2003, 04-18 Notice of Hazardous Conditions A nISTA S-0308(06-01)
NOTICE OF HAZARDOUS CONDITIONS
Utilities
Customer Name ,---, I m I f • Phone Numb ��� O,(
�?- , ". City `1
Address
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: SI�e-Gs-
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
o
I'
�
ff,
./ S Y /1‹,12.--4
I
I,
Meter Left ❑ Off On
Meter Number Meter Read
[�
1 /have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
lJ,,,' ;2r..,,,_,. ❑ Refused to Sign
Customer Signature ,c� ebf
�lJ I v Time am/pm
Date
Service Representative
.1 7 l��
White Copy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hard Copy-Appliance �-