2005, 03-19 Notice of Hazardous Conditions 4 1nST S-0308(08-01)
NOTICE OF HAZARDOUS CONDITIONS
Utilities
t. #/41.1, Phone Number
Customer Name
-A8 3 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 eauipment until it has been repaired.
Location:'
Equipment Type:
CONDITIONS ❑ Apparent cracked or restricted heat exchanger U 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
—
,.A z:
Li-
Meter Left ❑ Off ❑ On
Meter Number Meter Read 619
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
�,'. ,, • ❑ Refused to Sign
9.\
Service Representative , ,,
Customer Signature .F
! b Date '�—/4-C,��T.- Time /A2 %30ampm
i
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance