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2004, 08-16 Notice of Hazardous Conditions �u1�//STA' NOTICE OF HAZARDOUS CONDITIONS S-0308(08-01) Utilities � 11 Customer Name E"lv ! L. !0/4 R i b Phone Number Address / ©7 / ` jr 64-74A City TYPE OF ..,_, 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. r� Equipment Type: it int ti! //i.. 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 ❑ Other — MMIMI1.�rw _ /T�_ ow.. ,,e) f /' ,:4.,„� (� I +A!\ Li fct (`1 cit” T i/' W {j/ j � Meter Left ❑ Off ❑ On Meter Number Meter Read `\ I have read,understood and acknowledge receipt of this notice. ❑ Owner ❑ Tenant ❑ Agent -C) Customer Signature , .i.ot, r~'{Ant ❑ Refused to Sign Service Representative o * Date i ' /C Time am/pm WhiteCopy—Customer Yellow Copy—Attach to Service Order Pink Copy—Authority Having Jurisdiction HardCopy—Appliance