2005, 03-03 Notice of Hazardous Conditions Ani
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S-0308(08-01) �
Utilitie _ NOTICE OF HAZARDOUS CONDITIONS .
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Customer Name , I c .rc, Phone Number `.. y*'
Address =) : City
TYPE OF )5tHAZARD 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: r` i4 I` Location:
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
..0 , ,, s. c/ -c c-t,,
1 , 1-$ .
Meter Left ❑ Off "it On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
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Customer Signature ❑ Refused to Sign
Service RepresentativeOP/ Date ' -T�+' - Time 1"'" +1 I am niC
WhiteCopy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hard Copy-Appliance