2004, 08-28 Notice of Hazardous Conditions NIL
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NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name le..4 Phone Number
Address City '1,
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: Vit/ill I-4 Location: L ft... f / t,„
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
U Damaged or disconnected vent r❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
4,`i) - 7"
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/ / .
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
l
Customer Signature ❑ Refused to Sign
Service Representative Date Time am,./125)
White Copy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hard copy-Appliance \\P