2003, 05-15 Notice of Hazardous Conditions /Ilk_
�u®i/ISTA NOTICE OF HAZARDOUS CONDITIONS S-0306(06-01)
Utilities
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Customer Name `, " ! Phone Number—
Address
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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: Ya" .+ -t�i,h. ,..) ,....z..... Location: tell-.. ,,
CONDITIONS ❑ Apparent cracked or estricted 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 f Other
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Meter LeftOff ❑ On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
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Service Representative 6 Date5;1 �9 Time /7'
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1I White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance