2003, 04-04 Notice of Hazardous ConditionsS-0308 (06-01)
Utilities
Customer Name
Address
TYPE OF
NOTIFICATION:
NOTICE OF HAZARDOUS CONDITIONS
Phone Number
City
0 HAZARD The conditions noted below constitute an immediate hazard and may result in property damage, personal injury, or loss
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:
CONDITIONS
FOUND:
.0- Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
❑ Gas leak at gas equipment
Location.
❑ A gas leak in your house piping in the amount of
with all known appliances off
❑ Insufficient combustion/ventilation air
❑ Other
7", ...IS
CFH
c
Meter Left ❑ Off `ir]On Meter Number
I have read, understood and acknowledge receipt of this notice. 0' Owner ❑ Tenant
Customer Signature
Service Representative
White Copy -Customer Yellow Copy- Attach to Service Order
Date
Meter Read
❑ Agent
❑ Refused to Sign
Time
Pink Copy -Authority Having Jurisdiction Hard Copy -Appliance
am/pm