2004, 09-15 Notice of Hazardous Conditions fir
VISTA'
Utilities NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Customer Name i+` Phone Number
Address , City .li
TYPE OF ❑ HAZARD The conditions noted below constitute an immediate hazard and may result in property'Pla nage,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 ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
I
i
Meter Left ❑ Off `"On Meter Number Meter Read
I have read,understoodst �and acknowledge rpceipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature e ❑ Refused to Sign
Service Representative /44 73
Date Time �� am m,
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance