HomeMy WebLinkAboutDisposition Forms_02-17_01/03/2017_Utilities •'� '• • �• NO.
Revised : 1/22/14 PAGE 1 OF 1 PAGES
1. AGENCY 2. DEPARTMENT Water Plant 3. BUREAU
Village of Tequesta N/A
4. ADDRESS (Street, City, and Zip Code) 5. CONTACT (Name and Telephone Number)
345 Tequesta Drive Lori McWilliams, MMC
Tequesta, FL 33469 561- 768 -0440
6. SUBMITTED BY: I hereby certify that the records to be disposed of are 7. NOTICE OF INTENTION
correctly represented below, that any audit requirements for the records
have been fully justified, and that further retention is not required for any The scheduled records listed in Item 8 are to be disposed of in the
litigation pending or imminent. manner checked below (specify only one):
Only the Departm t Head has the authority to sign off on Item 6.
p Recycle
Signature / Date I !
Name
Title Sam L; Heady, Deputy Director Utilities
8. LIST OF RECORD SERIES
a. b. C. d. e. f.
9•
Schedule Item Title Retention Inclusive Volume Disposition
Item No. Dates in Action and Date
Cubic Completed After
Feet Authorization
GS14 82 Bacteriological Analysis 5 y r 2011
9. DISPOSAL AUTHORIZATION: Disposal for the above listed records 10. DISPOSAL CERTIFICATE The above listed records have been
authorized. Any deletions or modifications are indicated disposed of in the manner and on the date shown in column g.
1 (Witness to the Records Disposition)
t
Signature V lJ Date 11 Signature � ; Date f
Print Name: Lori McWilliams, MMC Print Name
vli
Print Title: Village Clerk Print Title
NOTE: Upon disposition retain this form for your records
Light gray shading indicaie� a ileiu requlreu i:o ue calrlpieted by department.
Print Form
Light blue requires a signature