2004, 01-27 Notice of Hazardous Conditions %�I�VISTA' S-0308(08-01)
NOTICE OF HAZARDOUS CONDITIONS
Utilities
M1
Customer Name rt Phone Number
City
Address a t✓`3 �a f
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 eauipment until it has been repaired.
Equipment Type:
Airl
Location: �`"' _ ,
CONDITIONS ❑ Apparent cracked or restricted heat exchanger U A gas leak in your house piping in the amount of C,FH
FOUND: U Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment CIOther }w
^ , 4. ,7 7:-/ tiaf,�!� >1*,
Meter Left U Off ❑ On Meter Number Meter Read /O'
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
❑ Refused to Sign
Customer Signature
Service Representative
77141/A/4/41 Date Time f?�2 v atm,
WhiteCopy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance