2003, 04-18 Notice of Hazardous Conditions /II/_ _ S-0308 06-01)
AudV/STAR NOTICE OF HAZARDOUS CONDITIONS
Utilities ��;yy
P., CA/b0 Phone Number .SCX 1 '
Customer Name t,'",--/U " d ( � �J a�Z �U �
� 3 CJ / / 2Y `:' City
Address
constitute an immediate hazard and TYPE OHAZARD pconditions
below may result property damage, injury,
j or loss
NOTIFIOFCATION: ofiTheequment has been disconnected or left inoperable,and shall of be turned back on untisuch repairshave 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: 4 ," �,.-,,.,.; Location:
CFH
CONDITIONS ❑ Apparent cracked or restricted heat exchanger CIA gas leak in your house piping in the amount of
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment U Other
tr 7 '_,. .444..J m
+ -
Meter Left ❑ Off ❑ On
Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature
1,7;. f ' ( y' ❑ Refused to Sign
•-7 c, Date
Time "/'i �"=am/pm�''
Service Representative
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance C7i