HomeMy WebLinkAbout2003, 10-27 Notice of Hazardous Conditionsviii /STA
Utilities
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Customer Name/ ./
Address / 0g
TYPE OF
NOTIFICATION:
NOTICE OF HAZARDOUS CONDITIONS
6 VAI let' t et 7
S-0308 (06-01)
Phone Number �!!7 r� , 1 20/^ ��
City ( J
C 1
❑ HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
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 cu rent safety standards. Do not
atterppt`to us this equipment until it has been repaired.
Equipment Type: (y I� y Location
y
CONDITIONS U Apparent cracked or restricted heat exchanger
FOUND: ❑ Damaged appliance connector
❑ Damaged or disconnected vent
O Gas leak at gas equipment
O A gas leak in your house piping in the amount of
with all known appliances off
O Insufficient combustion/ventilation air
O Other
-{-al N !A `. i di,) ff G 7 t. i e -/'J•
CFH
wtt"L, i�v (0
PSO
t> � ��v�otr
Meter Left 0 Off L#On Meter Number Meter
/Rek
I have read, understood and acknowledge receipt of this notice. ❑ Owner Tenant 0 Agent
Customer Signature 0 Refused to Sign
Service Representative t.rDate 1°/2"7/4) Time r C"vv am/pm
White Copy— Customer Yellow Copy—Attach to Service Order Pink Copy— AuthontyHaving Jurisdiction Hard Copy—Appliance