2000, 04-19 Notice of Unsatisfactory ConditionsJo isTAW
Utilities NOTICE OF UNSATISFACTORY CONDITIONS scaeaa eel
Customer Name Phone Number
Address — - City
TYPE OF I] 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 turned off pending further inspection and repairs, 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
❑ WARNING The conditions noted below constitute a potential hazard. Although the condition does not present an immediate
threat to life or property, failure to correct the condition may lead to a hazardous condition. Please contact a qualified HVAC dealer, !
contractor, or service agency to perform further inspections or to bring the equipment up to current safety standards.
Equipment Type:
LONOITIONS
UND:
Location: -
❑ Apparent cracked or restricted heat exchanger
❑ Spillage of exhaust at the draft hood after a
reasonable warm-up time
❑ Damaged appliance connector
❑ Damaged or disconnected vent
13 Defective limit central
❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
❑ Inoperative safety system
❑ Insufficient combustioniventilation air
O Gas leak at gas equipment
Q Other
I have read, understood and acknowledge receipt of this notice. 9 Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative Date Tme am/Pm
Equipment Disconnected? ❑ Yes ❑ No Equipment Tag Left? I] -Yes ❑ No Authority Notification Required? U Yes ❑ No
Equipment Left O On 0 Off Meter Left O Off LT On
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