2004, 10-15 Notice of Hazardous ConditionsA TSTA" NOTICE OF HAZARDOUS CONDITIONS
Utilities
Customer Name 6T .C> S
Address �'A Lik
TYPE OF
NOTIFICATION:
I-/ )1/1
-0308 (08-01)
Phone Number 5. 5 '5 -7 7
City '170
r
❑ 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 euuipment until it has been repaired.
> ,f `r_ ( }�? /(7-(--,� -� Location! 7fiz'"—
Equipment Type: / tt r
CONDITIONS ❑ Apparent cracked or restricted heat exchanger 0 A gas leak in your house piping in the amount of
FOUND: 0 Damaged appliance connector with all known appliances off
0 Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
0 Gas leak at gas equipment iCt. Other
(4i I J Ll f) -t ''
> 447
CFH
, 'u
Meter Left ❑ Off Kin
1, -"fl ?,)!/Jr
Meter Number Meter Read /
I have read, understood and acknowledge receipt of this notice. 0 Owner 0 Tenant 0 Agent
Customer Signature 0 Refused to Si
Service Representative 1 ////i/J /
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Date J -0 L/ Time am/pm)
White Copy .- Customer Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy - Appliance