2005, 04-21 Notice of Hazardous Conditions Ani_ _
Afi►►/ ®STA NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name L)( Tr' -' A./Ail,s5.' ' ' / Phone Number '7'='?/ �'Q/
Address • / '"f! =6--e City
TYPE OF D 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.
Equipment Type: Location: 4.10 05;
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
CaAckir-.,v,\❑ Gas leak at gas equipment ❑ Other
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Meter Left ❑ Off U On Meter Number Meter Read \
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
41ii '-' /- / . : <
Service Representative ` /C_. c. r) Time * ‘:, am
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hardcopy—Appliance