2004, 01-30 Notice of Hazardous Conditions VIIIrfISTA®
NOTICE OF HAZARDOUS CONDITIONS S-0308(°8-°')
Utilities
Customer Name ....s„.142,,r`7'7`C1" ,,y /-4#t olkiS Phone Number f7l.. ..,
Address if A' 1' 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 eauioment until it has been repaired.
Equipment Type: Location: / // (.4,r 'q' 14-/"-?'"""4e1-:T
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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1.: .c.:,-,, .... 4/W 7-/i o L.. y,..-i 4.. a c.,.. ' ,z, - ,,,,, - zis ovvq. ,
Meter Left ❑ Off ❑ On Meter Number Meter Read �D
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent t
❑ Refused to Sign
Signature 9n
Service Representative `w'C-il71A/ ‘ 'r• Date /34 "0V Time /Z .fi4;.-)am/pm
WhiteCopy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hardcopy-Appliance