2005, 06-23 Permit: E532 Notice of Haz. Conditionsflw
rJ v/STA'
NOTICE OF HAZARDOUS CONDITIONS S-0308 (08-01)
Utilities
11
Customer Name ti'%\� Phone Number.
Address City
TYPE OF IHAZARD The conditions noted bel,ove constitute an immediate hazard and may result in property damage, personal injury, or loss
NOTIFICATION: 0f 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 equui ment until it has been reoaired.
Equipment Type: r r� Location: 4E6
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
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. l Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative Date Time am/pm
WhiteCopy- Customer Yellow Copy- Attach to Service Order Pink Copy- Authority Having Jurisdiction HardCopy- Appliance
y r
Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. l Owner ❑ Tenant ❑ Agent
Customer Signature ❑ Refused to Sign
Service Representative Date Time am/pm
WhiteCopy- Customer Yellow Copy- Attach to Service Order Pink Copy- Authority Having Jurisdiction HardCopy- Appliance