2005, 01-11 Notice of Hazardous Conditions 4-ii V/STA
NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name t.1.2.‘,./,17.41-0/4,44_. J.1.,.." - ,. .. Phone Number
Address City
TYPE OF ❑ 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 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 equipment until it has been repaired.
Equipment Type: Location:
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air •
❑ Gas leak at gas equipment ❑ Other
C._�
Meter Left ❑ Off ❑ On Meter Number Meter Read ..,---1
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative -•<All ci /4 OA Date l — //- Ct Time am/pm
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance