2005, 01-25 Notice of Hazardous Conditions ����_ _
ArtfinSTA NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities '' ' � (�
Phone Number .5.::::-7
Customer Name ..4. City
f
Address
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.
,' 4 .. Location: -.--` r>st r'.
Equipment Type: `" /
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
i iif
Meter Left ❑ Off ❑ On Meter Number Meter Read
nd acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent 9 I
t/
V
I have read,understood a 9
❑ Refused to Sign
Customer Signature s _ ,._„,
Date Time am/pm
Service Representative
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance