2003, 09-26 Notice of Hazardous Conditions•
An.
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Utilities)
r' %' Phone Number
Customer Name / /0 1
Address ,7 9 / // 6 /�.5�;ii% V e City.._,
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
NOTICE OF HAZARDOUS CONDITIONS
5-0308 (06-01)
C7 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.
❑ Apparent cracked or restricted heat exchanger
❑ Damaged appliance connector
❑ Damaged or disconnected vent
a..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
�_.Y Other
CFH
—
/7.4
Meter Left L Off ❑ On Meter Numberhave read, understood and acknowledge receipt of t
// this notice. ❑ Owner ❑ Tenant d Agent
❑ Refused to Sign
—.7
Customer Signature
Meter Read
Date Time
Service Representative
White Copy —Customer Yellow Copy— Attach to Service Order Pink Copy —Authority Having Jurisdiction Hard Copy —Appliance
am/pm