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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 �-