2003, 04-28 Notice of Unsatisfactory Conditions �uVISTA" S-0308
NOTICE OF UNSATISFACTORY CONDITIONS -
(1-99)
Utilities
Customer Name Phone Number _
Address City t Z^ d Z (-3
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 turned off pending further inspection and repairs,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.
❑ WARNING The conditions noted below constitute a potential hazard. Although the condition does not present an immediate
threat to life or property,failure to correct the condition may lead to a hazardous condition. Please contact a qualified HVAC dealer,
contractor,or service agency to perform further inspections or to bring the equipment up to current safety standards.
Equipment Type: Location:
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ Inoperative safety system
FOUND: ❑ Spillage of exhaust at the draft hood after a ❑ Insufficient combustion/ventilation air
reasonable warm-up time ❑ Gas leak at gas equipment
❑ Damaged appliance connector ❑ Other
❑ Damaged or disconnected vent
❑ Defective limit control
❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
I have read, understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative Date Time am/pm
Equipment Disconnected? ❑ Yes ❑ No Equipment Tag Left? ❑ Yes ❑ No Authority Notification Required? ❑ Yes ❑ No
Equipment Left ❑ On ❑ Off Meter Left ❑ Off ❑ On
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance ^ \\C)