2005, 04-30 Notice of Hazardous Conditions ic
10uV/STA'
NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name , , 0 f` ' '`t Phone Number 4/7 o +"
Address 4" City /219 •
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: j ::' Location: d
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH k
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air ---,c,`
❑ Gas leak at gas equipment ❑ Other y/, }/♦ ,,� _.
v
Meter Left ❑ Off ❑ On Meter Number Meter Read PtA
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative " ,` " L" ,;` A t/A Date 14~ 3 C'� 0 Time 7)''5-1 am¢pm)
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance