2004, 05-23 Notice of Hazardous Conditions'AlIi/ISTA' NOTICE OF HAZARDOUS CONDITIONS
Utilities
Customer Name \�')OA/,k&/ /J le li /L L C G/ Phone Number
Address "S -' r. � Ciry
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 currentsafery standards. Do n0t
attemot to use this equipment until it has been retained. /
Equipment Type: /-/� ��Q'-"+-L Ur.! Location: `. ks,�-
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
Meter Left O Off 0 On Meter Number
I have read, understood and acknowledge receipt of this notice.
Meter Head
AOwner ❑ Tenant ❑ Agent I ``
Customer Signature,' ❑ Refused to Sign a
Service Representative k- Date Time am/pm
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Meter Left O Off 0 On Meter Number
I have read, understood and acknowledge receipt of this notice.
Meter Head
AOwner ❑ Tenant ❑ Agent I ``
Customer Signature,' ❑ Refused to Sign a
Service Representative k- Date Time am/pm
Whine Copv-Lusmmer hox. Copy -Anon. Senrte ONer Pini Copy-Aumor eeving Junsaiotion ema Copy-APPlianoe