2004, 02-17 Notice of Hazardous Conditions :our ifISTA
NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name .34 ell r'
/'� re,/ L, i0 Phone Number `�/�
+ 4-11 .7 54
Address ` / _3 z n City
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: Location: 1' '"s,4-A.,
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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t e.ti :., /QM. (:)ii : C>a wt!) --- 'JL ',N ("7'. ,./ 5 5
Meter Left ❑ Off On Meter Number Meter Read 44,5
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I have read,understood and acknowledge receipt of this notice. Owner ❑ Tenant ❑ Agent � `•. '
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Customer Signature,„ 4 "rfi' -`s'- S' ❑ Refused_to,SSign ,�`
Service Representative . .-.. /Sr.S e '41* f Date 7 7 ` `"'/ Time ` ` ''''-. ' am m
WhiteCopy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance