2003, 12-17 Notice of Hazardous Conditions ����- - 5-0308(OS-01)
J7IfISTA , NOTICE OF HAZARDOUS CONDITIONS
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Customer Name f R r'F r r� "..�`."'-�."...-. Phone Number
' l'� City
Address
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 eouipment until it has been repaired.
Equipment Type:
Location: 7:34 5-kr,/,_ f---4-' --
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 K,.
Meter Left ❑ Off ❑ On Meter Number Meter Read
1 have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
❑ Refused to Sign
Customer Signature
Service Representative
/' V
Date Time am/pm
White Copy-Customer Yellow Copy-Attach to Service Order Pink Copy-Authority Having Jurisdiction Hard Copy-Appliance JC \\4