2004, 02-24 Notice of Hazardous Conditions 4-0 Any_
NOTICE OF HAZARDOUS CONDITIONS S-0308(06-01)
Utilities
Customer Name Phone Number
Address ! L{' City
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:
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 Nig Insufficient combustion/ventilation air
❑ Gas leak at gas equipment Other
Meter Left ❑ Off ❑ On Meter Number Meter Read
1 have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative A< � Date "' Time - am/pm
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance