2003, 06-13 Notice of Hazardous Conditions mu
4' I'ISTAA
NOTICE OF HAZARDOUS CONDITIONS 5-0308(06-01)
Utilities _
Customer Name . , , iik, i /21...' / ' =i4...: Phone Number
Address 97Z. 'ry Vi 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: " ( ..„! 4 I , «f/\e'�..C . 4 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
Cl Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
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Meter Left ❑ Off ap.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
''' `' 4r,.J6,Xi� Date Time am/pm
Willis Copy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction HardCopy-Appliance ";-,2-\\ C