2003, 10-08 Notice of Hazardous Conditions �i�i V/STA® NOTICE OF HAZARDOUS CONDITIONS
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i Utilities
Customer Name Phone Number
Address City Tvid_.
TYPE OF ❑ HAZARD The conditions noted below constitute an immediate hazard and may result in property damage,personal injury,or loss. i n32
NOTIFICATION: of life.The equipment has been disconnected or left inoperable,and shall not be turned back on until such repairs have been completed tUG"
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:•---Cr;4. C-4/,,41,4,4f_� Location: 4"16`t, `G
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
C7 Gas leak at gas equipment ,, Other
Meter Left ❑ Off U On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature / / ❑ Refused to Sign
Service Representative f7<= Date ! r ° Time,�r� am/{gym
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance 'Q\\0