2004, 12-06 Notice of Hazardous ConditionsAaVISTAr
Utilities NOTICE OF HAZARDOUS CONDITIONS ff��
Customer Name /'/H ~644fif '111,10<_.Phone Number !d�' %%
%/U
Address i GEJ!'�--7—City
S-0308 (08-01)
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
D 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 eauipment until it has been repaired.
I j � C. 4 /1( -%Location- f, Li "C p":"d
O Apparent cracked or restricted heat e
o Damaged appliance connector
❑ Damaged or disconnected vent
O Gas leak at gas equipment
xchanger ❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
O Insufficient combustion/ventilation air
O Other
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Meter Left ❑ Off ;4 On Meter Number
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Meter Read
I have read, understood and acknowledge receipt of this notice. ❑ 0 Agent
Customer Signature 0 Refused to Sign
Service Representative Date � '
Owner gl Tenant
White Copy - Customer Yellow Copy - Attach to Service Order
Time /1:5`) Lam/pm
Pink Copy - Authority Having Jurisdiction Hard Copy Appliance