2005, 06-15 Notice of Hazardous Conditions Ire N J !fN e.r-..,. ANM ..,.F�►, q..._M,AII 11►,AM,e�.•..,. t, - Y fir, s ?a
• ie
=�iiVISTA" \\ i NOTICE OF HAZARDOUS CONDITIONS ( ( � GO S-0308(08-01)
Utilities
Customer Name \. .--4/4-1: #;yr.. ..at Phone Number
Address �:.- , -?',/ ,' City ")
TYPE OF HAZARD The conditions noted below constitute an immediate hazard and may result in property‘age,personal injury,or loss
NOTIFICATION: ,o e.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: ii i'i t 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
1-4i-i. .-_;-/4 1,
Meter Left ❑ OffXOn Meter Number Meter Read .4)
I have read,understood and acknowledge regeipt of this notice. Owner ❑ Tenant ❑ Agent V
l ,.M ❑ Refused to Sign
Signature
Service Representative Date Time �%pm "
WhiteCopy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance