2004, 02-06 Notice of Hazardous Conditions Amy_VISTA' NOTICE OF HAZARDOUS CONDITIONS S-0308(06-01)
Utilities
Customer Name nf_ tr- \ ` `�a k ,-(----Al. Phone Number (—
Address .) -3 96' ,. City c )7✓>U V (( 7
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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.
Equipment Type: - - f • 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 ,/t• ` ❑ Other
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Meter Left ❑ Off ❑ On Meter Number Meter Read
I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent
Customer Signature Y- U 4a�' A ` �' ❑ Refused to Sign
Time �v ''7 -44 m
Service Representative Date
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White Copy-Customer Yellow Copy-Attach to Seniice Order Pink Copy-Authority Having Jurisdiction Hard Copy-Appliance .....,\,