2005, 01-29 Notice of Hazardous Conditions /nom _
�ui /STANOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name (^ '' - I• _ Phone Number
Address ,j° .? 1/ 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.
Equipment Type: Location: '(,` '1r,�'l,
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
t ❑ Gas leak at gas equipment ❑ Other -;
s ./' Li( /i.: �.d
F r r- 11(3)
r
Meter Left ❑ Off ❑ On Meter Number Meter Read
1 have read,understood and acknowledge receipt of this notice. CI Owner ❑ Tenant 0 Agent \Di
Customer Signature Lk
'Yt l ❑ Refused to Sign
Service Representative `" '' Date 61'1- Time am:pm
White Copy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hard Copy-Appliance