2005, 03-03 Notice of Unsatisfactory Condition APii1fISTA
NOTICE OF UNSATISFACTORY CONDITIONS s-osos(1-99)
Utilities
Customer Name -•_.. I1 sit- � Phone Number ' /
Address :r,reu/' t I: City
5
Ci
TYPE OF >4IAZARD 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 turned off pending further inspection and repairs,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.
❑ WARNING The conditions noted below constitute a potential hazard. Although the condition does not present an immediate
threat to life or property,failure to correct the condition may lead to a hazardous condition. Please contact a qualified HVAC dealer,
contractor,or service agency to perform further inspections or to bring the equipment up to current safety standards.
Equipment Type: Location:
CONDITIONSApparent cracked or restricted heat exchanger ❑ Inoperative safety system
FOUND: ❑ Spillage of exhaust at the draft hood after a ❑ Insufficient combustion/ventilation air
reasonable warm-up time ❑ Gas leak at gas equipment
CI Damaged appliance connectorbther , r 'G c'
❑ Damaged or disconnected vent ^f
❑ Defective limit control -t > --+i f- P
❑ A gas leak in your house piping in the amount of CFH
with all known appliances off { -� 7,ty l� if.;
7/,'" /2,\4
Dave read, understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
ustomer Signature _ _ _ CI Refused to Sign
Service Representative Date /j(o., -S Time am/pm
Equipment Disconnected? Yes NI Equipment Tag Left? *Yes ❑ No Authority Notification Required? ❑ Yes ❑ No
Equipment Left ❑ On Off Meter Left ❑ Off On •
WhiteCopy—Customer Yellow Copy—Attach to S ice Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance