2004, 08-30 Notice of Hazardous Condition�u VISTA'
NOTICE OF HAZARDOUS CONDITIONS S-0308 ,08-01)
Utilities
Customer Name t r< r'K;,.) l7 Phone Number fes" 9- ` r—
Address A!�: Cit`
TYPE OF �.J HAZARD The conditions noted below constitute an immediate hazard and may result in property daage, 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
attemDtto use this eauipment until it has been repaired.
Equipment Type:
CONDITIONS 0 Apparent cracked or restricted heat exchange
FOUND: ❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
Location: Lj+(--" /;
r ❑ A gas leak in your house piping in the amount of CFH
with all known appliances off
❑ Insufficient combustion/ventilation air
`Z Other
Meter Left ❑ Off Ek On Meter Number
1 have read, understood and acknowledge receipt of this
Customer Signature
Service Representative
Meter Read
ce. A_ Owner ❑ Tenant ❑ Agent
Date
❑ Refused to Sign
Time y:, any/pm
White Copy - Customer Yellow Copy -Attach to Service Order Pink Copy- Authority Having Jurisdiction Hard Copy - Appliance