2003, 04-05 Notice of Hazardous Conditions Aim__
NOTICE OF HAZARDOUS CONDITIONS S-0308(06-01)
Utilities
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Customer Name ' � Phone Number
Address (/c/j Gc"-( 5 07ty
4
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: r 1"! Location: �' '� t'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 ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
4 /' 1,-•1 C 0
Meter Left ❑ Off , On Meter Number �'�-- Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ^Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative t C./6 ` Date Time am/pm
v^.
White Copy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hard Copy-Appliance (j-s V\D