2003, 10-02 Notice of Hazardous Conditions Aoul fi/ISTAS-07,3(O6-o1)
NOTICE OF HAZARDOUS CONDITIONS / (� „ ��
Customer Name
Utilities
Phone Number
City ,--'
Address '
TYPE OF U HAZARD The conditions noted below constitute an immediate hazard and may result in property damage,personal injury,or loss
NOTIFICATION: of le•The dubeen
disconnected or eft pinoperable,
be tur
ned back on l su
ch repairs
byaqualfeHVAC dealer,contractor,or servicagency,and the equipmenthas been brought uptocurret safety standards.completed
attempt to use this equipment until it has been repaired. «y�--
Equipment Type: �4r-tc.-" ' '' Location:
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
U Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other �y
r- .=:,J <..... .� - ,�- '"S_
f, f: / GI r g ,c't'"r
Meter Left ❑ Off ❑ On
Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. U Owner U Tenant ❑ Agent
❑ Refused to Sign
Customer Signature
,+4-2_ -c.-,3 Time am/pm
Representative -'"" ` `" Date
p Bance �+ �\�
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—AuthorityHavingJurisdiction Hard Coy—App