2004, 09-07 Notice of Hazardous Conditionsui/1STA'
Utilities NOTICE OF HAZARDOUS CONDITIONS
Customer Name ///i91J '52 ) i ,1 ILL Phone Number Z9/ - 7 70
Address 4E: • /�� ! c ' City (/c=/.2
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
S-0308 (08-01)
/
❑ 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 eauioment until it has been repaired.
7 4 S i't )41 t" 1 . C)4 r101,., Location: .4 r
❑ Apparent cracked or restricted heat exchanger
O Damaged appliance connector
O Damaged or disconnected vent
O Gas leak at gas equipment
❑ A gas leak in your house piping in the amount of
with all known appliances off
O Insufficient combustion/ventilation air
O Other
CFH
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Meter Left 'Off 0 On . Meter Number Meter Read
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I have read, understood and acknowledge receipt of this notice.
0 Owner 0 Tenant
0 Agent
Customer Signature ❑ Refused to Sign
Service Representative
6 A ,3 /;7C"7 t'/t.,,,- ''-)
White Copy - Customer Yellow Copy - Attach to Service Order
Date
7. 6..'Y Time • 36 amC)
Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance