2004, 10-08 Notice of Hazardous Conditions 17vISTA.
NOTICE OF HAZARDOUS CONDITIONS S-0308(08-o,)
Utilities /�Y 7/,„"
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Customer Name lit
Phone Number
Address ' t City
TYPE OF LI 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
attemot to use this eauioment until it hastbeen repaired.
Equipment Type: { '� i` ?' Location:
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
❑ Gas leak at gas equipment ❑ Other
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Meter Left ❑ Off ❑ On Meter Number Meter Read
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I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature I A,./ /0.-...1--..› ❑ Refused to Sign
Service Representative ! Date / �- Time ' amCp5)
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hardcopy—Appliance