2004, 06-18 Notice of Hazardous ConditionsApril i/7STA
Utilities
Phone Number j'% /• 0/7
Customer Name
Address (:
TYPE OF
NOTIFICATION:
NOTICE OF HAZARDOUS CONDITIONS
Equipment Type:
CONDITIONS
FOUND:
City r,) fir) . t:/1:J 1 L
-0308 (08-01)
HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
of li e. 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
attemotto use this eauioment until it has been reoaired.
Location:
r rF
❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of
LI Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
CFH
1 : '
Meter Left ❑ Off Q On Meter Number
I have read, understood and acknowledge receipt of this notice. 1St Owner ❑ Tenant
Customer Signature
Meter Read
❑ Agent
❑ Refused to Sign
Time
Service Representative —
White Copy - Customer Yellow Copy- Attach to Service Order
Date
Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance