2004, 02-25 Notice of Hazardous Conditionsuii/'/STA
Utilities
Customer Name
Address
NOTICE OF HAZARDOUS CONDITIONS
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
/
S-0308 (08-01)
Phone Number
.;ir _,.^ � 2' - City _ J. e .. e
1.
AZARD The conditions noted below constitute an immediate hazard and may result in property damageersonal injury, or loss
f 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 eauioment until it has been repaired.
Apparent cracked or restricted heat exchanger
amaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
Location:
❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
O Insufficient combustion/ventilation air
O Other
Meter Left Off ❑ On
Meter Number
Meter Read
t have read, u derstood and acknowledge receipt of this notice.Owner ❑ Tenant
Customer Signature
Service Representative Date
❑ Agent
0 Refused to Sign
•;i' ;-;:-.1/4//: Time/ii "'
f d
White Copy - Customer Yellow Copy - Attach to Service Order Pink Copy -Authority Having Jurisdiction Hard Copy - Appliance