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2003, 04-29 Notice of Hazardous Conditions "17— �iliVISTA® NOTICE OF HAZARDOUS CONDITIONS s-0308(06-01) Utilities 1 G� ,,� V 3 33 ,, Customer Name /I:Phone Numberit / Address City -7 6 1 i 2O(s2 —54.3e-) TYPE OF U HAZARD The conditions noted below constitute an immediate hazard and may result in property damage,personal injury,or loss ti NOTIFICATION: of life.The equipment has been disconnected or left inoperable,and shall not be turned back on until such repairs have been completed d 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: '` 'C^ 4'4.' CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH t. FOUND: ❑ Damaged appliance connector with all known appliances off ❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air ❑ Gas leak at gas equipment ❑ Other 1 Ili Meter Left ❑ Off ❑ On Meter Number Meter Read I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent Customer Signature ,�yJ ��,� ❑ Refused to Sign Service Representative %'� 1' / � %'"y`'e ' Date - Time am/pm White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance --.)