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