2003, 05-15 Notice of Hazardous Conditionsc�
�V/STA NOTICE OF HAZARDOUS CONDITIONS Irl
Utilities �7. p
Customer Name �:�r _T 1 Phone Numbe 72 (00
Address CiryI
TYPE OF HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or lass
NOTIFICATION: of life.The equipmenthes been disconnected or left inoperable, and shall notbe turned hack 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 no
attempt to use this equipment until it h""a""s��k''e``e��n ropeoa'red ,
Equipment Type: �'�`<Cz-C �'^LncU(�. Location:
CONDITIONS U Apparent cracked or restricted heat exchanger U A gas leak in your house piping in the amount of CFH
FOUND: U Damaged appliance connector with all known appliances off
U Damaged or disconnected vent U Insufficient combustion/ventilation air
,�Gas leek at gas equipment U Other
Meter Left U Off AOn Meter Numi Meter Read
Ihave read, understood and acknowledge receipt of this mitice. �}/..0 Owner .4jenant U Agent
Customer Signature `r-= / -'F x—�^� U Refused to Sign
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Service Representative/ —1-13 Time �� r `' ami
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