2005, 01-25 Notice of Hazardous Conditions Ain_ _
j 47i ISTA° NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Utilities
Customer Name Phone Number
Address X Citypy-.ter
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: Location: ',,,c .. ,- , / '-r"".. .z- --.-- 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
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 1/
I 1- Date -/-2S'`r- Time /t.
Service Representative �am/pm
WhiteCopy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction HardCopy-Appliance