2004, 06-02 Notice of Hazardous Conditions� 7M
�-STA
Utilities
Customer Name
Address
NOTICE OF HAZARDOUS CONDITIONS
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
f i 3 70 vt`t
Phone Number
City
S-0308 (08-01)
9
.(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.
Location•
C/,(. -°jj,
❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
Other
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
CFH
1
7
Meter Left 0 Otf On Meter Number Meter Read
/ have read, understood and acknowledge receipt of this notice. ❑ Owner .4a' Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative 1, Date Time
White Copy - Customer Yellow Copy - Attach to Service order Pink Copy- Authority Having Jurisdiction HardCopy- Appliance
am/pm