2004, 10-29 Notice Of Hazardous Conds... s , rn. i'"J:xi1`4 Fv �:1 •k..'TC..y�C�� r_
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,0g1V/STA NOTICE OF HAZARDOUS CONDITIONSs-0308(08-01
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Customer Name?ili1 Phone Number I
Address L^ /� dv / City
TYPE OFHAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
NOTIFICATION: of e. 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
atteinotto use this eouioment until it has been reoaired.
Equipment Type: Location:
y ' 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 eronrent p Offer
Meter Left;q Off ❑ On Meter Number Meter Read
I have read, understood and acknowledge receiptof this notice. ❑ Owner Tenant ❑ Agent
{
Customer Signature ❑ Refused to Sign
Service Representative I� �. / Date Time a/pm
White Copy -Customer Yellow Copy- Attach to Service Order Pink Copy-Autherdy Having Jurisdiction Hard Copy -Appliance