2004, 09-14 Notice of Hazardous Conditions mil VISTA
NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name f'-`)/ AJ Phone Number `' f
41fq
Address /,. r% Z:....- City
TYPE OF U 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/ Location:
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
Meter Left ❑ Off A On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ' ',1G! Tenant LI Agent
Customer Signature �, CI Refused to Sign
Service Representative /1 `f r Date Time am
WhiteCopy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance