2005, 01-25 Notice of Hazardous Conditions 4 sTIE
NOTICE OF HAZARDOUS CONDITIONS s-0308(08-01)
Utilities
Customer Name -51-e V t Cr/ ** 1r 1 y Phone Number
Address 2-/? o ` . City /11#41e
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.
I
Equipment Type: Location: ,�6.44,..‘c,.,_.._
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
77/f
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Meter Left ❑ Off ❑ On Meter Number Meter Read / j
f
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature / ❑ Refused to Sign
Service Representative �-Y' -7--i,. TimeGr am
WhiteCopy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction HardCopy-Appliance