2005, 05-27 Notice of Hazardous Conditionsi'ISTA
' Utilities
'Customer Name A ,rt%/'=' Phone Number
Address 3 - �l City
NOTICE OF HAZARDOUS CONDITIONS
S-0308 (08-01)
TYPE OF
NOTIFICATION:
❑ HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
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 TypeC.,41 / a, Location•
CONDITIONS
FOUND:
8` Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
CFH
Ae$ 44
1
' -
Meter Left ❑ Off , On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. ❑ Owner 0 Tenant ❑ Agent
Customer Signaturi, ❑ Refused to Sign
Service Representative dati"o Date �'7 ""t'• Time
3.:4/ andE)
White Copy - Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance