2004, 05-05 Notice of Hazardous Conditions-Wtr HtrCustomer Name
Address
TYPE OF
NOTIFICATION:
,ruri//STA NOTICE OF HAZARDOUS CONDITIONS
Utilities
KTEA/ Jii4/4
/ SSG, r : .- 'f2 , .S (.)
❑ HAZARD The conditions noted below csonstitute 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.
S-0308 (08-01)
Equipment Type:
CONDITIONS
FOUND:
❑ Apparent cracked or restricted heat exchanger ❑
O Damaged appliance connector
O Damaged or disconnected vent ❑
O Gas leak at gas equipment ❑
Location.
Phone Number
City
'I34:7F17c=;ifj
A gas leak in your house piping in the amount of
with all known appliances off
Insufficient combustion/ventilation air
Other
CFH
r' rl Np 1.1-1,i (1 6 E .6N
Meter Left 0 Off Wit., On Meter Number Meter Read
I have read, understood and acknowledge receipt of this notice. 0 Owner Tenant 0 Agent
Customer Signature ' 0 Refused toSign
Service Representative > — Date ,S ' or Time
White Ciipy - Customer
Yellow Copy -Attach to Service Order
Pink Copy -Authority Having Jurisdiction Hard Copy -Appliance