2003, 06-06 Notice of Hazardous Conditions1
iiia/STA® NOTICE OF HAZARDOUS CONDITIONS S-0308(063-01)
Utilities
Customer Name �' '` / ✓amu '.1 Phone Number-
Address �� Z.' 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 equipment until it has been repaired.
Equipment Type: 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 QK'Other
Meter Left ❑ Off • q On Meter Number
1 have read, understood and acknowledge receipt of this notice.
Customer Signature
Service Representative
Meter Read
❑ Owner Tenant ❑ Agent
D ate
❑ Refused to Sign
G'..STime � � `Grn
White Copy— Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction Hardcopy—Appliance