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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 jiatiarnwrimmarimmasigmfainffmrxr a�� 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 w�tirrr��