2003, 04-11 Notice of Hazardous Conditions Air
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NOTICE OF HAZARDOUS CONDITIONS S-0308(06-oi)
Utilities (r‘
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Customer Name 1..,�J�1.4" �'� v`�' JULY,1"--,--\ Phone Number t�~ �" '
Address ` re—‘.-- f1� wae""` City _ - (7c12-I —0 3 if-_
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: r 4 _z- o r'd•tsc..c _,,_,F, 4:; c;---.;e Location: .�G',/ks,..., /.- L -,...._._-._.
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
I have read,understood and acknowledge receipt of this notice. 0 Owner ❑ Tenant ❑ Agent
Customer Signature ' Ki 'arl..A.1 ❑ Refused tomaged
Service Representative Date Timea m
r)White Copy—Customer YellowCopy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance tom_ '\