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2003, 12-17 Notice of Hazardous Conditions ����- - 5-0308(OS-01) J7IfISTA , NOTICE OF HAZARDOUS CONDITIONS F Utilities ttt''} "- `1 (.f '2 .--7 M. '1 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