2005, 05-13 Notice of Hazardous Conditions Ai .. �/�ST/� S-0308(08-01)
NOTICE OF HAZARDOUS CONDITIONS
Utilities
•
Phone Number
Customer Name
Address
'7✓. 7 City `t
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:
r Location: 7 `.#., '
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
' ..\, .0;1
Meter Left CI Off ❑ On Meter Number
Meter Read i
I have read,understood and acknowledge receipt of this notice. XOwner ❑ Tenant ❑ Agent
❑ Refused to Sign
Customer Signature
Date Time am/pm
Service Representative
White Copy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hard Copy—Appliance