RECEIPT FOR ENERGY COMMISSION LETTER REGARDING NEW DUCT SEALING
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BOARD OF COUNTY COMMISSIONERS TRANSMITTAL AND RECEIPT PAGE 1 BROWARD COUNTY, FLORIDA FOR RECORDS STORAGE OF _____ PAGES COUNTY RECORDS DIVISION SEND ORIGINAL TO: ITEM # 1 TO BE COMPLETED BY RECORDS CENTER 1. ACCESSION # BROWARD COUNTY RECORDS CENTER 1600 W HILLSBORO BLVD DEERFIELD BEACH, FL 33441 2.AGENCY CODE (4 CHARACTERS) 3. FROM: (NAME & ADDRESS OF SUBMITTING AGENCY) 4. AGENCY CONTACT 5. LOCATION 6. TELEPHONE # 7. CUSTODIAN (SIGNATURE) 8. TITLE 9. DATE 10A. RESTRICTION ON USE OF RECORDS IF ANY) 10B. CITE AUTHORITY 11. CUBIC FEET TRANSFERRED RECORDS I IDENTIFIERS 12. LIST OF RECORDS TRANSFERRED (ITEM 12A TO BE COMPLETED BY RECORDS CENTER) A. RC BOX B. AGENCY C. RECORDS SERIES TITLE DATES D. RECORDS AGENCY USE FROM TO TOTAL 1. SEND ORIGINAL TO RECORDS CENTER 3. RETAIN (1) COPY UNTIL APPROVED FORM IS RETURNED 2. PLACE (1) COPY IN FIRST BOX OF SHIPMENT 4. RETAIN APPROVED FORM FOR AGENCY FILE CONTROL FORM 404-21 (REV.1/92) a. Indicate the number of pages included in this shipment. b. Item (1) is for RECORDS CENTER USE ONLY. c. Items (2-13) are as follows: 2. AGENCY CODE - This is the four character code that identifies your agency in the Records Management Computer Program. The Department Listing of agency codes in WordPerfect format is on the RCW. 3. FROM - Fill out the name and address of the agency. 4. AGENCY CONTACT - Put the name of the Records Management Coordinator here. This is the name of the person filling out the Transmittal. 5. LOCATION- The building and room number where the records are currently housed. EX. - GC 114, MR 3rd fl., or GC ANNEX 302. 6. TELEPHONE # - The Records Management Coordinator’s phone number. Do not put the main office number here. 7. CUSTODIAN - The signature of the agency director or in his or her absence, the assistant director or Sub-custodian. 8. TITLE - Of the Custodian who signs the form. 9. DATE - The day the form is completed. 10a. RESTRICTION ON USE - Are these records confidential and exempt from the Public Records Act? 10b. CITE AUTHORITY - If the answer to (10.a) is yes, write the statutory citation that validates an exemption from the Public Records Act for these records. 11. CUBIC FEET - A record storage box equals roughly one cubic foot. Count the number of boxes in this shipment and enter that number here. This number is automatically calculated on the electronic form. 12a. FOR RECORDS CENTER USE ONLY 12b. AGENCY BOX # - Start the box numbers at 1 for each shipment. Write the box number with a black wide-tip marker in the top left corner of a handle end on each box. Do not write anything else on the handle ends of the box. 12c. RECORD SERIES TITLE - Indicate the exact record series title from the retention schedule you are using. Do not enter anything other than a current State published record series title in this field. By assigning a Record Series Title and its corresponding Record Series Number (instruction 12d.) to the records in the box, the records are being scheduled for retention and ultimate destruction. Only records that have been scheduled are accepted by the Records Center. The from and to dates are essential and must be included. 12d. RECORD SERIES NUMBER - If you are using the General Records Schedule for Local Government Agencies (GS1), or another general records schedule, the prefix, a dash, the item number, and the copy indicator must be included. EX. - GS1- 6A (ATTENDANCE RECORDS), GS4-70A (RUN REPORTS: EMERGENCY), or GS2- 53A (INMATE INCARCERATION RECORDS). In the first example (GS1) is the prefix, (6) is the item number, and (A) is the master copy indicator. Do not enter anything other than a current State published record series number in this field. 13. TOTAL # OF BOXES - Add the number of boxes included in this shipment and put the total here. If using 404-21 continuation sheet(s), put the total number of boxes on the last sheet of the shipment. This number is automatically calculated on the electronic form. d. Two new fields have been incorporated in the transmittal that are optional and strictly for agency use. These fields are RECORDS IDENTIFIER(S) and AGENCY USE (RANGE). Both fields have a double line border. These fields will enable limited indexing capability for the agency, if used. If an agency requires a more detailed index, it must be generated on a separate document. e. A copy of the transmittal must be faxed to the Records Center for approval. The Fax number is (831-1438). The transmittal will not be approved unless it is completed correctly. The original Transmittal and Receipt for Records Storage form are then sent to the Records Center. If Facilities Management is needed to pick up and deliver the boxes, fill out a Service Requisition Form 104, attach it to the original 404-21, and forward both forms to the Records Center. f. Put a copy of the 404-21 in the first box of this shipment. g. Keep a file copy of the 404-21 until it can be replaced with the final copy that will be forwarded from the Records Center after the shipment has been processed. Attach the final 404-21 to your index. The final 404-21 contains Records Center RC Box Number information that you must have to accomplish records retrieval from the Records Center in the future.