2004, 10-13 Notice of Hazardous Conditions �iii v/ISTA
NOTICE OF HAZARDOUS CONDITIONS 5-0308(08-01)
Utilities
Customer Name Phone Number
Address / £ `k'C4if City ,ti, - 1410 'if
TYPE OFHAZARD 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: Q r.�,_3` ' 'PC, t I Location: Wt .""4.' fi •_
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 v
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
i t f r6. 7 e{ / /\
.
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
Service Representative Date Time '00 am/
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard copy—Appliance