2004, 10-04 Notice of Hazardous Conditions -iii/STA
NOTICE OF HAZARDOUS CONDITIONS c'r!. `-' - / z 5� S-0308(08-01)
. Utilities
Customer Name o'',/"-,- --"•t" ' )/,''il%J Phone Number 9 sli......
Address 14":.
'! . /'„ City ( 14i
TYPE OF HAZA/D 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: f 6i LI-)04 i . Location: # I , +i ' ')0
447
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
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Meter Left I Off ❑ On . Meter Number Meter Read .ii
I have read,understood and acknowledge receipt of this notice. U Owner ❑ Tenant ❑ Agent
it-
Customer Signature ❑ Refused to Signj�,�,
p _ �rAt , •`1C-J('.�`.c.Z Date /0' `ry Time— —a
Service Representative C/J s /
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance