2004, 01-03 Notice of Hazardous Conditions /III _
�u7W ESTA NOTICE OF HAZARDOUS CONDITIONS s-o308(08-01)
Utilities /
Customer Name
' "4"' `,fr / 4-f,.& – Phone Number
Address "21 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.
,/,..,'.124,4"- 1k41.*
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
444 C
'2 .
3.
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner Cl Tenant ❑ Agent
❑ Refused to Sign
Customer Signature
,r—r` Date Time am/pm
Service Representative
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard copy—Appliance