2004, 11-29 Notice of Hazardous Conditions Amy_ i
A*it VISTA'
Utilitie NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01)
Customer Name Vk a KiM I o Phone Number U fir— Q"Q9 — b tic ?
Address 6 ,' 'i,5" . ' 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 eauipment until it has been repaired.
Equipment Type: af. Location:
CONDITIONS ❑ Apparent cracked or restricted heat exchanger ❑ A gas leak in your house piping in the amount of CFH l
FOUND: ❑ Damaged appliance connector with all known appliances off
❑ Damaged or disconnected vent ❑ Insufficient combustion/ventilation air
❑ Gas leak at gas equipment ❑ Other
(
cbMeter Left ❑ Off >11On Meter Number Meter Read '�1I
\V
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature -1- - .‹� ❑ Refused to Sign
Service Representative '
( " "" Date Time f{� �3, am/pm
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance