2003, 10-23 Notice of Hazardous Conditions �u
� i//STA NOTICE OF HAZARDOUS CONDITIONS S-0308(06-01)
Utilities 'f / R
Customer Name ,9I //C. �i � Phone Number `'( 2�G" / /03
Address ./(;) C4 City -140, lqo 37
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: i i �`/ 4 Location: 4, i
•
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 .p Insufficient combustion/ventilation air
❑ Gas leak at gas equipment $Other
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/141.(-- 0Iis,f
( ,'"" ; (7-444 if-tl'i• //ta14/444- ., /7-CA( ,---/e..1,C-4`-'1-4/2-1 )
Meter Left ❑ Off 'On Meter Number Meter Read
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I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature '7,0,7, (---e--1- ! ❑ Refused to Sign
Service Representative ., J eri:% Date r0— Z 3 -m ime e` 3 0ambiTO
1 White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hardcopy—Appliance 1\k°