2004, 09-24 Notice of Hazardous ConditionswVISTA' NOTICE OF HAZARDOUS CONDITIONS
Utilities
Customer Name Phone Number
Address City
suaoa(oaa,)
TYPE OF ❑ HAZARD The conditions noted below constants 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. 2Q=
attempt to use this epuioment until it has been rewired.
Equipment TYPe:'i 1 Ar "M-' gt1 ,t`L Location:
CONDITIONS LI Apparent cracked or restricted heat excltanpQz�or ❑ A gas leak in your house piping in the amountof CFH
FOUND: ❑ Damaged appliance connectorwith all known appliances off
❑ Damaged or disconnected vent Insufficient combustion/ventilation air
❑ Gas leak sagas equipment ❑ Other
Meter Left ZI Off 00n Meter Number
I have read, understood and acknowledge receipt o/ this notice.
_ Meter Head
❑ Owner Tenant ❑ Agent
Customer Signature, �❑ Refused t0 Sign 77 �
Service Representative �`� Date Time_{2��ia"1
whae canY-Cuewwr YeaoW Copy -Avachro Serve order Pink Cepy- AUruimvH..gJunedloeon H.rdC p,-AAAaface