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CAUTION NOTICE
- Address Apt.
CityNillage/Town ;::. ~_: ~:• :~--
SIGNATURE:
Person notified of condition
^ Tenant ^ Owner ^ Other
Owner Phone
Address
METER ^ Left on ^ Turned off ^ Off at Appliance Valve
UNSAFE CONDITIONS FOUND: '
3
( )Leak in house piping.
( ) Unvented appliance.
( )Obstructed or rusted out vent or chimney.
(- )Defective safety or No safety pilot.
( )Defective heat exchanger.
( )Appliance producing carbon monoxide.
( )Other -See Remarks
( ) HW Rotary Valve ^ Safety O.K. ^ Thermal Vent Dam er
CODE VIOLATIONS: p
( )Solid fuel appliance vented in same chimney flue as Gas
appliance.
( )Other -See Remarks
REMARKS:
*PLEASE CALL WHEN REPAIRS ARE MADE
PHONE 1-800-450-7260
ADJUSTER: DATE:
IF YOU NEED ASSISTANCE IN CORRECTING THE ABOVE
CONDITION -- CALL YOUR APPLIANCE DEALER
Form 159-7402 Rev. 10/01 Canary -District Gas Department White -Heating/Building Inspector Tag -Appliance Tag
i' a i q y,
May 5, 2005
Wisconsin Public Service Corporation
la suosidiary of WPS Resources Corporationi
3300 N. Main Street
FO. Bex 420
Oshkosh, WI 54903-0420
1-800-450-7260
~~ ~~
J C Smith
PO Box 1294
Oshkosh WI 54903-1294
Dear J C:
Account # 3120295; 1402 Mount Vernon St., Oshkosh WI
Our gas mechanic has reported that an undesirable condition exists on your boiler.
This problem is classified as an immediate hazard by WPS. If not corrected, personal safety is at risk.
For health and safety reasons, we have turned offthe gas supply to this equipment. It is recommended that
use of this equipment be discontinued until the condition indicated with an (x) in the tabulation below has
been corrected.
1. ( )Leak in house piping.
2. ( ) Unvented appliance.
3. ( )Obstructed or rusted out vent or chimney.
4. (x) Defective safety or no safety pilot.
5. ( )Underground fuel run uses unapproved plastic material.
6. ( )Appliance producing carbon monoxide.
7. ( )Other.
We know that you are interested in keeping your gas equipment performing in a safe manner and suggest that
you give this matter your immediate attention.
Call your appliance dealer or other service agency to assist you in making the necessary repairs.
For informational purposes, a copy of this notice and the Caution Notice Tag are being forwarded to the
building inspector or code official in your area.
Please notify us when the above condition has been corrected. We can be reached 24 hours per day at 1-800-
450-7260.
Sincerely,
Manager customer Service -Gas
skm
C: Mr. Bruce Luedtke, Housing Inspector
215 Church Avenue. Oshkosh, WI X4901
www.wisconsinpublicservice.com