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2004, 08-28 Notice of Hazardous Conditions � ii7STA' NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01) Utilities Customer Name % 2-+4'C l ,.✓i3,. Phone Number Address /6/07 ,:'16.112/1.4-3/4"."/' '',,' City ". / TYPE OF AZARD 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: ° ' >` Location: !'71,/ /'/( <'-e- y 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 Meter Left ❑ Off ❑ On Meter Number Meter Read d". I ( V I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent Customer Signature , ❑ Refused to Sign Service Representative " ' /41}� !'' ,r e 1M Date " 7F.0-',/ Time 2 am pm White Copy—Customer yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance