2003, 05-01 Notice of Hazardous Conditions Amp_
NOTICE OF HAZARDOUS CONDITIONS s-osoa(os-o>)
Utilities
Customer Name _"7, ' C,; ,` >'(:-1 1 Phone Number ',
Address
' °�.. ''. City a 1 7 — 1 1 3 c
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: F. k .,;.:Li -ilii ; ;.1 °.'yII 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
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Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
2.
Service RepresentativeJk .V ' C44 A /fDate/! Time r'"' ' '5-4-,) amlpm
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance %? \,t