2004, 09-03 Notice of Hazardous Conditions m.t �iiri//STA NOTICE OF HAZARDOUS CONDITIONS
5-0308(08-01)
Utilities//f�
Customer Name 1"'C`... l 14... Phone Number
Address z 4 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: i•7/i 5 Ii/ 4:14,, Location: /' I/e:-.4/]"'
CONDITIONS ❑ Apparent cracked or restricted heat exchanger U 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
r1/1•;) A 1" `; t
•
+U 4 u /0 !r./V
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. r l Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative :f !�' !Date 5 Y-.3-5/ Time a/'')) am/pm-
White Copy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hard Copy-Appliance ea \\d