2004, 05-05 Notice of Hazardous Conditions-FurnaceMeter Left ra Off
1ii,STA
Utilities
Customer Name
Address
TYPE OF
NOTIFICATION:
Equipment Type:
CONDITIONS
FOUND:
NOTICE OF HAZARDOUS CONDITIONS
Phone Number
City
S-0308 (08-01)
t in
al
ury, or loss
❑ HAZARD The nt conditions
been disconnected or left inoperable, and shall not be turned balck onuntilproperty
ch repairs have been completed
of life. The equipment has been
by a qualified HVAC dealer, contractor, or service agency, and the equipment has been brought up to current safety standards. Dono
o ea this eauioment until it has been Poa
ire
❑ Apparent cracked or restricted heat exchanger ❑
❑ Damaged appliance connector
O 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
PE
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Meter Read
❑ Owner &Tenant ❑ Agent t O
On Meter Number
f have read, understood and acknowledge receipt of this notice.
Customer Signature
Service Representative
CFH
Date
❑ Refused to Sign
Time / • pm
ininuo r nv — Customer
Yellow Copy - Attach to Service Order Pink Copy - Authority Having Jurisdiction Hard Copy -Appliance
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