Abstract: At approximately 9:40 p.m. on January 28, 2008, Employee #1, a maintenance worker with Peacock Oil Company, was called into work on this Sunday evening to repair some equipment. A worker found Employee #1 unresponsive in a 30 ft by 8 ft equipment room for the car wash operations. Two police officers removed Employee #1, who died of acute carbon monoxide poisoning. Acute cocaine intoxication was also revealed by the autopsy. Surveillance video footage showed that approximately 95 minutes had elapsed between the time Employee #1 entered the room and the time he was removed. The police reported that two open tool kits were on top of drums of car wash chemicals in the room. Apparently, Employee #1 had been working on the car wash equipment. Possible sources of the carbon monoxide in the equipment room included a defective boiler exhaust system, a lack of make-up air, and a defective heat exchanger on a room heating unit. The defective boiler (Raypak Model Number 724 WP-B, Serial Number 0988106022) had several cracks in the top, the side panels, and the draft hood. Initial carbon monoxide measurements made by the fire department indicated 0 ppm carbon monoxide in the room; however, this measurement was made after the room was ventilated. The gas company made a carbon monoxide measurement after the defective boiler was activated; this measurement showed approximately 1,100 ppm of carbon monoxide near one of the cracks. Employee #1's carboxyhemoglobin level was 42.7 after he arrived at the hospital. Based on that level, his exposure to carbon monoxide was calculated to be approximately 258 ppm as an 8-hour time-weighted average, which is 5.15 times the PEL of 50 ppm.