2004, 12-25 Notice of Hazardous Conditions 4 7rnSTA
Utilities NOTICE OFfHAZARDOUS CONDITIONS 5-0308(08-01)
Customer Name r .'',:-11' �Y "'r''�14-lies-ThPhone Number i ry +l i''o
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Address .).1.14,r City
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.
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Equipment Type: 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 4
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Meter Left ❑ Off ❑ On Meter Nu b:7 Meter Read
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I have read,understood and acknowledge receipt.f his otice. CIOwner ❑ Tenant ❑ Agent V
Customer Signature - ._ ❑ Refused to Sign
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Service Representative -r. 4, //07Vooi
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Date 41 ` ","' t I {r Time am f)m
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance