(oa-oi)
r Utilities
Customer Name / Phone Number -'f �;
Address 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 equipment until it has been repaired.
Equipment Type: ` -'51-4 f Location:
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 ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
Meter Left ❑ Off On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. Owner ❑ Tenant ❑ Agent II 0
Customer Signature ❑ Refused to Sign
Service Representative Date Time am/pm
WhiteCopy-Customer yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction HardCopy-Appliance