2004, 12-25 Notice of Hazardous ConditionsuV/STA°
Utilities
NOTICE OF HAZARDOUS CONDITIONS
S-0308 (08-01)
Customer Name G' ( Phone Number
Address Y4!2't L /7":1414#-- _ City
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FO:
Prik
X.:1 HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
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.
,;;;72 -12 -c -e-
{ -Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
Location
❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
r✓rt
CFH
/"..‘44.64' • r f i L i`
i n, , .--„,,,.,„--7 /f):7 0 Pau C a . , .ryt , - 1',• rr r
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read, understood .and acknowied e receipt of this notice. O Owner ❑ Tenant CIAgent
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Customer Signature
Service Representative
7
SIfta❑ Refused to Sign
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Date — 7 —Ci Time am/pm
White Copy - Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance