2004, 09-29 Notice of Hazardous Conditions /III _
Aiki NISTA' NOTICE OF HAZARDOUS CONDITIONS
S-0308(OS-Ot)
Utilities "� NZ
Customer Name '^ it —'',;� ', e Phone Number � z)/ _ .1
Address e2 / '' City . ,i.""4:7-,.
TYPE OF HAZARD The conditions noted below constitute an immediate hazard and may result in property daniage,personal injury,or loss
NOTIFICATION: of .fe.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: Location: ,P5-1,5;:'‘
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 I
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other I
14/i t% 4 b L__,...-
1
Meter Left ❑ Off ❑ On Meter'Number Meter Read
I have read,understood and acknowledge receipt of this notice. CI Owner ` . Tenant ❑ Agent 1] D
❑ Refused to Sign l L
Customer Signature
Service Representative Date I / Time "L •Tarr�p/
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance